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.
Equity and HIV/AIDS
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.”
Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. This study in 2015 identified facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. The authors found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed.
Within the HIV public health domain, interest is growing in universal test and treat (UTT) strategies. This refers to the expansion of antiretroviral therapy (ART) in order to reduce onward transmission and incidence of HIV in a population, through a “treatment as prevention” (TasP). This paper focuses on how masculinity influences engagement with HIV care in the context of an on-going TasP trial. Data were collected in January–November 2013 using 20 in-depth interviews, 10 of them repeated thrice, and 4 focus group discussions, each repeated four times. The accounts detailed men’s unwillingness to engage with HIV testing and care, seemingly tied to their pursuit of valued masculinity constructs such as having strength and control, being sexually competent, and earning income. Given fears regarding getting an HIV-positive diagnosis, men preferred traditional medicine. Further primary health centres were not seen to be welcoming to men discouraging their readiness to test for HIV. These tensions were amplified by masculinity norms. Men struggled with disclosing their HIV status, and used various strategies to avoid or postpone disclosing, or disclose indirectly. In contrast women were found to access care readily. The authors argue that UTT and TasP promotion should use health service delivery models that address these tensions.
When Rose Matuulane was pregnant five years ago, she had to wait for a nurse to visit her small village, Otse in Botswana, to provide antenatal check-ups. When the nurse could not make it, Ms. Matuulane had to travel 84 km to the nearest clinic, in Shoghong, arriving the day before so that she could rise early and queue for hours. If she or any other woman additionally needed a family planning consultation, cervical cancer screening, HIV testing and counselling, or HIV treatment, they would have to come back another day, waiting again for hours. Ms. Matuulane, 24, is now a mother of two. The experience she had with her second pregnancy was worlds apart from the first. In 2011, shortly after she had her first baby, UNFPA helped to introduce integrated reproductive health care services at the Otse Health Post. It meant Ms. Matuulane no longer had to travel all the way to Shoshong. The new approach – called a “one-stop shop model” – also meant women no longer had to return time and again for different sexual and reproductive health services. The one-stop shop model is helping to increase women’s access to life-saving maternal health care and family planning. It is also a critical tactic in the fight against Botswana’s devastating HIV epidemic. The country has an HIV prevalence of 22 per cent among 15-to-49 year olds, according to 2015 UNAIDS estimates. A staggering 18 per cent of maternal deaths in the country are due to HIV-related causes. By integrating a full suite of reproductive health care together with a full range of HIV services – including prevention, testing and antiretroviral treatment – health workers have more opportunities to provide both kinds of care. The project – a partnership between the Ministry of Health, UNFPA and UNAIDS, with funding from the European Union, and the Swedish and Norwegian development agencies – is being piloted in seven countries in the East and Southern Africa Region. Botswana is the first of the pilot countries to implement the approach nationwide. Since the programme’s launch, the number of women visiting clinics for post-natal care, who are then able to simultaneously receive HIV and family planning services, has increased by 63 per cent, according to a recent report. The number of women seeking family planning, who are now able to access HIV services at the same time, has increased by 89 per cent.
HIV-related mHealth interventions have demonstrable efficacy in supporting treatment adherence, although the evidence base for promoting HIV testing is inconclusive. Progress is constrained by a limited understanding of processes used to develop interventions and weak theoretical underpinnings. This paper describes a research project that informed the development of a theory-based mHealth intervention to promote HIV testing amongst city-dwelling African communities in the conditions. A community-based participatory social marketing design was adopted. Six focus groups (48 participants in total) were undertaken and analysed using a thematic framework approach, guided by constructs from the Health Belief Model. Key themes were incorporated into a set of text messages, which were pre-tested and refined. The focus groups identified a relatively low perception of HIV risk, especially amongst men, and a range of social and structural barriers to HIV testing. In terms of self-efficacy around HIV testing, respondents highlighted a need for communities and professionals to work together to build a context of trust through co-location in, and co-involvement of, local communities which would in turn enhance confidence in, and support for, HIV testing activities of health professionals. Findings suggested that messages should: avoid an exclusive focus on HIV, be tailored and personalised, come from a trusted source, allay fears and focus on support and health benefits. HIV remains a stigmatised and de-prioritised issue within African migrant communities in the UK, posing barriers to HIV testing initiatives. A community-based participatory social marketing design can be successfully used to develop a culturally appropriate text messaging HIV intervention. Key challenges involved turning community research recommendations into brief text messages of only 160 characters.