The first new trial of a potential vaccine against HIV in seven years has begun in South Africa, raising hopes that it will help bring about the end of the epidemic. Although fewer people are now dying from Aids because 18.2 million are on drug treatment for life to suppress the virus, efforts to prevent people from becoming infected have not been very successful. The infection rate has continued to rise and experts do not believe the epidemic will be ended without a vaccine. The vaccine being tested is a modified version of the only one to have shown a positive effect, out of many that have gone into trials. Seven years ago, the vaccine known as RV144 showed a modest benefit of about 31% in a trial in Thailand. The aspiration is to push the effectiveness up from 31% to between 50% and 60% for use in combination with other prevention tools, such as condoms, antiretroviral drugs and circumcision. According to Professor Linda-Gail Bekker, of the University of Cape Town, “We’ve never treated our way out of an epidemic. There’s no doubt we have to have primary prevention alongside treatment in order to get HIV control, but we are not going to get HIV eradication without a vaccine. That is very clear.”
Equity and HIV/AIDS
In this study, researchers aimed to assess the prevalence of primary resistance in six African countries after anti-retroviral therapy (ART) roll-out and to determine if wider use of ART in sub-Saharan Africa is associated with rising prevalence of drug resistance. They conducted a cross-sectional study in antiretroviral-naive adults infected with HIV-1 who had not started first-line ART, recruited between 2007 and 2009 from 11 regions in Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe. Of a total of 2,590 participants, 2,436 (94.1%) had a pretreatment genotypic resistance result. Drug class-specific resistance prevalence was 2.5% for nucleoside reverse-transcriptase inhibitors (NRTIs), 3.3% for non-NRTIs (NNRTIs), 1.3% for protease inhibitors, and 1.2% for dual-class resistance to NRTIs and NNRTIs. The most common drug-resistance mutations were K103N (1.8%), thymidine analogue mutations (1.6%), M184V (1.2%), and Y181C/I (0.7%). The higher prevalence of primary drug resistance in Uganda than in other African countries is probably related to the earlier start of ART roll-out in Uganda, the authors conclude. Resistance surveillance and prevention should be prioritised in settings where ART programmes are scaled up.
HIV-positive children are at high risk of drug resistance, which is of particular concern in settings where antiretroviral options are limited. In this review, the authors explore resistance rates and patterns among children in developing countries in whom antiretroviral treatment has failed. They did a systematic search of online databases and conference abstracts and included studies reporting HIV-1 drug resistance after failure of first-line paediatric regimens in children (<18 years) in resource-poor regions (Latin America, Africa and Asia). They retrieved 1,312 citations, of which 30 studies reporting outcomes in 3,241 children were eligible. Viruses with resistance-associated mutations were isolated from 90% of children. The prevalence of mutations associated with nucleoside reverse transcriptase inhibitors was 80%, with non-nucleoside reverse transcriptase inhibitors was 88%, and with protease inhibitors was 54%. Methods to prevent treatment failure, including adequate paediatric formulations and affordable salvage treatment options are urgently needed, the authors conclude.
This study reports on HIV-free survival among nine- to 24-month-old children born to HIV-positive mothers in the national prevention of mother-to-child transmission (PMTCT) programme in Rwanda. Researchers conducted a national representative household survey between February and May 2009. Participants were mothers who had attended antenatal care at least once during their most recent pregnancy, and whose children were aged nine to 24 months. They found that out of 1,448 HIV-exposed children surveyed, 44 (3%) were reported dead by nine months of age. Of the 1340 children alive, 53 (4%) tested HIV positive. HIV-free survival was estimated at 91.9 % at nine to 24 months. Adjusting for maternal, child and health system factors, being a member of an association of people living with HIV improved by 30% HIV-free survival among children, whereas the maternal use of a highly active antiretroviral therapy (HAART) regimen for PMTCT had a borderline effect. HIV-free survival among HIV-exposed children aged nine to 24 months is estimated at 91.9% in Rwanda. The national PMTCT programme could achieve greater impact on child survival by ensuring access to HAART for all HIV-positive pregnant women in need, improving the quality of the programme in rural areas, and strengthening links with community-based support systems, including associations of people living with HIV.
Some HIV-positive people in Kenya are selling their antiretroviral drugs to buy food. Some people register at more than one treatment site so they can obtain extra drugs, which they then sell, Patricia Asero, a member of the Kenya Treatment Access Movement, said. She added that some HIV-positive people who get their antiretroviral drugs from a single treatment site sometimes sell their medications to buy food. These trends have raised concerns about drug-resistant strains of the virus developing in Kenya.
Kaposi's sarcoma (KS), an HIV-related cancer, is neglected in HIV and AIDS services in Africa, according to Medicines Sans Frontiers (MSF). How to administer chemotherapy at a small rural clinic is just one of the many difficulties faced by health workers treating patients with KS at 10 health facilities run by Medicines Sans Frontiers (MSF) in the Chiradzulu district of southern Malawi. Other challenges are the lack of infrastructure and safety equipment for injection-driven chemotherapy, poor case management and problematic drug supplies. MSF research, which was presented at the meeting of the Rural Doctors Association of Southern Africa (RuDASA) in Swaziland in August, found that about 7% of 11,100 ARV patients surveyed in Thyolo district had KS. Dr Francois Venter, head of the Southern African HIV Clinicians Society, said that the incidence rate in Africa is still lower than developed countries, but because of the sheer number of patients and because they present so late for treatment, KS remains an ever-present danger. He noted that the cancer was difficult to manage even in better-resourced healthcare settings like academic hospitals. MSF is now planning to train palliative care teams to handle difficult cases, and to develop a protocol to guide health workers regarding the special needs of KS patients, including how to dress lesions.
Ten per cent of individuals infected with TB develop the active disease but this is greatly increased in those whose immune systems have been weakened by HIV. This report from the Forum for Collaborative HIV Research highlights the difficulty in managing the co-epidemic of HIV and TB that is rapidly spreading in Sub-Saharan Africa. The report concludes that strategies for dealing with TB and HIV currently exist in isolation, often reinforced by vertical programme financing. Efforts must be made to integrate these disease treatment programmes that will involve stakeholders working together within an evidence-based collaborative framework.
By the end of 2000, over 36 million men, women and children around the world were living with HIV or AIDS and nearly 22 million had died from the disease. The same year saw an estimated 5.3 million new infections globally and 3 million deaths, the highest annual total of AIDS deaths ever. Currently, there are 15,000 new infections every day. AIDS is now the number one killer in Africa. This Guide, which is intended to supplement IPPF’s Advocacy Guide, describes what advocacy can do, often at little cost, in the prevention of HIV/AIDS.
Public health services are becoming increasingly important in Kenya, where more than 2.5 million people are living with HIV/AIDS. This paper in the International Journal for Equity in Health highlights the socio-economic impacts of HIV/AIDS on women. Two separate data sets from Western Kenya, one being quantitative and another qualitative data have been used. The authors argue that the socio-cultural beliefs that value the male and female lives differently lead to differential access to health care services. The position of women is exacerbated by their low financial base especially in the rural community where their main source of livelihood, agricultural production does not pay much. But even their active involvement in agricultural production or any other income ventures is hindered when they have to give care to the sick and bedridden friends and relatives. This in itself is a threat to household food security.
The HIV/AIDS epidemic in sub-Saharan Africa is deeply affecting rural livelihoods. The loss of adults of a working age means lower agricultural production, more households being headed by elderly people or children, and a breakdown in transmission of agricultural skills. The innovative experiences of non-governmental organisations (NGOs) in responding to these needs have rarely been documented or disseminated.