In this report, the UNAIDS Advisory Group strongly affirms that sex workers and their organisations play a crucial role in confronting HIV and in many places have an outstanding record in helping to achieve universal access. However, sex workers usually face human rights violations and struggle to access HIV and other health and social services. Stigma and discrimination within society results in repressive laws, policies and practices against sex work, as well as their economic disempowerment. Violence against sex workers is too often committed with impunity by state and civilian actors, exacerbating sex workers’ HIV vulnerability. They are often excluded from access to benefits and financial services available to the general population and prevented from forming organisations that enable economic empowerment and social inclusion. In this report, the Advisory Group argues it it necessary for sex workers to enjoy universal access to HIV services, highlighting good practices that enhance human rights protections for sex workers in the hope that the information presented here will help shape programmes and policies on HIV and sex work that are truly human rights-based.
Equity and HIV/AIDS
For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, the authors based their intervention on an existing evidence-based framework for successful community health worker (CHW) programmes. To assess CHWs’ experiences delivering the intervention, they conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study explored community health workers’ perceptions of how the intervention’s structure and management affected their performance, and considers implications for the programme’s future scale-up and adoption in other settings. Community health workers expressed strong motivation, commitment and job satisfaction. Intensive supervision and mentoring emerged as critical to ensuring community health workers long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and community health workers. Concerns raised by community health workers included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful community health workers programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies.
Three countries in Southern Africa have the highest adult HIV prevalence in the world: Swaziland (25.9%), Botswana (24.8%), and Lesotho (23.6%). Fiscal policy is crucial for addressing this HIV and AIDS crisis, according to the African Development Bank (ADB). Utilising a calibrated model, this paper investigates the impact of fiscal policy on reducing the HIV and AIDS incidence rates in these countries. In particular, ADB studied the welfare impact of different taxation and debt paths in these countries in reducing the HIV and AIDS prevalence rates. Results showed that tax policies that were associated with reduced HIV rates not only had positive societal effect but also positive fiscal effects.
It is commonly asserted that the sub-Saharan African HIV/AIDS epidemic is predominantly due to heterosexual transmission. However, recent re examination of the available evidence strongly suggests that unsafe health care is the more likely vector. The present report adds to the evidence for health-care transmission by showing that Kenyan women who received prophylactic tetanus toxoid injections during pregnancy are 1.89 times (95% confidence interval [CI]:1.03-3.47) more likely to be HIV-1 seropositive than women who did not receive this vaccination. In contrast, recent sexual behaviour (condom use, number of partners) was not related to HIV status. The results are consistent with health care being a very important vector for HIV in sub-Saharan Africa.
The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which researchers examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilisation of maternity services. From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up of whom 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews were conducted with community health workers, childbearing women and family members. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery. These findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.
The primary purpose of this study was to assess the role, status and scope of workplace HIV/AIDS committees as a means of effective workplace governance of the HIV/AIDS impact, and their role in extending social protective HIV/AIDS-related rights to employees. In-depth qualitative case studies were conducted in five South African small and medium-sized enterprises (SMEs) that were actively implementing HIV/AIDS policies and programmes. Companies commonly implemented HIV/AIDS policies and programmes through a workplace committee dedicated to HIV/AIDS or a generic committee dealing with issues other than HIV/ AIDS. Management, through the human resources department and the occupational health practitioner often drove initial policy formulation, and had virtually sole control of the HIV/AIDS budget. Employee members of committees were mostly volunteers, and were often production or blue collar employees, while there was a notable lack of participation by white-collar employees, line management and trade unions. While the powers of workplace committees were largely consultative, employee committee members often managed in an indirect manner to secure and extend social protective rights on HIV/AIDS to employees, and monitor their effective implementation in practice. In the interim, workplace committees represented one of the best means to facilitate more effective workplace HIV/AIDS governance. However, the increased demands on collective bargaining as a result of an anticipated rises in AIDS-related morbidity and mortality might prove to be beyond the scope of such voluntary committees in the longer term.
After a late start and poor initial performance, the South African Prevention of Mother-To-Child Transmission (PMTCT) programme achieved rapid progress in achieving effective national-scale implementation of a complex intervention across a large number of different geographic and socioeconomic contexts. This study shows how quality-improvement methods played a significant part in PMTCT improvements. The South African rollout of the PMTCT programme underwent significant evolution, from a largely ineffective, context-insensitive, top-down cascaded training approach to a sophisticated bottom-up health systems’ intervention that used modern adaptive designs. Several demonstration projects used quality-improvement methods to improve the performance of the PMTCT programme. These results prompted a national redesign of key elements of the PMTCT programme which were rapidly scaled up across the country using a unified, simplified data-driven approach. The scale up of the quality-improvement approach contributed to a dramatic fall in the nationally reported transmission rate for mother to child transmission of HIV. By 2012, measured infection rate of HIV-exposed infants at around 6 weeks after birth was 2.6%, close to the reported transmission rates under clinical trial conditions. Quality-improvement methods can be used to improve reliability of complex treatment programmes delivered at primary-care level. Rapid scale up and effective population coverage can be accomplished through a sequence of demonstration, testing and rapid spread of locally tested implementation strategies supported by real-time feedback of a simplified indicator dataset and multilevel leadership support.
The objective of this study was to gain a greater understanding of published safety data for candidate vaginal microbicides. It systematically reviewed twenty-one human safety trials in peer-reviewed journals, involving the use of 11 vaginal microbicides by a total of 1,465 women. There were few findings of significant difference between women in active and control arms of trials. Confidence intervals in the analyses were generally very wide, and most studies were unable to exclude differences of a substantial magnitude between treated and control women. Larger and longer safety studies are necessary to detect clinically important toxicities, including those that indicate a potential increase in HIV risk, before they are ready for large-scale effectiveness trials and use in the public sector.
Limited information about symptom prevalence exists about HIV infected persons in South Africa, in particular in the context of antiretroviral treatment (ART). The aim of this study was to assess HIV symptoms and demographic, social and disease variables of people living with HIV in South Africa. In 2007, 607 people living with HIV or AIDS (PLWHAs), sampled by all districts in the Eastern Cape Province and recruited through convenience sampling, were interviewed by PLWHAs at health facilities, key informants in the community and support groups. Symptom assessment provided information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life. Because of the high levels of symptoms reported (26.1 symptoms out of a possible 64), the results imply an urgent need for effective health care, home- and community-based and self-care symptom management.
In late 2003, largely as a result of pressure exerted by TAC, the government formally committed itself to rolling out HIV treatment. This policy shift has posed several questions related to TAC’s interim and long term political future, given the reality of the roll-out. Will the ‘centre fail to hold’ as factions emerged in the politically ‘broad umbrella’ social movement that is TAC? Will it simply become a service-delivery focused NGO working for the Department of Health? Will the government’s commitment to HIV treatment policy reform lead to TAC’s co-option? Will it render itself obsolete through its own success lobbying for wider HIV treatment access?