This book tracks the progress and pitfalls of the global fight against HIV and AIDS over the past 30 years. The book's strength lies in its methodical documenting of the medical community's response to the virus. Harden also seeks to explain how political and cultural ideas influenced the science of AIDS. In specific instances, such as explaining how stigma about a sexually transmitted disease initially associated with the gay community hampered early research in the United States, she succeeds. But she does not make the same effort to explain later shifts in political perceptions. There is very little discussion of former President George W Bush's decision to launch the President's Emergency Plan for AIDS Relief, for instance, or what impact it had. At a time when the US is projecting a vision of an AIDS-free generation, Harden's history shows that constant monitoring and new perspectives remain critical. She reminds us that the world only arrived at the idea of an AIDS-free generation through constant trial-and-error: first, in determining the causes and later in producing effective therapies to prolong the lives of infected people.
Equity and HIV/AIDS
Zimbabwe's ambitious plan to offer an HIV test to every household in the country is not yet under way but is already being met with scepticism by activists who feel this is not a priority for the country, especially with global HIV and AIDS funding on the decline. Zimbabwe Lawyers for Human Rights has warned of the possibility of compromising on informed consent and confidentiality when testing is done on a large scale. If not properly executed, ostracism, violence, stigma and abuse in the home can result from status disclosure. Door-to-door testing was successfully conducted in Uganda between 2005 and 2007, but Lesotho’s proposed door-to-door testing campaign has been criticised by researchers as substandard. Activists ask where additional funding will be found for the campaign, arguing that resources should instead be used for those who have already been identified as HIV positive and who need treatment now. They have also raised concerns about whether the testing campaign will go beyond merely testing people, and whether it will motivate them to change their sexual behaviours and also refer those testing positive to treatment facilities.
Paediatric antiretroviral adherence is difficult to assess, the authors of this paper argue, and subjective measures are affected by reporting bias, which in turn may depend on psychosocial factors such as alcohol use and depression. In this study, they enrolled 56 child caregiver dyads from Cape Town, South Africa, and followed their adherence over one month via various methods. The Alcohol Use Disorder Inventory Tool and Beck Depression Inventory 1 were used to assess participants’ alcohol use and levels of depression and their effect on drug adherence. The median age of the children was four years, and median time on antiretroviral therapy (ART) was 20 months. Increased time on ART was associated with poorer adherence via three-day recall. Alcohol use was inversely associated with adherence. Having a mother as a caregiver and shorter time on highly active antiretroviral therapy (HAART) were significantly associated with better adherence. The authors conclude that paediatric adherence is affected by caregiver alcohol use, but the caregiver’s relationship to the child is most important. This small study suggests that interventions should aim to keep mothers healthy and alive, as well as alcohol-free.
The objective of this study was to report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal, South Africa. Mothers with infants aged ≤16 weeks and fathers or legal guardians with infants aged 4–8 weeks who, between May 2008 and April 2009, attended immunisation clinics in six districts of KwaZulu-Natal were included. Findings indicated that, of the 19,494 mothers investigated, 89•9% reported having had an HIV test in their recent pregnancy. Of the 19,138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7,981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission and suggest that the elimination of paediatric HIV infections is feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.
Published data on adherence to antiretroviral therapy (ART) in Kenya is limited. This study assessed adherence to ART and identified factors responsible for non-adherence in Nairobi. This is a multiple facility-based cross-sectional study, where 416 patients aged over 18 years were systematically selected and interviewed using a structured questionnaire about their experience taking ART. Additional data was extracted from hospital records. Overall, 403 patients responded: 35% males and 65% females, of whom 18% were non-adherent, and the main (38%) reasons for missing therapy were being busy and forgetting. Accessing ART in a clinic within walking distance from home and difficulty with dosing schedule predicted non-adherence. The study found better adherence to HAART in Nairobi compared to previous studies in Kenya. However, the authors argue that adherence can be improved further by employing fitting strategies to improve patients' ability to fit therapy into their lifestyles and implementing cue-dose training to impact forgetfulness. Further work to determine why patients accessing therapy from ART clinics within walking distance from their residence did not adhere is recommended.
In this study, researchers evaluated the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting in western Kenya. The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High risk express care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of [less than or equal to]100 cells/mm3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of [less than or equal to]100 cells/mm3 were eligible for enrolment into HREC and for analysis. Between March 2007 and March 2009, 4,958 patients initiated cART. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality, and reduced loss to follow up compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up. The researchers conclude that frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.
This study reports on HIV-free survival among nine- to 24-month-old children born to HIV-positive mothers in the national prevention of mother-to-child transmission (PMTCT) programme in Rwanda. Researchers conducted a national representative household survey between February and May 2009. Participants were mothers who had attended antenatal care at least once during their most recent pregnancy, and whose children were aged nine to 24 months. They found that out of 1,448 HIV-exposed children surveyed, 44 (3%) were reported dead by nine months of age. Of the 1340 children alive, 53 (4%) tested HIV positive. HIV-free survival was estimated at 91.9 % at nine to 24 months. Adjusting for maternal, child and health system factors, being a member of an association of people living with HIV improved by 30% HIV-free survival among children, whereas the maternal use of a highly active antiretroviral therapy (HAART) regimen for PMTCT had a borderline effect. HIV-free survival among HIV-exposed children aged nine to 24 months is estimated at 91.9% in Rwanda. The national PMTCT programme could achieve greater impact on child survival by ensuring access to HAART for all HIV-positive pregnant women in need, improving the quality of the programme in rural areas, and strengthening links with community-based support systems, including associations of people living with HIV.
As external funders retreat from funding HIV prevention and treatment, national programmes reliant on external funding have become exceedingly vulnerable. Activists from East and Southern Africa are calling on governments to take increased ownership of these programmes to ensure treatment continues after donor funds have gone. According to Dr Mbulawa Mugabe, UNAIDS deputy regional director for East and Southern Africa, the region has made considerable progress towards reaching the universal HIV treatment access target of 80% coverage among those in need of antiretrovirals (ARVs). He added that the region is performing above average for low and middle-income countries. However, he indicated that hardly any of the region’s governments are contributing financially to the treatment response. “We cannot leave the lives of nationals to development partners," he emphasised. According to researchers, governments need to bridge the gap between domestic and external spending for ARVs but, without accurate country-level data, this gap is difficult to estimate.
The aim of this prospective study (20 months) was to assess HIV patients' use of Traditional, Complementary and Alternative Medicine (TCAM) and its effect on anti-retroviral (ARV) adherence at three public hospitals in KwaZulu-Natal, South Africa. Seven hundred and thirty-five (29.8% male and 70.2% female) patients who consecutively attended three HIV clinics completed assessments prior to ARV initiation, 519 after 6 months, 557 after 12 and 499 after 20 months on antiretroviral therapy (ART). Results indicate that following initiation of ARV therapy the use of herbal therapies for HIV declined significantly from 36.6% prior to ARV therapy to 8% after 6 months, 4.1% after 12 months and 0.6% after 20 months on ARVs. Faith healing methods (including spiritual practices and prayer) declined from 35.8% to 22.1%, 20.8% and 15.5%, respectively. In contrast, the use of micronutrients, such as vitamin supplements, significantly increased from 42.6% to 78.2%. Herbal remedies were mainly used for pain relief, as immune booster and for stopping diarrhea. As herbal treatment for HIV was associated with reduced ARV adherence, patient's use of TCAM should be considered in ARV adherence management, the authors conclude.
This intervention study aimed to assess the effectiveness of a rural community-based anti-retroviral therapy (ART) programme in a subcounty (Rwimi) of Uganda and compare treatment outcomes and mortality in a rural community-based ART programme with a well-established hospital-based programme. Successful treatment outcomes after two years in both the community and hospital cohorts were high. All-cause mortality was similar in both cohorts. However, community-based patients were more likely to achieve viral suppression and had good adherence to treatment. The community-based programme was slightly more cost-effective. The unpaid community volunteers showed high participation and low attrition rates for the two years that this programme was evaluated. Key successes of this study include the demonstration that ART can be provided in a rural setting, the creation of a research infrastructure and culture within Kabarole’s health system, and the establishment of a research collaboration capable of enriching the global health graduate programme at the University of Alberta.