You Can Count on Me is a Pepfar-funded programme in South Africa that aims to change men’s behaviour and to educate them about the prevention of HIV transmission from mother to child (PMTCT). The programme trains men to understand what HIV is, how it’s transmitted, how to prevent it in the general population, to protect babies from getting it and to help their partners along the journey of pregnancy. Model students in these workshops are then selected to train other men across the nine provinces. Approximately 10,000 men have been reached through face-to-face community meetings. The programme provides support for men to become involved in the pregnancy of their partners, as it regards men’s sexual behaviour as one of the main drivers of the HIV and AIDS epidemic in southern Africa.
Equity and HIV/AIDS
This study aimed to describe the scale-up of a decentralised HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population. A total of 5,719 adults who initiated ART between October 2004 and September 2008 were included and stratified into six-month groups. There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84%, while 10.9% died and 3.7% were lost to follow-up. Mortality was highest in the first three months after ART initiation, with 30.1 deaths per 100 person–years. At twelve months, 23% had a detectable viral load. The study concluded that outcomes were not affected by rapid expansion of this decentralised HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.
IRIN/PlusNews has put together a list of seven ways in which HIV service providers could cut costs and improve their efficiency. Task-shifting has already seen positive results in Ethiopia, Malawi and Mozambique, but insufficiently trained medical staff can be harmful to national antiretroviral (ARV) programmes. Community support also plays a significant role in HIV education and care in many poor countries where relatives and neighbours often help to monitor patients and raise awareness about HIV. The cost of combination ARV therapy has come down significantly from about US$10,000 per person per year in 2000 to about $88 a year. However, second- and third-line anti-retrovirals are still prohibitively expensive for low-income countries. Simpler drug delivery systems will help reduce the amount of money spent on non-drug-related costs, especially as between two-thirds and 80% of money spent on HIV is related to service delivery, patient monitoring and laboratory costs. Using technology, such as SMS-based check-ups, may help save patients the costs of travelling to a clinic every month. Country ownership and health system integration are also crucial for success in fighting HIV in developing countries.
This book is an in-depth evaluation of a new approach to create behavioural change that could affect the course of the global health crisis of HIV and AIDS. Taking a close look at the South African HIV and AIDS epidemic, it demonstrates that regular workers serving as peer educators can be as – or even more – effective agents of behavioural change than experts who lecture about the facts and so-called appropriate health care behaviour. After spending six years researching the response of large South African companies to the AIDS epidemic, Dickinson describes the promise of this grassroots intervention and the limitations of traditional top-down strategies. His case studies directly examine the South African workplace to tackle sexual, gender, religious, ethnic, and broader social and political taboos that make behaviour change so difficult, particularly when that behaviour involves sex and sexuality. Dickinson's findings show that people who are not officially health care experts or even health care workers can be skilled and effective educators. This book demonstrates how peer education can be used as a tool for societies grappling with the HIV and AIDS epidemic and why those interested in changing behaviours to ameliorate other health problems like obesity, alcoholism, and substance abuse have so much to learn from the South African context.
According to this article, the evidence that concurrency is driving the African AIDS epidemics is limited. There is as yet no conclusive evidence that concurrency is associated with HIV prevalence, nor that it increases the size of an HIV epidemic, the speed of HIV transmission and the persistence of HIV in a population. The article admits that concurrency could theoretically play a dominant role in transmission of HIV through networks, but it argues that this should not be taken to mean that it is or it has played that role. Little evidence supports the hypothesis that sexual behavior differs dramatically in Africa compared to the rest of the world, nor that sexual behavior in Africa is different in countries with high versus low HIV prevalence. Without strong data showing that people have more concurrent partnerships in Africa than elsewhere and that places with high levels of concurrency also have high levels of HIV, the authors conclude that only under certain conditions may concurrency be a significant driver of the HIV epidemics in sub-Saharan Africa. To definitively answer this question, additional studies are needed. Improved methods for measuring sexual behavior and particularly partnership duration and overlap are also required, with better study designs. Designing prevention interventions around concurrency without a better understanding of the intricacies of the relationship between concurrency and HIV transmission may well not produce the intended result of preventing new HIV infections.
In this statement, the South African Department of Health has given the go-ahead for patients on antiretroviral treatment (ART) to be given three months supply of medicines instead of one month. It will be more convenient for patients because they will have to make fewer trips to their health facility. It will also reduce patient-load on the health system, particularly on health facility pharmacies given the shortage of pharmacists in the public health system. The Department of Health states: ‘There is no indication of any legislation prohibiting the supply of medicines for three months to any one patient. This practice should only be implemented once the patient has proved stable on the regimen.’
This review aimed to identify the current modes of transmission of HIV in Uganda, as well as where and among whom incident HIV infections are occurring. It indicates that the previously heralded decline in prevalence from a peak of 18% in 1992 to 6.1% in 2002 may have ended. There is stabilisation of prevalence between 6.1 and 6.5% in some antenatal care sites and even a rise in others. This is accompanied by deterioration in behavioural indicators especially an increase in multiple concurrent partnerships. There has also been a shift in the epidemic from spreading mainly in casual relationships to also seeing a large proportion of new infections in people in long-term stable relationships. The main risk factors for transmission were identified as having, multiple partners, discordance and non-disclosure, lack of condom use, transactional sex, cross-generational sex, presence of herpes simplex and sexually transmitted infections, alcohol and drug use, and behavioural disinhibition due to anti-retroviral therapy.
This article argues that a population-wide interruption of risk behaviour for a set period of time could reduce HIV incidence and make a significant contribution to prevention efforts. If everyone in a population abstained from high-risk sex for a given period of time, in theory the viral loads of all recent seroconverters should pass through the acute infection period. When risk behaviour resumed there would be almost no individuals in the high-viraemic phase, thereby reducing infectivity, and HIV incidence would fall. The article calls for mathematical modelling of periodic risk behaviour interruptions, as well as encouragement of policy interventions to develop campaigns of this nature. A policy response, such as a ‘safe sex/no sex’ campaign in a cohesive population, deserves serious consideration as an HIV prevention intervention. In some contexts, periods of abstinence from risky behaviour could also be linked to existing religious practices to provide policy options, for example sexual abstinence practiced during the Muslim holy month of Ramadaan.
This review of the HIV and AIDS national strategic plan (NSP) since the NSP's inception in 2007, reports that condom use has almost doubled, treatment coverage among adults living with HIV has almost tripled, and prevention of mother-to-child HIV transmission (PMTCT) services among HIV-positive pregnant women has reached 76%. In contrast, the uptake of dual ARV therapy PMTCT has been problematic, and there are major shortcomings in monitoring and evaluation (M&E) that could leave decision-makers operating in a vacuum, the report warns. It notes that while provinces had adopted the dual therapy regimen and were training health workers to administer it, some districts were still using the outdated single dose of Nevirapine because funding to buy the ARVs for dual therapy was problematic. It also highlights a dearth of data on babies born HIV-positive, but quotes department of health estimates showing that almost 40% of infants exposed to HIV were put at risk of contracting the virus by incomplete provision of PMTCT services. Problems with monitoring and evaluation were also highlighted, with inadequate data on mothers, babies and HIV-positive patients awaiting treatment. The report suggests that measuring South Africa's success against numerous goals and objectives set by the NSP may be logistically and bureaucratically challenging. Despite a wealth of information on HIV and AIDS that is collected to fulfill government reporting requirements, the uneven quality, scope and availability of the data has presented considerable challenges to those trying to implement evidence-based HIV interventions.
According to this article, Swaziland has made remarkable progress in reducing HIV transmission from infected mothers to their babies, but health activists have raised concerns that this progress may be stalled or even reversed if lapses in basic health services are not addressed. Since prevention of mother-to-child transmission (PMTCT) services became available in 2003, HIV transmission has almost halved, from 40% of children becoming infected by their HIV-positive mothers to 21%. The number of teenage pregnancies has also fallen. As teen mothers are less likely to use antenatal care and PMTCT services, fewer teens giving birth means fewer HIV-positive babies. However, a significant proportion of pregnant women are giving birth at home, and so are not using PMTCT services. A rise in home deliveries appears to be a direct result of poor conditions at underfunded clinics and hospitals. Leaking roofs, unreliable water supplies and a lack of beds at clinics are contributing to the problem of ‘burnout’ among nurses. According to the latest World Health Organization (WHO) guidelines, a pregnant woman's HIV status should be determined in her first trimester so as to provide optimal PMTCT services, but Swazi tradition discourages women from talking about a pregnancy during the first 14 weeks and, as a result, women delay seeking treatment.