This paper assessed the extent in East Africa to which policies reflect calls for HIV-NCD service integration, through document review. Integrated delivery of HIV and NCD care is recommended in high level health policies and treatment guidelines in four countries in the East African region; Kenya, Rwanda, Tanzania and Uganda, mostly relating to integrating NCD care into HIV programmes, in response both to increasing levels of NCDs and more person-centred services for people living with HIV. Other countries, however, have no reported plans for HIV and NCD care integration.
Equity and HIV/AIDS
This paper explored child and care-giver experiences of the process of disclosing HIV statuses to children, including reasons for delay, through 22 in-depth interviews with care-givers and 11 in-depth interviews with HIV positive children in Kinshasa. Care-givers included biological parents, grandmothers, siblings and community members and 86% of them were female. Many care-givers had lost family members due to HIV and several were HIV positive themselves. Reasons for non-disclosure included fear of stigmatisation; wanting to protect the child and not having enough knowledge about HIV or the status of the child to disclose. Several children had multiple care-givers, which also delayed disclosure, as responsibility for the child was shared. In addition, some care-givers were struggling to accept their own HIV status and did not want their child to blame them for their own positive status by disclosing to them. The authors identify that child disclosure is a complex process for care-givers, health-care workers and the children themselves.
Recent data has shown that the COVID-19 pandemic has had an impact on HIV testing services, but the impact on HIV treatment is less than originally feared. As of August 2020, the UNAIDS, World Health Organization and United Nations Children's Fund data collection exercise to identify national, regional and global disruptions of routine HIV services caused by COVID-19 had collected treatment data from 85 countries. Of these, 22 countries reported data over a sufficient number of months to enable the identification of trends. Only five countries reported monthly declines in the number of people on treatment after April—these include Zimbabwe in June, Peru and Guyana in July, the Dominican Republic in April, and Sierra Leone in May through to July. The remaining 18 countries did not show a decline and some countries showed a steady increase (e.g. Kenya, Ukraine, Togo and Tajikistan). However, among the 22 countries with trend data on numbers newly initiating treatment, all countries except Jamaica showed declines for at least one month or more relative to January. Only around eight of those countries showed a rebound in the number of people newly initiating treatment between January and July.
More quickly than they could have anticipated, people living with (PLWH) and those at-risk for HIV felt the impact of the COVID-19 pandemic, as they were asked to shelter in place and distance themselves from others. In March and April 2020, community-based organizations (CBOs) closed, medical offices cut hours, and medical personnel shifted from primary care to COVID-19 hospital units, affecting the HIV Continuum of Care and Prevention—that is, testing, pre-exposure prophylaxis (PrEP), and primary care. The authors call for further research, review and monitoring to provide evidence on referral practices and links that could help clients access the HIV services to which they are referred (“referral completion”).
The authors determined the prevalence and sociodemographic predictors of HIV among pregnant women in Botswana through a cross-sectional study of 407 randomly enrolled women aged 18 to 49 years, attending 7 health facilities between November 2017 and March 2018. The HIV prevalence was 17%. Women aged 35 to 49 years had higher HIV prevalence than those 18 to 24 years. Illiterate and elementary school educated women had higher HIV prevalence than those with a tertiary education. Those with a history of alcohol intake had a higher HIV prevalence than those without. While HIV prevalence was lower than it was in 2011 the authors call for targeted interventions that integrate these identified dimensions of susceptibility.
The strain that the COVID-19 outbreak imposes on health systems will undoubtedly impact the sexual and reproductive health of individuals living in low- and middle-income countries (LMICs); however, sexual and reproductive health will also be affected by societal responses to the pandemic, such as when local or national lockdowns close services not deemed to be essential, as well as from consequences of travel restrictions and economic slowdowns. Previous public health emergencies have shown that the impact of an epidemic on sexual and reproductive health often goes unrecognized, because the effects relate to indirect consequences of strained health care systems, disruptions in care and redirected resources. The authors argue for the learning from prior epidemics to be used to put in place critical resources and systems, and ensuring the provision of essential sexual and reproductive health services to avoid health system disruptions that would have devastating, lasting effects on individuals and communities.
The authors explored how the nurse-led community-based ART programme in Malawi was perceived, through interview of patients and nurses providing the care. Patients reported saving money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations. Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. The patients interviewed in this study preferred the nurse-led community ART programme approach to the facility-based model of care because of the features above. The authors note that community-led healthcare programmes need to plan for the provision of transportation for care providers; the physical structure of community sites; the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles.
This study investigated the socio-demographic determinants of recent HIV testing among older persons in selected rural districts in Uganda using a cross-sectional survey of 649 older men and women age 50 years and older, from central and western Uganda. Prevalence of lifetime HIV testing was 82% and recent HIV testing was 53%. HIV testing in the last 12 months was associated with age, self-reported sexually transmitted infections, male circumcision, and sexual activity in the last 12 months. Recent HIV testing among older persons was associated with younger age, self-reported STIs, male circumcision, and sexual activity among older persons in rural Uganda. The authors propose that HIV testing interventions target persons 70 years and older, who were less likely to test.
n Zimbabwe, research was conducted to assess the acceptability and accuracy of human immunodeficiency virus (HIV) self-testing. During implementation, the authors evaluated sex workers’ preferences for and feasibility of distribution of test kits before the programme was scaled-up. In Malawi, the authors conducted a rapid ethnographic assessment to explore the context and needs of female sex workers and resources available, leading to a workshop to define the distribution approach for test kits. Once distribution was implemented, the authors conducted a process evaluation and established a system for monitoring social harm. In Zimbabwe, female sex workers were able to accurately self-test. The preference study helped to refine systems for national scale-up through existing services for female sex workers. The qualitative data helped to identify additional distribution strategies and mediate potential social harm to women. In Malawi, peer distribution of test kits was the preferred strategy. The authors identified some incidents of social harm among peer distributors and female sex workers, as well as supply-side barriers to implementation which hindered uptake of testing. Involving female sex workers in planning and ongoing implementation of human immunodeficiency virus self-testing is essential, along with strategies to mitigate potential harm. Optimal strategies for distribution and post-test support are argued to be context-specific and to need to consider existing support for female sex workers and levels of trust and cohesion within their communities.
The paper assessed preference and uptake for the enabling environment created to deliver the different community-based HIV testing services to female sex workers along the Malaba-Kampala highway. Malaba – Kampala high way is one of the major high ways with many different hot spots where the actual buying and selling of sex takes place. The authors defined female sex workers as any female, who undertakes sexual activity after consenting with a man for money or other items/benefits as an occupation or as a primary source of livelihood irrespective of site of operation within the past six months. The authors assessed the preference and uptake of different community-based HIV testing services delivery model among female sex workers based on the proportion of female sex workers who had an HIV counseling and testing in the last 12 months and the proportion of female sex workers who were positive and linked to care. Overall, 86% of the female sex workers had taken an HIV test in the last 12 months. Of the 390 Female Sex workers, 72% had used static facilities, 25% had used outreaches, and 3.3% used peer to peer mechanisms to have an HIV test. Overall, 35% of the female sex workers who had taken an HIV test were HIV positive. Of the 159, 83% were successfully linked into care. Ninety one percent reported to have been linked into care by static facilities. Challenges experienced included; lack of trust in the results given during outreaches, failure to offer other testing services including hepatitis B and syphilis during outreaches, inconsistent supply of testing kits, condoms, STI drugs, and unfriendly health services due to the infrastructure and non-trained health workers delivering KP HIV testing services. Most of the Female Sex workers had HIV counseling and testing services and were linked to care through static facilities. Community-based HIV testing service delivery models are challenged with inconsistent supply of HIV testing commodities and unfriendly services. The authors recommended strengthening of all HIV testing community-based HIV testing service delivery models by ensuring constant supply of HIV testing/AIDS care commodities offering Female Sex workers friendly services, and provision of comprehensive HIV/AIDS health care package.