This integrated biological and behavioural surveillance survey of migrant sex workers in Nairobi, Kenya's capital, reveals that HIV prevalence among migrant and Kenyan female sex workers stands at 23.1%, more than three times the national average of 6.3%. However, Kenyan sex workers were found to have better knowledge of HIV and health-seeking behaviour than their migrant counterparts, and nearly all Kenyan female sex workers (98%) had heard of sexual transmitted infections, compared to 70% of migrant female sex workers. The study was conducted in 2010, when just over half of the 628 participants said they had ever tested before for HIV, and 25.8% did not know that condoms protected against HIV. Only 72% of migrant female sex workers knew where to go for an HIV test, compared to 92% of women in the general population. Services for migrant sex workers need to be integrated into programmes for general sex workers, the authors argue. However, special care must be given to the language and cultural needs of the migrants. The authors also propose that role players lobby the Kenyan government to provide a legal framework for the regulation of sex work, which would increase access to services and provide protection for sex workers.
Equity and HIV/AIDS
With increased levels of school enrolment, more adolescents in Ethiopia are in school today than ever before, but few studies have assessed the sexual behaviour of these learners. This study addresses the research gap by assessing pre-marital sex and factors associated with it among school-going adolescents in Eastern Ethiopia. A cross-sectional school-based study was conducted using a facilitator-guided, self-administered questionnaire. Respondents were students attending regular school classes in fourteen high schools. Results showed that about one in four respondents who were unmarried (24.8%) reported pre-marital sex – of these 28.8% were males and 14.7% were females. Pre-marital sexual debut was more common among adolescents who had their parents in urban areas, who received higher pocket money per month, who perceived low self-educational rank and who lived in rented houses. The girls and those who were less influenced by external pressure were more protected against pre-marital sexual debut than their counterparts. The authors argue that public health interventions should consider the broader determinants of premarital sex, including the ecological factors in which the behaviour occurs.
The objective of this study was to use service data to inform HIV-free survival among HIV exposed children that received antiretroviral drugs to prevent mother-to-child transmission (PMTCT) of HIV. The study was conducted in two rural districts in Malawi between June 2005 and June 2009. Out of 438 children whose home addresses were available, 33 (8%) were lost to follow-up, 35 (8%) were alive but not tested for HIV by the time home visit was conducted, and 52 (12%) were confirmed deceased. A total of 318 children were alive at the time of the home visit and had an HIV antibody test done at median age 15 months. The resulting estimated 24-month probability of HIV-free survival over all children was 78%. Among children who did not receive nevirapine, the estimated 24-month probability of HIV-free survival was 61%, and among those who did receive it, the estimate was 82%. When mothers and newborns received nevirapine, the estimated 24-month probability of HIV-free survival among children was high at 82%. However, the authors warn that these promising findings should be interpreted cautiously due to the wide confidence interval and because the confidence interval range includes 55%, which is the natural HIV-free survival rate in the absence of a PMTCT intervention. This analysis highlighted the need of quality data and well-structured home visits to assess PMTCT effectiveness.
This study describes the design, implementation and evaluation of Project Mwana, a pilot project in Zambia’s rural Southern Province. The main aim of this project was to reduce the time between blood sampling for the detection of infant HIV infection and notification of the test results to the relevant point-of-care health facility by using an SMS-based system. Ten public health facilities within two districts in Zambia’s Southern Province were purposively selected for inclusion in the pilot SMS project. Results from this study suggest that in Zambia, particularly in rural areas, mobile phone texting can overcome the logistical and distance barriers that can impede the early diagnosis of HIV infection in infants. An automated SMS allowed the results of PCR testing of infant dried blood samples to be reported to the relevant point-of-care health facility or infant caregivers much faster than would have been possible by using a courier to deliver the results on paper to the relevant health facility. In addition, the results delivered through SMS texting were highly accurate by comparison with the results recorded on paper.
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.
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.