South Africa's Free State Province is again experiencing a crisis in the delivery of antiretroviral (ARV) treatment, with understaffed clinics, erratic drug supplies and long waiting lists preventing many dangerously ill patients from accessing the life-prolonging drugs, according to AIDS activists. Runaway overspending by the provincial health department in 2008 led to a moratorium on new patients starting ARV treatment that lasted from November until February 2009. The Southern African HIV Clinicians Society estimated that 30 people a day died during this three-month period because they could not access treatment. Now, several reports from the Free State suggest that many of the factors leading to last year's moratorium have not been addressed, and patients are again suffering the consequences. Trudie Harrison, director of the Anglican Church's Mosamaria AIDS Ministry, said that the crisis was the result of drug shortages and a dearth of health workers. At one ARV site she recently visited, normally staffed by three doctors, about 200 patients were waiting to see just one doctor.
Equity and HIV/AIDS
This paper’s aim is to review facility-based maternal deaths at a tertiary-level centre in Johannesburg, South Africa, from 2003 to 2007, and to investigate the proportion of deaths attributable to human immunodeficiency virus (HIV), the etiology of deaths, and the effects of antiretroviral treatment introduced in late 2004. Patient case files, birth registers, death certificates, and mortality summaries were reviewed. Cause of death was assigned through clinical case discussion. Annual maternal mortality ratios were calculated and disaggregated by HIV status. During the period reviewed, 106 maternal deaths occurred out of 36,708 births. In 72% of cases, HIV status was known, with the majority being HIV-infected (78%). Maternal mortality ratios in HIV-infected women were 95%, 6.2-fold higher than in HIV-negative women. Changes in mortality over time were not detected. Although HIV testing increased 1.4-fold each year and estimated coverage of antiretroviral treatment for pregnant women reached 59.2% in 2007, levels remain suboptimal. In Johannesburg, HIV remains the major cause of maternal mortality despite integration of antiretroviral treatment into prenatal services. Maternal health services should target barriers to uptake of HIV treatment and care.
People living with HIV in Kenya do not have adequate access to family planning services, even though most HIV-infected women do not want children in the immediate future. A recent study by the reproductive health NGO, Family Health International (FHI), in the Nakuru district of Rift Valley Province, found that 80% of HIV-positive women had no intention of having a child in the next two years. However, according to the 2007 Kenya AIDS Indicator Survey, only half the HIV-positive people needing family planning services had access to them. ‘Most prevention of mother-to-child transmission [PMTCT] programmes... looked at it only in the context of preventing transmission to an already conceived child, but meeting contraceptive needs of those living with HIV is a sure way of reducing transmission by avoiding unwanted pregnancies in the first place,’ said Maurine Kuyo, a project director at FHI. About 56% of women in the FHI study mentioned a fear of vertical transmission of HIV to their children as one the reasons they would not want another pregnancy, while 50% mentioned the risk of lowered immunity during pregnancy.
A six-year clinical trial in Thailand has yielded the first ever evidence that an AIDS vaccine can provide some protection against HIV infection. The trial team in Bangkok, Thailand's capital announced on 24 September that rates of HIV infection were 31% lower in trial participants who got the vaccine than in those who received a placebo. ‘These new findings represent an important step forward in HIV vaccine research,’ said Dr Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases (NIAID), the main funder of the trial. The study began enrolling 16,000 HIV-negative men and women between the ages of 18 and 30 in October 2003. Half the volunteers received a placebo; the other half were given shots containing two different vaccines. The trial was designed to evaluate whether the combined vaccines (ALVAC-HIV and AIDSVAX) lowered HIV infection risk, and whether they had any impact on viral load [the amount of HIV circulating in the bloodstream] in the volunteers who became infected. Of 8,197 people given the vaccine regimen, 51 became infected, compared to 74 of the 8,198 volunteers who received the placebo.
Carrying placards that read, ‘Huwezi Die Uki Abstain’, Swahili slang for ‘You won't die if you abstain [from sex]’, more than 3,000 young people recently marched through Nairobi in an effort to re-energise the campaign to keep teens from having sex too early. But beyond the placard-waving and slogan-chanting, march organisers were also trying to give young people the skills to avoid being pushed into sex before they are ready. James Kabucho, programmes director at Life Skills Promoters, one of the non-governmental organisations that organised the march, explained that the campaign was teaching young people negotiation skills. By acting out real-life scenarios, writing essays, and engaging peer educators in question and answer sessions, young people were able to talk about their experiences and learn to say ‘No’ to unwanted sexual advances. Research shows that early sexual initiation is associated with increased risk of HIV infection, while adolescents who engage in sex at an early age are likely to have more sexual partners than those who delay their sexual debut. Girls who engage in sex in their teens may also face the challenges of teenage pregnancy, unsafe abortions and dropping out of high school.
In 2007, South Africa, with 0·7% of the world's population, had 17% of the global burden of HIV infection, and one of the world's worst tuberculosis epidemics, compounded by rising drug resistance and HIV co-infection but, until recently, the government's response to these diseases has been marked by denial, lack of political will and poor implementation of policies and programmes. Nonetheless, there have been notable achievements in disease management, including substantial improvements in access to condoms, expansion of tuberculosis control efforts and scale-up of free antiretroviral therapy (ART). Using the framework of the Strategic Plans for South Africa for Tuberculosis and HIV/AIDS, this paper provides a prioritised four-step approaches for tuberculosis control, HIV prevention, and HIV treatment. Strong leadership, political will, social mobilisation, adequate human and financial resources, and sustainable development of health-care services are needed for successful implementation of these approaches.
Male-to-female transgender individuals, or transgender women (TW), are at high risk for HIV infection and face multiple barriers to HIV care. This article examines how a community-based clinic that offers free or low-cost care addresses the health care needs of TW. A total of twenty TW who attended a health care clinic dedicated to community-based health were interviewed regarding best practices for HIV prevention and primary care. In-depth interviews were conducted, transcribed, coded, and analysed. Factors reported to be effective for HIV prevention and primary care included access to health care in settings not dedicated to serving transgender and/or gay communities, a friendly atmosphere and staff sensitivity, and holistic care, including hormone therapy. Community-based health care settings can be ideal locales for HIV prevention and primary care for TW.
The re-use of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalised HIV epidemics. Several African governments have taken steps to control injecting equipment, including banning syringes that can be reused. However, injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region, having become increasingly common among young adults in sub-Saharan Africa and also associated with high-risk sex. Demand-reduction programmes based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services. Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm-reduction programmes. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia and North America.
Multiple partnerships may not be as common in South Africa as previously thought, according to a study presented at the recent AIDS Research Symposium at the University the Witwatersrand, in Johannesburg. Saul Johnson, managing director of Health & Development Africa (HDA), a health consultancy which conducted the research, said findings from four sites across the country showed about 26% of men and 5% of women reported having had more than one partner in the past year. ‘The perception out there is that [having multiple partners] is more common than it really is,’ he said. The reason may be that men tend to inflate their partner counts. Johnson and his team found that when men were asked to write down a figure for the number of partners they had had in the last twelve months they exaggerated, but when asked to plot their sexual encounters in more detail, using a sexual partner calendar, they often revised the number down slightly. Women's responses were more likely to be consistent.
In South Africa a generation of children who were born HIV-positive is reaching young adulthood, but they are not getting the type of message or psychosocial support they need from the public sector. ‘These kids are getting older on treatment and surviving on treatment; they're becoming sexually active, they want to get married,’ HIV paediatrician Dr Harry Moultrie told the annual University of the Witwatersrand AIDS Research Symposium in Johannesburg at the end of August. We’re seeing a lot of teen pregnancies, sexually transmitted diseases and poor developmental outcomes.’ Studies in the United States have shown that HIV-positive teens may be more likely to engage in risky behaviour. Similar studies have yet to be carried out in South Africa, but Moultrie noted that if the findings were similar, many doctors in South Africa would not be ready to deal with the challenge. Only 12 clinics in the country are offering specialised services to HIV-positive youth. Moultrie called on the government to re-examine the guidelines that sent children aged 14 years or older away from paediatric clinics and into adult facilities, which might not be able to offer them the services they needed. ‘You have to realise that a lot of these children have gone through multiple childhood traumas, including multiple changes in caregivers,’ he said.