Equity and HIV/AIDS

Influence of parental factors on adolescents’ transition to first sexual intercourse in Nairobi, Kenya: a longitudinal study
Okigbo C; Kabiru C; Mumah J; Mojola S; Beguy D: Reproductive Health 12(73), 2015

The objective of the study was to assess the influence of parental factors (monitoring, communication, and discipline) on the transition to first sexual intercourse among unmarried adolescents living in urban slums in Kenya. Longitudinal data collected from young people living in two slums in Nairobi, Kenya were used. The sample was restricted to unmarried adolescents aged 12–19 years. Parental factors were used to predict adolescents’ transition to first sexual intercourse. Relevant covariates including the adolescents’ age, sex, residence, school enrollment, religiosity, delinquency, and peer models for risk behaviour were controlled for. Approximately 6 % of the sample transitioned to first sexual intercourse within the one-year study period; there was no sex difference in the transition rate. In the multivariate analyses, male adolescents who reported communication with their mothers were less likely to transition to first sexual intercourse compared to those who did not. This association persisted even after controlling for relevant covariates. However, parental monitoring, discipline, and communication with their fathers did not predict transition to first sexual intercourse for male adolescents. For female adolescents, parental monitoring, discipline, and communication with fathers predicted transition to first sexual intercourse; however, only communication with fathers remained statistically significant after controlling for relevant covariates. This study provides evidence that cross-gender communication with parents is associated with a delay in the onset of sexual intercourse among slum-dwelling adolescents. Targeted adolescent sexual and reproductive health programmatic interventions that include parents may have significant impacts on delaying sexual debut, and possibly reducing sexual risk behaviours, among young people in high-risk settings such as slums.

Rising School Enrollment and Declining HIV and Pregnancy Risk Among Adolescents in Rakai District, Uganda, 1994–2013
Santelli J; Mathur S; Song X; Huang T; Wei Y; Lutalo T; Nalugoda F; Gray R; Serwadda D: Global Social Welfare 2(2), 87-103, 2015

Poverty, family stability, and social policies influence the ability of adolescents to attend school. Likewise, being enrolled in school may shape an adolescent’s risk for HIV and pregnancy. The authors identified trends in school enrollment, factors predicting school enrollment (antecedents), and health risks associated with staying in or leaving school (consequences). Data from the Rakai Community Cohort Study (RCCS) were examined for adolescents 15–19 years (n&#8201;=&#8201;21,735 person-rounds) from 1994 to 2013. Trends, antecedents, and consequences were assessed. Qualitative data were used to explore school leaving among HIV+ and HIV&#8722; youths (15–24 years). School enrollment and socioeconomic status (SES) rose steadily from 1994 to 2013 among adolescents and orphanhood declined after availability of antiretroviral therapy. Antecedent factors associated with school enrollment included age, SES, orphanhood, marriage, family size, and the percent of family members <20 years. In qualitative interviews, youths reported lack of money, death of parents, and pregnancy as primary reasons for school dropout. Among adolescents, consequences associated with school enrollment included lower HIV prevalence, prevalence of sexual experience, and rates of alcohol use and increases in consistent condom use. Young women in school were more likely to report use of modern contraception and never being pregnant. Young men in school reported fewer recent sexual partners and lower rates of sexual concurrency.

A comparative analysis of national HIV policies in six African countries with generalised epidemics
Church K; Kiweewa F; Dasgupta A; Mwangome M; Mpandaguta E; Gómez-Olivé F; Oti S; Todd J; Wringe A; Geubbels E; Crampin A; Nakiyingi-Miiro J; Hayashi C; Njage M; Wagner R; Ario A; Makombe S; Mugurungi O; Zaba B: Bulletin of the WHO 93(7) 437-512, July 2015

This study compared national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. The authors also compared the national policies with WHO guidance. There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy. Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. It is proposed that future research assess the extent of policy implementation and link these findings with HIV outcomes.

Doubt, defiance, and identity: Understanding resistance to male circumcision for HIV prevention in Malawi
Parkhurst J; Chilongozi D; Hutchinson E: Social Science and Medicine 135, 15-22, 2015

Global policy recommendations to scale up of male circumcision (MC) for HIV prevention tend to frame the procedure as a simple and efficacious public health intervention. However, there has been variable uptake of MC in countries with significant HIV epidemics. In this paper the authors present an in-depth analysis of Malawi's political resistance to MC, finding that ethnic and religious divisions dominating recent political movements aligned well with differing circumcision practices. Political resistance was further found to manifest through two key narratives: a ‘narrative of defiance’ around the need to resist 'donor manipulation', and a ‘narrative of doubt’ which seized on a piece of epidemiological evidence to refute global claims of efficacy. Further, the authors found that discussions over MC served as an additional arena through which ethnic identities and claims to power could themselves be negotiated, and therefore used to support claims of political legitimacy.

Students want HIV testing in schools: a formative evaluation of the acceptability of HIV testing and counselling at schools in Gauteng and North West provinces in South Africa
Madiba S; Mokgatle M: BMC Public Health 15(388), April 2015, doi:10.1186/s12889-015-1746-x

The proposal by the South African Health Ministry to implement HIV testing and counselling (HTC) at schools in 2011 generated debates about the appropriateness of such testing. However, the debate has been between the Ministries of Education and Health, with little considerations of the students. This study assessed the students’ opinions and uptake of HIV testing and counselling in general, and the acceptability of the provision of HIV testing and counselling in schools. A survey was conducted among grade 10–12 high school students in North West and Gauteng provinces, South Africa. Seventeen high schools (nine rural and eight urban) were randomly selected for the administration of a researcher-assisted, self-administered, semi-structured questionnaire. A total of 2970 students aged 14–27 years participated in the study. Having multiple sexual partners, age, and gender were significantly associated with increased odds of having had a HIV test. Fear, being un-informed about HTC, and low HIV risk perceptions were the reasons for not getting tested. The acceptability of HTC at school was high (n = 2282, 76.9%) and 2129 (71.8%) were willing to be tested at school. Appropriateness, privacy, and secrecy were the main arguments for and against HTC at school. One-third had intentions to disclose their HIV status to students versus 42.5% for teachers. Stigma, discrimination and secrecy were the primary reasons students did not intend to disclose. A high acceptability of HTC and willingness to be tested at school suggest that HIV prevention programs tailored to youth have a high potential of success given the readiness of students to uptake HTC. The authors conclude that bringing HIV testing to the school setting will increase the uptake of HTC among youth and contribute towards efforts to scale up HTC in South Africa.

Prevention of mother-to-child transmission of HIV in rural Uganda: Modelling effectiveness and impact of scaling-up PMTCT services
Woodward D: Glob Health Action 2015, 8 (26308), 2015

The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010, and this may be an overestimation as it does not measure completion. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care, HIV testing, and ARVs for the woman and the baby. This study was based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008–2010. Using modelling, it was estimated that HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction. The results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT.

Screening for tuberculosis and testing for human immunodeficiency virus in Zambian prisons
Maggard KR, Hatwiinda S, Harris JB, Phiri W, Krüüner A, Kaunda K, Topp SM, Kapata N, Ayles H, Chileshe C, Henostroza G, Reid SE: Bulletin of the World Health Organisation 93(2) 65-132, 2015

This study aimed to improve the Zambia Prisons Service’s implementation of tuberculosis screening and human immunodeficiency virus (HIV) testing. For both tuberculosis and HIV, the authors implemented mass screening of inmates and community-based screening of those residing in encampments adjacent to prisons. They also established routine systems – with inmates as peer educators – for the screening of newly entered or symptomatic inmates. We improved infection control measures, increased diagnostic capacity and promoted awareness of tuberculosis in Zambia’s prisons. In a period of 9 months, the authors screened 7638 individuals and diagnosed 409 new patients with tuberculosis. They tested 4879 individuals for HIV and diagnosed 564 cases of infection. An additional 625 individuals had previously been found to be HIV-positive. Including those already on tuberculosis treatment at the time of screening, the prevalence of tuberculosis recorded in the prisons and adjacent encampments was 18 times the national prevalence estimate of 0.35%. Overall, 22.9% of the inmates and 13.8% of the encampment residents were HIV-positive. Both tuberculosis and HIV infection are common within Zambian prisons. The authors enhanced tuberculosis screening and improved the detection of tuberculosis and HIV in this setting. These observations should be useful in the development of prison-based programmes for tuberculosis and HIV elsewhere.

Tenofovir substitution in Namibia based on an analysis of the antiretroviral dispensing database
Kalemeera F; Mengistu A; Gaeseb J: Journal of Pharmaceutical Policy and Practice 8(14), 2015

In the management of HIV infection, tenofovir (TDF) is preferred to its predecessors based on its safety profile, despite some adverse reactions which warrant its substitution for some patients. This review measured the rate of TDF’s substitution from January 1 2008 to November 30 2011, and compared the gender difference in these rates of substitution using dispensing records from the national antiretroviral dispensing database. No gender difference was observed and the authors indicate that further investigation is required to determine the clinical reasons for TDF’s withdrawal.

African ministers of finance call for increased investment to end the AIDS epidemic by 2030
UNAIDS, 1 April 2015

African ministers of finance and key partners in the AIDS response meeting in Addis Ababa, Ethiopia, have called for increased national investment to end the AIDS epidemic as a public health threat by 2030. The international community has committed to meeting the 90–90–90 treatment targets, under which 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression. If the 90–90–90 targets are met by 2020, ending the AIDS epidemic a decade later is achievable.

Hopes dashed as HIV measure found to be useless
Kahn T: BDLive, 25 February 2015

Hopes that a South African-developed vaginal gel containing tenofovir would protect women against HIV were dashed after a major new study found that it did not work. Scientists had been optimistic that the microbicide would protect millions of women from HIV, after a phase 2 study of 900 women in KwaZulu-Natal found it reduced the risk of getting the virus by 39%. The development was hailed as a breakthrough, though the scientists who led the work were careful to emphasise that further research was needed to replicate the findings. At that stage, 11 other trials testing six other products had failed. The findings had a wide margin of error, with the efficacy of HIV protection estimated to lie between 6% and 60%. A much larger Follow-on African Consortium for Tenofovir Studies (FACTS) 001 trial was launched in 2011 to confirm its findings. The consortium scientists announced at the annual Conference on Retroviruses and Opportunistic Infections in Seattle, however, that the tenofovir-containing microbicide provided to 2,059 women aged between 18 years and 30 years did not protect them from HIV.