The female condom is reported to have resurfaced in Uganda's prevention programme almost one and a half years after the government halted distribution of the prophylactic due to poor uptake by women. The Ministry of Health carried out a situation analysis to gauge the acceptability of the female condom by women across the country before it was reintroduced. It found that women wanted a method that would give them control in protecting themselves from sexually transmitted infections and unwanted pregnancy. However, women in western Uganda felt it went against their culture. The Ministry is reported to have plans to embark on a sensitisation campaign to ensure the prophylactic is accepted in all parts of the country and to distribute one hundred thousand female condoms to target groups that have showed interest in them, mainly in the eastern and central parts of the country.
Equity and HIV/AIDS
Whether it is relative wealth or relative poverty that drives the HIV epidemic in sub-Saharan Africa, is a controversial aspect of HIV/AIDS epidemiology. The authors suggest that the social epidemiology of HIV in Africa is changing. Previously, new infections were more rapidly acquired by those of relatively higher socioeconomic position (SEP). More recently, those of relatively low SEP are at greater risk. The authors explored in this paper whether the pattern would be compatible with the ‘inverse equity hypothesis’, that suggests that those of higher SEP benefit first from new health interventions. Using available evidence from the region, the authors suggest that in the early phase of the epidemic, HIV infections were concentrated among those of higher SEP in many countries. The inverse equity hypothesis suggests that new infections will increasingly concentrate among those of lower SEP. If further analysis confirms this hypothesis, the authors suggest that policy responses must be considered to ensure that interventions reach poorer groups and that structural approaches tackle the social determinants of HIV infection.
In November 2011, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) announced that its next scheduled funding round was cancelled. This report draws on recently collected field data from numerous countries where the International HIV/AIDS Alliance operates to explain why AIDS funding crisis requires urgent action. The authors note that countries like Zambia and Zimbabwe have so far been making strong progress towards reducing HIV infections and AIDS-related deaths but this progress is now under threat. The cancellation of funds will seriously affect the scale-up of the worldwide HIV response and important existing services will be reduced or eliminated in the absence of urgent measures. They argue that the Global Fund is the best mechanism the world has for realising the possibility of a world without AIDS but can only do so with sufficient investment. They recommend that external funders and other stakeholders must act very quickly to maintain and scale up critical HIV services so that lives are not put at risk, particularly ensuring that interventions with the highest impact on the epidemic are supported. In addition, national governments must increase investment in their own HIV responses and in the implementation of national AIDS strategies.
Global policy recommendations to scale up of male circumcision (MC) for HIV prevention tend to frame the procedure as a simple and efficacious public health intervention. However, there has been variable uptake of MC in countries with significant HIV epidemics. In this paper the authors present an in-depth analysis of Malawi's political resistance to MC, finding that ethnic and religious divisions dominating recent political movements aligned well with differing circumcision practices. Political resistance was further found to manifest through two key narratives: a ‘narrative of defiance’ around the need to resist 'donor manipulation', and a ‘narrative of doubt’ which seized on a piece of epidemiological evidence to refute global claims of efficacy. Further, the authors found that discussions over MC served as an additional arena through which ethnic identities and claims to power could themselves be negotiated, and therefore used to support claims of political legitimacy.
Zimbabwe's ambitious plan to offer an HIV test to every household in the country is not yet under way but is already being met with scepticism by activists who feel this is not a priority for the country, especially with global HIV and AIDS funding on the decline. Zimbabwe Lawyers for Human Rights has warned of the possibility of compromising on informed consent and confidentiality when testing is done on a large scale. If not properly executed, ostracism, violence, stigma and abuse in the home can result from status disclosure. Door-to-door testing was successfully conducted in Uganda between 2005 and 2007, but Lesotho’s proposed door-to-door testing campaign has been criticised by researchers as substandard. Activists ask where additional funding will be found for the campaign, arguing that resources should instead be used for those who have already been identified as HIV positive and who need treatment now. They have also raised concerns about whether the testing campaign will go beyond merely testing people, and whether it will motivate them to change their sexual behaviours and also refer those testing positive to treatment facilities.
This study explored factors influencing attendance at HIV clinic appointments among patients in a rural ward in north-west Tanzania. Forty-two in-depth interviews (IDI) and four focus group discussions were conducted with HIV-infected persons who had been referred to a nearby antiretroviral therapy (ART) clinic, and IDI were undertaken with eleven healthcare workers involved in diagnosis, referral and care of HIV-positive patients. Barriers to clinic attendance frequently included health systems factors, while physical and social benefits encouraged regular clinic attendance. Self-confidence in being able to sustain clinic attendance was often determined by patients' expectations or experiences of family support. These findings suggest that multi-faceted interventions are required to promote regular HIV clinic attendance, including on-going education, counselling and support in both clinic and community settings. These interventions also need to recognise the evolving needs of patients that accompany changes in physical health, and should address local beliefs around HIV aetiology. Decentralisation of HIV services to rural communities should be considered.
This global strategy is intended to guide the response of the health sector to HIV epidemics to achieve universal access to treatment, prevention, care and support, improve related health outcomes and strengthen health systems. In order to achieve the twin goals of no new HIV infections and long, healthy lives for all people living with HIV, the strategy takes four steps. First, it reaffirms global goals for the health-sector response to HIV. Second, it proposes four strategic directions to guide national responses and to provide a framework for action by the World Health Organization (WHO). Third, it prioritises five key contributions that underpin the strategic directions and that will be the focus of WHO’s efforts in the next five years. Fourth, it positions the health-sector response to HIV within the broader public health agenda and as part of a multisectoral response to HIV. The strategy is global in scope but recognises differences in types and stages of epidemics, contexts, needs and responses across regions and countries that require targeted and contextual approaches.
Since 2000, access to antiretroviral drugs to treat HIV infection has dramatically increased to reach more than five million people in developing countries. Essential to this achievement was the dramatic reduction in antiretroviral prices, the authors of this paper argue, which was a result of global political mobilisation that cleared the way for competitive production of generic versions of widely patented medicines. Despite these promising changes, a "treatment timebomb" awaits, the authors warn. First, increasing numbers of people need access to newer antiretrovirals, but treatment costs are rising since new ARVs are likely to be more widely patented in developing countries. Second, policy space to produce or import generic versions of patented medicines is shrinking in some developing countries. Third, funding for medicines is falling far short of needs. Expanded use of the existing flexibilities in patent law and new models to address the second wave of the access to medicines crisis are required. One promising new mechanism is the UNITAID-supported Medicines Patent Pool, which seeks to facilitate access to patents to enable competitive generic medicines production and the development of improved products. Such innovative approaches are possible today due to the previous decade of AIDS activism. However, the Pool is just one of a broad set of policies needed to ensure access to medicines for all; other key measures include sufficient and reliable financing, research and development of new products targeted for use in resource-poor settings, and use of patent law flexibilities. Governments must live up to their obligations to protect access to medicines as a fundamental component of the human right to health.
This paper’s objective was to assess the age and gender differences of clients accessing mobile HIV counselling and testing (HCT) compared with clients accessing facility-based testing, and to determine the difference in HIV prevalence and baseline CD4 counts. A prospective observational cross-sectional study was conducted of three different HIV testing services in Cape Town. The researchers compared data on age, sex, HIV status and CD4 counts collected between August and December 2008 from a mobile testing service (known as the Tutu Tester), a primary health care clinic, and a district hospital. A total of 3,820 individuals were tested. Of the HIV-infected individuals from the mobile service, 75% had a CD4 count higher than 350 cells/µl compared with 48% and 32% respectively at the clinic and hospital. Age- and sex-adjusted risk for HIV positivity was 3.5 and 4.9 times higher in the clinic-based and hospital-based services compared with the mobile service. The authors conclude that mobile services are accessed by a different population compared with facility-based services. Mobile service clients were more likely to be male and less likely to be HIV-positive, and those infected presented with earlier disease.
This paper investigated antiretroviral-treatment strategies in the Children with HIV Early Antiretroviral Therapy (CHER) trial. HIV-infected infants 6 to 12 weeks of age with a CD4 percentage of 25% or more were randomly assigned to receive antiretroviral therapy until the CD4 percentage decreased to less than 20% (or 25% if the child was younger than 1 year), specific clinical criteria were met or the child needed to immediately start on limited antiretroviral therapy. The children were followed up after 40 weeks and, after a review by the data and safety monitoring board, some of the infants were reassessed for the initiation of antiretroviral therapy. The paper concluded that early HIV diagnosis and early antiretroviral therapy reduced early infant mortality by 76% and HIV progression by 75%.