Observational studies have reported an association between male circumcision and reduced risk of HIV infection in female partners. This study assessed whether circumcision in HIV-infected men would reduce transmission of the virus to female sexual partners. Nine-hundred and twenty-two uncircumcised, HIV-infected, asymptomatic men aged 15–49 years with CD4-cell counts 350 cells per μL or more were enrolled in this unblinded, randomised controlled trial in Rakai District, Uganda. HIV-uninfected female partners of the randomised men were concurrently enrolled and followed up at 6, 12 and 24 months to assess HIV acquisition by male treatment assignment (primary outcome). The trial was stopped early because of futility. Seventeen (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up. It appears circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months – longer-term effects could not be assessed.
Equity and HIV/AIDS
At the recent UN meeting on AIDS, international organisations were disappointed that the declaration adopted by governments was weak on commitments to fight the disease, and that vulnerable groups have been left out in the document. The article outlines some of the concerns expressed by the participants.
While efforts have been made to assess the costs of providing antiretroviral therapy (ART) via accredited service points, little information is available on its downstream costs, particularly in public secondary level hospitals. This paper aims to determine the cost of care for inpatients and outpatients at a dedicated antiretroviral referral unit, the GF Jooste Hospital, during March 2005. This prospective costing study on 48 outpatients and 25 inpatients was conducted from a health system perspective. Incremental cost per outpatient was found to be R1,280 and R5,802 per inpatient. Costs were dominated by medical staff costs (62% inpatient and 58% outpatient, respectively). As the costs of providing secondary level care for patients on or immediately preceding ART initiation can be significant, the study recommends that they should be included in the government’s strategic planning so that the service can be expanded to meet current and future needs and to avoid crowding out other secondary level health services.
This study examines clinical waste disposal and handling in the context of a community home-based care (CHBC) programme in Kanye, southern Botswana. This qualitative study involved 10 focus group discussions with a total of 82 AIDS primary caregivers in Kanye, one-to-one interviews with the five nurses supervising the programme, and participant observation. Numerous aspects of clinical or healthcare waste management were found to be hazardous and challenging to the home-based caregivers in the Kanye CHBC programme, namely: lack of any clear policies for clinical waste management; unhygienic waste handling and disposal by home-based caregivers, including burning and burying healthcare waste, and the absence of pre-treatment methods; inadequate transportation facilities to ferry the waste to clinics and then to appropriate disposal sites; stigma and discrimination associated with the physical removal of clinical waste from homes or clinics; poor storage of the healthcare waste at clinics; lack of incinerators for burning clinical waste; and a high risk of contagion to individuals and the environment at all stages of managing the clinical waste.
In Stephen Lewis's last speech as UN Envoy for HIV and AIDS to the International HIV/AIDS conference in Toronto in August 2006 he comments on areas that have previously been of political controversy in the approach to the prevention of HIV/AIDS, including abstinence-only programmes, harm reduction programmes, circumcision, microbicides and nutrition and to the South African response to AIDS. He gives particular emphasis on gender and child inequalities in the acquisition and management of HIV/AIDS.
This evaluation report from the World Bank’s Operation Evaluation Department (OED) assesses the development effectiveness of the Bank’s country-level HIVand AIDS assistance. The report concludes that Bank assistance has persuaded governments to act earlier or in a more focused and cost-effective way. It also finds that whist Bank assistance has helped raise political commitment, these pledges have sometimes been overestimated and need to be constantly addressed in the country context. The authors recommend that the Bank, in order to have a sustainable impact on the HIV/AIDS epidemic, should help governments use human and financial resources more efficiently and effectively. They also recognise the need to strengthen local monitoring and evaluation practices and help improve the local evidence base for making decisions.
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.
High rates of attrition are weakening Mozambique’s national HIV Program’s efforts to achieve 80% treatment coverage. In response, Mozambique implemented a national pilot of Community Adherence and Support Groups (CASG). CASG is a model in which antiretroviral therapy (ART) patients form groups of up to six patients. On a rotating basis one CASG group member collects ART medications at the health facility for all group members, and distributes those medications to the other members in the community. Patients also visit their health facility bi-annually to receive clinical services. A matched retrospective cohort study was implemented using routinely collected patient-level data in 68 health facilities with electronic data systems and CASG programs. A total of 129,938 adult ART patients were registered in those facilities. Of the 129,938 patients on ART, 6,760 were CASG members. A propensity score matched analysis was performed to assess differences in mortality and loss to follow-up (LTFU) between matched CASG and non-CASG members. Non-CASG participants had higher LTFU rates than matched CASG participants; however, there were no significant mortality differences between CASG and non-CASG participants. Compared with the full cohort of non-CASG members, CASG members were more likely to be female, tended to have a lower median CD4 counts at ART initiation and be less likely to have a secondary school education. ART patients enrolled in CASG were significantly less likely to be LTFU compared to matched patients who did not join CASG. CASG appears to be an effective strategy to decrease LTFU in Mozambique’s national ART program.
The crucial role played by Community Based Organisations (CBOs) in the fight against HIV/AIDS is far from being recognized, says a report from SIDACTION. Until now, there was neither a record of what these organizations were doing nor any formalized description of the different kinds of activities which help facilitate access to treatment, so as to demonstrate the potential they might represent in terms of ARV access. SIDACTION sent out a concise questionnaire to more than a thousand organizations. Within a few weeks we received more than 300 responses from organizations expressing an interest in HIV care, treatment and support. There were many contrasts among the responses to the Community Access study conducted by SIDACTION: Uganda, Nigeria and Kenya accounted for 60 of the 300 continent-wide organizations that stated that they provide HIV care services.
The authors investigated the change in the community burden of undiagnosed HIV infection among older children and adolescents following implementation of provider-initiated testing and counselling (PITC) in Harare, Zimbabwe. Over the course of 2 years (2013–2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6–15 years. In 2015, the authors conducted a representative cross-sectional survey of 8–17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out. Of 7,146 children in 4,251 eligible households, 76.8% agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% and over a third of participants with HIV were undiagnosed. Based on extrapolation from the survey sample to the community, the authors estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures none of which are perfect. Facility-based approaches are argued to be inadequate in achieving universal coverage of HIV testing among older children and adolescents, and community-based approaches are identified as necessary in this age group.