Although loss to follow-up after antiretroviral therapy (ART) initiation is increasingly recognized, little is known about pre-treatment losses to care (PTLC) after an initial positive HIV test. The objective of this paper was to determine PTLC in newly identified HIV-infected individuals in South Africa. It examined records of patients presenting for HIV testing at two sites offering HIV and CD4 count testing and HIV care in Durban, South Africa. PTLC was defined as failure to have a test for CD4 count within eight weeks of HIV diagnosis. Infected patients were significantly more likely to have PTLC if they lived ≥10 kilometers from the testing centre, had a history of tuberculosis treatment or were referred for testing by a health care provider rather than self-referred. Patients with one, two or three of these risks for PTLC were 1.88, 2.50 and 3.84 times more likely to have PTLC compared to those with no risk factors. In conclusion, nearly half of HIV-infected persons at two high prevalence sites in Durban, South Africa, failed to have CD4 counts following HIV diagnosis. These high rates of pre-treatment loss to care highlight the urgent need to improve rates of linkage to HIV care after an initial positive HIV test.
Equity and HIV/AIDS
In this study, national antiretroviral therapy (ART) policy is examined over the period of 1999 to 2008, which coincided with the government of President Thabo Mbeki and his Minister of Health, Dr Manto Tshabalala-Msimang. The movement towards a national ART programme in South Africa was an ambitious undertaking, the likes of which had not been contemplated before in public health in Africa. One million AIDS-ill individuals were targeted to be enrolled in the ART programme by 2007/08. Fewer than 50% of eligible individuals were enrolled. This failure resulted from lack of political commitment and inadequate public health system capacity. The human and economic costs of this failure are large and sobering. The total lost benefits of ART not reaching the people who need it are estimated at 3.8 million life years for the period, 2000 to 2005. The economic cost of those lost life years over this period has been estimated at more than US$15 billion.
A new World Bank report on HIV/AIDS launched in the Rwandan capital, Kigali, says the mobilization of empowered 'grassroots' communities, along with delivering condoms and life-saving treatments, are beginning to slow the pace of the continent's epidemic, which last year killed more than 2 million African adults and children, and left another 24.7 million Africans struggling to live with its deadly effects. According to the new report, ultimate success in defeating HIV/AIDS will depend on marshalling effective prevention, care, and treatment, measures to boost 'social immune systems' in African countries—changing their beliefs, perceptions, and social and individual behaviors around the disease so that eventually they can reverse the advance of HIV and stop the damage done by AIDS. The report says these changes are taking place as the epidemic shows signs of slowing in Uganda, Kenya, and Zimbabwe, and in urban Ethiopia, Rwanda, Burundi, Malawi, and Zambia.
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).
In a previous issue of the Southern African Journal of HIV Medicine, Pillay and Black summarised the trade-offs of the safety of efavirenz use in pregnancy. Highlighting the benefits of the World Health Organisation’s proposed options for the prevention of mother-to-child transmission (PMTCT) of HIV, the authors argued that the South African government should adopt Option B as national PMTCT policy and pilot projects implementing Option B+ as a means of assessing the individual- and population-level effect of the intervention. The authors of this article echo this call and further propose that the option to remain on lifelong antiretroviral therapy, effectively adopting PMTCT Option B+, be offered to pregnant women following the cessation of breastfeeding, for their own health, following the provision of counselling on associated benefits and risks. Here they highlight the benefits of Options B and B+.
African church leaders met in Johannesburg in May 2010 to find common ground in response to HIV and AIDS. At the meeting, the church acknowledged that it has failed to react timeously and effectively to the challenge of AIDS. At the meeting, church leaders spoke out about the silence and judgmental stance that characterised their response to the HIV and AIDS epidemic. The church resolved to amend its ways.
While Zambia and South Africa are attempting to integrate public TB and HIV services to reach co-infected people, there is little evidence on how the synergy of co-infection with TB and HIV plays out for affected families in the context of poverty and overstretched public services. An anthropological study carried out in 2006/7 documented the social and economic impact of TB, HIV and food insecurity on poor households in rural Zambia and peri-urban SA. Anthropological research was conducted in 18 households affected by TB throughout the period of TB treatment and in 17 comparative non-affected households. Affected families suffered a double blow: they lost the productivity of an adult family member and at the same time needed to muster resources to seek treatment and adequately care for the patient. TB drugs are perceived as both causing hunger and demanding food intake. In South Africa and Zambia, inequities increased both vulnerability to infection and disease and likelihood of delayed diagnosis and delayed or interrupted treatment and care for TB and HIV. In Zambia, those in treatment for TB fell deeper into poverty and were in debt and short on food. In SA, affected households were kept buoyant by the disability grant and other welfare initiatives, but in the long-term most were unable to resume their previous livelihoods. This research recommends that, in the context of poverty, food aid and transport costs are made available to TB patients and PLWHs on ART.
Given the size of the HIV epidemic in South Africa and other developing countries, scaling up antiretroviral treatment (ART) represents one of the key public health challenges of the next decade. Appropriate priority setting and budgeting can be assisted by economic data on the costs and cost-effectiveness of ART. The objectives of this research were therefore to estimate HIV healthcare utilisation, the unit costs of HIV services and the cost per life year (LY) and quality adjusted life year (QALY) gained of HIV treatment interventions from a provider's perspective.
The authors of this study reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). They identified 19 articles published in nine journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings, as measured against accepted international benchmarks. The authors conclude that interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses should focus on local assessment of rapidly evolving HIV MTCT options, strategies to improve coverage and reach underserved populations, evaluation of a more comprehensive set of MTCT approaches, and the integration of HIV MTCT and other sexual and reproductive health services.
The authors of this study reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). They identified 19 articles published in nine journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings, as measured against accepted international benchmarks. The authors conclude that interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses should focus on local assessment of rapidly evolving HIV MTCT options, strategies to improve coverage and reach underserved populations, evaluation of a more comprehensive set of MTCT approaches, and the integration of HIV MTCT and other sexual and reproductive health services.