Southern and eastern Africa, with 6.2% of the world’s population, bear a disparate half of the world’s HIV infection burden and would benefit greatly from inexpensive innovations aimed at curtailing the epidemic. A recent modelling study showed that introducing a partially (30%) effective vaccine for HIV in resource-limited settings such as southern Africa would result in an estimated 67% reduction in HIV incidence compared to a non-vaccine scenario. As sub-Saharan Africa has the highest incidence of HIV infection in the world, that the introduction of a vaccine with only partial efficacy could have such a dramatic effect, despite the existing availability of comprehensive prevention methods, is argued by the authors to be strongly persuasive for the pursuit of a vaccine-based approach. Whilst there is great optimism that increasing access to antiretroviral treatment in the region will reduce infection incidence, there is also recognition that epidemic control will not be achieved without a substantial and sustained scale-up of additional primary prevention resources. There are challenges to HIV prevention in resource-limited settings that a vaccine alone is seen to be well positioned to meet. These include the rate of HIV infections and the scale and complexity of the HIV epidemic in the region, juxtaposed with ailing health systems ill equipped to respond effectively. Challenges with antiretroviral drug therapy adherence, poor linkage to care following diagnosis, multiple and diverse vulnerable populations who require population-specific services (such as women, adolescents, and men who have sex with men, stigma, and discrimination, as well as generally limited health care facilities and health personnel impair the region’s capacity to manage the scale of the epidemic. Even with the success of pre-exposure prophylaxis demonstration projects and the encouraging results emerging, the extent of protection relies on fidelity to adherence, continuous uninterrupted access, and sustainable resources for provision. It is well documented that in resource-restricted areas, where education levels and access to health care are low, reliance on behavioural and structural support is also an enormous challenge. A vaccine, even if partially effective, is argued by the authors to be a way of filling these prevention gaps in a cost-effective manner. Whilst countries in this region must find ways to access all the available opportunities that the modern HIV prevention toolkit has on offer, such a vaccine is seen to potentially change the prevention landscape.
Equity and HIV/AIDS
HIV related stigma and discrimination is a known barrier for HIV prevention and care. The authors aimed to assess the relationship between socio-economic status (SES) and HIV related stigma in Zimbabwe, using data from a project that examined the impact of community-based voluntary counselling and testing intervention on HIV incidence and stigma. A total of 2522 eligible participants responded to a psychometric assessment tool, which assessed HIV related stigma and discrimination attitudes on 4 point Likert scale. The tool measured three components of HIV related stigma: shame, blame and social isolation, perceived discrimination, and equity. Participants’ ownership of basic assets was used to assess the socio-economic status. Shame, blame and social isolation component of HIV related stigma was found to be significantly associated with medium and low SES indicating more stigmatising attitudes by participants belonging to medium and low SES in comparison to high SES.
The World Health Organization early warning indicators (EWIs) of HIV drug resistance (HIVDR) assess factors at individual ART sites that are known to create situations favourable to the emergence of HIVDR. In 2014, the Namibia HIV care and treatment program abstracted adult and paediatric EWIs from all public ART sites (50 main sites and 143 outreach sites) related to on-time pill pick-up, retention in care, pharmacy stock-outs, dispensing practices, and viral load suppression. Comparisons were made between main and outreach sites and between 2014 and 2012. The national estimates were: On-time pill pick-up 81.9% for adults and 82.4% for paediatrics, Retention in care 79% retained on ART after 12 months for adults and 82% for paediatrics, Pharmacy stock-outs 94% of months without a stock-out for adults and 88% for paediatrics. Viral load suppression was significantly affected by low rates of viral load completion. Main sites had higher on-time pill pick-up than outreach sites for adults and paediatrics and no difference between main and outreach sites for retention in care for adults or paediatrics. From 2012 to 2014 in adult and paediatric sites, on-time pill pick-up, retention in care and pharmacy stock-outs worsened. Results of EWIs monitoring in Namibia provide evidence about ART programmatic functioning and contextualise results from national surveys of HIVDR. These results are worrisome as they show a decline in program performance over time. The national ART program is taking steps to minimise the emergence of HIVDR by strengthening adherence and retention of patients on ART, reducing stock-outs, and strengthening ART data quality.
National surveys in Zimbabwe, Malawi, and Zambia reveal exceptional progress against HIV, with decreasing rates of new infection, stable numbers of people living with HIV, and more than half of all those living with HIV showing viral suppression through use of antiretroviral medication. For those on antiretroviral medication, viral suppression is close to 90%. These data are the first to emerge from the Population HIV Impact Assessment (PHIA) Project, a unique, multi-country initiative funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The project deploys household surveys, which measure the reach and impact of HIV prevention, care and treatment programs in select countries. The data demonstrate that the 90-90-90 global targets set forth by UNAIDS in 2014 are attainable, (that is for 90% of people with HIV to be diagnosed, 90% of those diagnosed to receive HIV treatment, and 90% of those on treatment to be effectively treated and achieve suppression of their infection). This would translate to 73% of all HIV-positive people being virally suppressed. The data show that once diagnosed, individuals are accessing treatment, staying on treatment, and their viral load levels are suppressed to levels that maintain their health and dramatically decrease transmission to others. Preliminary data analyses show that, as of 2016: In Zimbabwe, among adults ages 15 to 64, HIV incidence is 0.45%; HIV prevalence is 14.6% (16.7% among females and 12.4% among males); 60.4% of all HIV-positive people are virally suppressed, and 86% of those on treatment are virally suppressed. In Malawi, among adults ages 15 to 64, HIV incidence is 0.37%; HIV prevalence is 10.6% (12.8% among females and 8.2% among males); 67.6% of all HIV-positive people are virally suppressed, and 91% of those on treatment are virally suppressed. In Zambia, among adults ages 15 to 59 years, HIV incidence is 0.66%; HIV prevalence is 12.3% (14.9% among females and 9.5% among males); 59.8% of all HIV-positive people are virally suppressed, and 89% of those on treatment are virally suppressed. The results from the first three PHIA surveys are argued to compel the global community to strengthen its efforts to reach those who have yet to receive an HIV test and to engage, support, and enable those who test HIV-positive to start and stay on effective treatment in order to achieve long-term viral suppression.
Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women’s heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesised. The authors set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarise the findings through a meta-analysis. Nineteen papers from 16 studies met the inclusion criteria. Of these 16 studies, 14 provided data on women and 10 on men. The authors found a significant, positive, unadjusted or adjusted association between transactional sex and HIV in 10 of 14 studies for women, one of which used a longitudinal design. Out of 10 studies involving men, only two indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. The meta-analysis confirmed general findings from the systematic review. Transactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the causal pathways between transactional sex and HIV.
High rates of attrition are weakening Mozambique’s national HIV Program’s efforts to achieve 80% treatment coverage. In response, Mozambique implemented a national pilot of Community Adherence and Support Groups (CASG). CASG is a model in which antiretroviral therapy (ART) patients form groups of up to six patients. On a rotating basis one CASG group member collects ART medications at the health facility for all group members, and distributes those medications to the other members in the community. Patients also visit their health facility bi-annually to receive clinical services. A matched retrospective cohort study was implemented using routinely collected patient-level data in 68 health facilities with electronic data systems and CASG programs. A total of 129,938 adult ART patients were registered in those facilities. Of the 129,938 patients on ART, 6,760 were CASG members. A propensity score matched analysis was performed to assess differences in mortality and loss to follow-up (LTFU) between matched CASG and non-CASG members. Non-CASG participants had higher LTFU rates than matched CASG participants; however, there were no significant mortality differences between CASG and non-CASG participants. Compared with the full cohort of non-CASG members, CASG members were more likely to be female, tended to have a lower median CD4 counts at ART initiation and be less likely to have a secondary school education. ART patients enrolled in CASG were significantly less likely to be LTFU compared to matched patients who did not join CASG. CASG appears to be an effective strategy to decrease LTFU in Mozambique’s national ART program.
In an effort to support countries, programme managers, health workers and other stakeholders seeking to achieve national and international HIV goals, this 2016 update of the WHO guidelines issues new recommendations and additional guidance on HIV self-testing (HIVST) and assisted HIV partner notification services. The guidelines support the routine offer of voluntary assisted HIV partner notification services as part of a public health approach and provide guidance on how HIVST and assisted HIV partner notification services could be integrated into both community-based and facility-based approaches and be tailored to specific population groups. The guidelines support the introduction of HIVST as a formal intervention using quality-assured products that are approved by WHO and official local and international bodies.
National surveys in Zimbabwe, Malawi, and Zambia reveal exceptional progress against HIV, with decreasing rates of new infection, stable numbers of people living with HIV, and more than half of all those living with HIV showing viral suppression through use of antiretroviral medication. For those on antiretroviral medication, viral suppression is close to 90%. These data are the first to emerge from the Population HIV Impact Assessment (PHIA) Project, a multi-country initiative funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The project deploys household surveys, which measure the reach and impact of HIV prevention, care and treatment programs in select countries. Importantly, the data positively demonstrate that the 90-90-90 global targets set forth by UNAIDS in 2014 are attainable, even in some of the poorest countries in the world. The data show that once diagnosed, individuals are accessing treatment, staying on treatment, and their viral load levels are suppressed to levels that maintain their health and dramatically decrease transmission to others. In Zimbabwe, among adults ages 15 to 64, HIV incidence is 0.45%; HIV prevalence is 14.6% (16.7% among females and 12.4% among males); 60.4% of all HIV-positive people are virally suppressed, and 86% of those on treatment are virally suppressed. In Malawi, among adults ages 15 to 64, HIV incidence is 0.37%; HIV prevalence is 10.6% (12.8% among females and 8.2% among males); 67.6% of all HIV-positive people are virally suppressed, and 91% of those on treatment are virally suppressed. In Zambia, among adults ages 15 to 59 years, HIV incidence is 0.66%; HIV prevalence is 12.3% (14.9% among females and 9.5% among males); 59.8% of all HIV-positive people are virally suppressed, and 89% of those on treatment are virally suppressed. The results from the first three PHIA surveys compel the global community to strengthen its efforts to reach those who have yet to receive an HIV test and to engage, support, and enable those who test HIV-positive to start and stay on effective treatment in order to achieve long-term viral suppression.
The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centres and hospitals, offers such a model, providing access to proximate HIV care and minimising structural barriers to retention. In this paper the authors first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralisation of ART services and long-term retention of patients in care. They then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organisation committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organisations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralisation and retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. The authors conclude that PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works.
The first new trial of a potential vaccine against HIV in seven years has begun in South Africa, raising hopes that it will help bring about the end of the epidemic. Although fewer people are now dying from Aids because 18.2 million are on drug treatment for life to suppress the virus, efforts to prevent people from becoming infected have not been very successful. The infection rate has continued to rise and experts do not believe the epidemic will be ended without a vaccine. The vaccine being tested is a modified version of the only one to have shown a positive effect, out of many that have gone into trials. Seven years ago, the vaccine known as RV144 showed a modest benefit of about 31% in a trial in Thailand. The aspiration is to push the effectiveness up from 31% to between 50% and 60% for use in combination with other prevention tools, such as condoms, antiretroviral drugs and circumcision. According to Professor Linda-Gail Bekker, of the University of Cape Town, “We’ve never treated our way out of an epidemic. There’s no doubt we have to have primary prevention alongside treatment in order to get HIV control, but we are not going to get HIV eradication without a vaccine. That is very clear.”