This digest offers article abstracts from peer-reviewed literature related to HIV and AIDS in Southern Africa and is designed to keep readers in touch with the rapidly expanding evidence base pertaining to HIV in the region. For example in this issue there are 72 abstracts published April through May 2018 that feature articles from Botswana (4), Lesotho (2), Malawi (7), Mozambique (5), South Africa (43), Swaziland (2), Tanzania (4), Zambia (2) and Zimbabwe (9). Articles include a mixed methods study on access to HIV care and treatment for migrants between Lesotho and South Africa; findings from a cross-sectional study on HIV status disclosure among postpartum women with varied intimate partner violence experiences in Zambia; and lessons learned from the ZENITH trial in Zimbabwe on the role of community health workers in improving HIV treatment outcomes in children. The articles are catered to advocates, health care providers, implementers, lay health workers, policy makers and researchers.
Equity and HIV/AIDS
A systematic review of longitudinal studies suggests that intimate partner violence is associated with reduced contraceptive use. The authors used seven waves of data from the Rakai Community Cohort Study in Rakai, Uganda to estimate the effect of prior year intimate partner violence at one visit on women's current contraceptive use at the following visit. The analysis included 7923 women interviewed between 2001 and 2013. Women who experienced any form of prior year intimate partner violence were 20% less likely to use condoms at last sex than women who had not. The authors did not find evidence that intimate partner violence affects current use of modern contraception, however, current use of a partner-dependent method was 27% lower among women who reported any form of prior-year intimate partner violence compared to women who had not. Women who experienced prior-year intimate partner violence were less likely to use condoms and other forms of contraception that required negotiation with their male partners and more likely to use contraception that they could hide from their male partners. Longitudinal studies in Rakai and elsewhere have found that women who experience intimate partner violence have a higher rate of HIV than women who do not. The finding in this paper that women who experience IPV are less likely to use condoms may help explain the relation between intimate partner violence and HIV.
HIV and other sexually transmitted infections (STI) frequently co-occur. The authors conducted HIV diagnostic testing in an assessment of the etiologies of major STI syndromes in Zimbabwe. A total of 600 patients were enrolled at six geographically diverse, high-volume STI clinics in Zimbabwe in 2014–15: 200 men with urethral discharge, 200 women with vaginal discharge, and 100 men and 100 women each with genital ulcer disease (GUD). Patients completed a questionnaire, underwent a genital examination, and had specimens taken for etiologic testing. Patients were offered, but not required to accept, HIV testing using a standard HIV algorithm in which two rapid tests defined a positive result. A total of 489 participants accepted HIV testing; 201 tested HIV-1-positive, including 16 of 134 participants who reported an HIV-negative status at study enrollment, and 58 of 206 participants who reported their HIV status as unknown. Of 147 who self-reported being HIV-positive at study enrollment, 21 tested HIV negative. HIV infection prevalence was higher in women than in men, and was 28.5% in men with urethral discharge, 40.5% in women with vaginal discharge, 45.2% in men with GUD, and 59.8% in women with GUD. The high prevalence of HIV infection in STI clinic patients in Zimbabwe is argued by the authors to underscore the importance of providing HIV testing and referral for indicated prevention and treatment services for this population. The discrepancy between positive self-reported and negative study HIV test results highlights the need for operator training, strict attention to laboratory quality assurance, and clear communication with patients about their HIV infection status.
Lost earnings attributable to HIV and AIDS as a result of either death or inability to work have declined significantly globally as countries scale up antiretroviral therapy. In 2005 HIV and AIDS were believed to have resulted in about $17bn in lost income, but the figure is projected to fall to $7.2bn in 2020. A study released by the International Labour Organisation shows that the number of employees living with the virus and unable to work has fallen "dramatically" since 2005. South Africa has the biggest HIV epidemic in the world with more than 7-million people living with the virus in 2016 and a stubbornly high rate of new infections. The country also has the largest antiretroviral treatment programme, which has increased life expectancy from 61 years in 2010 to 67 in 2015. The Employee Assistance Professionals Association’s Dr Dennis Cronson said there had been a great improvement in the effect of the virus on workers, especially in South Africa. "Hundreds of thousands of people are on ARVs and corporate managed programmes, and it’s a major success story …. the impact on productivity and other factors have improved," Cronson said.
This paper provided an estimated use and outcomes of the Malawian programme for the prevention of mother-to-child transmission of human immunodeficiency virus. In a cross-sectional analysis of 33 744 mother–infant pairs, the authors estimated the weighted proportions of mothers who had received antenatal human immunodeficiency virus testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or human immunodeficiency virus testing. The authors calculated the ratios of mother-to-child transmission at 4–26 weeks postpartum for subgroups that had missed none or at least one of these four steps. The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant human immunodeficiency virus testing was 53.2%. Estimated ratios of mother-to-child transmission were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed human immunodeficiency virus testing and infant prophylaxis than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis and infant testing than women who had. Most women used the Malawian programme for the prevention of mother-to-child transmission. The risk of mother-to-child transmission increased if any of the main steps in the programme were missed.
For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, the authors based their intervention on an existing evidence-based framework for successful community health worker (CHW) programmes. To assess CHWs’ experiences delivering the intervention, they conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study explored community health workers’ perceptions of how the intervention’s structure and management affected their performance, and considers implications for the programme’s future scale-up and adoption in other settings. Community health workers expressed strong motivation, commitment and job satisfaction. Intensive supervision and mentoring emerged as critical to ensuring community health workers long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and community health workers. Concerns raised by community health workers included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful community health workers programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies.
This study examined determinants of facility readiness for integration of family planning with HIV testing and counseling services in Tanzania using data from the 2014–2015 Tanzania Service Provision Assessment Survey. A total of 1188 facilities were assessed and considered ready for integration of family planning with HIV testing and counseling services if they scored ≥ 50% on both family planning and HIV testing and counseling service readiness indices as identified by the World Health Organization. Of all the health facilities, 915 reported offering both family planning and HIV testing and counseling services, while only 536 were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned, having routine management meetings, availability of guidelines, in-service training of staff, and availability of laboratories for HIV testing. The authors judge the proportion of facility readiness for the integration of family planning with HIV testing and counseling in Tanzania to be unsatisfactory and suggest that the Ministry of Health distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and refresher training to health providers, as determinants of facility readiness.
This paper examines determinants of facility readiness for integration of family planning with HIV testing and counselling services in Tanzania using data from the 2014–2015 Tanzania Service Provision Assessment Survey. Facilities were considered ready for integration of family planning with HIV testing and counselling services if they scored ≥ 50% on both family planning and HIV testing and counselling service readiness indices as identified by the World Health Organization. A total of 1188 health facilities were included in the study. Of all of the health facilities, 915 reported offering both family planning and HIV testing and counselling services, while only 536 were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned; having routine management meetings, availability of guidelines, in-service training of staff, and availability of laboratories for HIV testing. The proportion of facility readiness for the integration of family planning with HIV testing and counselling in Tanzania was noted to be unsatisfactory. The authors argue that Ministry of Health should distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and the provision of refresher training to health providers, as these were among the determinants of facility readiness.
Despite recognition of gender in Tanzania’s political arena and prioritization of prevention of mother to child transmission (PMTCT) by the health sector, there is very little information on how well gender has been mainstreamed into National PMTCT guidelines and organizational practices at service delivery level. Using a case study methodology, the authors combined document review with key informant interviews to assess gender mainstreaming in PMTCT on paper and in practice in Tanzania. The authors reviewed PMTCT policy/strategy documents using the World Health Organisation’s Gender Responsive Assessment Scale. The scale differentiates between level 1 to 5. Key informant interviews were conducted with 26 leaders purposively sampled from three government health facilities in Mwanza city to understand their practices. The gender responsiveness of PMTCT policy/strategy documents varies. Those which are gender sensitive indicate gender awareness, but with no remedial action developed; while those which are gender specific go beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. The interviews suggested that there has been little attention to the holistic integration of gender in the delivery of PMTCT services.
This study seeks to understand the various factors influencing HIV-related risk behaviours and the resulting HIV positive status of Mozambican miners employed by South African mines to inform a broader and more effective HIV preventive framework in Mozambique. It used data sourced from the first integrated biological and behavioural survey among Mozambican miners earning their living in South African mines. The odds of reporting one sexual partner were roughly three times higher for miners working as perforators as opposed to other types of occupation. The odds of condom use – always or sometimes – for miners in the 31-40 age group were three times higher than the odds of condom use in the 51+ age group. Miners with lower education levels were less likely to use condoms. The odds of being HIV positive when the miner reports use of alcohol or drugs is 0.32 times lower than the odds for those reporting never use of alcohol or drugs. And finally, the odds of HIV positive status for those using condoms were 2.16 times that of miners who never used condoms, controlling for biological and other proximate determinants. In Mozambique, behavioural theory emphasising personal behavioural changes is the main strategy to combat HIV among miners. The findings suggested that there is a need to change thinking processes about how to influence safer sexual behaviour. This only stresses the need for HIV prevention strategies to exclusively transcend individual factors while considering the broader social and contextual phenomena influencing HIV risk among Mozambican miners.