Equity and HIV/AIDS

Socioeconomic inequalities in uptake of HIV testing during antenatal care: evidence from Sub-Saharan Africa
Dadzie L, Gebremedhin A, Salihu T, et al: International Journal for Equity in Health 23:4; 1-12, 2024

This paper assessed the socioeconomic inequalities in HIV testing during antenatal care in sub-Saharan Africa, using Demographic and Health Surveys data spanning from 2015 to 2022. Overall, 73.9% of women in sub-Saharan Africa tested for HIV during antenatal care. Being among the richer and richest wealth quintiles increased the odds of HIV testing during antenatal care. The authors emphasize the necessity for sub-Saharan Africa public health programs to think about concentrating their limited resources on focused initiatives to reach poorer women and should provide women with comprehensive HIV knowledge and decrease the number of lost opportunities for women to get tested for HIV.

Devastating harms of criminalisation laid bare by UNAIDS advisory group
Phillips H: Be in the Know, Online blog, 2023

An advisory group to UNAIDS has released “overwhelming and undeniable” evidence on the harm that criminalisation is having on public health and the goal of ending AIDS by 2030. Criminalising certain groups, such as sex workers, gay and trans people and people who use drugs was found to be driving HIV infections and violating human rights, as a barrier to achieving the goal of ending AIDS by 2030. Their report shows a clear link between the legal status of groups most affected by HIV and the level of stigma and discrimination they experience. The UNAIDS Reference Group on HIV and Human Rights is calling on UN member countries to work with community-led organisations to “immediately repeal or reform” laws that criminalise the following things: consensual same-sex sexual conduct and the expression of gender identity, sex work and related activities, drug use and simple possession of drugs for personal use and HIV transmission and non-disclosure.

People with HIV remain at higher risk of dying from COVID-19 in the Omicron era
Alcorn K: Aidsmap, Australia, 2023

Deaths from COVID-19 have fallen much less sharply in people with HIV compared with the rest of the population since the arrival of the Omicron variant of SARS-CoV-2, the World Health Organization (WHO) reported at the 12th International AIDS Society Conference on HIV Science (IAS 2023). Data from 821331 people admitted to hospital with COVID-19 in 38 countries found that one in five people with HIV admitted to hospital with COVID-19 died during the Omicron wave compared to one in ten people without HIV. The WHO study team say that the consistent finding that low CD4 counts increase the risk of death from COVID-19 highlights the need for intensified HIV testing and treatment initiation to reduce the risk of severe outcomes, and to give booster vaccine doses for all people living with HIV even during the less severe and low incidence SARS-CoV-2 variant waves.

Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda
Muyanga N, Isunju J B, Ssekamatte T, et al: BMC Women's Health 23:250;1-13, 2023

This participatory qualitative study using in-depth interviews and focus group discussions explored how gender-based violence affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area, Uganda. At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy. Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level and in services led to fear among transwomen traveling to healthcare facilities, and limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. Given its effects on HIV transmission, the authors argue for strategies/ interventions targeting a reduction in gender-based violence and to sensitize communities to accept transwomen, including in healthcare settings.

Living with COVID-19 and preparing for future pandemics: revisiting lessons from the HIV pandemic
Auerbach J; Forsyth A; Davey C; et al:The Lancet HIV, 1-7, doi: https://doi.org/10.1016/S2352-3018(22)00301-0, 2022

In April, 2020, just months into the COVID-19 pandemic, an international group of public health researchers published three lessons learned from the HIV pandemic for the response to COVID-19, which were to: anticipate health inequalities, create an enabling environment to support behavioural change, and engage a multidisciplinary effort. The authors revisit these lessons in light of more than 2 years' experience with the COVID-19 pandemic. With specific examples, the article details how inequalities have played out within and between countries, highlight factors that support or impede the creation of enabling environments, and note ongoing issues with the scarcity of integrated science and health system approaches. The authors argue that to better apply lessons learned as the COVID-19 pandemic matures and other infectious disease outbreaks emerge, it will be imperative to create dialogue among polarised perspectives, identify shared priorities, and draw on multidisciplinary evidence.

Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa
Comins C A; Guddera V; Parmley L E; et al: BMC Health Services Research 22(1166), 1-10, 2022

In South Africa, 60% of female sex workers (FSWs) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, the authors explored preferences for DTP among FSWs living with HIV in Durban, South Africa, using 39 semi-structured in-depth interviews. Respondents suggested that decentralized treatment provision should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. Antiretroviral therapy packaging and storage were important for community-based delivery, and participants suggested decentralized treatment provision should be implemented by sex work sensitized staff with discrete uniform and vehicle branding. The authors suggest the potential utility of decentralized treatment provision for female sex workers as a strategy to address those most marginalized from current antiretroviral therapy programs in South Africa.

Combining photo-elicitation and discourse analysis to examine adolescents’ sexuality in rural Zambia
Mulubwa C; Hurtig A; Zulu J M; et al: International Journal for Equity in Health 21(60), 1-13, 2022

This article analysed constructions of adolescents’ sexualities and sexual health and the consequences for adolescent exercise of their sexual reproductive health and rights in rural Zambia, using discourse analysis in interviews and focus group discussions. The authors identified three interpretative repertories that influenced youth sexual health, linked to adolescent 'immaturity'; and what was respectful behaviours for girls and for boys, that shape how adolescents negotiate, adopt and resist sexual reproductive health and rights interventions. Adolescents were conflicted between having and applying sexual reproductive health and rights knowledge. The authors suggest that interventions that target adolescents’ sexual reproductive health and rights must aim to address these perceptions and discourses that erect barriers against positive sexual behaviours, including access to services that promote safer sex.

Your status cannot hinder you”: the importance of resilience among adolescents engaged in HIV care in Kenya
Adams C; Kiruki M; Karuga R; et al: BMC Public Health 22(1272), 1-13, 2022

This paper identified key stigma-related barriers to ART adherence and strategies used by adolescents in overcoming these barriers. Data were collected by LVCT Health, a Kenyan organization with a programmatic focus on HIV testing, prevention, and care, interviewing 122 participants in Nairobi, Kisumu, and Mombasa, and in focus group discussions with adolescents living with HIV (ALHIV), peer leaders, and adolescents receiving HIV services in community settings irrespective of HIV status. Four major themes emerged. Knowledge and future-oriented goals can drive motivation for ALHIV to remain healthy. Disclosure to others strengthens support systems for ALHIV, medication-taking strategies and can overcome adherence challenges. A supportive clinic environment promotes continuous adolescent engagement in HIV care. These concepts were used to develop a model moderating negative effects of stigma among ALHIV. Strengths-based interventions, focused on increasing positive features in ALHIV in Kenya, and more formal involvement of adolescent peers to bolster adolescent support, are argued to have the potential to improve ART adherence among ALHIV.

COVID-19 pandemic restrictions did not harm HIV care outcomes in Uganda
Magak E: NAM AIDSMAP, Online 2022

Despite the strict COVID-19 pandemic restrictions in Uganda, viral load testing and viral load suppression rates improved by 68% and 35% during the first lockdown, while mortality reduced by 25% among people living with HIV in Kampala, according to a presentation by Dr Izudi, Makerere University, at the INTEREST 2022 conference. In 2020, modelling studies of the COVID-19 pandemic’s impact on HIV estimated that interruptions in ART would have the largest effect on HIV-related mortality in Africa, with a three-month interruption of ART supply in 13 African countries estimated to translate to a 35 to 131% rise in mortality in 2021. Observational data from six large HIV clinics and 9952 participants in Kampala compared a pre-pandemic cohort from March 2018 to February 2019 of people with HIV who had not experienced the COVID-19 restrictions, and an exposed cohort from June 2020 to June 2021 of people with HIV who experienced the restrictions. Patients exposed to restrictions had a 68% increase in viral load testing and a 35% increase in viral load suppression compared to the comparison group. Their mortality was also 25% lower than the control group,

“After 25 years of democracy we are still stigmatized and discriminated against…”: Health care experiences of HIV positive older black gay men in a township in South Africa
Mange T; Henderson N; Lukelelo N: The Journal of Practice Teaching and Learning 19(1-2). https://doi.org/10.1921/jpts.v19i1-2.1674, 2022

Older gay black men living with HIV and AIDS and their aging and health care concerns are reported to be invisible in research in South Africa, with the focus being on younger LGBTQI+ men. This qualitative study explored the aging and health-care experiences of older gay black men in a selected township in the Cape Metropole, with the purpose of finding strategies to deal with their real life concerns and also interviewed health professionals working at the local clinic. A key finding was that health-care professionals, particularly nurses at a local clinic, stigmatize older black men living with HIV and AIDS and that rejection by their families and the death of their life partners leads to isolation, loneliness and depression. The authors propose training of health-care professionals by social workers and workshops to educate families of older LGBTQI+ people on their aging concerns.