This study examined the utilisation of the prevention of mother to child transmission (PMTCT) services in five reproductive and child health clinics in 2007 and 2008 in Moshi, northern Tanzania, after the implementation of routine counselling and testing and explored the level of knowledge the postnatal mothers had about PMTCT. Researchers interviewed 446 mothers when they brought their four-week-old infants to five reproductive and child health clinics for immunization and conducted thirteen in-depth interviews with mothers and nurses, four focus group discussions with mothers, and four observations of mothers receiving counselling. The study found that nearly all mothers (98%) were offered HIV testing, and all who were offered accepted. However, the counselling was hasty with little time for clarifications. Mothers attending urban antenatal clinics tended to be more knowledgeable about PMTCT than the rural attendees. Compared with previous studies in the area, this study found that PMTCT knowledge had increased and the counsellors had greater confidence in their counselling. The study concludes that when the PMTCT programme has had time to get established, both its acceptance and the understanding of the topics dealt with during the counselling increases.
Equity and HIV/AIDS
South Africa is trying to pull off the most extensive global HIV testing campaign but the ambitious initiative is facing some daunting realities. Launched in April 2010, the campaign aims to test 15 million South Africans over 12 months. But five months in, Health Minister Aaron Motsoaledi has admitted the initiative has stalled. The government is preparing to re-launch the campaign and expand its reach to schools and workplaces. With an adult HIV prevalence of about 18%, just over one million South Africans were on antiretroviral (ARV) treatment as of May 2010, according to National Health Council data. If the campaign is successful in diagnosing more people with HIV and referring them to care, an additional 590,000 people could be eligible for treatment by April 2011, according to health department estimates. However, Mark Heywood, vice-chairman of the South African National AIDS Council (SANAC), referred to government statistics that show that between April and July 2010, about 1.7 million people were tested for HIV as part of the campaign, but, of 300,000 people who tested positive, only half were referred to any related health services. A poor referral system may also explain why, despite a surge in the uptake of voluntary counselling and HIV testing, only an additional 3,000 people were put on ARVs in the campaign's first two months.
This paper sought to study the progress and challenges with regard to universal antiretroviral (ARV) access in Free State Province, South Africa. Data from the first four years of the public sector ARV roll-out and selected health system indicators was used. Data was collected from the public sector ARV database in Free State Province for new patients on ARVs, average waiting times and median CD4 counts at the start of treatment. Information on staff training, vacancy rates and funding allocations for the ARV roll-out was obtained from official government reports. Projections were made of expected new ARV enrolments for 2008 and 2009 and compared with goals set by the National Strategic Plan (NSP) to achieve universal access to ARVs by 2011. The researchers found that new ARV enrolments increased annually to 25% of the estimated need by the end of 2007. Average waiting times to enrolment decreased from 5.82 months to 3.24 months. Median CD4 counts at enrolment increased from 89 to 124 cells/mm3. There is a staff vacancy rate of 38% in the ARV programme and an inadequate increase in budget allocations. The paper concludes that current vertical model of ARV therapy delivery is unlikely to raise the number of new enrolments sufficiently to achieve the goals of universal access by 2011 as envisaged by the NSP. The Free State is implementing a project (STRETCH trial) to broaden the ARV roll-out in an attempt to increase access to ARVs.
This study’s aim was to assess the evidence for a differential effect of positive prevention interventions among individuals infected and not infected with human immunodeficiency virus (HIV) in developing countries, and to assess the effectiveness of interventions targeted specifically at people living with HIV. The researchers conducted a systematic review and meta-analysis of papers on positive prevention behavioural interventions in developing countries published between January 1990 and December 2006. Nineteen studies met the inclusion criteria. The meta-analysis showed that behavioural interventions had a stronger impact on condom use among HIV-positive (HIV+) individuals than among HIV-negative individuals. Interventions specifically targeting HIV+ individuals also showed a positive effect on condom use. However, interventions included in this review were limited both in scope (most were HIV counselling and testing interventions) and in target populations (most were conducted among heterosexual adults or HIV-serodiscordant couples). Current evidence suggests that interventions targeting people living with HIV in developing countries increase condom use, especially among HIV-serodiscordant couples. Comprehensive positive prevention interventions targeting diverse populations and covering a range of intervention modalities are needed to keep HIV+ individuals physically and mentally healthy, prevent transmission of HIV infection and increase the agency and involvement of people living with HIV.
This Environmental Scan covers three broad research areas: clinical research (prevention of mother to child transmission, or PMTCT, and paediatric treatment), clinical research (women and antiretroviral therapy) and operations research (delivering treatment to women). A parallel consultative process, led by UNICEF, addressed operations research/implementation science questions related to PMTCT, including paediatric care, treatment and support. The report found that there has been substantial progress in improving access to anti-retroviral therapy (ART) in low- and middle-income countries in recent years. The need to better understand the potential role of sex differences in HIV disease progression and treatment response is being increasingly recognised by the research community as an understudied area of inquiry. To date, there is no evidence to support differential treatment strategies for men and women. Clinical trials addressing this question are still too few and too small to provide definitive answers. Women face greater threats to personal safety and financial security than men do and as a result, they experience HIV stigma more forcefully. Some studies have identified failure to successfully integrate HIV treatment programmes with other women’s health services as a particular barrier to accessing ART.
Recent data from antenatal clinic surveillance and general population surveys suggest substantial declines in human immunodeficiency virus (HIV) prevalence in Zimbabwe. The authors assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence. Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985-2007 was conducted. HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000. Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15-24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007. These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis level.
You Can Count on Me is a Pepfar-funded programme in South Africa that aims to change men’s behaviour and to educate them about the prevention of HIV transmission from mother to child (PMTCT). The programme trains men to understand what HIV is, how it’s transmitted, how to prevent it in the general population, to protect babies from getting it and to help their partners along the journey of pregnancy. Model students in these workshops are then selected to train other men across the nine provinces. Approximately 10,000 men have been reached through face-to-face community meetings. The programme provides support for men to become involved in the pregnancy of their partners, as it regards men’s sexual behaviour as one of the main drivers of the HIV and AIDS epidemic in southern Africa.
This study aimed to describe the scale-up of a decentralised HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population. A total of 5,719 adults who initiated ART between October 2004 and September 2008 were included and stratified into six-month groups. There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84%, while 10.9% died and 3.7% were lost to follow-up. Mortality was highest in the first three months after ART initiation, with 30.1 deaths per 100 person–years. At twelve months, 23% had a detectable viral load. The study concluded that outcomes were not affected by rapid expansion of this decentralised HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.
IRIN/PlusNews has put together a list of seven ways in which HIV service providers could cut costs and improve their efficiency. Task-shifting has already seen positive results in Ethiopia, Malawi and Mozambique, but insufficiently trained medical staff can be harmful to national antiretroviral (ARV) programmes. Community support also plays a significant role in HIV education and care in many poor countries where relatives and neighbours often help to monitor patients and raise awareness about HIV. The cost of combination ARV therapy has come down significantly from about US$10,000 per person per year in 2000 to about $88 a year. However, second- and third-line anti-retrovirals are still prohibitively expensive for low-income countries. Simpler drug delivery systems will help reduce the amount of money spent on non-drug-related costs, especially as between two-thirds and 80% of money spent on HIV is related to service delivery, patient monitoring and laboratory costs. Using technology, such as SMS-based check-ups, may help save patients the costs of travelling to a clinic every month. Country ownership and health system integration are also crucial for success in fighting HIV in developing countries.
This book is an in-depth evaluation of a new approach to create behavioural change that could affect the course of the global health crisis of HIV and AIDS. Taking a close look at the South African HIV and AIDS epidemic, it demonstrates that regular workers serving as peer educators can be as – or even more – effective agents of behavioural change than experts who lecture about the facts and so-called appropriate health care behaviour. After spending six years researching the response of large South African companies to the AIDS epidemic, Dickinson describes the promise of this grassroots intervention and the limitations of traditional top-down strategies. His case studies directly examine the South African workplace to tackle sexual, gender, religious, ethnic, and broader social and political taboos that make behaviour change so difficult, particularly when that behaviour involves sex and sexuality. Dickinson's findings show that people who are not officially health care experts or even health care workers can be skilled and effective educators. This book demonstrates how peer education can be used as a tool for societies grappling with the HIV and AIDS epidemic and why those interested in changing behaviours to ameliorate other health problems like obesity, alcoholism, and substance abuse have so much to learn from the South African context.