In this paper, the authors describe lifetime prevalence of consensual male–male sexual behaviour and male-on-male sexual violence (victimisation and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. The study was conducted in 2008 and included men aged 18–49 from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces, who provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimisation. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
Equity and HIV/AIDS
Widespread early therapy for HIV is intellectually compelling because it targets viral load, the major biological risk factor for transmission and disease progression. Delaying treatment until HIV has inflicted severe damage on the immune system and further transmission occurs is a different practice to the approach of other infectious diseases such as tuberculosis. Earlier diagnosis and treatment offer opportunity for ‘positive prevention’, emphasising other health interventions, as well as enhancing the sexual and reproductive health and rights of persons living with HIV. Papers published in 2008 suggested anti-retroviral therapy (ART) may be considered a means of limiting HIV spread, as it reduces viral load. One paper reported that annual universal voluntary HIV testing followed by immediate ART could reduce HIV incidence by about 95% within a decade, with cost-saving over the medium term. Nonetheless, the world requires stronger evidence before policy development on ART for HIV prevention can be envisaged.
Recent guidelines recommend that all HIV-infected women should receive highly active antiretroviral therapy throughout pregnancy and lactation, irrespective of whether or not they need it for their own health. This strategy for prevention of mother-to-child transmission (PMTCT) of HIV is more effective than the well-established use of single-dose nevirapine, but it is also a more costly alternative. In this economic evaluation, the researchers used a decision model to combine the best available clinical evidence with cost, epidemiological and behavioural data from Northern Tanzania. It found that a highly active antiretroviral therapy-based PMTCT Plus regimen is more cost effective than the current Tanzanian standard of care with single-dose nevirapine. Although PMTCT Plus is roughly 40% more expensive per pregnant woman than single-dose nevirapine, the expected health benefits are 5.2 times greater. The incremental cost effectiveness ratio of the PMTCT Plus intervention is calculated to be US$4,062 per child infection averted and $162 per disability-adjusted life year.
Criminalisation and legal and policy barriers play a key role in increasing HIV vulnerability for men who have sex with men (MSM) and transgender people, says the World Health Organisation in this report. More than 75 countries currently criminalise same-gender sexual activity and transgender people lack legal recognition in most countries. These legal conditions force MSM and transgender people to risk criminal sanctions if they want to discuss their level of sexual risk with a service provider and also give police the authority to harass organisations that provide services to these populations. Long-standing evidence indicates that MSM and transgender people experience significant barriers to quality health care due to widespread stigma against homosexuality and ignorance about gender variance in mainstream society and within health systems. Social discrimination against MSM and transgender people has also been described as a key driver of poor physical and mental health outcomes in these populations across diverse settings. In addition to being disproportionately burdened by STI and HIV, MSM and transgender people experience higher rates of depression, anxiety, smoking, alcohol abuse, substance use and suicide as a result of chronic stress, social isolation and disconnection from a range of health and support services.
Despite recognition of gender in Tanzania’s political arena and prioritization of prevention of mother to child transmission (PMTCT) by the health sector, there is very little information on how well gender has been mainstreamed into National PMTCT guidelines and organizational practices at service delivery level. Using a case study methodology, the authors combined document review with key informant interviews to assess gender mainstreaming in PMTCT on paper and in practice in Tanzania. The authors reviewed PMTCT policy/strategy documents using the World Health Organisation’s Gender Responsive Assessment Scale. The scale differentiates between level 1 to 5. Key informant interviews were conducted with 26 leaders purposively sampled from three government health facilities in Mwanza city to understand their practices. The gender responsiveness of PMTCT policy/strategy documents varies. Those which are gender sensitive indicate gender awareness, but with no remedial action developed; while those which are gender specific go beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. The interviews suggested that there has been little attention to the holistic integration of gender in the delivery of PMTCT services.
This cross-sectional facility-based survey was based on 70 structured face-to-face interviews combined with qualitative research that included two focus group discussions with pregnant women and five in-depth interviews with providers at antenatal care clinics in Marondera. Studies elsewhere have shown that the greatest barriers to the use of PMTCT services are linked to socio-cultural beliefs and influences, including fear of discrimination associated with testing and being HIV positive, and negative perceptions about the effectiveness of anti-retrovirals. None of these barriers were raised by participants in this study. Instead the main barriers were linked to the health system’s failure to meet the needs of pregnant women. Thus, SHIELD concludes, the main reasons why women cannot access PMTCT services are barriers faced in accessing antenatal services, including the cost and acceptability of these services. SHIELD makes a number of recommendations: remove or reduce the cost of antenatal care and delivery user fees for pregnant women, increase women’s access to reliable information, improve the quality of services, and provide training courses for health workers about how to engage with patients in a more acceptable manner.
The objective of this article is to describe the results of a 2-year pilot programme implementing prevention of mother to child HIV transmission (PMTCT) in a refugee camp setting. Interventions used were: community sensitization, trainings of healthcare workers, voluntary counselling and HIV testing (VCT), infant feeding, counselling, and administration of Nevirapine. Main outcome measures include: HIV testing acceptance rates, percentage of women receiving post test counselling, Nevirapine uptake, and HIV prevalence among pregnant women and their infants. Ninety-two percent of women (n=9,346) attending antenatal clinics accepted VCT. All women who were tested for HIV received their results and posttest counselling. The HIV prevalence rate among the population was 3.2%. The overall Nevirapine uptake in the camp was 97%. Over a third of women were repatriated before receiving Nevirapine. Only 14% of male counterparts accepted VCT. Due to repatriation, parent's refusal, and deaths, HIV results were available for only 15% of infants born to HIV-infected mothers. The PMTCT programme was successfully integrated into existing antenatal care services and was acceptable to the majority of pregnant women. The major challenges encountered during the implementation of this programme were repatriation of refugees before administration of Nevirapine, which made it difficult to measure the impact of the PMTCT programme.
The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010, and this may be an overestimation as it does not measure completion. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care, HIV testing, and ARVs for the woman and the baby. This study was based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008–2010. Using modelling, it was estimated that HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction. The results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT.
This paper provided an estimated use and outcomes of the Malawian programme for the prevention of mother-to-child transmission of human immunodeficiency virus. In a cross-sectional analysis of 33 744 mother–infant pairs, the authors estimated the weighted proportions of mothers who had received antenatal human immunodeficiency virus testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or human immunodeficiency virus testing. The authors calculated the ratios of mother-to-child transmission at 4–26 weeks postpartum for subgroups that had missed none or at least one of these four steps. The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant human immunodeficiency virus testing was 53.2%. Estimated ratios of mother-to-child transmission were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed human immunodeficiency virus testing and infant prophylaxis than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis and infant testing than women who had. Most women used the Malawian programme for the prevention of mother-to-child transmission. The risk of mother-to-child transmission increased if any of the main steps in the programme were missed.
You Can Count on Me is a Pepfar-funded programme in South Africa that aims to change men’s behaviour and to educate them about the prevention of HIV transmission from mother to child (PMTCT). The programme trains men to understand what HIV is, how it’s transmitted, how to prevent it in the general population, to protect babies from getting it and to help their partners along the journey of pregnancy. Model students in these workshops are then selected to train other men across the nine provinces. Approximately 10,000 men have been reached through face-to-face community meetings. The programme provides support for men to become involved in the pregnancy of their partners, as it regards men’s sexual behaviour as one of the main drivers of the HIV and AIDS epidemic in southern Africa.