There is an urgent need for valid, reliable, and simple-to-use screening tools for HIV-associated dementia (HAD) in South Africa, as little is known about its impact on South Africa's 5.5 million people living with HIV (PLWH). Screening for HAD in South Africa involves several challenges, including a lack of culturally appropriate and validated screening tools and a shortage of trained personnel to conduct screening. This study examined rates of positive HAD screens as determined by the cut-off score on the International HIV Dementia Scale (IHDS) administered by non-specialist community health workers (CHWs) in South Africa and examined associations between positive HAD screens and common risk factors for HAD. Sixty-five HIV-positive individuals on antiretroviral therapy (ART) with low CD4 counts and documented ART adherence problems were administered a battery of demographic, psychiatric and neurocognitive screening measures. Positive HAD screens were present in 80% of the sample. Presence of a current alcohol dependence disorder and CD4 counts of 200 or lower were significantly associated with positive HAD screens. HIV-positive South Africans on ART with low CD4 counts and ART adherence problems may be at a very high risk for HAD, the authors stress, highlighting the need for more routine screening and monitoring of neurocognitive functions among South Africa's millions of PLWH on ART. Future research is needed to validate IHDS performance against a gold standard neurocognitive battery for the detection of HAD and to compare performance of CHWs to expert health care personnel in administering the IHDS.
Equity and HIV/AIDS
This study aimed to improve the Zambia Prisons Service’s implementation of tuberculosis screening and human immunodeficiency virus (HIV) testing. For both tuberculosis and HIV, the authors implemented mass screening of inmates and community-based screening of those residing in encampments adjacent to prisons. They also established routine systems – with inmates as peer educators – for the screening of newly entered or symptomatic inmates. We improved infection control measures, increased diagnostic capacity and promoted awareness of tuberculosis in Zambia’s prisons. In a period of 9 months, the authors screened 7638 individuals and diagnosed 409 new patients with tuberculosis. They tested 4879 individuals for HIV and diagnosed 564 cases of infection. An additional 625 individuals had previously been found to be HIV-positive. Including those already on tuberculosis treatment at the time of screening, the prevalence of tuberculosis recorded in the prisons and adjacent encampments was 18 times the national prevalence estimate of 0.35%. Overall, 22.9% of the inmates and 13.8% of the encampment residents were HIV-positive. Both tuberculosis and HIV infection are common within Zambian prisons. The authors enhanced tuberculosis screening and improved the detection of tuberculosis and HIV in this setting. These observations should be useful in the development of prison-based programmes for tuberculosis and HIV elsewhere.
South African AIDS activist organisations, SECTION27 and the Treatment Action Campaign (TAC), have welcomed the government’s successful new anti-retroviral (ARV) tender, which covers the period 1 January 2011 to 31 December 2012 and will see the state procuring ARVs at the best prices available globally. This is in stark contrast to the previous tender, which resulted in South Africa paying significantly more than necessary for ARVs. For example, South Africa will now be paying – on average – about R115 per patient per month on standard combination treatment of three ARVs, compared to a previous cost of R110 for just one ARV. Also, the price of the paediatric version of abacavir has nearly halved since the last tender. SECTION27 notes, however, that the tender did not include any TDF-containing three-in-one fixed dose combinations, which would allow patients the convenience of taking all their medications in just one pill. The organisation calls for call for greater transparency in future tenders, with more autonomy for the Department of Health and less influence on the tendering process by the Treasury.
HIV and AIDS will slow Africa’s economic growth, but most important it will deplete human capital. Investment is declining as households, businesses and governments increase their recurrent expenditure to compensate for losses and disruptions because of sick or dead individuals. The health system – usually at the forefront in absorbing the impact of HIV and AIDS-related illnesses – is being eroded through the loss of many skilled personnel. Health staff are retiring, leaving for the private sector or other countries and succumbing to AIDS. In high-prevalence countries the epidemic is adversely affecting popular participation through attrition among the politically active age groups. The attrition among government officials and civil service personnel is compromising the state’s ability to implement decisions and policies. The epidemic is also likely to affect popular political opinion and levels of activism by reshaping political priorities and loyalties. But these challenges can be met if governance continues to improve across Africa.
According to this report, despite a broad awareness of HIV, comprehensive knowledge of HIV and how to prevent it is still low, even in countries that have been most affected by the epidemic. There are encouraging signs that HIV-prevention efforts are resulting in positive change in sexual behaviours, accompanied by declines in HIV prevalence among young people in the most-affected countries. This should not be cause for complacency, UNAIDS warns. Instead, these successful services and programmes should be built upon to further efforts to reverse the epidemic among young people. To effectively advance the response among young people, UNAIDS argues that there is a need to increase investments. However, it also cautions that simply directing more resources will not increase HIV testing and uptake of services among young people. Instead, empowering young people and particularly young women to exercise their rights to sexual and reproductive health, improve programmes for young people and repeal national laws and policies that restrict access to HIV services for young people is required to protect future generations from HIV. The report highlights that young people are a key resource to reverse the global AIDS epidemic and lead the response in decades to come, but it stresses that the legal and policy barriers that prevent young people from accessing HIV services must be addressed, and young people should be engaged more effectively in the response.
A one billion rand (US$123 million) shortfall in South Africa's public sector antiretroviral (ARV) programme could jeopardise treatment programmes as soon as September, a health expert has warned. Mark Heywood, deputy chairman of the South Africa National AIDS Council (SANAC), commented on the lack of funding at the relaunch of the National AIDS Charter on 18 June. Among the additions to the charter were an increased focus on vulnerable groups, and the inclusion of traditional leaders and their role in the epidemic. ‘We've made major strides, and one of the strengths of the charter was that it guided our progress on the national strategic framework at a time when people were still stoned to death [...] when kids were still taken out of school and people were chased out of their homes for being HIV-positive,’ Heywood said. ‘But […] we don't actually have ARV treatment for most of the people who need it.’ An estimated 700,000 people are on treatment in South Africa, but an estimated 1,000 die daily as a result of AIDS.
IRIN/PlusNews has put together a list of seven ways in which HIV service providers could cut costs and improve their efficiency. Task-shifting has already seen positive results in Ethiopia, Malawi and Mozambique, but insufficiently trained medical staff can be harmful to national antiretroviral (ARV) programmes. Community support also plays a significant role in HIV education and care in many poor countries where relatives and neighbours often help to monitor patients and raise awareness about HIV. The cost of combination ARV therapy has come down significantly from about US$10,000 per person per year in 2000 to about $88 a year. However, second- and third-line anti-retrovirals are still prohibitively expensive for low-income countries. Simpler drug delivery systems will help reduce the amount of money spent on non-drug-related costs, especially as between two-thirds and 80% of money spent on HIV is related to service delivery, patient monitoring and laboratory costs. Using technology, such as SMS-based check-ups, may help save patients the costs of travelling to a clinic every month. Country ownership and health system integration are also crucial for success in fighting HIV in developing countries.
This article summarises the challenges, opportunities and lessons learned from presentations, discussions and debates addressing major policy and programmatic responses to HIV in six geographical regions, including sub-Saharan Africa. It draws from AIDS 2008 Leadership and Community Programmes, particularly the six regional sessions, and Global Village activities. While the epidemiological, cultural and socio-economic contexts in these regions vary considerably, several common, overarching principles and themes emerged: advancing basic human rights, particularly for vulnerable and most at risk populations; ensuring the sustainability of the HIV response through long-term, predictable financing; strengthening health systems; investing in strategic health information; and improving accountability and the involvement of civil society in the response to AIDS. Equally important is the need to address political barriers to implementing evidence-based interventions such as opioid substitution therapy (OST), needle and syringe programmes (NSPs), comprehensive sexuality education for youth, and sexual and reproductive rights.
This systematic review synthesises the extant research on prevalence, factors associated with, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. Studies were located through electronic databases, grey literature, reference harvesting, and contact with researchers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies that reported on HIV-positive participants (10–24 year olds), included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy), and were conducted in sub-Saharan Africa were included. Forty-two records reported one or multiple sexual practices for 13,536 HIV-positive adolescents/youth from 13 sub-Saharan African countries. Seventeen cross-sectional studies reported on individual, relationship, family, structural, and HIV-related factors associated with sexual risk-taking. However, the majority of the findings were inconsistent across studies, and most studies scored <50% in the quality checklist. Living with a partner, living alone, gender-based violence, food insecurity, and employment were correlated with increased sexual risk-taking, while knowledge of own HIV-positive status and accessing HIV support groups were associated with reduced sexual risk-taking. Of the four intervention studies (three RCTs), three were effective at reducing sexual risk-taking, with one reporting no difference between the intervention and control groups. Sexual risk-taking among HIV-positive adolescents and youth is high, with inconclusive evidence on potential determinants and the authors argue for ffective and feasible low-cost interventions to reduce risk for this group.
This report consolidates all known information about sex work and HIV in Namibia, and aims to provide an objective knowledge base that can inform programming and advocacy efforts. In Namibia, sex work is formally illegal and criminalised. The author found that sex workers are severely affected by HIV (reportedly, around 70-75% HIV prevalence), and they are vulnerable to different health problems. This is compounded by problems in accessing services (i.e. stigma and discrimination), the excessive costs of obtaining services, and the frequent non-availability of drugs and staff. While overall knowledge of HIV seems to be acceptable, problems arise in negotiating condom use with clients, whereas alcohol and violence play an important role in facilitating sexual risk taking.