Equity and HIV/AIDS

Antiretroviral Therapy for Refugees and Internally Displaced Persons: A Call for Equity
Mendelsohn JB, Spiegel P, Schilperoord M, Cornier N, Ross DA: PLoS Med 11(6), 10 June 2014

Available evidence suggests that refugees and internally displaced persons (IDPs) in stable settings can sustain high levels of adherence and viral suppression. Moral, legal, and public health principles and recent evidence strongly suggest that refugees and IDPs should have equitable access to HIV treatment and support. Exclusion of refugees and IDPs from HIV National Strategic Plans suggests that they may not be included in future national funding proposals to major funders. Levels of viral suppression among refugees and nationals documented in a stable refugee camp suggest that some settings require more intensive support for all population groups. Detailed recommendations are provided for refugees and IDPs accessing antiretroviral therapy in stable settings.

The HIV/AIDS epidemic in South Africa: Convergence with tuberculosis, socioecological vulnerability, and climate change patterns
Abayomi A, Cowan MN: South African Medical Journal104(8):583, 9 July 2014

Recent assessment reports suggest that climate change patterns are threatening social and ecological vulnerability and resilience, with the strong potential of negatively affecting human health. Persons living with HIV/AIDS (PLWHA) have weakened physiological responses and are immunologically vulnerable to pathogens and stressors in their environment, putting them at a health disadvantage in climate-based rising temperatures, water scarcity, air pollution, potential water- and vector-borne disease outbreaks, and habitat redistributions. These climatic aberrations may lead to increased surface drying and decreased availability of arable land, threatening food/nutrition security and sanitary water practices. Coupled with HIV/AIDS, climate change threatens ecological biodiversity via a larger-scale socio-economic recourse to natural resources. Corresponding human and environmental activity shape conditions conducive to exacerbating high rates of HIV/AIDS. In South Africa, this epidemic is forming a ‘syndemic’ with tuberculosis (TB), which has come to include multidrug-resistant TB (MDR-TB) and extremely drug-resistant TB (XDR-TB) strains. Be-cause of high convergence rates, one epidemic cannot be addressed without understanding the other. Concurrent climate change mitigation and adaptation strategies are becoming increasingly important to curb changes that negatively affect the biospheres on which civilisation is ultimately dependent – from an agricultural, a developmental, and especially a health standpoint. Mitigation strategies such as reducing carbon emissions are essential, but may be only partially effective in slowing the rate of surface warming. However, global climate assessments assert that these are not sufficient to halt climate change patterns. Regionally specific climate research, socioecologically sustainable industrialisation paths for developing countries, and adoption of health system strengthening strategies are therefore vital.

Equity in utilisation of antiretroviral therapy for HIV-infected people in South Africa: a systematic review
Tromp N, Michels C, Mikkelsen E, Hontelez J, Baltussen R: International Journal for Equity in Health (13) 60, August 2014

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 on equity in utilisation of ART among HIV-infected people in South Africa. The authors conducted a literature search based on the Cochrane guidelines. 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 on that criterion. 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. The authors suggest 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.

The end of AIDS: Possibility or pipe dream? A tale of transitions
Whiteside A and Strauss M: African Journal of AIDS Research (2) 13, 101–108, 2014

Globally, in the last 20 years health has improved. In this generally optimistic setting HIV and AIDS accounts for the fastest growing burden of disease. The data show the bulk of this is experienced in Southern Africa. In this region, HIV and AIDS (and tuberculosis [TB]) peaks among young adults. Women carry the greater proportion of infections and provided most of the care. South Africa has the dubious distinction of having the largest number of people living with HIV in the world, 6.4 million. HIV began spreading from about 1990 and today the prevalence among antenatal clinic attendees is 29.5%. A similar situation exists in other nations of the region. It is an expensive disease, requiring more resources than are available, and it is slipping off the global agenda, both in terms of attention and international funding. Those halcyon days of the decade from 2000 to 2010 are over. This paper explores the concept of three transition points: economic, epidemiological and programmatic. The first two have been developed and written about by others. The authors add a third transition point, namely programmatic, argue this is an important concept, and show how it can become a powerful tool in the response to the epidemic. The economic transition point assesses HIV incidence and mortality of people infected with HIV. Until the number of newly infected people falls below the number of deaths of people living with HIV, the demand for treatment and costs will increase. This is a concern for the health sector, finance ministry and all working in the field of HIV. Once an economic transition occurs the treatment future is predictable and the number of people living with HIV and AIDS decreases. This paper plots two more lines. These are the number of new people from the HIV infected pool initiated on treatment and the number of people from the HIV infected pool requiring treatment. This introduces new transition points on the graph. The first when the number of people initiated on treatment exceeds the number of people needing treatment. The second when the number initiated on treatment exceeds the new infections. That is the theory. When applying South African data from the ASSA2008 model, the authors were able to plot transition points marking progress in the national response. They argue these concepts can and should be applied to any country or HIV epidemic.

Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind
Burford G: CAFOD August 2014

This commentary was written on the International AIDS Conference in Melbourne 20-25 July 2012, the 20th gathering of the largest regular conference of any health or development issue, bringing together politicians, scientists, epidemiologists, practitioners, policy makers, the private sector and communities of people living with and affected by HIV. There is uniqueness in this fight against HIV in that it is a social movement, pulling people together and putting people at the forefront of the response to sustain efforts on addressing HIV. The theme of the 2014 conference was ‘Stepping up the Pace,’ and the author comments that we must redouble our efforts on areas like stigma and discrimination, which after 30 years is still increasing in some regions. 'We have the tools; we need to step up the pace.’ Today, there are 15 million people on treatment, yet there are still alarming challenges that must be tackled in order to even contemplate an AIDS free generation. Statistics from 2013 show there were 1.5 million HIV deaths, 2.1 million new infections and 35 million people living with HIV. Of the 35 million people living with HIV, 55% (19 million) don’t know they have the virus. They haven’t been tested and if they don’t find this out, they will die. The conference highlighted many reasons as to why people do not access or drop out of treatment. The author argues that people must not become those tired advocates beating the same drum, but come back from the conference championing the successes of work over the last 30 years and enter a phase of renewed energy to step up the pace and most importantly leave no one behind.

ICYMI: Ten Things You Should Know From AIDS 2014
Lewis S: AIDS Free World 25 July 2014

The author lists ten things raised at the 2014 Global AIDS conference in Melbourne Australia, listing backwards from 10 to 1: 10. There may be fewer people living with HIV than we thought. 9. Decriminalizing commercial sex work could significantly decrease new HIV infections among sex workers. 8. Ninety is the new zero. For years now, we’ve been hearing a chorus of ‘zero new HIV infections, zero HIV-related discrimination, and zero AIDS-related deaths.’ But this week, UNAIDS changed course, promising to have 90% of all people with HIV aware of their status, 90% of people on treatment, and 90% of those on treatment with lasting viral suppression by the year 2020. 7. Women using injectable hormonal contraceptives are at greater risk of contracting HIV, but WHO isn’t planning to inform women before they choose birth control methods. 6. UNAIDS is still leaving out one of the most at-risk groups of all: women. 5. Children and adolescents are dying at an alarming rate. 4. There is a huge shortfall in funding for harm reduction. 3. HIV-positive women are being pressured to undergo sterilization by health workers. 2. Undetectable viral loads.Calling it “the closest thing we have to a cure for HIV,” activists issued a challenge this week to bring viral loads to undetectable levels by 2020. and 1. Funding for activists is drying up, and with it, the voices to spur governments and agencies to action. Section27's Mark Heywood issued a cri de coeur to delegates of AIDS 2014, lamenting that "AIDS is fast becoming just another disease of the poor, criminalised and marginalised...just another manifestation of global complacency about poverty and inequality."

Age-disparate relationships and HIV incidence amongst rural South Africa women
Harling G: Global Health and Population, Harvard School of Public Health: Conference on Retroviruses and Opportunistic Infections 2014

Sex with older men is not placing women under 30 at higher risk of HIV infection in rural South Africa, and relationships with older men may even be protecting women over 30 from infection, according to results from a eight-year study presented at the 21st Conference on Retroviruses and Opportunistic Infections (CROI) in Boston.

MPs pass Bill that will make men test for HIV alongside their wives
Nalugo M, Ayebazibwe A: Daily Monitor May 14 2014

If President Museveni assents to the new HIV/Aids Prevention and Control Bill, 2010, passed by Parliament in May, it will be criminal for a person to ‘willfully’ or ‘intentionally’ infect another with the HIV/Aids virus.
Under Clause 41(1), a person who knowingly transmits HIV/Aids to another shall, on conviction, be liable to a fine of not more that Shs4.8 million or imprisonment for a term not exceeding 10 years or both. Additionally, Clause 14 of the BIll makes it mandatory for men to test alongside their pregnant partners with a view of placing an obligation on both parents to be responsible and protect the unborn child from acquiring the disease. The Bill also establishes a fund, the HIV Trust Fund, which will help boost the fight against the pandemic. The proposed fund imposes an obligation on the government to make quarterly contributions to ministry of Health. Government will contribute 2 per cent to the fund off levies from beer, bottled water and soft drinks.

Strengthening the enabling environment for women and girls: what is the evidence in social and structural approaches in the HIV response?
Hardee K, Gay J, Croce-Galis M, Peltz A: Journal of International Aids Society 17(1): 7 January 2014

There is growing interest in expanding public health approaches that address social and structural drivers that affect the environment in which behaviour occurs. Half of those living with HIV infection are women. The sociocultural and political environment in which women live can enable or inhibit their ability to protect themselves from acquiring HIV. This paper examines the evidence related to six key social and structural drivers of HIV for women: transforming gender norms; addressing violence against women; transforming legal norms to empower women; promoting women’s employment, income and livelihood opportunities; advancing education for girls and reducing stigma and discrimination. The paper reviews the evidence for successful and promising social and structural interventions related to each driver. This analysis contains peer-reviewed published research and study reports with clear and transparent data on the effectiveness of interventions. Structural interventions to address these key social and structural drivers have led to increasing HIV-protective behaviours, creating more gender-equitable relationships and decreasing violence, improving services for women, increasing widows’ ability to cope with HIV and reducing behaviour that increases HIV risk, particularly among young people.

Faith and HIV prevention: the conceptual framing of HIV prevention among Pentecostal Batswana teenagers
Mpofu E, Nkomazana F, Muchado JA, Togarasei L, Bingenheimer JB: BMC Public Health 14(225): 5 March 2014

There is a huge interest by faith-based organizations (FBOs) in sub-Saharan Africa and elsewhere in HIV prevention interventions that build on the religious aspects of being. Successful partnerships between the public health services and FBOs will require a better understanding of the conceptual framing of HIV prevention by FBOS to access for prevention intervention, those concepts the churches of various denominations and their members would support or endorse. This paper reports the findings of a study on the conceptual framing of HIV prevention among church youths in Botswana. The findings suggest the church youth to conceptually frame their HIV prevention from both faith-oriented and secular-oriented perspectives, while prioritizing the faith-oriented concepts based on biblical teachings and future focus. In their secular-oriented framing of HIV prevention, the church youths endorsed the importance to learn the facts about HIV and AIDS, understanding of community norms that increased risk for HIV and prevention education. However, components of secular-oriented framing of HIV prevention concepts were comparatively less was well differentiated among the youths than with faith-oriented framing, suggesting latent influences of the church knowledge environment to undervalue secular oriented concepts. Older and sexually experienced church youths in their framing of HIV prevention valued future focus and prevention education less than contrasting peer cohorts, suggesting their greater relative risk for HIV infection.