The objective of this paper was to describe the long-term virological, immunological and mortality outcomes of providing highly active antiretroviral therapy (HAART) with strong adherence support to African HIV-infected female sex workers (FSWs) and contrast outcomes with those obtained in a cohort of regular HIV-infected women. FSWs and non-FSWs initiated on HAART between August 2004 and October 2007 were included in the study. Patients were followed monthly for drug adherence (interview and pill count), and at six-monthly intervals for monitoring CD4 counts and HIV-1 plasma viral loads (PVLs) and clinical events. Results showed no statistical differences between outcomes of FSWs and non-FSWs. The authors conclude that clinical and biological benefits of HAART can be maintained over the long term among FSWs in Africa and could also lead to important public health benefits.
Equity and HIV/AIDS
The experiences of the past ten years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings. Achieving the levels of antiretroviral (ARV) coverage necessary to impact the course of the HIV epidemic remains a challenge and ARV coverage in most nations remains short of even current recommendations. Though treatment as prevention and seek, test, treat and retain strategies are attractive, the authors of this article argue that realising the benefits of these strategies means that they must cover hard to reach populations such as sex workers. While evidence on reach of these populations in research settings is encouraging, there are questions on the sustainability of these efforts as patients are transitioned back into national HIV control programmes, many of which are struggling even to maintain the current coverage in the face of declining external funding. The authors conclude that advocacy from both medicine and public health providers will be critical to sustain and enhance the necessary HIV and AIDS treatment and prevention programmes worldwide.
Highly Active Antiretroviral Therapy (HAART) has been available free of charge in Tanga, Tanzania since 2005, yet many women referred from prevention of mother-to-child transmission services to the Care and Treatment Clinics (CTC) for HAART never registered at the CTCs. In this study, researchers focused on the motivating and deterring factors to presenting for HAART, particularly in relation to women. A qualitative approach was used, including in-depth interviews and focus group discussions. Researchers found that the main deterrent to presenting for treatment appears to be fear of stigmatisation including fear of ostracism from the community, divorce and financial distress. Participants indicated that individual counselling and interaction with other people living with HIV would encourage women to present for HAART, to do so, and indicated that the entrance to the CTC should be placed to allow discreet access. Necessary steps towards encouraging HIV infected women to seek treatment include reducing self-stigma, assisting them to form empowering relationships and to gain financial independence and emphasising the beneficial effect of treatment for themselves and for their children by example.
In this study, researchers conducted a qualitative study to explore risk situations that can explain the high HIV prevalence among youth in Kisumu town, Kenya. They conducted in-depth interviews with 150 adolescents aged 15 to 20, held four focus group discussions, and made 48 observations at places where youth spend their free time. Porn video shows and local brew dens were identified as popular events where unprotected multipartner, concurrent, coerced and transactional sex occurs between adolescents. Forced sex, gang rape and multiple concurrent relationships characterised the sexual encounters of youth, frequently facilitated by the abuse of alcohol, which is available for minors at low cost in local brew dens. A substantial number of girls and young women engaged in transactional sex, often with much older, wealthier partners. The authors conclude that local brew dens and porn video halls facilitate risky sexual encounters between youth and should be regulated and monitored by the government. Young men should be targeted in prevention activities, to change their attitudes related to power and control in relationships, while girls should be empowered how to negotiate safe sex, and their poverty should be addressed through income-generating activities.
Are Uganda’s health systems are being strengthened to sustain access to antiretroviral therapy (ART)? This study applies systems thinking to assess supply chain management, the role of external support and whether investments create the needed synergies to strengthen health systems. The authors combined data from the literature and key informant interviews with observations at health service delivery level in a study district. Findings indicate that current drug supply chain management in Uganda is characterised by parallel processes and information systems that result in poor quality and inefficiencies. Less than expected health system performance, stock outs and other shortages affect ART and primary care in general. Poor performance of supply chain management is amplified by weak conditions at all levels of the health system, including the areas of financing, governance, human resources and information. Governance issues include the lack to follow up initial policy intentions and a focus on narrow, short-term approaches. In conclusion, the study indicates serious missing system prerequisites. The findings suggest that root causes and capacities across the system have to be addressed synergistically to enable systems that can match and accommodate investments in disease-specific interventions. The multiplicity and complexity of existing challenges require a long-term and systems perspective essentially in contrast to the current short term and programme-specific nature of external assistance.
According to this report, despite a broad awareness of HIV, comprehensive knowledge of HIV and how to prevent it is still low, even in countries that have been most affected by the epidemic. There are encouraging signs that HIV-prevention efforts are resulting in positive change in sexual behaviours, accompanied by declines in HIV prevalence among young people in the most-affected countries. This should not be cause for complacency, UNAIDS warns. Instead, these successful services and programmes should be built upon to further efforts to reverse the epidemic among young people. To effectively advance the response among young people, UNAIDS argues that there is a need to increase investments. However, it also cautions that simply directing more resources will not increase HIV testing and uptake of services among young people. Instead, empowering young people and particularly young women to exercise their rights to sexual and reproductive health, improve programmes for young people and repeal national laws and policies that restrict access to HIV services for young people is required to protect future generations from HIV. The report highlights that young people are a key resource to reverse the global AIDS epidemic and lead the response in decades to come, but it stresses that the legal and policy barriers that prevent young people from accessing HIV services must be addressed, and young people should be engaged more effectively in the response.
The public health response to sexually transmitted infections, particularly HIV, has been and continues to be overwhelmingly focused on risk, disease and negative outcomes of sex, while avoiding discussion of positive motivations for sex like pleasure, desire and love. Recent advocacy efforts have challenged this approach and organisations have promoted the eroticisation of safer sex, especially in the context of HIV prevention.
This paper is a case study of one of these organisations – the Pleasure Project. The authors give a brief background on the public-health approach to sex and sexual health, and recommend an alternative approach that incorporates constructs of pleasure and desire into sexual health interventions. The Pleasure Project’s aims and unorthodox communications strategies are described, as are the response to and impact of its work, lessons learned and ongoing challenges to its approach. Despite the backdrop of sex-negative public health practice, there is anecdotal evidence that safer sex, including condom use, can be eroticised and made pleasurable, based on qualitative research by the Pleasure Project and other like-minded organisations. Yet there is a need for more research on the effectiveness of pleasure components in sexual health interventions, particularly in high-risk contexts, the authors argue. This need has become urgent as practitioners look for new ways to promote sexual health and as new prevention technologies (including female condoms and microbicides) are introduced or disseminated.
Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. The authors estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs. For Hlabisa subdistrict, KwaZulu-Natal, they predicted the HIV epidemic dynamics, number on ART and programme costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. Calculations indicated that during the first five years, the new WHO treatment guidelines will require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years. The findings strengthen the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients.
The purpose of this study was to evaluate the relationship between the coping self-efficacy (CSE) scale and adherence to HIV medication in men and women enrolled in a large HIV treatment programme in Kenya. Data were collected from a sample of 354 volunteers attending Nazareth Hospital's nine satellite clinics located in parts of Nairobi, and the central province of Kenya. A social demographic survey, Adult Clinical Trials Group adherence questionnaire, and CSE scale were used to obtain information. Descriptive statistics and logistic regressions were performed to analyse data and to test study hypotheses. The researchers found that females were less likely to be nonadherent than males: the odds of adherence for females were 3.7 of the odds of adherence for males. When controlling for gender, CSE was found to be significant. Adherence to antiretroviral therapy can be partially explained by CSE, the authors conclude. Efforts aimed at building self-efficacy are likely to improve and maintain adherence to HIV and other medication, they argue.
Concurrent sexual partnerships are widely believed to be one of the main drivers of the HIV epidemic in sub-Saharan Africa. For this population-based cohort study, researchers used data from the Africa Centre demographic surveillance site in KwaZulu-Natal, South Africa, to try to find support for the concurrency hypothesis. A total of 2,153 sexually active men and 7,284 HIV-negative women from the surrounding local community were included in the study. During five years' follow-up, 693 new female HIV infections occurred and the researchers found that - after adjustment for individual-level sexual behaviour and demographic, socioeconomic and environmental factors associated with HIV acquisition - mean lifetime number of partners of men in the immediate local community was predictive of hazard of HIV acquisition in women. A high prevalence of partnership concurrency in the same local community was not associated with any increase in risk of HIV acquisition. The researchers argue that, in similar hyperendemic sub-Saharan African settings, there is a need for straightforward, unambiguous messages aimed at the reduction of multiple partnerships, irrespective of whether those partnerships overlap in time.