Equity and HIV/AIDS

Challenges to antiretroviral adherence among MSM and LGBTI living with HIV in Kampala, Uganda
Therkelsen D: HEARD, Durban, December 2015

‘Treatment as prevention’ has become the cornerstone of UNAIDS’s post-2015 global strategy to end AIDS by 2030. As the expansion of treatment provision continues, and access improves, adherence becomes a determining factor in the impact of ART for both treatment and prevention. HEARD are conducting a number of small scoping studies on challenges to ART adherence in men who have sex with men (MSM) and lesbian, gay, bisexual, transgender, and intersex (LGBTI) communities living with HIV in East and Southern Africa (ESA), as key populations in the AIDS response. This report presents findings from a scoping study carried out in Kampala, Uganda, in December 2015. The findings suggest that (double) stigma and criminalisation of behaviour of people living with HIV (PLHIV) in MSM and LGBTI communities cut across almost every perceived challenge to ART adherence as a driving or contributory factor. As a result, indications suggest MSM and LGBTI experience challenges that are similar in type to the general population, but that these population groups experience the challenges more often, more acutely, and with less opportunity to overcome the challenges.

‘The mercurial piece of the puzzle’: Understanding stigma and HIV/AIDS in South Africa
Gilbert L: Journal of Social Aspects of HIV/AIDS Research Alliance (SAHARA-J)13(1) 8-16

Although stigma and its relationship to health and disease is not a new phenomenon, it has not been a major feature in the public discourse until the emergence of HIV. The range of negative responses associated with the epidemic placed stigma on the public agenda and drew attention to its complexity as a phenomenon and concept worthy of further investigation. Despite the consensus that stigma is one of the major contributors to the rapid spread of HIV and the frequent use of the term in the media and among people in the street, the exact meaning of ‘stigma’ remains ambiguous. This paper re-visits some of the scholarly deliberations and further interrogates their relevance in explaining HIV-related stigma evidenced in South Africa. In conclusion a model is presented. Its usefulness – or explanatory potential – is that it attempts to provide a comprehensive framework that offers insights into the individual as well as the social/structural components of HIV-related stigma in a particular context. As such, it is argued by the authors to have the potential to provide more nuanced understandings as well as to alert us to knowledge-gaps in the process.

Agenda for zero discrimination in health care
UNAIDS, Geneva, 2016

People around the world face barriers to accessing quality health care and enjoying the highest attainable standard of health. Why this occurs varies between countries and communities, but some barriers are present everywhere. These include the various forms of discrimination faced by people who are marginalized, stigmatized, criminalized and otherwise mistreated because of their gender, nationality, age, disability, ethnic origin, sexual orientation, religion, language, socio-economic status, or HIV or other health status, or because of selling sex, using drugs and/or living in prison. One in eight people living with HIV report having been denied health care. Examples of HIV-related stigma and discrimination go beyond denial of care or lower quality care, and include forced sterilization, stigmatizing treatment, negative attitudes and discriminatory behaviour from providers, lack of privacy and/or confidentiality and mandatory testing or treatment without informed consent. UNAIDS argue that such discriminatory practices undermine people’s access to HIV prevention, treatment and care services and the quality of health-care delivery, as well as adherence to HIV treatment.

Relationship between power, communication, and violence among couples: results of a cluster-randomised HIV prevention study in a South African township
Minnis A; Doherty I; Kline T; Zule W; Myers B; Carney T; Wechsberg W: International Journal of Women's Health, 7, 517–525, 2015

Inequitable gender-based power in relationships and intimate partner violence contribute to persistently high rates of HIV infection among South African women. The authors examined the effects of two group-based HIV prevention interventions that engaged men and their female partners together in a couples intervention (Couples Health CoOp [CHC]) and a gender-separate intervention (Men’s Health CoOp/Women’s Health CoOp [MHC/WHC]) on women’s reports of power, communication, and conflict in relationships. Of the 290 couples enrolled, 255 women remained in the same partnership over 6 months. Following the intervention, women in the CHC arm compared with those in the WHC arm were more likely to report an increase in relationship control and gender norms supporting female autonomy in relationships. Women in the MHC/WHC arm were more likely to report increases in relationship equity, relative to those in the CHC arm, and had a higher odds of reporting no victimisation during the previous 3 months. Male partner engagement in either the gender-separate or couples-based interventions led to modest improvements in gender power, adoption of more egalitarian gender norms, and reductions in relationship conflict for females. The aspects of relationship power that improved, however, varied between the couples and gender-separate conditions, highlighting the need for further attention to development of both gender-separate and couples interventions.

“You are wasting our drugs”: health service barriers to HIV treatment for sex workers in Zimbabwe
Mtetwa S; Busza J; Chidiya S; Mungofa S; Cowan F: BMC Public Health 13(698), July 2013,

In Zimbabwe, despite the existence of well-attended services targeted to female sex workers (SWs), fewer than half of women diagnosed with HIV took up referrals for assessment and ART initiation; just 14% attended more than one appointment. The authors conducted a qualitative study to explore the reasons for non-attendance and the high rate of attrition, through three focus group discussions (FGD) in Harare with HIV-positive SWs. SWs emphasised supply-side barriers, such as being demeaned and humiliated by health workers, reflecting broader social stigma surrounding their work. Sex workers were particularly sensitive to being identified and belittled within the health care environment. Demand-side barriers also featured, including competing time commitments and costs of transport and some treatment, reflecting SWs’ marginalised socio-economic position. Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. The authors suggest that programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.

Equity in utilisation of antiretroviral therapy for HIV-infected people in South Africa: a systematic review
Tromp N; Michels C; Mikkelsen,E; Hontelez J; Baltussen R: International Journal for Equity in Health 13(60) 2014

About half a million people in South Africa are deprived of antiretroviral therapy (ART), and there is little systematic knowledge on who they are – e.g. by severity of disease, sex, or socio-economic status (SES). The authors performed a systematic review to determine the current quantitative evidence-base on equity in utilisation of ART among HIV-infected people in South Africa. The authors conducted a literature search based on the Cochrane guidelines. A study was included if it compared for different groups of HIV infected people (by sex, age, severity of disease, area of living, SES, marital status, ethnicity, religion and/or sexual orientation (i.e. equity criteria)) the number initiating/adhering to ART with the number who did not. The authors considered ART utilisation inequitable for a certain criterion (e.g. sex) if between groups (e.g. men versus women) significant differences were reported in ART initiation/adherence. Twelve studies met the inclusion criteria. For sex, 2 out of 10 studies that investigated this criterion found that men are less likely than women to utilise ART, while the other 8 found no differences. For age, 4 out of 8 studies found inequities and reported less utilisation for younger people. For area of living, 3 out of 4 studies showed that those living in rural areas or certain provinces have less access and 2 out of 6 studies looking at SES found that people with lower SES have less access. One study which looked at the marital status found that those who are married are less likely to utilise ART. For severity of disease, 5 out of 6 studies used more than one outcome measure for disease stage and reported within their study contradicting results. One of the studies reported inconclusive findings for ethnicity and no study had looked at religion and sexual orientation. It seems that men, young people, those living in certain provinces or rural areas, people who are unemployed or with a low educational level, and those being unmarried have less access to ART. As studies stem from different contexts and use different methods conclusions should be taken with caution.

Improved identification and enrolment into care of HIV-exposed and -infected infants and children following a community health worker intervention in Lilongwe, Malawi
Ahmed S; Kim MH; Dave AC; Sabelli R; Kanjelo K; Preidis GA; Giordano TP; Chiao E; Hosseinipour M; Kazembe PN; Chimbwandira F; Abrams EJ: Journal of the International AIDS Society 18(1),19305, 2015

Early identification and entry into care is critical to reducing morbidity and mortality in children with HIV. The objective of this report is to describe the impact of the Tingathe programme, which utilises community health workers (CHWs) to improve identification and enrolment into care of HIV-exposed and -infected infants and children. Three programme phases are described. During the first phase, Mentorship Only (MO) (March 2007–February 2008) on-site clinical mentorship on paediatric HIV care was provided. In the second phase, Tingathe-Basic (March 2008–February 2009), CHWs provided HIV testing and counselling to improve case finding of HIV-exposed and -infected children. In the final phase, Tingathe-PMTCT (prevention of mother-to-child transmission) (March 2009–February 2011), CHWs were also assigned to HIV-positive pregnant women to improve mother-infant retention in care. The authors reviewed routinely collected programme data from HIV testing registers, patient mastercards and clinic attendance registers from March 2005 to March 2011. During MO, 42 children (38 HIV-infected and 4 HIV-exposed) were active in care. During Tingathe-Basic, 238 HIV-infected children (HIC) were newly enrolled, a six-fold increase in rate of enrolment from 3.2 to 19.8 per month. The number of HIV-exposed infants (HEI) increased from 4 to 118. During Tingathe-PMTCT, 526 HIC were newly enrolled over 24 months, at a rate of 21.9 patients per month. There was also a seven-fold increase in the average number of exposed infants enrolled per month (9.5–70 patients per month), resulting in 1667 enrolled with a younger median age at enrolment (5.2 vs. 2.5 months). During the Tingathe-Basic and Tingathe-PMTCT periods, CHWs conducted 44,388 rapid HIV tests, 7658 (17.3%) in children aged 18 months to 15 years; 351 (4.6%) tested HIV-positive. Over this time, 1781 HEI were enrolled, with 102 (5.7%) found HIV-infected by positive PCR. Additional HIC entered care through various mechanisms (including positive linkage by CHWs and transfer-ins) such that by February 2011, a total of 866 HIC were receiving care, a 23-fold increase from 2008. A multipronged approach utilising CHWs to conduct HIV testing, link HIC into care and provide support to PMTCT mothers can dramatically improve the identification and enrolment into care of HIV-exposed and -infected children.

Results Report
The Global Fund: Geneva, 2015

This report delivers a summary of the impact and results the Global Fund partnership was able to achieve by 2015, showing cumulative progress since the Global Fund was created in 2002. It is a collective effort, combining the strong contributions made by governments, civil society, the private sector and people affected by HIV, TB and malaria. Here are the cumulative highlights: 17 million lives saved; on track to reach 22 million lives saved by the end of 2016, a decline of one-third in the number of people dying from HIV, TB and malaria since 2002, in countries where the Global Fund invests, 8.1 million people on antiretroviral treatment for HIV, 13.2 million people have received TB treatment and 548 million mosquito nets distributed through programs for malaria. Building resilient and sustainable systems for health is critically important to end HIV, TB and malaria as epidemics. Overall, more than one-third of the Global Fund’s investments go to building resilient and sustainable systems for health. The Global Fund estimates that approximately 55 to 60 percent of its investments benefit women and girls, with a positive impact on reproductive health.

The role of quality improvement in achieving effective large-scale prevention of mother-to-child transmission of HIV in South Africa
Barker P; Barron P; Bhardwaj S; Pillay Y: AIDS 29 (Suppl), S137–S143

After a late start and poor initial performance, the South African Prevention of Mother-To-Child Transmission (PMTCT) programme achieved rapid progress in achieving effective national-scale implementation of a complex intervention across a large number of different geographic and socioeconomic contexts. This study shows how quality-improvement methods played a significant part in PMTCT improvements. The South African rollout of the PMTCT programme underwent significant evolution, from a largely ineffective, context-insensitive, top-down cascaded training approach to a sophisticated bottom-up health systems’ intervention that used modern adaptive designs. Several demonstration projects used quality-improvement methods to improve the performance of the PMTCT programme. These results prompted a national redesign of key elements of the PMTCT programme which were rapidly scaled up across the country using a unified, simplified data-driven approach. The scale up of the quality-improvement approach contributed to a dramatic fall in the nationally reported transmission rate for mother to child transmission of HIV. By 2012, measured infection rate of HIV-exposed infants at around 6 weeks after birth was 2.6%, close to the reported transmission rates under clinical trial conditions. Quality-improvement methods can be used to improve reliability of complex treatment programmes delivered at primary-care level. Rapid scale up and effective population coverage can be accomplished through a sequence of demonstration, testing and rapid spread of locally tested implementation strategies supported by real-time feedback of a simplified indicator dataset and multilevel leadership support.

Rising School Enrollment and Declining HIV and Pregnancy Risk Among Adolescents in Rakai District, Uganda, 1994–2013
Santelli J; Mathur, S; Song X; Huang T; Wei Y; Lutalo T; Nalugoda F; Gray R; Serwadda D: Global Social Welfare 2(2), 87-103, 2015

Poverty, family stability, and social policies influence the ability of adolescents to attend school. Likewise, being enrolled in school may shape an adolescent’s risk for HIV and pregnancy. In this paper the authors identified trends in school enrolment, factors predicting school enrolment (antecedents), and health risks associated with staying in or leaving school (consequences). Data from the Rakai Community Cohort Study (RCCS) were examined for adolescents 15–19 years. School enrolment and socioeconomic status (SES) rose steadily from 1994 to 2013 among adolescents; orphanhood declined after availability of antiretroviral therapy. Antecedent factors associated with school enrolment included age, SES, orphanhood, marriage, family size, and the percent of family members <20 years. In qualitative interviews, youths reported lack of money, death of parents, and pregnancy as primary reasons for school dropout. Among adolescents, consequences associated with school enrolment included lower HIV prevalence, prevalence of sexual experience, and rates of alcohol use and increases in consistent condom use. Young women in school were more likely to report use of modern contraception and never being pregnant. Young men in school reported fewer recent sexual partners and lower rates of sexual concurrency. Rising SES and declining orphanhood were associated with rising school enrolment in Rakai. Increasing school enrolment was associated with declining risk for HIV and pregnancy.