This paper explored the extent to which public sector roll-out has met the estimated need for paediatric treatment in a rural South African setting. Local facility and population-based data were used to compare the number of HIV infected children accessing HAART before 2008, with estimates of those in need of treatment from a deterministic modeling approach. The impact of programmatic improvements on estimated numbers of children in need of treatment was assessed in sensitivity analyses. It found that, if PMTCT uptake were extended to reach 100% coverage, the annual number of infected infants could be reduced by 49.2%. Despite progress in delivering decentralised HIV services to a rural sub-district in South Africa, substantial unmet need for treatment remains. In a local setting, very few children were initiated on treatment under one year of age and steps have now been taken to successfully improve early diagnosis and referral of infected infants.
Equity and HIV/AIDS
This study set out to assess paediatric antiretroviral treatment (ART) outcomes and their associations from a collaborative cohort representing 20% of the South African national treatment programme. It took the form of a multi-cohort study of 7 public sector paediatric ART programmes in Gauteng, Western Cape and KwaZulu-Natal provinces. The subjects were ART-naïve children (≤16 years) who commenced treatment with ≥3 antiretroviral drugs before March 2008. The study found that the median (IQR) age of 6,078 children with 9,368 child-years of follow-up was 43 months, with 29% being <18 months. Most were severely ill at ART initiation. More than 75% of children were appropriately monitored at 6-monthly intervals with viral load suppression (<400 copies/ml) being 80% or above throughout 36 months of treatment. Mortality and retention in care at 3 years were 7.7% (95% confidence interval 7.0 - 8.6%) and 81.4% (80.1 - 82.6%), respectively. Dramatic clinical benefit for children accessing the national ART programme is demonstrated. Higher mortality in infants and those with advanced disease highlights the need for early diagnosis of HIV infection and commencement of ART.
HIV and AIDS will slow Africa’s economic growth, but most important it will deplete human capital. Investment is declining as households, businesses and governments increase their recurrent expenditure to compensate for losses and disruptions because of sick or dead individuals. The health system – usually at the forefront in absorbing the impact of HIV and AIDS-related illnesses – is being eroded through the loss of many skilled personnel. Health staff are retiring, leaving for the private sector or other countries and succumbing to AIDS. In high-prevalence countries the epidemic is adversely affecting popular participation through attrition among the politically active age groups. The attrition among government officials and civil service personnel is compromising the state’s ability to implement decisions and policies. The epidemic is also likely to affect popular political opinion and levels of activism by reshaping political priorities and loyalties. But these challenges can be met if governance continues to improve across Africa.
This article summarises the challenges, opportunities and lessons learned from presentations, discussions and debates addressing major policy and programmatic responses to HIV in six geographical regions, including sub-Saharan Africa. It draws from AIDS 2008 Leadership and Community Programmes, particularly the six regional sessions, and Global Village activities. While the epidemiological, cultural and socio-economic contexts in these regions vary considerably, several common, overarching principles and themes emerged: advancing basic human rights, particularly for vulnerable and most at risk populations; ensuring the sustainability of the HIV response through long-term, predictable financing; strengthening health systems; investing in strategic health information; and improving accountability and the involvement of civil society in the response to AIDS. Equally important is the need to address political barriers to implementing evidence-based interventions such as opioid substitution therapy (OST), needle and syringe programmes (NSPs), comprehensive sexuality education for youth, and sexual and reproductive rights.
In this study, 202 isiXhosa speaking older caregivers from Motherwell in the Eastern Cape Province of South Africa were trained to provide care for grandchildren and adult children living with HIV or AIDS. Based on a community needs assessment, a health education intervention comprising four modules was designed to improve skills and knowledge which would be used to assist older people in their care-giving tasks. Some topics were HIV and AIDS knowledge, effective intergenerational communication, providing home-based basic nursing care, accessing social services and grants, and relaxation techniques. Structured one-on-one interviews measured differences between pre-intervention and post-intervention scores among those who attended all four modules vs. those that missed one or more of the sessions. The results demonstrated that older people who participated in all four workshops perceived themselves more able and in control to provide nursing care. The participants also showed a more positive attitude towards people living with HIV or AIDS and reported an increased level of HIV and AIDS knowledge.
More than four million people in low- and middle-income countries were receiving antiretroviral therapy (ART) at the close of 2008, representing a 36% increase in one year and a ten-fold increase over five years, according to this report. It highlights other gains, including expanded HIV testing and counselling and improved access to services to prevent HIV transmission from mother to child. Access to antiretroviral therapy continues to expand at a rapid rate. Of the estimated 9.5 million people in need of treatment in 2008 in low- and middle-income countries, 42% had access, up from 33% in 2007. The greatest progress was seen in sub-Saharan Africa, where two-thirds of all HIV infections occur. Prices of the most commonly used antiretroviral drugs have declined significantly in recent years, contributing to wider availability of treatment. The cost of most first-line regimens decreased by 10–40% between 2006 and 2008. However, second-line regimens continue to be expensive. Despite recent progress, access to treatment services is falling far short of need and the global economic crisis has raised concerns about their sustainability. Many patients are being diagnosed at a late stage of disease progression resulting in delayed initiation of ART and high rates of mortality in the first year of treatment.
The Ugandan parliament's house Committee on HIV/AIDS and related matters has appealed to the government to increase its funding for HIV, especially as infection rates remain high and the country continues to experience frequent shortages of anti-retroviral medicines. ‘As a committee we are advocating for the government to increase its funding on HIV/AIDS activities in the country to at least 15% [of the national budget],’ said Beatrice Rwakimari, chair of the committee. Uganda's most recent budget allocated about US$30 million to the purchase of anti-retrovirals and anti-malaria medication, and gave the Uganda AIDS Commission about US$3 million to fight HIV, while US$500,000 was earmarked for prevention programmes. The total allocation to HIV programmes – which makes up 6% of the national budget –marks an increase on previous years, but members of Parliament say it is still not nearly enough to roll back the effects of the pandemic. ‘This funding is too little, as we continue to get new infections every year,’ Rwakimari said. Uganda's HIV prevalence has risen marginally from a low of 6% in 2000 to 6.4%, according to the government.
Zimbabwe's adult HIV prevalence rate is continuing its downward trend, showing a drop from 14.1% in 2008 to 13.7% in 2009, according to new estimates released by the Ministry of Health and Child Welfare. The 2009 Antenatal Clinic (ANC) Surveillance Survey, based on blood specimens collected from 7,363 pregnant women anonymously screened at 19 clinic sites throughout the country, estimated that 1.1 million Zimbabweans in a probable population of around 11 million were living with HIV. The prevalence rate is expected to continue decreasing; investigations have shown that the decline ‘most likely resulted from a combination of an increase in adult mortality and a decline in HIV incidence, resulting from adoption of safer sexual behaviours’, said Douglas Mombeshora, Deputy Minister of Health and Child Welfare. ‘When prevention programmes achieve heightened awareness, significant changes in behaviour will occur, and one of the main outcomes is the significant reduction in the need for PMTCT [prevention of mother-to-child transmission] services, as well as a reduced number of new HIV infections,’ he noted.
As part of a broader initiative to monitor the implementation of the national antiretroviral therapy (ART) programme, this qualitative study investigated the impact of ART availability on perceptions of HIV in a rural ward of north Tanzania and its implications for prevention. A mix of qualitative methods was used including semi-structured interviews with 53 ART clinic clients and service providers. Four group activities were conducted with persons living with HIV. People on ART often reported feeling increasingly comfortable with their status reflecting a certain ‘normalisation’ of the disease. Overcoming internalised feelings of shame facilitated disclosure of HIV status, helped to sustain treatment, and stimulated VCT uptake. However ‘blaming’ stigma – where people living with HIV were considered responsible for acquiring a ‘moral disease’ – persisted in the community and anticipating it was a key barrier to disclosure and VCT uptake. As long as an HIV diagnosis continues to have moral connotations, a de-stigmatisation of HIV paralleling that occurring with diseases like cancer is unlikely to occur.
A large supply of paediatric antiretroviral medication donated by the Clinton Foundation could expire in Ugandan medical stores because of low demand. ‘There are few children who are receiving the drugs; they are going to expire by March [2010],’ said Zainabu Akol, head of HIV programming in the Ministry of Health. Fewer than a quarter of the 125,000 Ugandan children who need life-prolonging anti-retroviral treatment (ART) have access to it, mainly because of stigma and inadequate education of parents, say specialists. ‘Due to stigma, parents have failed to take their children for ART,’ said Goretti Nakabugo, from a local non-governmental organisation, called Strengthening HIV/AIDS Counsellor Training. ‘They believe if their children start ART, they will be shunned by the community and pupils at school. People don't yet believe that HIV/AIDS is not transmitted through casual contact; a child with rashes is always shunned,’ she added. Many parents cannot face the idea of telling their children they have a potentially life-threatening illness and they live in denial.