In recent years, the ways in which HIV and AIDS-focused programmes interact with the delivery of other health services is often discussed, but the evidence as to whether HIV and AIDS programmes strengthen or distort overall health services is limited. The aim of this study was to examine the effect of a PEPFAR-funded HIV and AIDS programme on six government-run general clinics in Kampala, Uganda. Longitudinal information on the delivery of health services was collected at each clinic. Monthly changes in the volume of HIV and non-HIV services were analysed, along with a cross-sectional survey utilising patient exit interviews to compare perceptions of the experiences of patients receiving HIV care and those receiving non-HIV care. All HIV service indicators showed a positive change after the HIV programme began. For non-HIV and AIDS health services, TB lab tests and diagnoses increased significantly, and malaria service indicators also improved. Patients’ overall impressions were positive in both the HIV and non-HIV groups, with more than 90% responding favourably about their experiences. This study shows that when a collaboration is established to strengthen existing health systems, in addition to providing HIV and AIDS services in a setting in which other primary health care is being delivered, there are positive effects not only on HIV and AIDS services, but also on other essential services.
Equity and HIV/AIDS
Globally, in the last 20 years health has improved. In this generally optimistic setting HIV and AIDS accounts for the fastest growing burden of disease. The data show the bulk of this is experienced in Southern Africa. In this region, HIV and AIDS (and tuberculosis [TB]) peaks among young adults. Women carry the greater proportion of infections and provided most of the care. South Africa has the dubious distinction of having the largest number of people living with HIV in the world, 6.4 million. HIV began spreading from about 1990 and today the prevalence among antenatal clinic attendees is 29.5%. A similar situation exists in other nations of the region. It is an expensive disease, requiring more resources than are available, and it is slipping off the global agenda, both in terms of attention and international funding. Those halcyon days of the decade from 2000 to 2010 are over. This paper explores the concept of three transition points: economic, epidemiological and programmatic. The first two have been developed and written about by others. The authors add a third transition point, namely programmatic, argue this is an important concept, and show how it can become a powerful tool in the response to the epidemic. The economic transition point assesses HIV incidence and mortality of people infected with HIV. Until the number of newly infected people falls below the number of deaths of people living with HIV, the demand for treatment and costs will increase. This is a concern for the health sector, finance ministry and all working in the field of HIV. Once an economic transition occurs the treatment future is predictable and the number of people living with HIV and AIDS decreases. This paper plots two more lines. These are the number of new people from the HIV infected pool initiated on treatment and the number of people from the HIV infected pool requiring treatment. This introduces new transition points on the graph. The first when the number of people initiated on treatment exceeds the number of people needing treatment. The second when the number initiated on treatment exceeds the new infections. That is the theory. When applying South African data from the ASSA2008 model, the authors were able to plot transition points marking progress in the national response. They argue these concepts can and should be applied to any country or HIV epidemic.
This report looks at the armies of Botswana, Swaziland, Tanzania, Zambia and Zimbabwe in the context of the HIV and AIDS epidemic. These armies report HIV rates between 20 to 40 percent, with some sections having a rate between 50 to 60 percent. The report explores approaches to reduce HIV rates among soldiers and recognises that the inherent structure and discipline of armies and their ability to follow set regimes, means that they can become change agents in their societies in the fight against HIV and AIDS.
The Farmer Life School (FLS) is an innovative approach to integrating HIV education into life skills and technical training for farmers. This study aims to gain insight into the strengths and weaknesses of this relatively new approach, through the implementation of an adapted version in South Africa. The results are presented of a pilot with three groups of community gardeners, predominantly women, attending weekly sessions. Impact was assessed in terms of three key elements: participation, learning and empowerment. Data was collected through extensive session reports, follow-up interviews and reflection exercises with facilitators, participating groups and individuals. The results suggest that a group-based discovery learning approach such as the FLS has great potential to improve food security and wellbeing, while allowing participants to explore issues around HIV/AIDS. However, the analysis also shows that HIV/AIDS-related illness and death, and the factors that drive the epidemic and its impact, undermine farmers' ability to participate, as well as the safety and trust required for learning and the empowerment process. Participatory approaches such as the FLS require a thorough understanding of and adaptation to the context in which they are to be used.
Prevention of mother-to-child transmission of HIV (PMTCT) is a major public health challenge in Zimbabwe. Using trained peer counselors, a nevirapine (NVP)-based PMTCT programme was implemented as part of routine care in urban antenatal clinics. This paper documents the successes and challenges of the programme and concludes that peer counselors were a definite advantage in PMTCT.
In this report, the authors calculate and analyse the fiscal costs of HIV and AIDS for Botswana, South Africa, Swaziland and Uganda, interpreting the HIV and AIDS response as a long-term fiscal commitment, and including certain costs such as specific social grants that are not normally included in HIV and AIDS costing studies. From a microeconomic perspective, the authors calculate, for each country, the fiscal commitment that, under the parameters of the national HIV and AIDS programme, is incurred by a single HIV infection. Similarly, they calculate costs and savings associated with HIV and AIDS-related interventions, concluding that these costs can be substantial, nearly equal to GDP per capita (South Africa) up to 12 times GDP per capita (Uganda). On the macroeconomic level, they aggregate the costs incurred by new infections to track the evolving fiscal burden of HIV and AIDS over time. They found that newly incurred costs are generally lower than current spending, and that the fiscal burden of HIV and AIDS is declining over the projection period, perhaps reflecting a projected decline in HIV incidence. At the same time, the fiscal costs remain large, and increasingly reflect the success or failure of the HIV and AIDS programme in preventing new infections.
What care do sufferers of AIDS receive in sub-Saharan Africa (SSA)? If their lives cannot be saved, are their last days made as comfortable as possible? As more funding is made available for the care of terminally-ill AIDS patients, it is important to look at the level of care currently available. King’s College London, together with the US Office of National AIDS Policy, conducted a survey across 14 SSA countries to discover the end-of-life care AIDS patients are currently receiving. As hospitals cannot cope with the sheer numbers of patients, care must take place in the community. Nevertheless, while home-based care seems the only possible solution due to the scale of the epidemic, communities can be overwhelmed by the burden placed on them.
Stigma and discrimination are still huge obstacles to progress on AIDS: the association of HIV/AIDS with marginalised populations has consistently been a major factor impeding action. Furthermore, the involvement of HIV positive people in policymaking and programme delivery is essential to success, and such involvement requires partnership and respect, not sympathy and tolerance. This is according to an article by the International HIV/AIDS Alliance (2003) that presents an assessment of the successes and failures of the global response to AIDS from 1993-2003.
The authors of this study argue that the promotion of harm reduction as part of a more united and comprehensive global effort will be essential to halving HIV infections among people who inject drugs by 2015. They call for legal reform aligned with HIV prevention and treatment, complemented by the meaningful involvement of people who use drugs in policy formulation, arguing that drugs users who inject are often the most marginalised in the global HIV response. However, establishing the prevalence of drug use among men who have sex with men (MSM) in different parts of the world remains a challenge, as homosexuality is criminalised and stigmatised in many countries. Recommendations to government include ensuring sufficient programme funding and staff training to generate new interventions aimed at injecting drug users and MSM, as well as disseminating information to users regarding the risks of drug abuse. The authors also call for decriminalisation of users, provided that drug rehabilitation interventions are adequately devised and implemented.
While health outcomes of HIV and AIDS treatments in terms of increased longevity has been the subject of much research, there appears to be very limited research on the improved health-related quality of life (HRQL) that can be applied in cost-utility analyses in Africa south of the Sahara. In this study, a systematic review of the literature on HRQL weights for people living with HIV and AIDS in Africa was performed, and the study also used focus group discussions in panels of clinical AIDS experts to test the preference based on a generic descriptive system EQ-5D. It contrasted quality of life with and without antiretroviral therapy (ART), and with and without treatment failure. It found that only four papers estimated the HRQL weights for HIV and AIDS in sub-Saharan Africa with generic preference based methodologies that can be directly applied in economic evaluation. A total of eight studies were based on generic health profiles. The focus group discussions revealed that HRQL weights are strongly correlated to disease stage. Furthermore, clinical experts consistently report that ART has a strong positive impact on the HRQL of patients, although this effect appears to rebound in cases of drug resistance. The study concluded that EQ-5D appears to be an appropriate tool for measuring and valuing HRQL of HIV and AIDS in Africa. More empirical research is needed on various methodological aspects in order to obtain valid and reliable HRQL weights in economic evaluations of HIV and AIDS prevention and treatment interventions.