The paper describes the effects of HIV and AIDS on each of the MDGs in turn. This approach does not attempt to capture all the interactions among these development outcome measures.
Equity and HIV/AIDS
Putting it together: AIDS and the Millennium Development Goals
Quarterly report antiretroviral treatment programme in Malawi with results up to 30 September 2009
Malawi Department of Health: 2009
By the end of September 2009, there were 236 static ART clinics in Malawi in the public and private health sector; 22 of these static clinics provided ART at a total of 103 outreach or mobile sites, bringing the total to 339 ART service delivery points in Malawi in Q3 2009. In the third quarter of 2009 (July to September) a total of 18,292 new patients initiated ART and 3,030 ART patients transferred between clinics, resulting in a total of 21,322 ART clinic registrations (39% male, 61% female; 91% adults and 9% children). Improved integration of the supervision system for the public and private sector has led to a revision of previous M&E data in the private sector and patient outcomes in the private sector are similar to those in the public sector. The National programme has been affected by serious ARV drug supply shortage during Q3 due to the delayed release of funding and the ensuing logistical complications resulting in widespread drug re-allocations between sites. However a targeted survey revealed that patients were affected only in isolated cases, requiring regimen changes or short-term treatment interruption.
Rapid advice: Antiretroviral therapy for HIV infection in adults and adolescents
World Health Organization: 30 November 2009
In 2006, the World Health Organization (WHO) recommended that all patients start anti-retroviral therapy (ART) when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms. WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives. The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.
Rapid advice: Infant feeding in the context of HIV
World Health Organization: 30 November 2009
World Health Organization (WHO) recommendations on infant feeding and HIV were last revised in 2006. Significant programmatic experience and research evidence regarding HIV and infant feeding have accumulated since then. In particular, evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding. This has major implications for how women living with HIV might choose to feed their infants, and how health workers should counsel mothers when making these choices. The potential of ARVs to reduce HIV transmission throughout the period of breastfeeding also highlights the need for guidance on how child health services should commu¬nicate information about ARVs to prevent transmission through breastfeeding, and the implications for feeding of HIV exposed infants through the first two years of life.
Rapid advice: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants
World Health Organization: 30 November 2009
In 2006, the World Health Organization (WHO) recommended that ARVs be provided to HIV-positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother-to-child transmission of HIV. At the time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period. WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs during that period. This will reduce the risk of HIV transmission and improve the infant's chance of survival. ‘In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs,’ said Daisy Mafubelu, WHO's Assistant Director General for Family and Community Health. National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.
Rapid implementation of an integrated large-scale HIV counselling and testing, malaria and diarrhoea prevention campaign in rural Kenya
Lugada E, Millar D, Haskew J, Grabowsky M, Garg N, Vestergaard M et al: PLoS One 5(8), 6 August 2010
This study is based on a one-week integrated multi-disease prevention campaign in Lurambi, Western Kenya. The aim was to offer services to at least 80% of those aged 15-49. Thirty-one temporary sites in strategically dispersed locations offered: HIV counselling and testing, 60 male condoms, an insecticide-treated bed net, a household water filter for women or an individual filter for men, and, for those testing HIV+, a three-month supply of cotrimoxazole and referral for follow-up care and treatment. Over seven days, 47,311 people attended the campaign with a 96% uptake of the multi-disease preventive package. Of these, 99.7% were tested for HIV (80% had previously never tested), of whom 4% tested positive. Three-hundred and eighty-six certified counsellors attended to an average of 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age and tended to correlate with an ended marriage and unemployment. Always using condoms with a non-steady partner was more common among HIV-infected women participants who knew their status compared to those who did not. The study concludes that integrated campaigns can efficiently cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services to help achieve various national and international health development goals.
Rationing Antiretroviral Therapy for HIV/AIDS
In the past three years, expanding access to antiretroviral therapy (ART) for HIV/AIDS has become a global objective and a national priority for many countries in sub-Saharan Africa. Large-scale treatment programs have been launched in countries spanning the continent from Lesotho to Ghana, paid for by domestic funds mobilized by African governments and by international donor contributions. While these funds, which reach into the billions of dollars, will pay for ART for many thousands of HIV-positive Africans, there is almost no chance that African countries will have the human, infrastructural, or financial resources to treat everyone who is in need.
rationing antiretroviral therapy for HIV/AIDS in Africa
As the world intensifies its fight against the global AIDS epidemic, African countries have begun to develop largescale prevention and treatment programmes. A combination of funds from African governments and international donors are paying for drugs, diagnostics, clinic and laboratory infrastructure, and medical personnel. Although these funds, which reach into the billions of dollars, will pay for antiretroviral therapy for many thousands of HIV-positive Africans, there is almost no chance that African countries will have the human, infrastructural, or financial resources to treat everyone who is in need, at least in the early years.
Reasons for loss to follow-up among mothers registered in a prevention-of-mother-to-child transmission program in rural Malawi
Bwirire LD, Fitzgerald M, Zachariah R, Chikafa V, Massaquoi M, Moens M, Kamoto K, Schouten EJ: Transactions of the Royal Society of Tropical Medicine and Hygiene, 16 May 2008
This study was conducted to identify reasons for a high and progressive loss to follow-up among HIV-positive mothers within a prevention-of-mother-to-child HIV transmission (PMTCT) program in a rural district hospital in Malawi. Three focus group discussions were conducted among a total of 25 antenatal and post-natal mothers as well as nurse midwives (median age 39 years, range 22–55 years). The main reasons for loss to follow-up included: not being prepared for HIV testing and its implications before the antenatal clinic (ANC) visit; fear of stigma, discrimination, household conflict and even divorce on disclosure of HIV status; lack of support from husbands who do not want to undergo HIV testing; the feeling that one is obliged to rely on artificial feeding, which is associated with social and cultural taboos; long waiting times at the ANC; and inability to afford transport costs related to the long distances to the hospital. This study reveals a number of community- and provider-related operational and cultural barriers hindering the overall acceptability of PMTCT that need to be addressed urgently. Mothers attending antenatal services need to be better informed and supported, at both community and health-provider level.
Reasons for poor adherence to antiretroviral therapy postnatally in HIV-1 infected women treated for their own health: experiences from the Mitra Plus study in Tanzania
Ngarina M, Popenoe R, Kilewo C, Biberfeld G and Ekstrom AM: BMC Public Health 13(450), 7 May 2013
In a study of prevention of mother-to-child transmission of HIV (PMTCT) by triple antiretroviral therapy (ART) in Dar es Salaam, Tanzania (the Mitra Plus study), retrospective viral load testing revealed a high and increasing frequency of detectable viral load during follow-up for two years postnatally in women given continuous ART for their own health suggesting poor adherence. This study explored women’s own perceived barriers to adherence to ART post-delivery so as to identify ways to facilitate better drug adherence. Semi-structured interviews were conducted with 23 of the 48 women who had detectable viral load at 24 months postnatally. Most women in the study did not acknowledge poor adherence until confronted with the viral load figures. Then they revealed multiple reasons for failing to adhere to ART, which included lack of motivation to continue ART after weaning the child, poverty and stigma. PMTCT and ART projects need to address these issues, as well as women’s lack of empowerment. The authors argue that the new World Health Organisation’s proposal to start all HIV-infected pregnant women on lifelong ART regardless of CD4 cell count needs to address the challenging realities of women in resource-poor contexts if it is to be successful.