Increased fertility rates in HIV-infected women receiving antiretroviral therapy (ART) have been attributed to improved immunological function; it is unknown to what extent the rise in pregnancy rates is due to unintended pregnancies. In this study, non-pregnant women ages 18–35 from four public-sector ART clinics in Johannesburg, South Africa, were enrolled into a prospective cohort and followed from August 2009 to March 2011. Fertility intentions, contraception and pregnancy status were measured at participants' routine ART clinic visits. Of the 850 women enrolled, 170 pregnancies were detected, of which 105 (62%) were unplanned. Unmet need for contraception was 50% higher in women initiating ART in the past year as compared to women on ART for longer than one year. Eight hormonal contraceptive failures were detected. Overall 47% (80/170) of pregnancies were not carried to term. The researchers conclude that integration of contraceptive services and counselling into ART care is necessary to reduce maternal and child health risks related to mistimed and unwanted pregnancies. Further research into injectable contraceptive failures on ART is warranted.
Equity and HIV/AIDS
In this study, researchers explored the lessons learnt by health workers involved in the provision of prevention of mother-to-child transmission (PMTCT) services in eastern Uganda to better understand what more needs to be done to strengthen the PMTCT programme. A qualitative study was conducted at Mbale Regional Referral Hospital, The AIDS Support Organisation (TASO) Mbale and at eight neighbouring health centres in eastern Uganda, between January and May 2010. Data were collected through 24 individual interviews with the health workers involved in the PMTCT programme and four key informants (two district officials and two officials from TASO). Study themes and sub-themes were identified following multiple reading of interview transcripts. The key lessons for programme improvement were: ensuring constant availability of critical PMTCT supplies, such as HIV testing kits, antiretroviral drugs (ARVs) for mothers and their babies, regular in-service training of health workers to keep them abreast with the rapidly changing knowledge and guidelines for PMTCT, ensuring that lower level health centres provide maternity services and ARVs for women in the PMTCT programme and provision of adequate facilities for effective follow-up and support for mothers.
Three countries in Southern Africa have the highest adult HIV prevalence in the world: Swaziland (25.9%), Botswana (24.8%), and Lesotho (23.6%). Fiscal policy is crucial for addressing this HIV and AIDS crisis, according to the African Development Bank (ADB). Utilising a calibrated model, this paper investigates the impact of fiscal policy on reducing the HIV and AIDS incidence rates in these countries. In particular, ADB studied the welfare impact of different taxation and debt paths in these countries in reducing the HIV and AIDS prevalence rates. Results showed that tax policies that were associated with reduced HIV rates not only had positive societal effect but also positive fiscal effects.
In this paper, UNAIDS argues that enhancing African ownership of the AIDS response will further the health gains made so far and will also further enhance economic growth. UNAIDS points out that only half of Africans living with HIV who are eligible for treatment are able to access it currently. African governments invest less on AIDS than would be expected, while external assistance dominates HIV investment in most countries in Africa, which destabilises the AIDS response. Africa should pursue a more balanced partnership with international partners in the AIDS response, according to the paper, using health insurance as a mechanism to channel health spending more efficiently and equitably. UNAIDS urges African governments to set up new industrial policies that can support local pharmaceutical industries. It argues that Africa can bridge the resource gap with strong political leadership, leveraging the strong economic growth, and by adopting innovative funding opportunities.
Little is known about antiretroviral therapy (ART) outcomes in prisoners in Africa. To address this gap, researchers conducted a retrospective review of outcomes of a large cohort of prisoners referred to a public sector, urban HIV clinic. A total of 148 inmates (133 male) initiated on ART were included in the study. By week 96 on ART, 73% of all inmates enrolled in the study and 92% of those still accessing care had an undetectable viral load. By study end, 96 (65%) inmates had ever received tuberculosis (TB) therapy with 63 (43%) receiving therapy during the study: 28% had a history of TB prior to ART initiation, 33% were on TB therapy at ART initiation and 22% developed TB whilst on ART. Nine (6%) inmates died, seven in the second year on ART. While inmates responded well to ART, there was a high frequency of TB/HIV co-infection. The authors recommend that attention should be directed towards ensuring eligible prisoners access ART programmes promptly and that inter-facility transfers and release procedures facilitate continuity of care. Institutional TB control measures should remain a priority.
In March 2012, the World Bank issued a report: ‘The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda’. The report, the author of this article argues, is not new because it represents a recurrent theme in the World Bank approach from the earliest days of the global AIDS pandemic – it’s not fiscally sustainable to treat people living with HIV in high-impact, low-resource countries – instead the world must focus on prevention measures. The author disagrees, and points out a number of significant flaws in the report. First, the report is already out of date since it relies almost exclusively on pre-2009 data and fails to take into account increased efficiencies in AIDS programming, which have been significant in the past several years. The World Bank has also ignored the exciting new research that shows that suppressive anti-retroviral therapy reduces the risk of onward transmission of HIV by at least 96%. Second, there is growing evidence, again ignored by the Bank, that even a moderate expansion of investments now in treatment scale-up and in diffusion of scaleable prevention methods like condoms and needle-exchange can have significant impacts on new infections and thus future treatment costs. Third, the Bank fails to use evidence to rally support for (unspecified) “prevention” activities and does not call for innovative global financing, like a financial transaction tax. Fourth, the report appears to neglect the economic and social benefits of a healthier population and to ignore some of the costs of premature deaths by focusing on fiscal costs of treatment, while ignoring the huge social and economic benefits of the survival of the vital age 25-45 cohort.
In November 2011, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) announced that its next scheduled funding round was cancelled. This report draws on recently collected field data from numerous countries where the International HIV/AIDS Alliance operates to explain why AIDS funding crisis requires urgent action. The authors note that countries like Zambia and Zimbabwe have so far been making strong progress towards reducing HIV infections and AIDS-related deaths but this progress is now under threat. The cancellation of funds will seriously affect the scale-up of the worldwide HIV response and important existing services will be reduced or eliminated in the absence of urgent measures. They argue that the Global Fund is the best mechanism the world has for realising the possibility of a world without AIDS but can only do so with sufficient investment. They recommend that external funders and other stakeholders must act very quickly to maintain and scale up critical HIV services so that lives are not put at risk, particularly ensuring that interventions with the highest impact on the epidemic are supported. In addition, national governments must increase investment in their own HIV responses and in the implementation of national AIDS strategies.
This study in Mombasa Kenya explored sexual behaviours of people living with HIV (PLHIV) who are not receiving any HIV treatment. Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships. Main risk factors associated with unsafe sex were found to be non-disclosure of HIV status, stigma and the belief that condoms reduce sexual pleasure. In conclusion, high-risk sexual behaviours were found to be common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. The authors urge government to identify and reach this population to provide health services.
In this report, the authors calculate and analyse the fiscal costs of HIV and AIDS for Botswana, South Africa, Swaziland and Uganda, interpreting the HIV and AIDS response as a long-term fiscal commitment, and including certain costs such as specific social grants that are not normally included in HIV and AIDS costing studies. From a microeconomic perspective, the authors calculate, for each country, the fiscal commitment that, under the parameters of the national HIV and AIDS programme, is incurred by a single HIV infection. Similarly, they calculate costs and savings associated with HIV and AIDS-related interventions, concluding that these costs can be substantial, nearly equal to GDP per capita (South Africa) up to 12 times GDP per capita (Uganda). On the macroeconomic level, they aggregate the costs incurred by new infections to track the evolving fiscal burden of HIV and AIDS over time. They found that newly incurred costs are generally lower than current spending, and that the fiscal burden of HIV and AIDS is declining over the projection period, perhaps reflecting a projected decline in HIV incidence. At the same time, the fiscal costs remain large, and increasingly reflect the success or failure of the HIV and AIDS programme in preventing new infections.
Uganda's HIV and AIDS prevalence rate has risen slightly from 6.4% to 6.7% among adults aged between 15 and 49, according to the government’s recently released national AIDS Indicator Survey. HIV prevalence for women stands at 7.7%, with men at 5.6%. The Ministry of Health argues that the increase is small and is due to HIV-positive children growing up and entering the age bracket of 15 to 19 years old. However, activists are concerned that the lack of progress indicated by the new statistics is the result of gaps in the government's HIV prevention programmes, such as lack of supplies like condoms. They are also becoming increasingly concerned about risk compensation as a result of failing HIV prevention messages, especially since the survey found that just 28.1% of women and 31.4% of men aged between 15 and 19 used a condom during their last sexual encounter, dropping to 6.7% and 12.2% respectively among 30- to 39-year-olds. The full report is due for release in June 2012.