This Environmental Scan covers three broad research areas: clinical research (prevention of mother to child transmission, or PMTCT, and paediatric treatment), clinical research (women and antiretroviral therapy) and operations research (delivering treatment to women). A parallel consultative process, led by UNICEF, addressed operations research/implementation science questions related to PMTCT, including paediatric care, treatment and support. The report found that there has been substantial progress in improving access to anti-retroviral therapy (ART) in low- and middle-income countries in recent years. The need to better understand the potential role of sex differences in HIV disease progression and treatment response is being increasingly recognised by the research community as an understudied area of inquiry. To date, there is no evidence to support differential treatment strategies for men and women. Clinical trials addressing this question are still too few and too small to provide definitive answers. Women face greater threats to personal safety and financial security than men do and as a result, they experience HIV stigma more forcefully. Some studies have identified failure to successfully integrate HIV treatment programmes with other women’s health services as a particular barrier to accessing ART.
Equity and HIV/AIDS
Recent data from antenatal clinic surveillance and general population surveys suggest substantial declines in human immunodeficiency virus (HIV) prevalence in Zimbabwe. The authors assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence. Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985-2007 was conducted. HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000. Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15-24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007. These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis level.
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.
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.