From 8 to 10 June 2016, heads and representatives of states and governments, along with other key stakeholders, assembled at the United Nations (UN) in New York, for the High-Level Meeting on Ending AIDS. There are three reasons why this meeting is an important milestone for the global response against human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). First, the meeting provides an opportunity to reflect on the extent of progress and unprecedented achievements that have been made in responding to the AIDS epidemic, as described in the UN Secretary-General’s report. Second, the meeting served as an occasion to galvanise support from the global community to scale up the AIDS response. The 90–90–90 treatment target calls for 90% of people living with HIV to know their status, 90% of people who know their HIV status to have access to treatment and 90% of people on treatment to achieve suppressed viral loads by 2020. Third, the meeting was an opportunity to reflect on specific challenges that need to be addressed going forward. Among them is a treatment gap and inadequate global investments in prevention. The UNAIDS 2016–2021 Strategy integrated efforts towards ending the AIDS epidemic fully into Transforming our world: the 2030 agenda for sustainable development. The strategy sets out the links between the HIV response and several sustainable development goals (SDGs), from SDG 1 on ending poverty to SDG 16 on promoting inclusive societies.
Equity and HIV/AIDS
Pain has been reported as the second most commonly reported symptom in people living with HIV. In South Africa, there are more than five million people living with HIV. Approximately, two million belong to the Xhosa cultural group. A culturally appropriate, valid, and reliable instrument is required to measure pain and its impact in this population. This article documents the process of translation of the Brief Pain Inventory (BPI) into the BPI-Xhosa and presents the results of the validity and reliability testing of the instrument. The translated BPI-Xhosa, a demographic questionnaire and the European Quality of Life-5 Dimensions Xhosa version (EQ-5D-Xhosa) health-related quality of life instrument were administered to 229 amaXhosa women living with HIV in a resource-poor urban settlement in South Africa. A 74% prevalence of pain was recorded. The BPI-Xhosa had good concurrent validity when compared with the previously validated EQ-5D-Xhosa. The BPI-Xhosa was found to be a valid instrument to measure pain prevalence, severity, and interference in amaXhosa women living with HIV.
HIV testing of African immigrants in Belgium showed that HIV existed among Africans by 1983. However, the epidemic was recognized much later in most parts of sub-Saharan Africa due to stigma and perceived fear of possible negative consequences to the countries’ economies. This delay had devastating mortality, morbidity, and social consequences. In countries where earlier recognition occurred, political leadership was vital in mounting a response. The response involved establishment of AIDS control programs and research on the HIV epidemiology and candidate preventive interventions. Over time, the number of effective interventions has grown. Triple antiretroviral therapy (ART) has led to a rapid decline in HIV-related morbidity and mortality in addition to prevention of onward HIV transmission. Other effective interventions include safe male circumcision, and pre- and post-exposure prophylaxis. However, since none of these is sufficient by itself, the authors argue for a combination package of these interventions in the public health response.
The high prevalence of chronic diseases in Tanzania is putting a strain on the already stretched health care services, patients and their families. This study sought to find out how health care for diabetes and HIV is perceived, practiced and experienced by patients and family caregivers, to inform strategies to improve continuity of care. Thirty two in-depth interviews were conducted among 19 patients (10 HIV, 9 diabetes) and 13 family caregivers (6 HIV, 7 diabetes). The innovative care for chronic conditions framework informed the study design. Three major themes emerged; preparedness and practices in care, health care at health facilities and community support in care for HIV and diabetes. In preparedness and practices, HIV patients and caregivers knew more about aspects of HIV than did diabetes patients and caregivers on diabetes aspects. Continued education on care for the conditions was better structured for HIV than diabetes. On care at facilities, HIV and diabetes patients reported that they appreciated familiarity with providers, warm reception, gentle correction of mistakes and privacy during care. HIV services were free of charge at all levels. Costs involved in seeking services resulted in some diabetes patients to not keep appointments. There was limited community support for care of diabetes patients. Community support for HIV care was through community health workers, patient groups, and village leaders. Diabetes and HIV have socio-cultural and economic implications for patients and their families. The HIV programme is successfully using decentralization of health services, task shifting and CHWs to address these implications. For diabetes and NCDs, decentralization and task shifting are also important and, strengthening of community involvement is warranted for continuity of care and patient centeredness in care. While considering differences between HIV and diabetes, the authors show that Tanzania's rich experiences in community involvement in health can be leveraged for care and treatment of diabetes and other NCDs.
‘Treatment as prevention’ has become the cornerstone of UNAIDS’s post-2015 global strategy to end AIDS by 2030. As the expansion of treatment provision continues, and access improves, adherence becomes a determining factor in the impact of ART for both treatment and prevention. HEARD are conducting a number of small scoping studies on challenges to ART adherence in men who have sex with men (MSM) and lesbian, gay, bisexual, transgender, and intersex (LGBTI) communities living with HIV in East and Southern Africa (ESA), as key populations in the AIDS response. This report presents findings from a scoping study carried out in Kampala, Uganda, in December 2015. The findings suggest that (double) stigma and criminalisation of behaviour of people living with HIV (PLHIV) in MSM and LGBTI communities cut across almost every perceived challenge to ART adherence as a driving or contributory factor. As a result, indications suggest MSM and LGBTI experience challenges that are similar in type to the general population, but that these population groups experience the challenges more often, more acutely, and with less opportunity to overcome the challenges.
Although stigma and its relationship to health and disease is not a new phenomenon, it has not been a major feature in the public discourse until the emergence of HIV. The range of negative responses associated with the epidemic placed stigma on the public agenda and drew attention to its complexity as a phenomenon and concept worthy of further investigation. Despite the consensus that stigma is one of the major contributors to the rapid spread of HIV and the frequent use of the term in the media and among people in the street, the exact meaning of ‘stigma’ remains ambiguous. This paper re-visits some of the scholarly deliberations and further interrogates their relevance in explaining HIV-related stigma evidenced in South Africa. In conclusion a model is presented. Its usefulness – or explanatory potential – is that it attempts to provide a comprehensive framework that offers insights into the individual as well as the social/structural components of HIV-related stigma in a particular context. As such, it is argued by the authors to have the potential to provide more nuanced understandings as well as to alert us to knowledge-gaps in the process.
People around the world face barriers to accessing quality health care and enjoying the highest attainable standard of health. Why this occurs varies between countries and communities, but some barriers are present everywhere. These include the various forms of discrimination faced by people who are marginalized, stigmatized, criminalized and otherwise mistreated because of their gender, nationality, age, disability, ethnic origin, sexual orientation, religion, language, socio-economic status, or HIV or other health status, or because of selling sex, using drugs and/or living in prison. One in eight people living with HIV report having been denied health care. Examples of HIV-related stigma and discrimination go beyond denial of care or lower quality care, and include forced sterilization, stigmatizing treatment, negative attitudes and discriminatory behaviour from providers, lack of privacy and/or confidentiality and mandatory testing or treatment without informed consent. UNAIDS argue that such discriminatory practices undermine people’s access to HIV prevention, treatment and care services and the quality of health-care delivery, as well as adherence to HIV treatment.
Inequitable gender-based power in relationships and intimate partner violence contribute to persistently high rates of HIV infection among South African women. The authors examined the effects of two group-based HIV prevention interventions that engaged men and their female partners together in a couples intervention (Couples Health CoOp [CHC]) and a gender-separate intervention (Men’s Health CoOp/Women’s Health CoOp [MHC/WHC]) on women’s reports of power, communication, and conflict in relationships. Of the 290 couples enrolled, 255 women remained in the same partnership over 6 months. Following the intervention, women in the CHC arm compared with those in the WHC arm were more likely to report an increase in relationship control and gender norms supporting female autonomy in relationships. Women in the MHC/WHC arm were more likely to report increases in relationship equity, relative to those in the CHC arm, and had a higher odds of reporting no victimisation during the previous 3 months. Male partner engagement in either the gender-separate or couples-based interventions led to modest improvements in gender power, adoption of more egalitarian gender norms, and reductions in relationship conflict for females. The aspects of relationship power that improved, however, varied between the couples and gender-separate conditions, highlighting the need for further attention to development of both gender-separate and couples interventions.
In Zimbabwe, despite the existence of well-attended services targeted to female sex workers (SWs), fewer than half of women diagnosed with HIV took up referrals for assessment and ART initiation; just 14% attended more than one appointment. The authors conducted a qualitative study to explore the reasons for non-attendance and the high rate of attrition, through three focus group discussions (FGD) in Harare with HIV-positive SWs. SWs emphasised supply-side barriers, such as being demeaned and humiliated by health workers, reflecting broader social stigma surrounding their work. Sex workers were particularly sensitive to being identified and belittled within the health care environment. Demand-side barriers also featured, including competing time commitments and costs of transport and some treatment, reflecting SWs’ marginalised socio-economic position. Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. The authors suggest that programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.
About half a million people in South Africa are deprived of antiretroviral therapy (ART), and there is little systematic knowledge on who they are – e.g. by severity of disease, sex, or socio-economic status (SES). The authors performed a systematic review to determine the current quantitative evidence-base on equity in utilisation of ART among HIV-infected people in South Africa. The authors conducted a literature search based on the Cochrane guidelines. A study was included if it compared for different groups of HIV infected people (by sex, age, severity of disease, area of living, SES, marital status, ethnicity, religion and/or sexual orientation (i.e. equity criteria)) the number initiating/adhering to ART with the number who did not. The authors considered ART utilisation inequitable for a certain criterion (e.g. sex) if between groups (e.g. men versus women) significant differences were reported in ART initiation/adherence. Twelve studies met the inclusion criteria. For sex, 2 out of 10 studies that investigated this criterion found that men are less likely than women to utilise ART, while the other 8 found no differences. For age, 4 out of 8 studies found inequities and reported less utilisation for younger people. For area of living, 3 out of 4 studies showed that those living in rural areas or certain provinces have less access and 2 out of 6 studies looking at SES found that people with lower SES have less access. One study which looked at the marital status found that those who are married are less likely to utilise ART. For severity of disease, 5 out of 6 studies used more than one outcome measure for disease stage and reported within their study contradicting results. One of the studies reported inconclusive findings for ethnicity and no study had looked at religion and sexual orientation. It seems that men, young people, those living in certain provinces or rural areas, people who are unemployed or with a low educational level, and those being unmarried have less access to ART. As studies stem from different contexts and use different methods conclusions should be taken with caution.