This paper describes the experience of Zimbabwe in establishing a baseline for its National Action Plan for Orphans and Other Vulnerable Children (NAP for OVC) using the 10 core indicators developed by the UNAIDS Global Monitoring and Evaluation Reference Group in 2004. Through a population-based household survey in rural and urban high-density areas and the OVC policy and planning effort index assessment tool, a baseline was established. The survey found that 43.6% of children under 18 years were orphaned or made vulnerable by HIV/AIDS. Half of all households with children care for one or more OVC. While the large majority of OVC continued to be cared for by the extended family, its capacity to care for these children appeared to be under pressure. OVC were less likely to have their basic minimum material needs met, more likely to be underweight, less likely to be taken to an appropriate health provider when sick and less likely to attend school. Medical support to households with OVC was found to be relatively high (26%). Other support, such as psychosocial support (2%) and school assistance (12%), was lower. The OVC Effort Index assessment indicates that serious efforts are being made. The increase in the effort index between 2001 and 2004 in the areas of consultative efforts, planning and coordinating mechanisms reflects the strengthened commitment. Monitoring and evaluation and legislative review are the weakest areas of the OVC response. The findings of the baseline exercise point to the need for continued and additional efforts and resources to implement the NAP for OVC, the priorities of which were confirmed by the survey as critical to improve the welfare of the OVC in Zimbabwe.
Equity and HIV/AIDS
The diagnosis and management of childhood tuberculosis (TB) are major challenges in countries such as Malawi with high incidence of TB and human immunodeficiency virus (HIV) infection. Diagnosis of TB in children often relies only on clinical features but clinical overlap with the presentation of HIV and other HIV-related lung disease is common. The tuberculin skin test (TST), the standard marker of M. tuberculosis infection in immune competent children, has poor sensitivity in HIV-infected children and is not usually available in Malawi. HIV test should be routine in children with suspected TB as it improves clinical management. HIV-infected children are at increased risk of developing active disease following TB exposure which justifies the use of isoniazid preventive therapy (IPT) once active disease has been excluded but this is difficult to implement and appropriate duration of IPT is unknown. HIV-infected children with active TB experience higher mortality and relapse rates on standard TB treatment compared to HIV-uninfected children, highlighting the need for further research to define optimal treatment regimens. HIV-infected children should also receive appropriate supportive care including co-trimoxazole prophylaxis and anti-retroviral treatment (ART) if indicated. There are concerns about concurrent use of some anti-TB drugs such as rifampicin with some ARTs.
In 2004, South Africa had one of the highest rates of HIV infection in the world and the province of KwaZulu-Natal (KZN) reported the peak of 40.7% positivity among the antenatal population. The purpose of this study was to identify measures to improve the quality of an HIV prevention program targeted at reducing the rate of mother-to-child transmission of HIV infection (MTCT). A cross-sectional observational (non-experimental) study was conducted from Empangeni hospital (i) using antenatal clinic registers between May 2002 and April 2003 and (ii) applied a questionnaire survey to a randomly selected sample of 306 HIV infected women who delivered between April and June 2004. The results showed that among 3774 antenatal attendees, 2528 (67%) accepted pre-test counselling and 2390 (63%) HIV testing. Majority (95%) of those who had (2528) pre-test counselling accepted HIV testing, post test counselling and test results. The prevalence of HIV infection was 41% (980) (95% CI, 39%-43%). Among them (980 HIV positive), 73% (716) received nevirapine during the antenatal period yielding an overall antenatal nevirapine prophylaxis (uptake) rate of 46% (based on an estimate of 41% HIV prevalence rate for total antenatal population of 3774 during the study period). Between April to June 2004, 2393 women delivered at Empangeni hospital of which 39% (933) were HIV positive. The coverage of pretest counselling for HIV testing (67%) and nevirapine use (46%) was low. We found in the questionnaire survey that the participating women had adequate knowledge and compliance on the use of nevirapine. Strategies are needed to improve program uptake and effectiveness of the prevention of mother-to-child transmission of HIV infection (PMTCT) program in rural South Africa.
Ten per cent of individuals infected with TB develop the active disease but this is greatly increased in those whose immune systems have been weakened by HIV. This report from the Forum for Collaborative HIV Research highlights the difficulty in managing the co-epidemic of HIV and TB that is rapidly spreading in Sub-Saharan Africa. The report concludes that strategies for dealing with TB and HIV currently exist in isolation, often reinforced by vertical programme financing. Efforts must be made to integrate these disease treatment programmes that will involve stakeholders working together within an evidence-based collaborative framework.
This book examines the global governance of the AIDS epidemic, interrogating the role of this international system and global discourse on interventions. The geographical focus is Sub-Saharan Africa since the region has been at the forefront of these interventions. There is a need to understand the relationship between the international political environment and the impact of resulting policies on HIV and AIDS in the context of people's lives. There is a certain disjuncture between this governance structures and the way people experience the disease in their everyday lives. Although the structure allows people to emerge as policy relevant target groups and beneficiaries, the articulation of needs and design of policy interventions tends to reflect international priorities rather than people's thinking on the problem and the nature of the system does not allow interventions to be far reaching and sustainable.
This review of progress made on a three-year tuberculosis TB/HIV plan implemented in Malawi between 2003 and 2005 found that barriers to testing TB patients for HIV include: irregular supplies of HIV-testing reagents, staff forgetting to refer patients or patients themselves not undergoing HIV testing and counselling after being registered and placed on anti-TB treatment. The authors recommend that ways to improve HIV-testing uptake need to be found, including the integration of HIV testing with the TB registration process itself. The monitoring systems for HIV and TB need to explicitly include the relevant parameters, for example, TB monitoring tools which include data on numbers of TB patients who have been tested for HIV, who are HIV-positive, and who have started antiretroviral therapy.
Currently South Africa does not have national HIV incidence data based on laboratory testing of blood specimens. The 2005 South African national HIV household survey was analysed to generate national incidence estimates stratified by age, sex, race, province and locality type, to compare the HIV incidence and HIV prevalence profiles by sex, and to examine the relationship between HIV prevalence, HIV incidence and associated risk factors. HIV incidence in the study population aged 2 years and older was 1.4% per year, with 571 000 new HIV infections estimated for 2005. An HIV incidence rate of 2.4% was recorded for the age group 15-49 years. The incidence of HIV among females peaked in the 20-29-year age group at 5.6%, more than six times the incidence found in 20-29-year-old males (0.9%). Among youth aged 15-24 years, females account for 90% of the recent HIV infections. Non-condom use among youth, current pregnancy and widowhood were the socio-behavioural factors associated with the highest HIV incidence rates. The HIV incidence estimates reflect the underlying transmission dynamics that are currently at work in South Africa. The findings suggest that the current prevention campaigns are not having the desired impact, particularly among young women.
In settings of armed conflict, traditional HIV prevention programmes that promote risk avoidance via abstinence and fidelity and risk reduction via condom use and needle exchange are not viable. In such contexts, HIV risk depends less on personal choice than on exposure to physical, emotional and structural violence. War in northern Uganda has created three realities (internally displaced people's camps, night commuters and child abductions) which increase vulnerability to HIV transmission. Based upon this analysis of northern Uganda, we offer a conceptual framework for HIV transmission in conflict settings that recognizes the importance of local and global context in creating vulnerability to HIV infection. This framework is then used to delineate strategies for HIV prevention in northern Uganda, namely the provision of a safe physical environment and access to education, medical and psychological support, and the promotion of conflict resolution strategies and human rights law.
The interaction between HIV and AIDS, and nutritional status has been a defining characteristic of the disease since the early years of the epidemic. HIV and AIDS are associated with poor nutritional status and weight loss, and weight loss is an important predictor of death from AIDS. These links suggest that nutrition may have an important role to play in slowing progression of the disease and in contributing to successful antiretroviral (ARV) therapy. HIV and AIDS can also inhibit a person’s ability to secure adequate nutrition through inability to work, loss of appetite or increased need for nutrients as a result of the disease itself. Addressing impact on livelihoods and food security is therefore another important aspect of interventions for HIV and AIDS, and nutrition. This guide reviews the evidence base for current nutrition interventions for HIV and AIDS, and looks at the scientific background, trends and challenges in implementation, and implications for policy and planning.
The objective of this article is to describe the results of a 2-year pilot programme implementing prevention of mother to child HIV transmission (PMTCT) in a refugee camp setting. Interventions used were: community sensitization, trainings of healthcare workers, voluntary counselling and HIV testing (VCT), infant feeding, counselling, and administration of Nevirapine. Main outcome measures include: HIV testing acceptance rates, percentage of women receiving post test counselling, Nevirapine uptake, and HIV prevalence among pregnant women and their infants. Ninety-two percent of women (n=9,346) attending antenatal clinics accepted VCT. All women who were tested for HIV received their results and posttest counselling. The HIV prevalence rate among the population was 3.2%. The overall Nevirapine uptake in the camp was 97%. Over a third of women were repatriated before receiving Nevirapine. Only 14% of male counterparts accepted VCT. Due to repatriation, parent's refusal, and deaths, HIV results were available for only 15% of infants born to HIV-infected mothers. The PMTCT programme was successfully integrated into existing antenatal care services and was acceptable to the majority of pregnant women. The major challenges encountered during the implementation of this programme were repatriation of refugees before administration of Nevirapine, which made it difficult to measure the impact of the PMTCT programme.