New national treatment guidelines are set to make the world's largest antiretroviral (ARV) programme even bigger as South Africa extends treatment to more HIV-positive infants, pregnant women and people battling HIV-tuberculosis (TB) co-infection. Dr Nono Simelela, CEO of the South African National AIDS Council (SANAC), confirmed that the revised guidelines were in the final stages of editing and would go to print in March, while implementation is scheduled to begin on 1 April 2010. Major changes to the guidelines include providing ARVs to all HIV-positive infants less than one year old regardless of their CD4 count – which measures immune system strength – without having an expensive polymerase chain reaction (PCR) test that is not widely available at clinics to confirm their HIV status. Pregnant HIV-positive women will be able to start treatment at a new, higher CD4 count of 350, as will all TB/HIV co-infected patients, rather than having to wait until their CD4 counts fell to 200 or below as was previously the case. TB remains the leading cause of death among people living with HIV. The shifts in treatment could significantly reduce infant and maternal mortality due to HIV, and lower the rate of new infections.
Equity and HIV/AIDS
At the XVII International AIDS Conference in Mexico City WHO unveiled a package of priority interventions designed to help low- and middle-income countries move towards universal access to HIV/AIDS prevention, treatment, care and support. The package includes everything from how to expand condom programming to the latest in treatment recommendations, guidelines and standards. The document is intended to help countries with limited resources meet the commitment made two years ago at the UN General Assembly High-Level Meeting on AIDS to provide universal access to HIV prevention, treatment, care and support by 2010.
This study reports on a ten-step Nurse Initiation Management of Antiretroviral Treatment (NIMART) rollout intervention in which 45 nurses from 17 primary healthcare centres (PHCs) in Johannesburg, South Africa, were trained and mentored in NIMART to commence patients on antiretroviral treatment (ART). A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. By the end of September 2011, all 17 PHCs were initiating patients on ART. Total initiations significantly increased by 99 patients immediately after NIMART rollout and continued to increase by an average of 9 every month, while referral facility initiations decreased by 12 immediately after NIMART and then decreased by an average of 18 every month. In conclusion, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, the authors argue that it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients.
Zimbabwe has been widely hailed as a success story in the fight against AIDS since reporting in October 2005 a decline in HIV prevalence among adults from 25% in 2001 to 20% in 2004. In the face of the devastating impact of HIV/AIDS on the country, a declining economy, growing international isolation, decreased funding from international donors for HIV/AIDS prevention and treatment, and a disintegrating public health sector, Zimbabwe’s achievement was indeed significant. Despite the positive news, however, the HIV/AIDS epidemic in Zimbabwe remains a serious crisis with some three hundred and fifty thousand of the 1.6 million people carrying the virus in immediate need of life-saving antiretroviral (ARV) drugs and another six hundred thousand in need of care and support. The paper argues that the progress gained so far could be undermined by policies and practices that violate the rights of people living with HIV/AIDS (PLWHA) and those most at risk of infection.
In this report, Médecins Sans Frontières (MSF) notes that major funders now seem to be withdrawing HIV and AIDS funding to countries like Malawi, Mozambique, Zimbabwe, South Africa, Lesotho, Kenya, Uganda and the Democratic Republic of Congo. According to MSF, PEPFAR has flatlined its funding for 2009-2014 and as of 2008-9, further decreased its annual budget allocations for the coming years by extending the period to be covered with the same amount of money. The World Bank currently prioritises investment in health system strengthening and capacity building in planning and management over HIV-dedicated funding, thereby reducing their support for HIV and AIDS care. In addition, UNITAID is phasing out its funding for drugs and other medical commodity procurement through the Clinton Foundation. By 2012, funding for second-line anti-retrovirals (ARVs) and paediatric commodities should end in Zimbabwe, Mozambique, the Democratic Republic of Congo and Malawi. The Global Fund is also currently facing a serious funding shortfall. To compound the problem further, MSF adds that all current funding scenarios are inadequately reflecting demand, as none includes the additional resources required to implement the new World Health Organization guidelines on earlier treatment and improved drug regimens.
This paper sought to estimate the burden of noncommunicable diseases (NCDs) among people living with HIV (PLHIV) enrolled in HIV care and treatment in Kenya between 2003 and 2013. The authors conducted a nationally representative retrospective medical chart review of HIV-infected adults aged ≥15 years enrolled in HIV care in Kenya from October 1, 2003 through September 30, 2013. The authors estimated proportions of four NCDs categories among PLHIV at enrolment into HIV care, and during subsequent HIV care visits from 3170 records of PLHIV, 2115 of whom were women and just over half from PLHIVs aged above 35 years. Close to two-thirds of PLHIVs were on ART. The proportion of any documented NCD among PLHIV was 11.5%, with elevated blood pressure as the most common NCD. Despite this observation, only 17 patients had a corresponding documented diagnosis of hypertension in their medical record. Overall NCD incidence rates for men and women were and 31.6%, slightly more in men than in women but with no differences in NCD incidence rates by marital or employment status. At one year of follow up 43.8% of PLHIV not on ART had been diagnosed with an NCD compared to 3.7% of patients on ART; at five years the proportions with a diagnosed NCD were 88.8 and 39.2%, respectively. PLHIV in Kenya are thus noted to have a high prevalence of NCD, but in the absence of systematic, effective screening, the NCD burden is likely to be underestimated in this population. The authors recommend that systematic screening and treatment for NCDs using standard guidelines be integrated into HIV care and treatment programs in sub-Saharan Africa.
In settings of armed conflict, traditional HIV prevention programmes that promote risk avoidance via abstinence and fidelity and risk reduction via condom use and needle exchange are not viable. In such contexts, HIV risk depends less on personal choice than on exposure to physical, emotional and structural violence. War in northern Uganda has created three realities (internally displaced people's camps, night commuters and child abductions) which increase vulnerability to HIV transmission. Based upon this analysis of northern Uganda, we offer a conceptual framework for HIV transmission in conflict settings that recognizes the importance of local and global context in creating vulnerability to HIV infection. This framework is then used to delineate strategies for HIV prevention in northern Uganda, namely the provision of a safe physical environment and access to education, medical and psychological support, and the promotion of conflict resolution strategies and human rights law.
The interaction between HIV and AIDS, and nutritional status has been a defining characteristic of the disease since the early years of the epidemic. HIV and AIDS are associated with poor nutritional status and weight loss, and weight loss is an important predictor of death from AIDS. These links suggest that nutrition may have an important role to play in slowing progression of the disease and in contributing to successful antiretroviral (ARV) therapy. HIV and AIDS can also inhibit a person’s ability to secure adequate nutrition through inability to work, loss of appetite or increased need for nutrients as a result of the disease itself. Addressing impact on livelihoods and food security is therefore another important aspect of interventions for HIV and AIDS, and nutrition. This guide reviews the evidence base for current nutrition interventions for HIV and AIDS, and looks at the scientific background, trends and challenges in implementation, and implications for policy and planning.
On 1 December 2011, World AIDS Day, United States (US) President, Barack Obama, pledged to provide antiretroviral treatment to some six million people globally by 2013, an increase of two million on the previous target. However, there will still be no increase in funding from the US President's Emergency Plan for AIDS Relief (PEPFAR), which pledged US$48 billion in 2008 for five years. Consequently, although costs of HIV and AIDS programmes have come down, PEPFAR is having to look at smarter programming and greater efficiencies to increase roll out. PEPFAR noted that the US was also working to persuade other wealthy countries, such as China, Germany and Sweden, to take greater responsibility in the fight against HIV and AIDS. Obama's announcement has been welcomed with cautious optimism in developing countries, who are concerned that the rich countries of the North may not keep their pledges to the Global Fund – the main HIV and AIDS funder for many poor countries – in the current global recession.
In 2008, the Capacity Project partnered with the Lesotho Ministry of Health and Social Welfare in a study of the gender dynamics of HIV and AIDS caregiving in three districts of Lesotho to account for men's absence in HIV and AIDS caregiving and investigate ways in which they might be recruited into the community and home-based care (CHBC) workforce. The researchers used qualitative methods, including 25 key informant interviews with village chiefs, nurse clinicians, and hospital administrators and 31 focus group discussions with community health workers, community members, ex-miners, and HIV-positive men and women. Study participants uniformly perceived a need to increase the number of CHBC providers to deal with the heavy workload from increasing numbers of patients and insufficient new entries. HIV and AIDS caregiving is a gender-segregated job, at the core of which lie stereotypes and beliefs about the appropriate work of men and women. This results in an inequitable, unsustainable burden on women and girls. The authors recommend that HIV and AIDS and human resources stakeholders must address occupational segregation and the underlying gender essentialism and male primacy if there is to be more equitable sharing of the HIV and AIDS caregiving burden and any long-term solution to health worker shortages.