The authors of this study argue that the promotion of harm reduction as part of a more united and comprehensive global effort will be essential to halving HIV infections among people who inject drugs by 2015. They call for legal reform aligned with HIV prevention and treatment, complemented by the meaningful involvement of people who use drugs in policy formulation, arguing that drugs users who inject are often the most marginalised in the global HIV response. However, establishing the prevalence of drug use among men who have sex with men (MSM) in different parts of the world remains a challenge, as homosexuality is criminalised and stigmatised in many countries. Recommendations to government include ensuring sufficient programme funding and staff training to generate new interventions aimed at injecting drug users and MSM, as well as disseminating information to users regarding the risks of drug abuse. The authors also call for decriminalisation of users, provided that drug rehabilitation interventions are adequately devised and implemented.
Equity and HIV/AIDS
The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which researchers examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilisation of maternity services. From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up of whom 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews were conducted with community health workers, childbearing women and family members. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery. These findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.
Women comprise nearly half of the HIV-infected population worldwide, but these 15.5 million women tend to be under-represented in clinical trials of anti-HIV drug therapies, according to this study. The authors used the US Food and Drug Administration (FDA) database created from 40 clinical studies to assess gender differences in the efficacy of antiretroviral treatments. They found that women represented only about 20% of the subjects in randomised clinical trials submitted to the FDA between 2000 and 2008. When they compared the effectiveness of anti-HIV drug regimens reported for women versus men overall and among various subgroups, they found no statistically or clinical significant differences between women and men in outcomes with regard to viral load after 48 weeks. However, they did report significant gender differences favouring males based on subgroup analyses. They argue that this is a critical area of research in terms of developing new HIV therapies, as mounting evidence indicates that metabolism of certain drugs varies in men vs. women, and side effects that interfere with adherence to these medications may also be manifested differently.
Stigma is increasingly regarded as a key driver of the HIV and AIDS epidemic and has a major impact on public health interventions. The objective of this ‘creativity initiative’ was to provide activities in an HIV clinic while patients waited to be seen by healthcare professionals. It was envisaged this would contribute to reduction of clinic-based stigma felt by clients. The study took the form of a cross-sectional survey carried out in October-November 2005 and March-April 2007 at the Infectious Diseases Institute clinic (IDC) at Mulago, the national referral hospital in Uganda. Comparisons were made between patients who took part in activities and those who did not. Results suggest that clients who attended the IDC before the creativity intervention were about twice as likely to fear catching an infection as those who came after the intervention. The proportion that had fears to be seen by a friend or relative at the clinic decreased. Thus during the implementation of the creativity intervention, HIV-related stigma was reduced in this clinic setting.
In this paper, the author investigates uptake of prevention of mother-to-child transmission of HIV (PMTCT) services, infant feeding recommendations and specific drug regimens necessary to achieve the virtual elimination of paediatric HIV in Zimbabwe. She used a computer model to simulate a cohort of HIV-infected pregnant or breastfeeding women, and evaluated three PMTCT regiments: single-dose nevirapine; ‘Option A’ from the 2010 World Health Organisation guidelines (zidovudine in pregnancy, infant nevirapine throughout breastfeeding for women without advanced disease, lifelong combination antiretroviral (ARV) therapy for women with advanced disease); and WHO ‘Option B’ (limited combination ARV drug regimens without advanced disease during pregnancy and breastfeeding; lifelong ARV therapy with advanced disease). Results indicated that the latest WHO PMTCT guidelines (Options A and B) plus better access to PMTCT programmes, better retention of women in care, and better adherence to drugs are needed to eliminate paediatric HIV in Zimbabwe.
Punitive laws and human rights abuses are costing lives, wasting money and stifling the global AIDS response, according to a report by the Global Commission on HIV and the Law, an independent body of global leaders and experts. The Commission report, "HIV and the Law: Risks, Rights and Health," finds evidence that governments in every region of the world have wasted the potential of legal systems in the fight against HIV. The report also concludes that laws based on evidence and human rights strengthen the global AIDS response - these laws exist and must be brought to scale urgently."Bad laws should not be allowed to stand in the way of effective HIV responses," said Helen Clark, United Nations Development Programme Administrator. "In the 2011 Political Declaration on HIV and AIDS, Member States committed to reviewing laws and policies which impede effective HIV responses."
In recent years, innovative contraceptive methods that are discreet and female-initiated have expanded contraceptive access to millions of women who wish to prevent, space, or limit pregnancies but must do so without their partners’ cooperation. The International Partnership for Microbicides (IPM), developers of a new microbicide ring currently undergoing clinical trial in South Africa, hope to apply this same principle to HIV prevention. If proven safe for long-term use, the monthly vaginal ring, which steadily releases the antiretroviral (ARV) drug dapivirine, will serve as a valuable HIV prevention option for women, particularly those who wish to become pregnant or who are unable to safely negotiate condom use or monogamy with their partners. Offering new HIV prevention options to women is particularly important in high-prevalence regions like sub-Saharan Africa, where 60 percent of HIV infections are among women and girls.
This book is a collection of essays that critique leadership on HIV and AIDS in Africa from the 1980s to the present. They examine the rhetoric on HIV and AIDS, which has influenced culture and behaviour, service delivery, policy, the design of national interventions and the varied success of different countries in containing the pandemic. African scholars contextualise a host of public and scholarly disputes, ranging from AIDS exceptionalism, racialised data manipulation and ‘denialism’ to the racist debates on ‘African promiscuity’ and the recent revival of assertions that homosexuality is not ‘African’ behaviour. The book refers to the record of governments in a wide range of African countries with case studies drawing on the rhetoric of governments and the nature of leadership in Ethiopia, the Gambia, Morocco, South Africa and Zambia. What emerges is that the rhetoric is diverse, occasionally logical and effective in terms of informing systemic HIV and AIDS interventions that improve the welfare of people, and sometimes it is contradictory to the point of absurdity.
The World Health Organisation recommends HIV-infected mothers exclusively breastfeed their infants, unless replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS). The aim of this study was to develop and content validate an AFASS assessment tool that could be used for infant feeding counselling in sub-Saharan Africa (SSA). An AFASS assessment tool consisting of 15 questions was developed based on the evidence and tools available regarding why replacement feeding is not AFASS in the region. Fifty-seven experts involved in prevention of mother-to-child HIV transmission (PMTCT) programmes in five SSA countries were approached to participate as members of the Delphi expert panel, reduced to a final panel of 15 experts. Thirteen of the 15 questions in the tool achieved consensus agreement among panel members and they also reached consensus regarding the applicability and appropriateness of the tool within the regional context. Suggestions made by the expert panel were incorporated into the revised tool. Ideally the revised tool should be tested by providers of infant feeding advice with the aim of adoption into routine PMTCT programmes in SSA, but within the context of the 2010 WHO guidelines which advocate a public health rather than an individualised approach, it may inform the WHO process of improving counselling tools for health care workers involved in PMTCT programmes.
Although Madagascar and its neighbouring islands states of Comoros, Mauritius and Seychelles have extremely low HIV prevalence rates at around 0.37% (or 24,000 confirmed cases), they are reporting problems with supplying health services to HIV-positive people. Recent stock-outs have sometimes left patients without treatment for months, exposing them to the risk of developing drug-resistance. The Malagasy Ministry of Health and its private sector distributor, Salama, have reported experiencing problems placing orders because suppliers are not interested in providing small quantities, making it difficult to keep adequate supplies of antiretrovirals in stock. One possibility being explored is putting in place a central purchasing mechanism for the four Indian Ocean countries. This facility would fall under the oversight of the High Level Partnership Forum, which is expected to be set up after discussions with the Indian Ocean Commission, an inter-governmental cooperation group. The forum would include Ministers of Foreign Affairs, Ministers of Health, networks of people living with HIV, support groups and various financial partners.