How is the HIV/AIDS pandemic affecting food security in Lesotho, Malawi and Mozambique? How can humanitarian agencies speed up their response to hunger crisis in Africa? These are just two of many questions emerging from an independent evaluation of the 2002-2003 Disasters Emergency Committee Southern Africa Crisis Appeal. In 2001, abnormal rains led to flooding and water logging, substantially reducing maize production. Unable to store maize, farmers were forced to sell at low prices early in the season, and buy back at inflated prices later. The food crisis situation in Malawi - combined with chronic poverty, HIV/AIDS, poor governance, political instability, and misguided market reforms of neighboring countries – led to catastrophe throughout the region.
Equity and HIV/AIDS
This paper looks at the increasing burden of hypertension across sub-Saharan Africa where HIV prevalence is the highest in the world, but current care models are inadequate to address the dual epidemics. Little data exist on the effectiveness of integrated HIV and chronic disease care delivery systems on blood pressure control over time. Population screening for HIV and hypertension, among other diseases, was conducted in ten communities in rural Uganda as part of the SEARCH study. Individuals with either HIV, hypertension, or both were referred to an integrated chronic disease clinic. Based on Uganda treatment guidelines, follow-up visits were scheduled every 4 weeks when blood pressure was uncontrolled, and either every 3 months, or in the case of drug stock-outs more frequently, when blood pressure was controlled. The authors described demographic and clinical variables among all patients and used multilevel mixed-effects logistic regression to evaluate predictors of hypertension control. Following population screening of 34,704 adults age ≥ 18 years, 4554 individuals with hypertension alone or both HIV and hypertension were referred to an integrated chronic disease clinic. Within 1 year 2038 participants with hypertension linked to care and contributed 15,653 follow-up visits over 3 years. Hypertension was controlled at 15% of baseline visits and at 46% of post-baseline follow-up visits. Hypertension control at follow-up visits was higher among HIV-infected patients than uninfected patients and improved hypertension control was achieved in an integrated HIV and chronic care model.
New data presented at the IAS Conference for 2009 is already having an impact on HIV policy and practice on a global scale. Results of several basic research studies provided the field with a better understanding of the elevated HIV infection risk among African women due to chronically activated T-cells in genital tract mucosa, how complex genetic variables may affect HIV acquisition and disease progression, and how early antiretroviral therapy (ART) can substantially reduce the size of latent HIV reservoirs, a significant clinical issue in chronic HIV infection. Findings demonstrating that maternal triple-drug ART used throughout pregnancy and breastfeeding reduced vertical transmission to 1% are expected to inform revised World Health Organization (WHO) and South African national guidelines on antiretroviral prophylaxis. Also, research delineating the impact of antiretroviral therapy on reducing coincident tuberculosis and malaria epidemics in HIV-prevalent regions argued for wider and earlier access to treatment.
The author lists ten things raised at the 2014 Global AIDS conference in Melbourne Australia, listing backwards from 10 to 1: 10. There may be fewer people living with HIV than we thought. 9. Decriminalizing commercial sex work could significantly decrease new HIV infections among sex workers. 8. Ninety is the new zero. For years now, we’ve been hearing a chorus of ‘zero new HIV infections, zero HIV-related discrimination, and zero AIDS-related deaths.’ But this week, UNAIDS changed course, promising to have 90% of all people with HIV aware of their status, 90% of people on treatment, and 90% of those on treatment with lasting viral suppression by the year 2020. 7. Women using injectable hormonal contraceptives are at greater risk of contracting HIV, but WHO isn’t planning to inform women before they choose birth control methods. 6. UNAIDS is still leaving out one of the most at-risk groups of all: women. 5. Children and adolescents are dying at an alarming rate. 4. There is a huge shortfall in funding for harm reduction. 3. HIV-positive women are being pressured to undergo sterilization by health workers. 2. Undetectable viral loads.Calling it “the closest thing we have to a cure for HIV,” activists issued a challenge this week to bring viral loads to undetectable levels by 2020. and 1. Funding for activists is drying up, and with it, the voices to spur governments and agencies to action. Section27's Mark Heywood issued a cri de coeur to delegates of AIDS 2014, lamenting that "AIDS is fast becoming just another disease of the poor, criminalised and marginalised...just another manifestation of global complacency about poverty and inequality."
This study investigated whether or not antiretroviral therapy (ART) influences pregnancy rates. It analysed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multi-country HIV care and treatment programme for women, children and families. From eleven programmes in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals, while ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. The study found that ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioural or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services.
The study seeks to raise awareness and expand knowledge about the deleterious effect of HIV/AIDS mortality on South Africa's life expectancy, a country with a relatively high HIV/AIDS prevalence rate (19%). Using the multiple and associated single decrement life table techniques, the study estimates the total number of South Africans who would die from HIV/AIDS by the time they reach age 75 from a hypothetical cohort of 100,000 live births, assuming that the mortality conditions of 1996 for South Africa prevailed. The findings indicate that 5.7% of babies will eventually die of AIDS. Furthermore, 7.7% and 11.5% of those aged 60 years, and 75 years and above respectively will die of AIDS. Overwhelming majority of deaths will come from persons within the reproductive and productive age groups. A tremendous gain in life expectancy to the tune of about 26 years would result in the absence of HIV. The elderly persons, who are the grandmothers and grandfathers, are likely to manage family affairs following the death of their adult children. This condition is likely to impoverish the elderly population. Everything should be done to reduce AIDS mortality in order to increase life expectancy in the country.
Stepping Stones, a 50-hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. This article details the results of a randomised trial to measure the impact of the programme on HIV and herpes rates in rural South Africa. The trial also measured unwanted pregnancy, reported sexual practices, depression, and substance misuse. The article shows how there was no evidence that Stepping Stones lowered the incidence of HIV. However, it significantly improved a number of reported risk behaviours in men, with a lower proportion of men acting violently towards their intimate partners and less transactional sex and drinking problems. In women, desired behaviour changes were not reported.
This study assessed the adoption of World Health Organization guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus and monitored implementation of the guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania. The authors summarized national PMTCT policies and World Health Organization guidance for 15 indicators across the cascades of maternal and infant care over 2013–2016. Two survey rounds were conducted in 46 health facilities serving five health and demographic surveillance system populations. Structured questionnaires were administered to facility managers to describe service delivery. In all countries, national policies influencing the maternal and infant prevention of mother-to-child transmission cascade of care aligned with World Health Organization guidelines by 2016; most inter-country policy variations concerned linkage to routine human immunodeficiency virus care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy initiation, antenatal care and antiretroviral therapy provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock-outs of human immunodeficiency virus test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds. Progress has been made in implementing prevention of mother-to-child transmission policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant human immunodeficiency virus elimination goals.
In Mozambique, pulmonary tuberculosis is primarily diagnosed with sputum smear microscopy. However this method has low sensitivity, especially in people infected with human immunodeficiency virus (HIV). Patients are seldom tested for drug-resistant tuberculosis. The national tuberculosis programme and Health Alliance International introduced rapid testing of smear-negative sputum samples. Four machines were deployed in four public hospitals along with a sputum transportation system to transfer samples from selected health centres. Laboratory technicians were trained to operate the machines and clinicians taught to interpret the results. The results indicated that using rapid tests to diagnose tuberculosis is promising but logistically challenging. More affordable and durable platforms are needed. All patients diagnosed with tuberculosis need to start and complete treatment, including those who have drug resistant strains.
The World Health Organization released revised principles and recommendations for HIV and infant feeding in November 2009. The recommendations are based on programmatic evidence and research studies that have accumulated over the past few years within African countries. This document urges national or sub-national health authorities to decide whether health services should mainly counsel and support HIV-infected mothers to breastfeed and receive antiretroviral interventions, or to avoid all breastfeeding, based on estimations of which strategy is likely to give infants in those communities the greatest chance of HIV-free survival. South Africa has recently revised its clinical guidelines for prevention of mother-to-child HIV transmission, adopting many of the recommendations in the November 2009 World Health Organization’s rapid advice on use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. However, one aspect of the new South African guidelines gives cause for concern: the continued provision of free formula milk to HIV-infected women through public health facilities. This paper presents the latest evidence regarding mortality and morbidity associated with feeding practices in the context of HIV and provides suggestions for the modification of current policy to prioritise child survival for all South African children.