This review of Global Fund projects in 2010 includes some chapters on projects they have funded in the east, central and southern African region. A chapter on HIV prevention in South Africa focuses on peer education in townships, while prevention of mother-to-child transmission of HIV in Namibia is also covered in terms of breaking the stigma surrounding the disease. Malaria prevention in Zambia is presented as a success story, as clinics are reported to be 'empty of patients', and a chapter on malaria prevention in Swaziland outlines the country's ambitious plan to eliminate malaria by 2015.
Equity and HIV/AIDS
Stories of innovation and impact: The Global Fund 2010
The Global Fund to Fight AIDS, Tuberculosis and Malaria: 2010
Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa
Hargreaves JR, Bonell CP, Boler T, Boccia D, Birdthistle I, Fletcher A, Pronyk PM and Glynn JR: AIDS 22:403–414, January 2008
This paper assesses evidence on the association between educational attainment and risk of HIV infection over time in sub-Saharan Africa through a systematic review of published peer-reviewed articles. Approximately 4,000 abstracts and 1,200 full papers were reviewed, of which 36 were included in the study, containing data on 72 discrete populations from 11 countries between 1987 and 2003, and representing over 200,000 individuals. Studies on data collected prior to 1996 generally found either no association or the highest risk of HIV infection among the most educated. Studies conducted from 1996 onwards were more likely to find a lower risk of HIV infection among the most educated. HIV prevalence appeared to fall more consistently among highly educated groups. In several populations, associations suggesting greater HIV risk in the more educated at earlier time points were replaced by weaker associations later. It seems that HIV infections are shifting towards higher prevalence among the least educated in sub-Saharan Africa, reversing previous patterns. Policy responses that ensure HIV-prevention measures reach all strata of society and increase education levels are urgently needed.
Universal access by 2010: Scaling up for success
International AIDS Society Policy Paper: March 2010
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%.
Will we end the HIV epidemic? The impact of HIV treatment on HIV prevention and implications for the 2010 replenishment of the Global Fund to Fight AIDS, TB and Malaria
International AIDS Society: March 2010
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?
'Side dishes' campaign in Uganda gets people talking
Plus News: 24 March 2010
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.
A cluster randomized trial of routine HIV-1 viral load monitoring in Zambia: Study design, implementation, and baseline cohort characteristics
Koethe JR, Westfall AO, Luhanga DK, Clark GM and Goldman JD et al: Public Library of Science ONE 5(3), 12 March 2010
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.
Adolescent HIV: Cause for concern in southern Africa
Gray GE: Public Library of Science Medicine 7(2): 2 February 2010
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.
Causes of acute hospitalization in adolescence: Burden and spectrum of HIV-related morbidity in a country with an early-onset and severe HIV epidemic: A prospective survey
Ferrand RA, Bandason T, Musvaire P, Larke N, Nathoo K, Mujuru H, Ndhlovu CE, Munyati S, Cowan FM, Gibb DM and Corbett EL: Public Library of Science Medicine 7(2): 2 February 2010
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.
Gaps in HIV prevention for pregnant Kenyan women
Plus News: 22 March 2010
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.
High uptake of HIV testing for tuberculosis patients in an integrated primary health care HIV/TB programme in rural KwaZulu-Natal
Wallrauch C, Heller T, Lessells R, Kekana M, Barnighausen T, Newell M: South African Medical Journal 100(3): 146–147, March 2010
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.