This study sought to quantify the number of cases and prevalence of human immunodeficiency virus (HIV) infection among older adults in sub-Saharan Africa. It reviewed data from Demographic and Health Surveys (DHS), of which 8 surveys contained data on HIV infection among men aged ≥ 50 years. Data was also extrapolated from the Joint United Nations Programme on HIV/AIDS on the estimated number of people living with HIV and on HIV infection prevalence among adults aged 15–49 years. The study found that, in 2007, approximately 3 million people aged ≥ 50 years were living with HIV in sub-Saharan Africa. The prevalence of HIV infection in this group was 4.0%, compared with 5.0% among those aged 15–49 years. Of the approximately 21 million people in sub-Saharan Africa aged ≥ 15 years that were HIV+, 14.3% were ≥ 50 years old. The study concludes that to better reflect the longer survival of people living with HIV and the ageing of the HIV+ population, indicators of the prevalence of HIV infection should be expanded to include people > 49 years of age. Little is known about comorbidity and sexual behaviour among HIV+ older adults or about the biological and cultural factors that increase the risk of transmission. HIV services need to be better targeted to respond to the growing needs of older adults living with HIV.
Equity and HIV/AIDS
Much of the debate as to whether or not the scaling up of HIV service delivery in Africa benefits non-HIV priority services has focused on the use of nationally aggregated data. This paper analyses and presents routine health facility record data to show trend correlations across priority services. The authors conducted a review of district office and health facility client records for 39 health facilities in three districts of Zambia, covering four consecutive years (2004-2007). Intra-facility analyses were conducted, service and coverage trends assessed and rank correlations between services measured to compare service trends within facilities. Voluntary counselling and testing, antiretroviral therapy and prevention of mother-to-child transmission client numbers and coverage levels were found to have increased rapidly during the period. There were some strong positive correlations in trends within facilities between reproductive health services (family planning and antenatal care) and antiretroviral therapy and prevention of mother-to-child transmission. Childhood immunisation coverage also increased. Stock-outs of important drugs for non-HIV priority services were significantly more frequent than were stock-outs of antiretroviral drugs. The analysis shows scale-up in reproductive health service numbers in the same facilities where HIV services were scaling up. While district childhood immunisations increased overall, this did not necessarily occur in facility catchment areas where HIV service scale-up occurred. The paper demonstrates an approach for comparing correlation trends across different services, using routine health facility information. Larger samples and explanatory studies are needed to understand the client, facility and health systems factors that contribute to positive and negative synergies between priority services.
Delayed test results often mean HIV patients in Mozambique fail to get timely treatment, but new technology is reducing the need to send tests to far away laboratories, and speeding up test results and HIV treatment. After a successful 2009 pilot, the country has nationally rolled out SMS or text message printers, which transmit the results of infant HIV tests electronically from two central reference laboratories in Maputo and the northern provincial capital, Nampula, to more than 275 health centres. Previously, test samples and results would have taken on average three weeks and up to several months to be transported to and from clinics via car, plane and even kayak in remote parts of the country. According to research conducted by the Ministry of Health and the Clinton Health Access Initiative (CHAI), who developed the technology, the time it took for clinics to receive test results dropped from an average of about three weeks to about three days after the printers were introduced. This, in turn, reduced the time it took to start infants on antiretroviral (ARV) treatment as part of national prevention of mother-to-child (PMTCT) HIV transmission services by about four months. The number of infants starting treatment also increased by 60%.
This study is based on a one-week integrated multi-disease prevention campaign in Lurambi, Western Kenya. The aim was to offer services to at least 80% of those aged 15-49. Thirty-one temporary sites in strategically dispersed locations offered: HIV counselling and testing, 60 male condoms, an insecticide-treated bed net, a household water filter for women or an individual filter for men, and, for those testing HIV+, a three-month supply of cotrimoxazole and referral for follow-up care and treatment. Over seven days, 47,311 people attended the campaign with a 96% uptake of the multi-disease preventive package. Of these, 99.7% were tested for HIV (80% had previously never tested), of whom 4% tested positive. Three-hundred and eighty-six certified counsellors attended to an average of 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age and tended to correlate with an ended marriage and unemployment. Always using condoms with a non-steady partner was more common among HIV-infected women participants who knew their status compared to those who did not. The study concludes that integrated campaigns can efficiently cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services to help achieve various national and international health development goals.
This case study on Rwanda investigates the links between investments in the AIDS response (specifically, Millennium Development Goal 6) and progress towards other health-related Millennium Development Goals (MDGs). The methodology used for this study draws on a rapid assessment approach, with significant study limitations, and the authors caution that their study should only be seen as a step-wise contribution to a more rigorous, research-based analysis. They also emphasise that recent developments in the health sector have a bearing on this study, such as decentralisation of healthcare services with structural integration and establishment of a cadre of community health workers, as well as scaling up of performance-based financing and community-based health insurance. Overall, Rwanda has made good progress in addressing MDG 6. The multisectoral AIDS response, which is based on the principles of the ‘Three Ones’, has resulted in a decline in HIV prevalence to 3% (from 11% in 2000), with some 76,726 individuals receiving ART in 2009 (representing around 77% of those in need). In terms of the other health-related MDGs, investments in the scale-up of prevention of mother-to-child transmission and paediatric ART are likely to have contributed to the reduction of child mortality in Rwanda (MDG 4), while the country shows a 25% reduction in maternal mortality between 2000 and 2005 (MDG 5), and investments from the AIDS response are suggested to have contributed to the prevention and mitigation of violence against women (MDG 3).
Home-based voluntary counseling and testing (HCT) presents a novel approach to early diagnosis. This study sought to describe uptake of pediatric HIV testing, associated factors, and HIV prevalence among children offered HCT in Kenya. HCT was offered to 2,289 children (18 months to 13 years) and accepted for 1,294 (57%). Children were more likely to be tested if more information was available about a suspected or confirmed maternal HIV infection, if parents were not in household, if they were grandchildren of head of household, or if their father was not in household. Of the eligible children tested, 60 (4.6%) were HIV infected. The paper concludes that HCT provides an opportunity to identify HIV among high-risk children, but acceptance of HCT for children was limited. Further investigation is needed to identify and overcome barriers to testing uptake.
This 2010 update of the original 2006 publication by the World Health Organization (WHO) outlines a public health approach to the delivery of anti-retroviral therapy (ART) for adults and adolescents in settings with limited health systems capacity and resources. The recommendations encourage earlier HIV diagnosis and earlier antiretroviral treatment, and promote the use of less toxic regimens and more strategic laboratory monitoring. The guidelines identify the most potent, effective and feasible first-line, second-line and subsequent treatment regimens, applicable to the majority of populations, the optimal timing of ART initiation and improved criteria for ART switching, and introduce the concept of third-line antiretroviral regimens. The primary audiences are national treatment advisory boards, partners implementing HIV care and treatment, and organisations providing technical and financial support to HIV care and treatment programmes in resource-limited settings. WHO notes that it is critical that national ART programme and public health leaders consider these recommendations in the context of countries’ HIV epidemics, the strengths and weaknesses of health systems, and the availability of financial, human and other essential resources and adapt the guidelines carefully. It is similarly important to ensure that the adaptation of these guidelines do not stifle ongoing or planned research, since the new recommendations reflect the current state of knowledge and new information for sustainability and future modifications of existing guidelines will be needed.
This study compares effectiveness of antiretroviral therapy (ART) services between primary healthcare (PHC) facilities and hospitals in low-income settings. A retrospective cohort study was conducted including ART-naïve adults from 59 facilities in four provinces in South Africa, enrolled between 2004 and 2007. A total of 29,203 adults from 47 PHC facilities, nine district hospitals and three regional hospitals were included. Patients at PHC facilities had more advanced WHO stage disease when starting ART. Retention in care was 80.1%, 71.5% and 68.7% at PHC, district and regional hospitals respectively, after 24 months of treatment. The study concludes that ART outcomes were superior at PHC facilities, despite PHC patients having more advanced clinical stage disease when starting ART, suggesting that ART can be adequately provided at this level and supporting the South African government's call for rapid up-scaling of ART at the primary level of care. Further prospective research is required to determine the degree to which outcome differences are attributable to either facility level characteristics or patient co-morbidity at hospital level.
The aims of this study were to determine the relative incidence of tuberculosis (TB) by HIV or anti-retroviral therapy (ART) status and the effect of the ART roll-out on TB incidence trends in Karonga District, Malawi. Data from the Karonga Prevention Study was analysed, including TB epidemiological studies done since 1985 and data on ART services available since 2005. The study found that relative incidence of TB was high early after initiation on ART and decreases with time, but still remains elevated. Recommendations include starting ART earlier, further collaboration between and greater integration of TB and ART programmes, and intensified case finding for TB in high-risk populations of patients receiving ART.
Recent preliminary results of Caprisa's study of the microbicide gel, Tenofovir, which showed that it can protect women from HIV infection by about 39%, have sparked concern that people might be less cautious about the use of condoms. Communities activists say condoms are already being used sparingly, with some suggesting that use of the gel might worsen the rate of condom use. Vusi Msiza, a South African community activist from Kwa-Tema, on Gauteng’s East Rand, said that the results have brought hope, but cautioned that they could also create a misperception. He urged that the message needs to be clear: there is a need to advocate use of the gel, but he also urged men to take initiative by using condoms. But other members of his community have hailed the results of the Caprisa study, saying it will give women some power as there are perceived stereotypes in using condoms. Charles Hlatshwayo who is part of a community advisory board on clinical trials in Soweto, said that the results spell good news. However, he cautioned that there might be resistance towards using the gel.