Sustainable HIV prevention possibilities present choices, challenges

via Science Speaks, by Antigone Barton

When he looks at what biomedical science can do in the next decade to prevent HIV transmission, Jim Turpin of the National Institutes of Health said, he thinks of the lyrics of a Timbuk3 song: “The future’s so bright I gotta wear shades.”

By, which, actually, he means — don’t get blinded by the light; the search for answers will require focus.
“The challenge is not the lack of options,” he said, “but prioritizing the best options.”

Turpin, program officer and branch chief in the Prevention Sciences Program in the Division of AIDS at NIH”s  National Institute of Allergy and Infection Disease spoke this morning in webinar titled “The HIV Prevention Pipeline: A Future of Possibilities.” The webinar was sponsored by the International Rectal Microbicide Advocates (IRMA) and AVAC Global Advocacy for HIV Prevention.

After a series of disappointments in the quest for a vaccine or microbicide to prevent HIV transmission, the last two years offered hope, in strategies using antiretroviral medicine to prevent acquiring HIV, organizers point out. But, with a diversity of prevention needs and challenges among women and men worldwide still demanding answers, is that all there is?

Or, as Turpin put it, “Do we currently have what it takes to create a sustainable prevention pipeline?”

Read the rest.


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Views of policymakers, healthcare workers and NGOs on HIV pre-exposure prophylaxis (PrEP): a multinational qualitative study

[This is of great interest to the Mapping Pathways team as our work is quite similar. Very interesting!]


via British Medical Journal, by Ana Wheelock, Andreas B Eisingerich, Gabriela B Gomez, Emily Gray, Mark R Dybul, Peter Piot

Abstract

Objectives To examine policymakers and providers' views on pre-exposure prophylaxis (PrEP) and their willingness to support its introduction, to inform policy and practice in this emerging field.

Design Semistructured qualitative interview study.

Setting Peru, Ukraine, India, Kenya, Uganda, Botswana and South Africa.

Participants 35 policymakers, 35 healthcare workers and 21 non-governmental organisation representatives involved in HIV prevention.

Results Six themes emerged from the data: (1) perceived HIV prevention landscape: prevention initiatives needed to be improved and expanded; (2) PrEP awareness: 50 of 91 participants had heard of PrEP; (3) benefits of PrEP: one component of the combination prevention arsenal that could help prioritise HIV prevention, empower key populations and result in economic gains; (4) challenges of PrEP: regimen complexity, cost and cost-effectiveness, risk compensation, efficacy and effectiveness, stigmatisation and criminalisation, information and training and healthcare system capacity; (5) programmatic considerations: user eligibility, communication strategy, cost, distribution, medication and HIV testing compliance and (6) early versus late implementation: participants were divided as to whether they would support an early introduction of PrEP in their country or would prefer to wait until it has been successfully implemented in other countries, with around half of those we spoke to supporting each option. Very few said they would not support PrEP at all.

Conclusions Despite the multiple challenges identified, there was general willingness to support the introduction of PrEP. Yet, strengthening existing HIV prevention efforts was also deemed necessary. Our results suggest that an effective PrEP programme would be delivered in healthcare facilities and involve non-governmental organisations and the community and consider the needs of mobile populations. Comprehensive information packages and training for users and providers would be critical. The cost of PrEP would be affordable and possibly segmented. Extensive counselling and innovative monitoring measures ought to be considered.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

High HIV Prevalence Calls for Stronger Commitment Towards Treatment and Care in Thailand

via Press Tv Bangkok, by Sonia Labboun

The concern is that the disease is increasingly affecting youngsters; about 25% of the total diagnosed patients are in the working group aged between 30-34 years old.

Experts say that schools and universities lack the means to give a proper education about the dangers of HIV and how the disease is transmitted, making this group age an ideal focal for its spread.

In a move to show the government's commitment to combat the disease, the National Health Security Office has announced a subsequent budget of nearly $100 million for HIV care and treatment and is already planning to increase the amount to almost $114 million for 2013.

In a major blow to global pharmaceutical firms, Thailand issued licenses for cheap HIV drugs between 2006 and 2008, a move that has angered industries from the US, Germany and Switzerland who until recently had the monopoly in HIV treatments.

Recently The world bank has pointed out at the fiscal burden of HIV, they say it shouldn't be considered only as a health problem, but also as an economic problem because of the huge costs in treating patients, highlighting as well the importance of effective prevention in order to lessen future costs.

In early 1990s, Thailand has overcome predictions that four million of the 65 million population could become infected by 2000 thanks to successful Aids education and prevention campaign that the current government wishes to revive.

The government is concerned that even though a cheap alternative for HIV treatments is available, the number of new infections is still rising. Experts blame it on poor education at schools and lack of prevention campaign in the media; deficiencies which the current government has promised to take action on."

Check out a video here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

CROI 2012: Researchers Compare Differences in Progession to AIDS Between Races

via POZ Treatment News, by Tim Horn

Some sobering news from the Women’s Interagency HIV Study (WIHS): Black women living with HIV are more likely to progress to AIDS and twice as likely to die of its complications compared with white women living with HIV, according to new results from the cohort presented Tuesday, March 6, at the 19th Conference on Retroviruses and Opportunistic Infections in Seattle. Though black women were significantly less likely to adherence to antiretroviral (ARV) therapy in the analysis, their risk of AIDS-related deaths were still significantly higher after accounting for this.

Eighty percent of HIV infections globally occur in women and people of African descent, but the majority of studies on antiretroviral (ARV) therapy have been conducted in men of European descent, Kerry Murphy, MD, of Albert Einstein College of Medicine in New York and her WIHS colleagues explained in their introduction comments.

Though previous data from the WIHS—one of the largest and longest cohort studies following women living with HIV in the United States—pointed to better survival among white women in the United States, the finding was not statistically significant, at least not when the results were published in 2005. The study has been under way since 1993, with sites in Brooklyn, the Bronx, Chicago, Los Angeles, Northern California and Washington, DC.

With additional follow-up data now available, the WIHS researchers again revisited potential associations between race, AIDS-related deaths, non-AIDS related deaths and the new AIDS-related illnesses in the cohort.

Included in the analysis reported by Murphy and her colleagues at CROI were 1,471 women living with HIV on continuous ARV therapy.

Compared with white women in the cohort, black women were twice as likely to die of an AIDS-related complication. This finding was statistically significant and accounted for other known predictors of AIDS death, including high depression scores, high pre-treatment viral loads, low pre-treatment CD4 cell counts, hepatitis C coinfection and a history of illicit drug use.

Read the Rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

The Impact 'Treatment as Prevention' has on HIV Incidence in Africa

via AidsMap.com, by gus Cairns

A longitudinal study from KwaZulu Natal province in South Africa is the first study from the global south to relate an increase in the proportion of adults on HIV treatment to a fall in HIV incidence, the 19th Conference on Retroviruses and Opportunistic Infections was told last week.

The study found evidence of a threshold effect; incidence started to fall once the proportion of all adults diagnosed with HIV in the area who were on treatment exceeded 30%.

Meanwhile, a study that took place in a week-long intensive health campaign in Uganda, as well as studies from areas as diverse as San Francisco and Swaziland, documented large increases in the proportion of people with HIV who are on treatment.

Falls in incidence in KwaZulu Natal

National surveys in South Africa have found evidence of significant falls in HIV incidence in recent years, but have related this to behavioural change rather than treatment. In the study presented at CROI, of a rural area of northern KwaZulu Natal centred on the mining town of Somkhele (Tanser), the researchers found a relationship between HIV treatment and a fall in infections.

They made use of a population-based HIV surveillance survey that has sampled 10,000 adults a year from 2004 onwards, by identifying 16,558 people who had taken at least two HIV tests during this period in order to gauge incidence rates. They then compared these data to individually linked data from the district-based HIV treatment and care programme.

Adult HIV prevalence in the area is high – 24%. The rate of new infections peaks at 8% a year in women in their early 20s and 5% a year in men in their late 20s. HIV testing rates are also high; researchers estimate that only 30% of the HIV-positive population is undiagnosed, a low proportion for Africa, and 75% of HIV-negative adults who have tested for HIV have done so more than once.

Since 2004, there has been a huge scale-up of HIV treatment, with 20,000 patients starting antiretroviral therapy since then, and by 2001 more than 40% of all adults diagnosed with HIV were on antiretroviral therapy (ART), and over 60% with a baseline CD4 count below 350 cells/mm3. HIV treatment at this CD4 threshold was only introduced in August 2011; previous to this it was 200 cells/mm3.

HIV incidence between 2004 and 2011 averaged 2.64% a year but was lower after 2009, when for the first time more than 30% of the diagnosed population was on ART. It was 3.0 to 3.5% 2007-09 but fell to 2.5% in 2010 and 2.0% in 2011.

After adjusting for HIV prevalence in the immediate area and demographic and behavioural variations, the researchers found that for every 10% increase in the proportion of adults on ART, the HIV incidence rate fell by 17%. Incidence was 40% lower when over 30% of the adult population was treated than when fewer than10% were. 

Read the Rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Uganda Needs to Re-Discover its Prevention Success of the 1990s

via AllAfrica.com, by Henry Zakumumpa

"The trouble for us in Uganda is that we are falling behind in global efforts to rein in new HIV infection rates an endeavor we were renowned for in the 1990s.

What is troubling is that many more people in Uganda are going to need AIDS treatment because of the spike in new HIV infections, driven primarily by married couples, but also because people with HIV/AIDS are now living longer, at a time when western donor countries are actually cutting AIDS funding.

Many AIDS treatment centres in Uganda are already turning away new patients due to donor funding caps, with some centres tragically sharing drugs amongst their patients. What is going to happen when thousands of Ugandans newly require AIDS treatment and they are turned away at treatment centres?

Sadly, Uganda's losing HIV prevention effort is out of step with the rest of the world where prevalence is actually going down. Even the worse- hit Southern African countries have registered a 25% reduction in HIV prevalence according to UNAIDS."

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Experts say HIV programs should target unorganized labor in India

via The Hindu

HIV prevention programmes need to reach out to the vast, unorganised labour class, according to experts at a workshop here on Tuesday.

Though the corporate sector has responded to the magnitude of HIV/AIDS — an estimated 90 per cent of HIV infections being reported are in the productive 15-49 year age group — through various measures, the sector needs to closely partner with the government in extending programmes to the unorganised labour segment, participants at the event hosted by the Confederation of Indian Industry (CII) said.

Addressing the meet on ‘HIV/AIDS: Partnerships in Prevention, Treatment, Care and Support', V. Palanikumar, Project Director and Member Secretary Tamil Nadu State AIDS Controls Society (TANSACS), said studies had shown that the informal/unorganised sector, which was significantly at higher infection risk than the general population, was also the most difficult segment to reach.

Of the 400 million members of the workforce in India, only 7 per cent are in the organised sector, leaving 93 per cent in the unorganised and migrant sectors.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Kashmir Gets a Grip on AIDS

via IPS News, by Sana Altaf

When the sole Community Care Centre in Jammu and Kashmir providing medical and psychosocial services to people living with HIV/AIDS (PLWHA) closed down for lack of patients it was a sure sign that the north Indian state had beaten back dire forecasts.

"There were few people coming in and fewer new cases," Dr. M. A. Wani, former director of the Jammu and Kashmir AIDS Prevention and Control Society (JKAPCS), told IPS, explaining the closure six months ago.

The latest sentinel survey conducted by the JKAPCS in 2010 shows an HIV prevalence of 0.03 percent - down from the 1.2 percent in the survey conducted in 2009.

According to official statistics, of the 4,846 test samples taken in the year 2008 only three persons were found to be HIV positive, and of the 4,840 samples tested in 2009 not one was found positive.

Such figures contrast sharply with grim projections made by the National Aids Control Organisation (NACO) in 2002-2003 that some 40,000 people would be infected with HIV within two years in Jammu and Kashmir and that 20,000 people would die of AIDS by 2015.

Since 1997, only 193 new patients have tested positive for HIV, most of them urban males in the 15 – 45 age group. There are now 2,787 PLWHA, including 800 women and 176 children, in this state with a population of 12.5 million people.

NACO figures released in June say there are 683 people on anti-retroviral therapy (ART) in Jammu and Kashmir where the total number of people recorded as ever getting full-blown AIDS stands at 1,123 - out of which 203 have died.

The low and declining rates have not made life easier for PLHWA, because of the strong social stigma attached to the disease and difficulties in accessing anti-retroviral drugs.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Notes from India: Concerns and Challenges Around PrEP

At present, India has approximately 2.4 million people living with HIV out of its total population of approximately 1,210 million people (a prevalence of 0.03%). In 2009, close to 1.2 million people were newly infected. According to a recent United Nations report, there has been a 50 percent decline in the number of new HIV infections in the country over the last decade.

India has made significant strides in tackling HIV/AIDS in recent years, with the government’s efforts actively being supported by the Bill & Melinda Gates Foundation, the World Bank, and the United States Agency for International Development. Many Indian NGOs work to provide care facilities, ARV medicines and education for people living with HIV. There has also been consistent work towards spreading awareness, from communicating key messages though concerts, radio shows, and TV spots with famous Bollywood stars to innovative initiatives such as promoting condom use through kite flying during popular festivals.

However, much remains to be done. “Most importantly, the government needs to step in because we need better laws – laws that will enable behavior change and help us fight HIV effectively. There are some draconian laws that stigmatize sex workers and intravenous drug users, making life very unsafe for them. MSM community building is nearly impossible due to the hostile environment. Sex education also needs to be made legally mandatory in the school system. These steps would help bring about real change,” says Anjali Gopalan, Executive Director of NAZ India, a Mapping Pathways partner organization.

How is India responding to pre-exposure prophylaxis (PrEP)? Says Anjali, “My sense is that many people are still very uncomfortable and not quite able to figure out why we’re talking about PrEP in the Indian context. Many senior people in the field feel the focus needs to be on TLC+.” There could be a few reasons for this view. First, India is a low-prevalence country, and people in the HIV prevention field believe this makes it very different from places like South Africa where the prevalence among the general population is very high. Second, there have been great difficulties in procuring ARV drugs for people living with HIV recently. “There are massive stockouts – the government is saying they don’t have the money to buy more drugs – we’re trying to move drugs from centers where they are less utilized to others where they are needed more. There is a lot of concern in the country, especially with global funding not available right now,” explains Anjali.

When it comes to PrEP, the common view in India (and elsewhere) appears to be that to take away dwindling funding and hard-to-get ARV drugs from HIV-positive people and directing them toward HIV-negative people is not a realistic or justifiable step. Of course, others are quick to point out that it is not a case of either/or – PrEP is simply one more new tool with which to prevent HIV infections. The public health community is still in the phase of gathering data on PrEP and figuring out the best possible way to utilize this new option in a variety of regions with different target populations.

Cultural differences may also play a part. For instance, homosexuality is still largely taboo in India and drug users are commonly seen as people who “knowingly put themselves at risk”. Discordant couples face a similar issue: No-one sees a problem with giving ARV drugs to people who are infected. But some doctors and social workers have indicated an aversion to giving drugs to those who are not infected on the assumption that they may indulge in high-risk behavior.

There are other significant questions for India, and for other countries contemplating whether they will implement PrEP or not: How does one ensure compliance among people who are healthy?  How does one ensure that side-effects, if any, are taken care of? How would one follow up? Will private practitioners be involved? India is still grappling with basic infrastructural and supply-chain issues, which makes these extremely important concerns.

“The Mapping Pathways team is trying to help answer these very questions,” says Jim Pickett, Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago, chair of IRMA (International Rectal Microbicide Advocates), and a member of the Mapping Pathways team. “It’s time to gather all of this new data that’s pouring in and make sense of it, see how it can be applied in real scenarios. PrEP might make sense for some communities and situations, and it might not for others. Our end goal is to give decision-makers all the information they need to make informed decisions.”


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Models: Tools to Improve Decision Making about HIV

Via AIDS.gov, by Ronald Valdiserri, M.D., M.P.H.

For those of us who work in the HIV/AIDS field, the month of July was dominated by exciting HIV prevention news coming out of the International AIDS Society meeting in Rome. Results from the HPTN 052 study showed that early, compared to delayed, antiretroviral treatment resulted in a 96% reduction in HIV transmission to uninfected partners. The TDF2 study conducted by CDC in partnership with the Botswana Ministry of Health, found that a once-daily pill containing two anti-HIV drugs reduced the risk of acquiring HIV infection by about 63% in a study population of healthy, heterosexual men and women. These and other study findings continue to add weight to the notion that HIV treatment is prevention. All of us are encouraged when we think about how these findings could be translated into real world settings in a way that would bring us closer to achieving the goals of the National HIV/AIDS Strategy.

Without minimizing the tremendous enthusiasm that rightly attends the prevention breakthroughs that were presented in Rome, I would like to talk about another scientific discussion that took place in July. As it turns out, this meeting was also held in a world capital, although to a much smaller audience. And while the results of this two-day meeting didn’t garner media attention the same way as the Rome meeting did, the topics under discussion were no less consequential.  In mid-July, I was very fortunate to attend a two-day workshop on “Modeling and Evidence-Based Decision Making” sponsored by amfAR, the Foundation for AIDS Research and cosponsored by the Kaiser Family Foundation, the National Alliance of State and Territorial AIDS Directors, and the Urban Coalition for HIV/AIDS Prevention Services. Meeting participants included colleagues from state and local departments of health, academia, federal government, and professional and community-based organizations.

Colleagues from Los Angeles, San Francisco, Maryland, and New York City shared with us their experiences with using various models to assist in making decisions about “optimizing” HIV prevention investments. Using different approaches, each of these health departments was trying to answer the same question, “What combination of prevention services and activities will result in the greatest reduction of the number of new HIV infections?”

At the onset of the meeting, we were reminded that modeling is used in other areas of health and public policy decision-making, especially when leaders are trying to combine diverse information from a variety of sources in order to make sound decisions at a population level.  However, even the biggest fans of modeling reminded us that a model is not a “crystal ball” nor is it infallible.  Instead, what models do is provide a tool to help us make better decisions about complex realities. Good models should always be clear about the inputs and assumptions that were used to generate the results. And perhaps most importantly, they should be used to guide rather than to conclude any discussions about how best to allocate resources.

Read the rest here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

IN CONVERSATION WITH DR. SONALI KOCHHAR: PrEP in India

Dr. Sonali Kochhar, medical director India of OneWorld Health and one of the two Indian women chosen for the prestigious 2011 Yale World Fellows leadership initiative, provides a thoughtful discussion on PrEP within the Indian context.

MP: Could you please briefly introduce yourself, and tell us how you got involved in the field of HIV prevention?

SK: I was the Medical Director, India for the International AIDS Vaccine Initiative for seven years and was involved in the preparation and conduct of the first ever AIDS vaccine trials conducted in India.

I got involved in the field of HIV prevention because early on in my medical training, I saw firsthand how diseases like HIV not only severely impacted the person infected but also their whole families. The severe stigma and discrimination associated with the disease in developing countries like India only worsens the issues. Seeing women being disowned by their families and children thrown out of schools and shunned by society convinced me that it is imperative that safe, effective and accessible preventive options are found at the earliest to prevent these tragedies. History has shown that vaccines are often the most powerful and cost-effective disease prevention tools available. It is hoped that a preventive AIDS vaccine will stem the global HIV pandemic.   

MP: What are your thoughts on PrEP, particularly within the Indian context?

SK: There is mounting evidence that pre-exposure prophylaxis might prove to be an important new prevention approach. The results of from the iPrEx trial were promising in showing that in MSM and transgendered women who have sex with men, daily TDF/FTC (tenofovir disoproxyl fumarate plus emtricitabine, Truvada) reduced the risk of HIV by 44 percent.

If proven safe and effective in all populations[1], PrEP could help address the urgent need for a female-controlled prevention method for women who are often unable, because of cultural and financial barriers, to negotiate condom use.

It could be used by men and women at risk due to sexual or drug-using behaviors, when combined with prevention measures like reducing the number of sexual partners, HIV counseling and testing, condom use, use of sterile syringes etc.

  

MP: What are the particular pros and cons, challenges, or issues of rolling out PrEP here? Do you think it should be made accessible to everyone?

SK: There are numerous questions about the implementation of PrEP outside of the research setting especially in the context of countries like India with problems like the lack of a strong evidence base on which to formulate decision making, an unregulated health sector and a highly vulnerable population often severely disadvantaged in terms of income, education, power structures and gender.

These include whether the intermittent use of the drugs will be effective, how the cost will be borne and how would the health and safety of PrEP users be monitored. The impact of PrEP may be strongly diminished or even reversed by behavioral disinhibition (increased risky sexual behavior because people may feel protected against HIV infection), especially in scenarios with low coverage and low effectiveness. PrEP would need to be used with other preventive modalities but it is not certain how this can best be done.

Large-scale PrEP use might encounter problems such as poor adherence and resistance. One of the problems of intermittent use, besides reduced effectivity, is possible emergence of resistant viruses.

If clinical trials demonstrate efficacy of PrEP, as many expect, the demand for its provision may increase rapidly. Indian Policymakers, Program Planners and Public Health Workers will need to prepare for this. This will include the development of national testing and assessment protocols, behavioral interventions, ensuring uninterrupted supply of PrEP and monitoring the population-level impacts of PrEP use.

To support the use of PrEP as a population-level prevention strategy, I feel that the following issues need to be resolved:

1) PrEP drugs – The challenges encountered in countries like India would include ensuring financing for an uninterrupted supply of drugs, training and retaining health workers; establishing and maintaining clinical, laboratory, and public health infrastructure; overcoming barriers to accessing care such as stigma, lack of awareness, and geographical distance; implementing appropriate monitoring and evaluation systems; sustaining patient adherence; and managing drug-related toxicity and resistant infections. Guidelines for PrEP eligibility, optimal PrEP dosing, necessary adherence, route of administration and channels for PrEP prescription and monitoring would need to be developed.

2) Safety screening – To address the risk of new HIV infection, including the acquisition of drug-resistant HIV and the development of secondary resistance in PrEP users, repeated and frequent HIV testing would be required. This will require  laboratory costs and infrastructure expansion. PrEP may only be cost effective for individuals at high risk for HIV. Side effects of PrEP like loss of bone density or renal impairments, will require ongoing clinical and laboratory monitoring.

3) Integration of PrEP as part of comprehensive care – As PrEP implementation requires clinical assessment, prescription, routine testing, and long-term monitoring of PrEP users, it will require a frequent and stable interface between PrEP users and clinical providers in an ideal scenario.

MP: Looking at the big picture, who do you think would benefit most from PrEP?

SK: Keeping in mind the above mentioned challenges, initial efforts might target members of known high-risk groups, such as sex workers, high-risk men who have sex with men, HIV negative individuals in serodiscordant sexual partnerships, and high-risk injection drug users.

MP: Is there any experience that stands out to you from your time on the field, which had an impact on you or that you can’t forget?

SK: Working with vulnerable populations like transgender individuals and men who have sex with men (MSM) was really an eye opener. These are people who often have nothing to their name (often not even a roof over their head), are disowned by society and their families and are completely discriminated and stigmatized against.[2] Yet a number of them were keen to help spread awareness about HIV/AIDS, prevention options and vaccines so that others may benefit from the information and not get infected with HIV. This degree of humanity is truly remarkable.

Dr. Sonali Kochhar is currently the medical director for India at OneWorld Health, where she leads efforts to develop safe, affordable, and accessible drugs and vaccines for diseases prevalent in the developing world.

---

[1] Since the time of this interview – two additional studies – the Partners PrEP study and the CDC Bostswana study have shown that PrEP works in heterosexual individuals.

[2] To know more about HIV/AIDS in LGBT communities,  read HIV Prevention and LGBT Communities: Syndemics, Resilience, and Real Change.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

The Great Paradox of the HIV Epidemic

Mark Chataway is co-chairman of Baird’s CMC, a Mapping Pathways partner organisation. Here, he discusses the HIV landscape in Botswana and Zimbabwe.

"Every now and then, it strikes me that despite all our progress in the field of HIV, there is still so much for us to find out. This seems most apparent when I consider the HIV situation in two African countries: Botswana and Zimbabwe.

In 2001, Botswana’s then-president, Festus Mogae, said, “We are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of the first magnitude.” The government acknowledged that tackling the epidemic was a matter of national importance, and it acted accordingly – Botswana became the first African country to declare its objective of providing ARV drugs to all its needy citizens. As in so many other fields, Botswana was to become a model for the rest of the world. (Having worked for the Government of Botswana as a consultant, I often wish that we, in the UK, were governed with equivalent honesty, efficiency and vision.)

Botswana has two significant HIV/AIDS-related initiatives with international partners: ACHAP (African Comprehensive HIV/AIDS Partnerships) and BOTUSA. Its own funding for HIV programmes has increased steadily. Botswana has achieved universal treatment access (that means at least 80% of Batswana who need HIV treatment are receiving it). Almost every major political and religious leader has addressed AIDS openly and often. There are enormous, well-financed programmes focussed on behaviour change and risk reduction. Yet, HIV prevalence is not falling nearly as fast as many think it should have done (click here for prevalence details).

On the other hand, there is the puzzling case of Zimbabwe, where HIV prevalence has fallen dramatically over the last decade or so – it peaked at 26.5% in 1997 and, according to government figures, fell to 14.3% in 2010. While this is an excellent development, it is also rather inexplicable. Access to treatment is very limited. A long-serving health minister was accused of sexually molesting adolescents (although he vehemently denied it) and other political leaders have addressed AIDS only sporadically. Sustained persecution of men who have sex with men has driven the gay community underground. Many of the urban poor have been driven from their homes and forced to live as refugees in rural areas. According to everything we know, Zimbabwe’s political upheaval, economic distress, and the collapse of many primary healthcare services should have exacerbated the epidemic. While some researchers claim the declining prevalence is a result of successful public-awareness and behaviour-change programmes, there are many troubling doubts in the international public health community about whether those factors really constitute an adequate explanation. The real explanation is probably complicated and involves the rising mortality from other causes, the inability of people to travel and the disappearance of much of the middle class.

The difference between these two countries brings into sharp relief the great paradox of the HIV epidemic – we just do not know why the epidemic seems intractable in some places but declines rapidly in others (or fails ever to take hold). There is no model that explains Botswana and Zimbabwe. There are similar paradoxes all over the world: for example, in India, Tamil Nadu has more AIDS cases than any other state, but it has an excellent healthcare system, relatively good status for women and very high levels of literacy and health literacy. Bihar is almost the opposite on every count but has very low HIV prevalence.

For me, it highlights how, even after living with HIV/AIDS for nearly three decades, the world still has so much to learn about the dynamics of HIV and how it functions in various scenarios. The need of the hour is well controlled, randomised clinical trials and policy analysis. We can then create more effective programmes based on good science."

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

The Economic Effect: HIV/AIDS in the US

At the CROI conference earlier this year, Julie Davids asked a question that lies at the very heart of HIV prevention – “What needs to happen to ensure that PrEP doesn’t become a hard-to-get intervention?” Now, halfway through the year, we checked in with her. Below, Julie shares her thoughts on how dollars-and-cents issues have serious repercussions with regard to the HIV/AIDS situation in the US.

“While there has been much debate over the use of antiretrovirals (ARVS) for HIV prevention, the entire HIV prevention and treatment landscape overall is also in a state of flux in the US. In the era of the National HIV/AIDS Strategy, many questions have arisen. Perhaps the most important is this – what prevention/treatment methods can be brought to scale for population-level impact? There has been lots of effective work that has helped prevent HIV and save lives, but what can be scaled up to a point where it can start to reduce incidence? There are initiatives that work very well but are too expensive to bring to larger scale. People are also wondering if there are targeted ways of delivering PrEP to ensure maximum impact without incurring enormous amounts of expenditure.

The global economic crisis has only exacerbated the situation. The effects of the sustained downturn in the US are deep and hard to untangle. In some areas, the impact is specific and tangible: many organizations and initiatives that provide HIV prevention, treat and care are shutting down and others are under lot of duress. So, understandably, when it comes to using ARVs for prevention, people are saying, “We’ve been told not to expect any new money – in fact, we’ve braced ourselves for cuts in funding. If we’re talking about adding something new, where is the money going to come from? And is this the best use of the available resources?”

But the effects are also larger and more intangible, in terms of a generalized anxiety and fear. The recession is hitting the most marginalized the most severely. One of the main drivers of HIV incidence in the US is poverty – and we’re seeing a sharp increase in poverty and homelessness. People are scrambling to find housing and put food on table, to retain a sense dignity as they struggle to provide for their families. These factors create vulnerability to health challenges and in this regard HIV/AIDS is more the rule than the exception. We may sharpen and tailor HIV prevention to be more effective, but I fear this could be counterbalanced by the effects of the downturn, leading to persistently high HIV incidence.

I believe that it is a political, economic and human tragedy that the first time our country has had a national HIV/AIDS strategy is exactly at the same time that we’re being told there are no resources to put it fully into place. We’re being told that other things in the country, such as the income of bankers, remain more important than people’s health. We are, in significant ways, being restrained from putting our best minds and hearts at the forefront of this effort. When we get to the end of the day, there are good ideas, and then there are good ideas that are fully funded. In the history of the HIV/AIDS epidemic, there have been some excellent ideas but they have languished because they just aren’t resourced at the appropriate level – I think we may see a lot of this in the next few years. The impact of economic injustice, which was already driving the epidemic, will remain a deciding factor in the HIV/AIDS context for some time to come.”

Julie Davids is the Director of National Advocacy and Mobilization at AIDS Foundation of Chicago, a Mapping Pathways partner organization. She coordinates the HIV Prevention Justice Alliance (HIV PJA).

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

HIV/AIDS: Young people at highest risk of HIV infection

Via PlusNews.

That young people are particularly vulnerable to HIV and AIDS is well established, but a new report reveals for the first time new data on HIV prevalence in this group, which accounts for almost half of new adult infections globally.

The Opportunity in Crisis report, released on 1 June by the UN Children’s Fund (UNICEF), UNAIDS and other UN agencies, found that an estimated 2,500 young people aged 15-24 become infected with HIV every day, with young women and girls particularly vulnerable.

“The picture is grim,” said Elhadj As Sy, UNICEF director for eastern and southern Africa, at the launch of the report in Johannesburg. “The faces of young people living with HIV are predominantly African and female… of the five million HIV-positive young people, close to four million are in sub-Saharan Africa. More than 60 percent are young women and in sub-Saharan Africa, this share jumps to 72 percent.”

While the report suggest that prevention is working, and some progress has been made, Susan Kasedde, senior specialist in HIV Prevention with UNICEF, warned that countries were falling “far, far short” in their efforts to address HIV among young people and had not invested enough in these programmes.

“Strategies and plans are devised, but money is not allocated, or when it is, efforts are not effectively coordinated, and are not at sufficient scale or are not [of] sufficient quality to ensure the greatest impact from the investment,” the report found.

At the UN General Assembly Special Session (UNGASS) on HIV/AIDS in 2001, countries agreed to cut HIV infection among young people by 25 percent by 2010, but only a 12 percent reduction has been achieved.

As Sy said the greatest barrier was stigma and discrimination, particularly in relation to young people at high risk of infection, such as young men who have sex with men, sex workers and injecting drug users, who have been driven underground by discrimination that often prevents them from accessing HIV services.

Read the rest here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

95,000 Adolescents Living With HIV in India: UN Report

Via DNA India.

India, where 95,000 adolescents are living with HIV, has been listed along with the sub-Saharan countries having the highest number of youngsters infected by the deadly virus, according to a UN report.

In the age group of 10-19 years, India with 46,000 infected girls and 49,000 boys, has been ranked tenth in the list of countries most affected with HIV in 2009, the report 'Opportunity in Crisis: Preventing HIV from early adolescence to young adulthood' said.

Read the rest here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

South Africa and HIV: Insights

Mark Chataway is co-chairman of Baird’s CMC, a Mapping Pathways partner organisation. Here, he talks about his visit to South Africa and his thoughts on the region in the context of HIV treatment and prevention strategies.

I was in South Africa last week, working with our Mapping Pathways colleagues to finalise the ExpertLens survey questionnaire. It’s a very exciting time – we’re going use this survey for in-depth discussions with high-level policymakers, key opinion leaders and pivotal civil society figures. The information we get will help us crystallise the project’s outputs. The idea is to make sure we provide data and analyses that are relevant and helpful for all the key stakeholders.

My visit to the country once again brought into sharp focus for me just how significant South Africa and the rest of the southern African region are in the context of HIV treatment and prevention strategies.

Sub-Saharan Africa is the most heavily affected region in the world with regard to HIV. Swaziland has an adult HIV prevalence of 26% (the highest in the world) – the epidemic reduced the country’s life expectancy rate to 31 years as of 2007. South Africa has the highest number of people living with HIV in the world – 5.7 million as of 2007. The incidence rate in South Africa is declining, but not nearly as fast as it needs to.

The pressure on South African decision-makers is even greater because of the manner in which the HIV situation was handled by former president, Thabo Mbeki, and his government. The links were often parodied: Mbeki did question the very link between HIV and AIDS as well as the value of antiretroviral drugs for treatment, but he was never as hostile as many suggested he was.  The Health Minister, Dr Manto Tshabalala-Msimang, suggested the use of garlic, lemon juice and beetroot but, probably, not as substitutes for antiretrovirals (although she was widely reported as having done so), rather as a way of managing opportunistic infections. There is no evidence that beetroot ever helped anyone but some traditional African medicines do seem to hold promise in managing fatigue and diarrhoea (in well-controlled trials, no less). There have been non-political controversies too; for instance, the evaluation of a US-funded behaviour change programme called LoveLife.

Keeping in mind the scale of the HIV epidemic, South African policymakers’ decisions about prevention and treatment are going to be crucial not just for their own country but for the entire region. They’ll have to take a call on where to spend money in the future, and the range of options is growing: circumcision, behaviour change, treatment, microbicides and vaccine research, just to name a few. South Africa has, in the past, funded a big AIDS vaccine research programme – in fact, I was on the government panel that reviewed it. The government is now making great efforts to get the funding required for larger trials for microbicides – it has put in a lot of its own money in and is hoping international donors will also provide funds.

The HIV budget is a massive part of South African government spending, and it will have to be justified in years to come. With all the other demands on government funding (education, housing, other health demands), decision-makers need to see whether their efforts are paying off and will continue to do so. The all-important question will remain: will continued action help force this epidemic into faster reverse?

I have worked in Southern Africa since the late 1980s and I think that governments in much of the region – and in South Africa, in particular – have more capacity now to act on good research than they have ever had before. Many South African government officials are very impressive and are hungry for objective findings with which to provide advice for their ministers. That’s why I think that Mapping Pathways is so important.



On a related note, the Mapping Pathways project is also in the process of trying to gather perspectives on these questions from folks in our current focus areas – the US, South Africa, and India. If you’re interested in new ways to prevent transmission of HIV – and want to help shape our project goals and deliverables – we encourage you to take a few minutes and fill in our survey.

Your efforts will be greatly appreciated!

Take the survey now.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]