Equity and HIV/AIDS

US PEPFAR abstinence and faithfulness funding had no impact on sexual behaviour in Africa
Alcorn K: aidsmap, 25 February 2015

Nearly US$1.3 billion spent on US-funded programmes to promote abstinence and faithfulness in sub-Saharan Africa is argued by the author of this paper to have had no significant impact on sexual behaviour in 14 countries in sub-Saharan Africa, as shown from an analysis of sexual behaviour data. The preliminary findings were presented by Nathan Lo of Stanford University School of Medicine at the Conference on Retroviruses and Opportunistic Infections (CROI 2015) in Seattle, USA. The Pepfar programmes aimed to delay sexual debut in order to reduce the period of high risk during adolescence, especially for girls, and to reduce partner numbers. The study investigated trends in sexual behaviour derived from national Demographic and Health Surveys in 14 PEPFAR focus countries before and after the beginning of PEPFAR funding in 2004, and compared these to a counterfactual: trends in eight other African countries – largely in West Africa – where PEPFAR funding was not determining the content of prevention campaigns. They found no significant change in PEPFAR countries relative to non-PEPFAR countries over time for any of the measures assessed, for men or women, although there was a trend towards a lower number of reported sexual partners for men in both PEPFAR and non-PEPFAR countries.

Towards elimination of mother-to-child transmission of HIV in Ghana: an analysis of national programme data
Dako-Gyeke P; Dornoo B; Ayisi Addo S; Atuahene M; Addo NA; Yawson AE: Int Jo Equity Health. 15: 5.2016

Sub-Saharan Africa alone contributes more than 90 % of global Mother-to-Child Transmission (MTCT) burden. As part of efforts to address this, African countries were earmarked in 2009 for rapid Preventing Mother to child HIV Transmissions (PMTCT) interventions scale-up within their primary care system for maternal and child health. In this study, the authors reviewed records in Ghana, on ANC registrants eligible for PMTCT services to describe regional disparities and national trends in key PMTCT indicators. They also assessed distribution of missed opportunities for testing pregnant women and treating those who are HIV positive across the country. Although there was a decline in HIV prevalence among pregnant women, untested ANC registrants increased from 17 % in 2011 to 25 % in 2013. There were varying levels of missed opportunities for testing across the ten regions of Ghana. Overall, HIV positive pregnant women initiated onto ARVs remarkably increased from 57% (2011) to 82 % (2013). Missed opportunities to test pregnant women for HIV and also initiate those who are positive on ARVs across all the regions pose challenges to the quest to eliminate mother-to-child transmission of HIV in Ghana. For some regions these missed opportunities mimic previously observed gaps in continuous use of primary care for maternal and child health in those areas. The authors contend that increased national and regional efforts aimed at improving maternal and child healthcare delivery, as well as HIV-related care, is paramount for ensuring equitable access across the country.

African leaders reaffirm commitment to the AIDS response and women’s empowerment
UNAIDS: Geneva, February 2015

The 24th Summit of the African Union and related events reaffirmed that Africa is committed and will remain committed to women’s empowerment and to ending the AIDS epidemic by 2030. The Summit took place in Addis Ababa, Ethiopia, from 23 to 31 January 2015 under 2015 annual African Union theme of “Women empowerment and development towards Africa’s Agenda 2063”. This report outlines the importance of ending AIDS was particularly articulated during the gender pre-summit meeting, at which the participants noted that member states should ensure that ending the AIDS epidemic by 2030 is part of Agenda 2063 and that it has an inclusive human rights approach that leaves no one behind, including children, adolescents, women of child-bearing age and women and girls in conflict and post-conflict settings.

Implementing rapid testing for tuberculosis in Mozambique
Cowan J, Michel C, Manhiça I, Monivo C, Saize D, Creswell J, Gloyd S, Micek M: Bulletin of the World Health Organisation 93(2) 65-132

In Mozambique, pulmonary tuberculosis is primarily diagnosed with sputum smear microscopy. However this method has low sensitivity, especially in people infected with human immunodeficiency virus (HIV). Patients are seldom tested for drug-resistant tuberculosis. The national tuberculosis programme and Health Alliance International introduced rapid testing of smear-negative sputum samples. Four machines were deployed in four public hospitals along with a sputum transportation system to transfer samples from selected health centres. Laboratory technicians were trained to operate the machines and clinicians taught to interpret the results. The results indicated that using rapid tests to diagnose tuberculosis is promising but logistically challenging. More affordable and durable platforms are needed. All patients diagnosed with tuberculosis need to start and complete treatment, including those who have drug resistant strains.

When HIV is ordinary and diabetes new: Remaking suffering in a South African Township
Mendenhall E, Norris SA: Global Public Health, DOI: 10.1080/17441692.2014.998698 2015

Escalation of non-communicable diseases (NCDs) among urban South African populations disproportionately afflicted by HIV/AIDS presents not only medical challenges but also new ways in which people understand and experience sickness. In Soweto, the psychological imprints of political violence of the Apartheid era and structural violence of HIV/AIDS have shaped social and health discourses. Yet, as NCDs increasingly become part of social and biomedical discussions in South African townships, new frames for elucidating sickness are emerging. This article employs the concept of syndemic suffering to critically examine how 27 women living with Type 2 diabetes in Soweto, a township adjacent to Johannesburg known for socio-economic mobility as well as inequality, experience and understand syndemic social and health problems. For example, women described how reconstructing families and raising grandchildren after losing children to AIDS was not only socially challenging but also affected how they ate, and how they accepted and managed their diabetes. Although previously diagnosed with diabetes, women illustrated how a myriad of social and health concerns shaped sickness. Many related diabetes treatment to shared AIDS nosologies, referring to diabetes as ‘the same’ or ‘worse’. These narratives demonstrate how suffering weaves a social history where HIV becomes ordinary, and diabetes new.

Feasibility and acceptability of a bar-based sexual risk reduction intervention for bar patrons in Tshwane, South Africa
Morojele NK, Kitleli N, Ngako K, Kekwaletswe CT, Nkosi S, Fritz K, Parry CDH: SAHARA J (Journal of Social Aspects of HIV/AIDS Research Alliance) 11(1), 2014

Alcohol consumption is a recognised risk factor for HIV infection. Alcohol serving establishments have been identified as appropriate venues in which to deliver HIV prevention interventions. This paper describes experiences and lessons learnt from implementing a combined HIV prevention intervention in bar settings in one city- and one township-based bar in Tshwane, South Africa. The intervention consisted of peer-led and brief intervention counselling sub-components. Thirty-nine bar patrons were recruited and trained, and delivered HIV and alcohol risk reduction activities to their peers as peer interventionists. At the same time, nine counselors received training and visited the bars weekly to provide brief motivational interviewing counselling, advice, and referrals to the patrons of the bars. The intervention was overall well received and suggests that bar patrons and servers can accept a myriad of intervention activities to reduce sexual risk behaviour within their drinking settings. However, HIV- and AIDS-related stigma hindered participation in certain intervention activities. The buy-in received from the relevant stakeholders (i.e. bar owners/managers and patrons, and the community at large) was an important contributor to the feasibility and acceptability of the intervention.

Fertility Desires and Intentions among HIV-Positive Women during the Post-natal period in Uganda
Gutin SA, Namusoke F, Shade SB, Mirembe F: African Journal of Reproductive Health 18(3), September 2014

This study describes the fertility intentions and discusses the potential reproductive health needs of post-natal HIV-infected Ugandan women. HIV-infected mothers attending post-natal services in Kampala, Uganda participated in this cross-sectional study using structured interviewer administered questionnaires. Among 403 participants, 35% desired more children. Of these, 25% wanted another child within 2 years and 75% within 3 years or more. In multivariable analyses, believing that one’s partners wanted more children was associated with the desire for future children while having more living children was negatively associated with the desire for future children. A minority of women desired future pregnancies, and most wanted to delay pregnancy for 3 years. These women are in need of family planning methods to meet stated desires to delay or end future pregnancies. Perceived partner desire for children also impacts on women’s fertility intentions, highlighting the importance of engaging men during the post-natal period.

HIV in (and out of) the clinic: Biomedicine, traditional medicine and spiritual healing in Harare
O’Brien S, Broom A: SAHARA J (Journal of Social Aspects of HIV/AIDS Research Alliance) 11(1), 14 July 2014

Contemporary lived experiences of the human immunodeficiency virus (HIV) are shaped by clinical and cultural encounters with illness. In sub-Saharan countries such as Zimbabwe, HIV is treated in very different ways in various therapeutic contexts including by biomedical experts, traditional medicine and faith healers. The co-existence of such expertise raises important questions around the potencies and limits of medicalisation and alternative healing practices in promoting HIV recovery. First, in this study, drawing on in-depth qualitative interviews with 60 people from poor urban areas in Harare, the authors explore the experiences of people living with and affected by HIV. They sought to document, interrogate and reflect on their perceptions and experiences of biomedicine in relation to traditional medicine and spiritual healing. Their accounts indicate that traditional medicine and spiritual beliefs continue to significantly influence the way in which HIV is understood, and the forms of help and care people seek. The authors observe the dramatic and overwhelmingly beneficial impact of Antiretroviral Therapy and conclude through Zimbabwean’s own stories that limitations around delivery and wider structural inequalities impede its potential. The authors explore some practical implications of the biomedical clinic (and alternative healing practices) being understood as sites of ideological and expert contestation.

World AIDS Day: What does HIV teach us about access to medicines for Ebola?
Kamal-Yanni M: Oxfam UK, November 2014

In 2001, the new antiretroviral medicines had started to work miracles, bringing people from their deathbeds back to life. Yet as a Ugandan doctor truly said: ‘the medicine is in the North but the disease is in the South’. The author argues that the pharmaceutical industry was happy to sell the medicines at very high prices in rich countries while turning a blind eye to the rest of the world. It was largely thanks to a huge global mobilisation of civil society led by people living with HIV that leaders and pharmaceutical companies started to feel embarrassed about denying access to life-saving medicines to millions of people. But it was only after generic competition kicked in that access to medicines became something policymakers talked about. An offer by an Indian company to sell a cocktail of the three basic medicines for one dollar a day slashed the prices of antiretrovirals, meaning that today over 9 million people are on treatment,, including over 7 million in Africa. The profit from treatment of HIV infected people in rich country provided the necessary market that has stimulated R&D for antiretroviral medicines. This is not the case for the Ebola market, which consists of small numbers of people in poor countries. Pharmaceutical companies had no commercial incentive to enter into R&D for vaccines or medicines for Ebola – or any other haemorrhagic fever. For this reason Ebola is the other side of the coin to HIV as the intellectual property rights system allows the market to shape R&D priorities, rather than public health needs. The author argues that it is not ethical, sustainable nor safe to leave commercial interests decisions and financing for R&D for products, capable of modifying global health threats, to be dictated by the commercial interests of pharmaceutical companies.

Intimate Partner Violence after Disclosure of HIV Test Results among Pregnant Women in Harare, Zimbabwe
Shamu S, Zarowsky C, Shefer T, Temmerman M, Abrahams N: PLoS ONE 9(10), October 2014

HIV status disclosure is a central strategy in HIV prevention and treatment but in high prevalence settings women test disproportionately and most often during pregnancy. This study reports intimate partner violence (IPV) following disclosure of HIV test results by pregnant women. The study demonstrated the interconnectedness of IPV, HIV status and its disclosure with IPV which was a common experience post disclosure of both an HIV positive and HIV negative result. The authors argue that health services must give attention to the gendered nature and consequences of HIV disclosure such as enskilling women on how to determine and respond to the risks associated with disclosure. Efforts to involve men in antenatal care must also be strengthened.