This paper presents data to show how under-financing the global response to AIDS has proven disastrous in the past. The lack of an early, well-financed and effective response to AIDS in the 1980s and 1990s provided an opportunity for this epidemic to grow rapidly when a sustained, global response could have prevented the spread of HIV and the resulting impact on the health, economies and communities of the world’s poorest nations. Recent increases in dedicated AIDS financing, however, particularly over the last five years, have produced impressive gains across a wide range of health, development, economic and social indicators. Increases in the number of people on HIV treatment tracks the increase in donor financing for AIDS. In 2008 alone, funding for HIV-specific programmes from wealthy countries grew to US$7.7 billion – a 56% increase from 2007. The brief urges governments and other stakeholders to adopt progressive financing mechanisms for health. It notes that, if full investments were made in country-level universal access targets by 2010 that: the number of new HIV infections averted in 2009-2010 alone would be 2.6 million; the number of deaths averted over that year would be 1.3 million; and incidence of HIV over that year would be cut by nearly 50%.
Equity and HIV/AIDS
According to this article, since the 2005 commitment by G8 leaders – and thereafter all United Nations Member States – to work towards universal access to HIV treatment, prevention and care by 2010, many resource-limited countries have been highly successful in decreasing AIDS-related morbidity and mortality and slowing down the spread of HIV. The efforts to achieve this scale up have been driven by governments and civil society in these countries, with much of the resources provided by external partners, in particular the United States' PEPFAR2 and the Global Fund to Fight AIDS, TB and Malaria. Since its inception in 2002, the investments made through the Global Fund are estimated to have saved five million lives, including through the provision of HIV treatment to 2.5 million people. This article poses a question to donors to the Global Fund: How many more lives they are prepared to save in the next three years? And will they make the bold investments required to make a real change to the future course of the HIV epidemic?
A national campaign to encourage sexual fidelity in Uganda is reported to have got the country talking. The nine-month-long 'One Love' campaign is in the second of three phases, which uses television and radio ads that highlight AIDS-related deaths from 'eating a side dish' - a euphemism for having a sexual relationship outside marriage. The intention of the second phase is to bring home the effects of infidelity, not just on health, but on the lives of the people they care for most. The first phase - which ended in February - introduced the public to sexual networks, using forum theatre in rural communities and billboards, TV ads and radio spots in towns urging people to 'get off the sexual network'. Previous prevention campaigns have failed to directly address married and cohabiting Ugandans, the most likely group to become HIV infected. Beyond the traditional routes of advertising, the campaign has also employed mobile-phone technology and the social networking site Facebook to engage with younger people in a higher socio-economic group.
This study took the form of a cluster randomised controlled trial to compare the use of routine viral load (VL) testing for antiretroviral therapy (ART) versus local standard of care (which uses immunological and clinical criteria to diagnose treatment failure, with discretionary VL testing when the two do not agree). Twelve ART clinics in Lusaka, Zambia were included. The study was powered to detect a 36% reduction in mortality at 18 months. From December 2006 to May 2008, the study completed enrolment of 1,973 participants. Measured baseline characteristics did not differ significantly between the study arms. Enrolment was staggered by clinic pair and truncated at two matched sites. A large clinical trial of routing VL monitoring was successfully implemented in a dynamic and rapidly growing national ART program. Close collaboration with local health authorities and adequate reserve staff were critical to success. Randomised controlled trials such as this will likely prove valuable in determining long-term outcomes in resource-constrained settings.
In 2006, the Society for Adolescent Medicine issued its second position paper on HIV/AIDS in adolescents. It noted that although great progress had been made in the scientific understanding, diagnosis and treatment of HIV, and the prevention of perinatal transmission, there was a growing HIV crisis in the developing world. At least half of all new infections in the developing world were amongst youth and young adults, and a substantial number of teenagers and young adults were already living with HIV and AIDS. As HIV epidemics mature, increasing numbers of children infected perinatally survive and will present with HIV-related symptoms in older childhood and adolescence. Whilst the epidemiology of sexually acquired HIV infection amongst 15–24 year olds is well described in southern Africa, few data on the prevalence and disease pattern of perinatally acquired HIV infection in older children and adolescence exist. Recent data from a household survey conducted in South Africa in 2008 estimated the prevalence of HIV in children aged 2–14 years to be 2.5%. The survey indicates the relatively high prevalence of HIV in children and adolescents in this region. Most of these infections are acquired early in life and are probably undiagnosed.
Survival to older childhood with untreated, vertically acquired HIV infection, which was previously considered extremely unusual, is increasingly well described. However, the overall impact on adolescent health in settings with high HIV sero-prevalence has not previously been investigated. Adolescents (aged 10–18 y) systematically recruited from acute admissions to the two public hospitals in Harare, Zimbabwe, answered a questionnaire and underwent standard investigations including HIV testing, with consent. Pre-set case-definitions defined cause of admission and underlying chronic conditions. Participation was 94%. One hundred and thirty-nine (46%) of 301 participants were HIV-positive, but only four were positive for herpes simplex virus-2 (HSV-2). Case fatality rates were significantly higher for HIV-related admissions (22% versus 7%, p<0.001), and significantly associated with advanced HIV, pubertal immaturity, and chronic conditions. The paper concluded that HIV is the commonest cause of adolescent hospitalisation in Harare, mainly due to adult-spectrum opportunistic infections plus a high burden of chronic complications of paediatric HIV/AIDS. Low HSV-2 prevalence and high rates of maternal orphanhood provide further evidence of long-term survival following mother-to-child transmission. Better recognition of this growing phenomenon is needed to promote earlier HIV diagnosis and care.
The Kenyan government is considering a policy of repeat HIV testing during pregnancy. 'Currently, the lack of it is a gap in our policies,' said Peter Cherutich, head of HIV prevention at the National AIDS and Sexually Transmitted Infections Control Programme. 'Testing should be done periodically, even after childbirth, because a mother can become infected even during the breastfeeding period.' At present, HIV-positive mothers and their babies in Kenya are given a combination of three antiretroviral drugs after a single test, usually carried in the early stages of the pregnancy. 'If a woman tests negative during her prenatal test, gets infected during the pregnancy, and is not given the necessary medication during labour to protect the child, she stands a chance of infecting her child at birth or even during breastfeeding and you go back to square one,' Cherutich said. Infants contracting HIV through their mothers account for about 20% of an estimated 166,000 annual HIV infections in Kenya.
Tuberculosis (TB) is the leading cause of morbidity and mortality in the HIV-infected African population. The need for improved integration of HIV and TB services was highlighted by the World Health Organization (WHO) several years ago, but implementation of recommendations has been slow. HIV testing for TB patients is the gateway for combined HIV and TB treatment, care and prevention yet, in 2007, only 37% of TB patients in the WHO African region were tested for HIV. While some countries reported testing rates above 75%, a testing rate of only 39% was reported in South Africa, the country with the largest burden of HIV/TB co-infection. This study describes efforts to ensure high HIV testing rates in TB patients via an integrated programme at primary health care level in rural KwaZulu-Natal.
In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest, which prompted this review to assess youth HIV-prevention interventions in the country since 2000. Eight interventions were included, all of which were similar in HIV prevention content and objectives, but varied in thematic focus, hypothesised causal pathways, theoretical basis, delivery method, intensity and duration. Interventions were school- or group-based, involving in- and out-of-school youth. Primary outcomes included HIV incidence, reported sexual risk behaviour alone, or with alcohol use. Interventions led to reductions in sexually transmitted infections and reported sexual or alcohol risk behaviours, although effect size varied. All but one targeted at least one structural factor associated with HIV infection: gender and sexual coercion, alcohol/substance use or economic factors. Delivery methods and formats varied, and included teachers, peer educators and older mentors. School-based interventions experienced frequent implementation challenges. Key recommendations include: address HIV social risk factors, such as gender, poverty and alcohol; target the structural and institutional context; work to change social norms; and engage schools in new ways, including participatory learning.
This study investigated whether or not antiretroviral therapy (ART) influences pregnancy rates. It analysed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multi-country HIV care and treatment programme for women, children and families. From eleven programmes in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals, while ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. The study found that ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioural or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services.