tag:theconversation.com,2011:/fr/topics/antiretroviral-drugs-1336/articlesAntiretroviral drugs – The Conversation2023-10-05T15:50:48Ztag:theconversation.com,2011:article/2150802023-10-05T15:50:48Z2023-10-05T15:50:48ZJerry Coovadia: the South African doctor who led the fight against HIV in children<p>South African-born Professor Hoosen “Jerry” Coovadia, renowned academic and prominent anti-apartheid activist, passed away on <a href="https://www.news24.com/news24/southafrica/news/hivaids-expert-professor-jerry-coovadia-dies-aged-83-leaves-behind-an-immeasurable-legacy-20231004">4 October</a>. As a paediatrician I was privileged to know and work with him over two decades. Prior to that I knew him when we were both health activists in apartheid South Africa.</p>
<p>In 2019 Coovadia was <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61581-6/fulltext">profiled</a> in the leading health academic journal, The Lancet, as an icon in South African health. The profile described him as the “Nelson Mandela of health”. This was in tribute to his dedication to ameliorating the diseases that afflicted children of South Africa, like malnutrition, measles and HIV, and his role in health activism. </p>
<p>In 2014, in my capacity as the president of the South African Medical Research Council, I was honoured to award him the <a href="https://www.samrc.ac.za/about-us/2014-scientific-merit-awards">SAMRC Presidential Award</a> in recognition of his life-long work in child health, his impact in the area of preventing mother-to-child transmission of HIV and the huge influence he had on health in South Africa. </p>
<p>Jerry was pivotal in proposing the use of maternal antiretroviral therapy to prevent breast milk transmission, which has now become the norm at a global level. His role in research that led to the control of HIV infection in children was so great that, in my view, it cannot be quantified in any meaningful way.</p>
<h2>Who was Jerry Coovadia?</h2>
<p>Jerry was born in Durban, on the east coast of South Africa, <a href="https://www.sahistory.org.za/people/professor-hoosen-mahomed-jerry-coovadia">in 1940</a>.</p>
<p>He knew instinctively from a young age that he would become a doctor. He did some of his medical training in India, and then returned to South Africa, where he was exposed to the atrocities of a two-tiered health system under which black South Africans bore the brunt of poor healthcare.</p>
<p>As a paediatrician, he excelled academically, training in immunology and eventually heading the Department of Paediatrics and Child Health at the University of Natal. </p>
<p>During his time as an academician he became prominent in the anti-apartheid movement. </p>
<h2>The AIDS fight</h2>
<p>I began working with Jerry in the mid 1990s. His path and mine would intertwine over the next 20 years as we bore witness to the <a href="https://academic.oup.com/ije/article/31/1/37/655915">explosion of HIV</a> in children. He was working at the King Edward Hospital in KwaZulu-Natal while I was at the Chris Hani Baragwanath Academic Hospital in Soweto. </p>
<p>Over the next decade we would “cross horns” on the various interventions to prevent mother-to-child transmission of HIV. </p>
<p>We didn’t always agree on interventions to prevent<a href="https://www.ncbi.nlm.nih.gov/books/NBK555904/"> post-partum</a> transmission through breastfeeding. </p>
<p>Even though our strategies differed, we were completely aligned in our common goal of trying to mitigate the scourge of HIV in the children we were trained to care for. </p>
<p>His textbook <a href="https://global.oup.com/academic/product/coovadias-paediatrics-and-child-health-a-manual-for-health-professionals-in-developing-countries-9780199053940?cc=za&lang=en&">Paediatrics and Child Health</a> was my Bible. My colleagues and I revered him as the doyen of child health in South Africa. </p>
<p>It was a huge privilege to collaborate with him on research to deliver antiretroviral therapy as an intervention to prevent mother-to-child transmission of HIV. </p>
<p>We worked together on studies seeking the most cost-effective way of preventing paediatric HIV using the least amounts of antiretrovirals at a time when these were prohibitively expensive. The two biggest were the <a href="https://pubmed.ncbi.nlm.nih.gov/11955535/">PETRA</a> study, evaluating various short courses of <a href="https://www.britannica.com/science/AZT">AZT</a> and <a href="https://www.news-medical.net/drugs/3TC-Tablets.aspx">3TC</a> to interrupt perinatal transmission, and the <a href="https://jamanetwork.com/journals/jama/fullarticle/199058">SAINT</a> trial, which evaluated the role of <a href="https://www.ncbi.nlm.nih.gov/books/NBK554477/#:%7E:text=Nevirapine%20is%20a%20drug%20used,antiretroviral%20therapy%20(ART)%20medications.">Nevirapine</a> for preventing mother-to-child transmission. </p>
<p>Over the years, we would co-publish on these studies and the effect of these various interventions to minimise breast milk transmission. </p>
<h2>Activist years</h2>
<p>Before I worked with Jerry as a young doctor, we were both health activists. I belonged to the Health Workers Association, which later became the South African Health Workers Congress; he was a member of the National Medical and Dental Association and was a leader in the talks to merge these two organisations.</p>
<p>I appreciated his activism and his vision for an equitable health system which he channelled into his work as a paediatrician and his work as a scientist.</p>
<p>He demonstrated to us as young doctors the role of social activism in health and that ill health is inextricably linked to socio-economic and political factors. If we were to be meaningful in our role as doctors, we had to address these factors with the same vigour as we demonstrated in the wards where we treated sick children.</p>
<p>Jerry encompassed what it means to be a doctor. He always lived by the Hippocratic Oath, basing his practice in medicine on the principles of beneficence, non-maleficence, justice and respect. </p>
<p>I am deeply grateful to have brushed shoulders with this great man. Go well Jerry, a life well lived, and many thanks to your family for sharing you with us.</p><img src="https://counter.theconversation.com/content/215080/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Glenda Gray receives funding from USAID and the NIH</span></em></p>A Lancet profile of Jerry Coovadia described him as the ‘Nelson Mandela’ of healthcare. Glenda Gray pays tribute to a legendGlenda Gray, Research Professor, Perinatal HIV Research Unit and President, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2091652023-07-27T14:25:51Z2023-07-27T14:25:51ZSouth Africa is failing to live up to its constitution. Gains made since democracy are being squandered – report<figure><img src="https://images.theconversation.com/files/538308/original/file-20230719-27-hdh5us.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Extreme poverty has seen shack settlements mushroom in South Africa.</span> <span class="attribution"><span class="source">Brooks Kraft LLC/Sygma via Getty Images</span></span></figcaption></figure><p>The end of apartheid in 1994 and advent of constitutional democracy resulted in major societal changes in South Africa. The aim was to forge a “united and democratic” society. The new nation was to be based on justice and human rights.</p>
<p>The country’s <a href="https://www.gov.za/documents/constitution/constitution-republic-south-africa-1996-1">constitution</a> commits the government to take remedial action to address the legacy of past discrimination and injustice. It must improve the quality of life of all citizens and promote equality. It must also enable people to achieve their potential and promote nation-building.</p>
<p>Initially, this was to be achieved through the <a href="https://www.gov.za/sites/default/files/governmentgazetteid16085.pdf">Reconstruction and Development Programme</a> macroeconomic policy. It sought to promote the socioeconomic inclusion of those who had been excluded during colonialism and apartheid. It also aimed to combat disparities and discrimination on the basis of race, gender and disability. Since then, other macroeconomic policies have included the <a href="https://www.treasury.gov.za/publications/other/gear/chapters.pdf">Growth, Employment and Redistribution</a> and <a href="https://www.sahistory.org.za/sites/default/files/asgisa.pdf">Accelerated and Shared Growth Initiative for South Africa</a> policies. The current <a href="https://www.gov.za/sites/default/files/gcis_document/201409/ndp-2030-our-future-make-it-workr.pdf">National Development Plan</a>, adopted in 2012, seeks to eradicate poverty and inequality by 2030.</p>
<p>Last year, my colleagues and I at the <a href="https://www.uj.ac.za/">University of Johannesburg</a>, <a href="https://mistra.org.za/">Mapungubwe Institute for Social Reflection</a> and the Presidency of South Africa examined how the country had fared in achieving these goals and the challenges encountered. </p>
<p>Our report, <a href="https://mistra.org.za/mistra-research-projects/2022-macro-social-report-msr/">Macro Social Report 2022</a>, builds on the first report published by the presidency <a href="https://www.gov.za/documents/nation-making-discussion-document-macro-social-trends-south-africa">in 2006</a>. The 2006 report concluded that the government had succeeded in improving the quality of life for citizens. This greatly contributed to a sense of unity, national pride and reconciliation. </p>
<p>However, the 2006 report found that persistent inequality, crime, micro-level racism (racism experienced at an individual level) and mass migration to urban areas were countering any positive gains.</p>
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Read more:
<a href="https://theconversation.com/south-africa-needs-strategic-leadership-to-weather-its-storms-its-presidents-have-not-been-up-to-the-task-194296">South Africa needs strategic leadership to weather its storms. Its presidents have not been up to the task</a>
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<p>The updated 2022 report explored social structure and social mobility (ability of people to elevate their social status) and demographics of “race”, language, age, gender and disability. We also considered migration, causes of mortality, crime, social cohesion and the organisation of social life (how social groups are formed and interact with each other) as well as social networks (social and personal relationships). </p>
<p>The findings show a decline in essential socio-economic indicators since 2006. Most South Africans continue to face socio-economic exclusion and persistent discrimination on the basis of “race”, gender and disability. The findings matter because they show that the government has been unable to fully uphold the rights enshrined in the country’s globally revered constitution. </p>
<h2>A poor performance</h2>
<p>The report is based on relevant primary and secondary literature obtained from academic publications, government reviews and international institutions which specialise in socioeconomic and development policy. The research also included interviews with ordinary citizens in order to capture their lived experiences. </p>
<p>We found that South Africa still had a dual economy. Wealth is concentrated in the hands of a white minority. The country is one of the <a href="https://www.worldbank.org/en/news/press-release/2022/03/09/new-world-bank-report-assesses-sources-of-inequality-in-five-countries-in-southern-africa">most unequal</a> globally. </p>
<p>Extreme inequality has a profound impact on social and personal relationships as well as social cohesion. The major gap between rich and poor makes it difficult for people to relate to one another and form strong bonds.</p>
<p>The COVID-19 pandemic exacerbated poverty and inequality. According to World Bank estimates, South Africa’s poverty rate was <a href="https://www.worldbank.org/en/country/southafrica/overview">63% percent in 2022</a>. Poverty is most pervasive among black people: 64% of Black, 41% of Coloured, 6% Indians and 1% White South Africans <a href="https://www.sahrc.org.za/index.php/sahrc-media/news/item/1442-kate-wilkinson-stats-about-poverty-stricken-sa-whites-are-not-true">live in poverty</a>. </p>
<p>The quality of basic services in some communities is <a href="https://theconversation.com/south-africans-are-revolting-against-inept-local-government-why-it-matters-155483">poor</a>. </p>
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Read more:
<a href="https://theconversation.com/1-in-5-south-african-households-begs-for-food-the-link-between-food-insecurity-and-mental-health-202360">1 in 5 South African households begs for food – the link between food insecurity and mental health</a>
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<p>South Africa ranks the worst globally in terms of intergenerational income mobility (the ability of children to change their level of income compared to their parents). Limited access to quality education has prevented many people from moving to middle class status. This has prevented the growth of a dynamic middle class. </p>
<p>We also found persistent racial disparities. This causes unequal societal power relations (one “racial” group holding power over others) and has a negative impact on social cohesion. </p>
<p>White and Indian people have living conditions, education patterns (for example, access to higher education) and employment outcomes that far surpass those of the <a href="https://www.britannica.com/topic/Coloured">coloured</a> and black populations.</p>
<p>White and Indian women benefit disproportionately from redress policies compared to coloured and black women. Black women continue to shoulder a double burden in that they must contend with both racism and patriarchy. They are underrepresented across senior and intermediary occupational positions. </p>
<p>While some good progress has been made on gender rights and women’s participation in politics (as shown by the engagement and <a href="https://revistaidees.cat/en/women-in-south-african-politics/">representation of women in government</a>), people with disability are still largely marginalised. </p>
<p>Only marginal progress has been made in reducing crime. Case numbers of serious crimes went down by only 11% between 2015 and 2020. South Africa still has <a href="https://www.saps.gov.za/services/crimestats.php">high crime rates</a>. </p>
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Read more:
<a href="https://theconversation.com/genetically-modified-crops-may-be-a-solution-to-hunger-why-there-is-scepticism-in-africa-207364">Genetically modified crops may be a solution to hunger - why there is scepticism in Africa</a>
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<p>On a more positive note, we found that mortality rates had dropped since 2006. Fewer people are dying prematurely. This has mainly been due to the government’s rollout of antiretrovirals <a href="https://pubmed.ncbi.nlm.nih.gov/25310359/">since 2008</a>. </p>
<p>Lastly, the report shows nation-building efforts have been undermined by growing inequalities, decline in good governance and persistent corruption. This has been evident in unethical political leadership, <a href="https://www.statecapture.org.za/">state capture</a>, institutional decay and low levels of public trust in government. </p>
<h2>Progress undermined</h2>
<p>The socioeconomic and political changes South Africa made in the first decade of democracy produced positive results. But these have been undermined by weak governance and poor economic performance since 2006. </p>
<p>Addressing the socioeconomic and political challenges will be indispensable to the strengthening and consolidation of its democracy. </p>
<p>Social cohesion programmes and government initiatives must address these pressing concerns if the country is to build a close-knit society.</p><img src="https://counter.theconversation.com/content/209165/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marcel Nagar receives funding from NRF. </span></em></p>On the positive side, good progress has been made on gender equality and fewer people are dying of unnatural causes.Marcel Nagar, Senior Postdoctoral Research Fellow, University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1949082023-01-24T13:23:01Z2023-01-24T13:23:01ZGrassroots AIDS activists fought for and won affordable HIV treatments around the world – but PEPFAR didn’t change governments and pharma<figure><img src="https://images.theconversation.com/files/505231/original/file-20230118-18-a5un95.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">AIDS activists have used protests to demand access to treatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-from-africa-action-mark-world-aids-day-with-a-rally-news-photo/78178017">Jim Watson/AFP via Getty Images</a></span></figcaption></figure><p>The <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/">President’s Emergency Program for AIDS Relief, or PEPFAR</a>, has revolutionized the fight against global AIDS over the last 20 years. <a href="https://www.state.gov/wp-content/uploads/2021/12/PEPFAR-Latest-Global-Results.pdf">In that time</a>, the U.S. program has brought antiretroviral treatment to nearly 19 million people living with HIV, the virus that causes AIDS; prevented mother-to-child transmission of HIV for 2.8 million babies; and brought HIV testing and prevention services to millions of others. </p>
<p>But this program would not be so successful – and might not even exist – without the work of grassroots AIDS activists around the world.</p>
<p>As a <a href="https://scholar.google.com/citations?user=pTaBXaIAAAAJ&hl=en">historian of social movements</a>, I spent years interviewing AIDS activists, digging through their papers and scanning old websites, group email lists and message boards. These sources showed that, over the course of more than a decade, these activists challenged the status quo to demand – and deliver – HIV treatment to millions of poor people around the world.</p>
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<figcaption><span class="caption">Treatment Action Campaign activists in South Africa put pressure on drugmakers and governments for access to HIV medication.</span></figcaption>
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<h2>AIDS drugs for Africa</h2>
<p>In his <a href="https://www.washingtonpost.com/wp-srv/onpolitics/transcripts/bushtext_012803.html">2003 State of the Union address</a>, then-U.S. President George W. Bush announced the creation of PEPFAR when he called for an astounding US$15 billion in funding over five years for the fight against AIDS in Africa and the Caribbean.</p>
<p>His announcement did not come out of nowhere. By that point, AIDS activists had spent years fighting to bring treatments for HIV to low- and middle-income countries hardest hit by the epidemic. My book, “<a href="https://uncpress.org/book/9781469661339/to-make-the-wounded-whole">To Make the Wounded Whole</a>,” describes how members of the AIDS Coalition to Unleash Power (ACT UP) Philadelphia linked their own struggles for affordable, quality health care for poor people with AIDS in the U.S. to similar struggles around the world.</p>
<p>This fight began in earnest in the late 1990s when highly effective antiretrovirals to treat HIV became available, giving a new lease on life to those who could access them. But the new drugs were expensive, and activists saw that their high cost would <a href="https://actupny.org/Vancouver/sawyerspeech.html">put them out of reach for most who needed them</a>.</p>
<p>Some low- and middle-income countries took their own steps to make life-saving antiretrovirals available. In 1997, South Africa, in the midst of a rapidly growing HIV epidemic, passed the <a href="https://www.jstor.org/stable/24115724">Medicines and Related Substances Act</a>, allowing the government to produce or acquire less-expensive generic versions of the drugs. Meanwhile, <a href="https://doi.org/10.1016/s0140-6736(02)11775-2">domestically produced generics</a> were a cornerstone of Brazil’s program to provide access to free antiretrovirals for people living with HIV/AIDS in the country.</p>
<p><a href="https://web.archive.org/web/20000524182434/http://www.aegis.com:80/news/ct/1999/ct990404.html">Pharmaceutical companies opposed these efforts</a>, with a representative of the Pharmaceutical Research and Manufacturers Association (PhRMA) claiming that countries that produced generics committed “a form of patent piracy.” So, too, did the Clinton administration, claiming that South Africa and Brazil violated intellectual property agreements under the World Trade Organization. In particular, former Vice President Al Gore, acting as chair of the U.S.-South Africa Binational Commission, and Charlene Barshefsky, the U.S. Trade Representative, <a href="http://www.cptech.org/ip/health/sa/stdept-feb51999.html">pressured their South African counterparts</a> to change the law in 1999.</p>
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<a href="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Activists marching with signs reading 'Europe! Hands off our medicine'" src="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">AIDS activists in Nairobi, Kenya, protested against a free trade agreement between the European Union and India that would have phased out generic AIDS drugs.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/KenyaAIDS/a45c66d0b20044878765422e1f099f09">Khalil Senosi/AP Photo</a></span>
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<p>Activists fought back against both the pharmaceutical industry and the policymakers who put intellectual property rules, and the corporate profits they protected, ahead of saving people’s lives. Members of ACT UP Philadelphia, along with others, <a href="https://actupny.org/actions/gorezaps.html">hounded Gore on the presidential campaign trail</a>, chanting, “Gore is killing Africans – AIDS drugs now,” and <a href="https://www.democracynow.org/1999/11/19/act_up_activists_storm_office_of">occupied Barshefsky’s office in Washington</a>. They also participated in a massive demonstration at the 2000 International AIDS Conference in Durban, South Africa, with thousands of marchers from around the world crying “<a href="https://actupny.org/reports/durban-march.html">Phansi, Pfizer, phansi!</a>” (“phansi” is Zulu for “down”) to demand a reduction in the drug company’s AIDS treatment prices.</p>
<p>All of this agitation worked. Clinton <a href="https://www.sfgate.com/health/article/Poor-Nations-Given-Hope-on-AIDS-Drugs-New-2892857.php">curbed his administration’s pressure campaign</a> against South Africa. Thanks in part to the wider availability of generics, the average cost of antiretrovirals <a href="https://www.msf.org/patents-prices-patients-example-hivaids">fell dramatically</a>. And the <a href="https://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm">2001 World Trade Organization Ministerial Conference in Doha, Qatar</a>, affirmed that public health and “access to medicines for all” would be paramount in the fight against HIV/AIDS and other epidemics.</p>
<p>Having succeeded in making antiretrovirals more affordable, activists pressed for an international program to purchase and distribute them. According to journalist Emily Bass, <a href="https://www.publicaffairsbooks.com/titles/emily-bass/to-end-a-plague/9781541762459/">external pressure from grassroots activists</a> gave global health advocates within the Bush administration, including National Institute of Allergy and Infectious Diseases Director and chief medical advisor Anthony Fauci, the opportunity to push forward their proposal for a massive effort by the U.S. to treat AIDS in Africa. That proposal quickly evolved into PEPFAR.</p>
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<figcaption><span class="caption">John Robert Engole was the first patient to receive HIV treatment under PEPFAR.</span></figcaption>
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<p>Activists continued to shape PEPFAR as the program came together. They advocated for people with AIDS to be treated with generic antiretrovirals, which allowed more people to be treated than would otherwise be possible with patented drugs. And when it came time to renew PEPFAR in 2008, they <a href="https://healthgap.org/wp-content/uploads/2018/11/Bird-dogging-101.pdf">extracted promises from presidential candidates</a> to <a href="https://fpif.org/how_to_stop_aids_now/">reauthorize the program at $50 billion</a>, over three times Bush’s initial pledge.</p>
<p>Today, PEPFAR <a href="https://www.state.gov/where-we-work-pepfar/">works in over 50 countries</a>, including in Central and South America, Southeast Asia and the former Soviet Union. Since 2003, the program has injected <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/">over $100 billion</a> into the fight against global AIDS, although <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/#endnote_link_559116-23">annual funding levels have been flat for most of that time</a>. Yet despite stagnant funds, PEPFAR has brought treatment to an increasing number of people in need. That it has done so is in no small part thanks to the AIDS activists who fought to make generic antiretrovirals available, allowing the program to treat many more people than would otherwise be possible.</p>
<h2>Lessons unlearned</h2>
<p>To be sure, the Bush administration had its own reasons to address AIDS in Africa. National security experts at the U.S. State Department had <a href="https://uncpress.org/book/9780807872116/infectious-ideas/">long worried that AIDS would destabilize the continent</a>, as historian Jennifer Brier has shown, and PEPFAR burnished the president’s commitment to “<a href="https://newrepublic.com/article/86075/compassionate-conservative-hiv-pepfar-bush-gop-budget">compassionate conservatism” and faith-based social programs</a>. </p>
<p>But by the time of Bush’s announcement, grassroots activists had already spent years arguing in public that treating AIDS in Africa was not only possible but imperative. And their advocacy for low-cost generic antiretrovirals paved the way for global AIDS treatment on a scale that had once been thought impossible.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protestors holding a black coffin, wearing paper skull masks and signs reading 'I died on an ADAP waiting list' and 'Gilead gouges gov' AIDS dollars'" src="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">AIDS protestors called upon pharmaceutical companies to lower drug pricing to affordable levels.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSHealthcareFoundationProtestatGileadSciences/3937be37fe0b45339e1518d5ad3c48b2">Alison Yin/AP Images for AIDS Healthcare Foundation</a></span>
</figcaption>
</figure>
<p>Unfortunately, U.S. responses to recent viral epidemics have not shown evidence that the nation has learned from the PEPFAR example. The <a href="https://doi.org/10.1038/d41586-022-03529-3">hoarding of COVID-19 vaccines</a> by the U.S. and other wealthy nations shows the same persistent disregard for human life that was evident in attempts to block generic medicines from reaching people who needed them. At the same time, millions of doses of a highly effective vaccine against mpox in the U.S. national vaccine stockpile were <a href="https://www.nytimes.com/2022/08/01/nyregion/monkeypox-vaccine-jynneos-us.html">allowed to expire</a> while outbreaks of the virus <a href="https://doi.org/10.1038/d41586-022-01686-z">raged in West and Central Africa</a> in 2022. And early 2023 announcements that Pfizer and Moderna may both price their COVID-19 vaccines at <a href="https://arstechnica.com/science/2023/01/moderna-may-match-pfizers-400-price-hike-on-covid-vaccines-report-says/">well over $100 per dose</a> in the U.S. recalls the exorbitant drug prices that aroused activist fury in the fight against AIDS.</p>
<p>PEPFAR has saved millions of lives, in no small part because activists thought big and fought hard for justice in the U.S. response to global AIDS. Although the program is far from perfect, it serves as a reminder of what is possible when solidarity guides responses to humanity’s biggest challenges, and the power of grassroots organizing in turning principles into policy.</p><img src="https://counter.theconversation.com/content/194908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dan Royles has received funding from the National Endowment for the Humanities and the National Park Service. He is affiliated with the Miami-Dade Democratic Party. </span></em></p>The US PEPFAR initiative has brought HIV medication to millions of people globally. Behind this progress are the activists that pressured politicians and companies to put patients over patents.Dan Royles, Associate Professor of History, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1955422022-12-01T21:03:51Z2022-12-01T21:03:51ZOn World AIDS Day, Canada must lead the way in combating HIV-AIDS<figure><img src="https://images.theconversation.com/files/498368/original/file-20221201-12-91tm7n.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C3888%2C2566&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Provinces like British Columbia have reduced infection rates thanks to successful treatment and prevention measures. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Dec. 1 marks <a href="https://www.worldaidsday.org/">World AIDS Day</a>. As researchers focused on fighting the HIV-AIDS epidemic, we are increasingly concerned all the progress made in the fight against the virus is at risk. </p>
<p>In 1996, the first remarkable breakthrough against the HIV-AIDS epidemic came with the novel combination of drugs that became known as <a href="https://www.ncbi.nlm.nih.gov/books/NBK554533/">Highly Active Antiretroviral Therapy (HAART)</a>.</p>
<p>For the first time, HAART was able to stop viral replication and render the virus undetectable in blood and bodily fluids, and consequently promote immune reconstitution. This in turn would prevent an HIV infection from developing into AIDS, significantly reducing premature deaths.</p>
<h2>Treatment as prevention</h2>
<p>The next major breakthrough came in the early 2000s. Through close monitoring of the epidemic in British Columbia, our research documented that HIV infected individuals who have consistent viral suppression with HAART are virtually unable to transmit the infection. This led us to recommend initiating HAART immediately following HIV diagnosis to accelerate overall HIV/AIDS control. </p>
<p>We called the strategy <a href="https://bccfe.ca/tasp/about">Treatment as Prevention</a> (TasP) to illustrate the fact that HAART simultaneously stops progression to AIDS, premature death and HIV transmission.</p>
<p>TasP was enthusiastically embraced by the Joint United Nations (UN) Programme on HIV/AIDS (UNAIDS), in 2010. However, it soon became apparent that the TasP strategy was too ill defined, and this open the door for it to be inconsistently deployed between regions.</p>
<p>In 2014, <a href="http://www.unaids.org/sites/default/files/media_asset/JC2670_UNAIDS_Treatment_Targets_en.pdf">UNAIDS unveiled two sequential TasP-inspired targets</a> to quantify the proportion of people living with HIV who need to be diagnosed, the proportion of diagnosed people who need to be on HAART, and the proportion of people on HAART who need to be <a href="https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treatment/viral-suppression">virologically suppressed</a> by 2020 and 2025. Viral suppression is defined by having less than 200 copies of HIV per milliliter of blood.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&rect=0%2C300%2C3085%2C1958&q=45&auto=format&w=1000&fit=clip"><img alt="A white flag with the words World Aids day and a red ribbon flies in front of the peace tower." src="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&rect=0%2C300%2C3085%2C1958&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Canada has made breakthroughs in the fight against HIV-AIDS, but more must be done to make access to treatment more equitable.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
</figcaption>
</figure>
<p>These targets were specifically designed so that by 2030 the world would see a 90 per cent decrease in AIDS mortality and new HIV infections, and meet the goal of ending the HIV-AIDS pandemic. In 2015, the UN <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/june/20210608_hlm-opens">formally endorsed</a> the <a href="https://doi.org/10.7448%2FIAS.19.1.20917">90-90-90 by 2020</a> target. It endorsed our subsequent <a href="https://bccfe.ca/blog/united-nations-adopts-ambitious-95-95-95-95-target">95-95-95 by 2025</a> target in 2021. </p>
<p>However, a lack of leadership and resources have hampered progress towards the UN targets around the world. This has been exacerbated by the COVID-19 pandemic, which disrupted some medical services, decreased HIV testing, interrupted the provision of HAART and diverted funding. </p>
<h2>Differing success rates across Canada</h2>
<p>In 2020, the Public Health Agency of Canada (PHAC) released a much-awaited <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/hiv-canada-surveillance-report-december-31-2020.html">epidemiological HIV/AIDS update</a>. The update came ahead of the <a href="https://aids2022.org/2022/04/29/the-international-aids-conference-returns-to-montreal/">International AIDS Conference</a> held in Montréal in July 2022. </p>
<p>Unfortunately, the results were rather concerning. HIV cases in Canada have remained flat since the 1990s, but there is a marked contrast between British Columbia and the rest of the country. While B.C. saw a steady decline in cases between 1996 and 2020, the rest of Canada saw no further reduction in cases over the same period. </p>
<p>HIV cases peaked throughout Canada in the early 80s. But a decrease in high-risk sexual practices led to a substantial reduction in cases. After that, the course of the epidemics diverged. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="HIV incidence across Canada and B.C. from 1980-2020" src="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=263&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=263&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=263&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=330&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=330&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=330&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">HIV cases from 1980 until 2020 in Canada and British Columbia.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<p>The reason for this discrepancy can be explained by the success of TasP in B.C., where the strategy originated. The graph below compares progress toward the UN’s 2020 target across Canada’s provinces and territories.</p>
<p>B.C., Nova Scotia, Newfoundland and Labrador and the three territories are the only Canadian jurisdictions that surpassed all three components of the <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html#s10">benchmark target</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A chart showing Canadian provinces' progress towards the UNAIDS 90-90-90 targets" src="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Estimated percentage of people living with HIV diagnosed, on treatment and virally suppressed by selected regions in Canada at the end of 2020.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<p>A failure to optimally implement TasP nationally has led to markedly different <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html">HIV rates</a> across the country. In 2020, the national HIV incidence rate was 4.8 per 100,000 people. B.C., which had the highest domestic incidence rate at the peak of the epidemic in the 1980s, was well below the national average, at 2.5 per 100,000 population. The province is now at the low end of the national spectrum, together with the territories and Atlantic provinces at 2.1 and 2.2 per 100,000 population, respectively. </p>
<p>Alberta and Ontario were within the range of the national average at 4.2 and 4.1 per 100,000 population. At the other end, Saskatchewan, Manitoba and Québec were above the national average at 23.0, 7.7 and 5.8 per 100,000 population, respectively. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Map of Canadian provinces & territories showing HIV incidence rates in 2020." src="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=497&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=497&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=497&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=625&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=625&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=625&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">HIV rates in Canada by province and territory in 2020.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<h2>What Canada needs to do</h2>
<p>Clearly, Canada has the tools and the means to end the epidemic. The question remains, are we up to the task? The key requirements are well known: </p>
<ol>
<li>Normalize HIV testing to ensure everybody knows their HIV status.</li>
<li>Remove barriers to <a href="https://www.ohtn.on.ca/out-of-pocket-costs-associated-with-hiv-in-publicly-funded-high-income-health-care-settings/">accessing health services</a>. </li>
<li>Expand support for affected populations, with particular emphasis on harder-to-reach and most affected populations (men who have sex with men, people dealing with substance use, sex workers, inmates, immigrants and First Nations Peoples).</li>
<li>Make free harm reduction services widely available (condoms, lubricants, injection and smoking paraphernalia, supervised injection and smoking consumption sites and safer drug supply programs).</li>
<li><a href="https://doi.org/10.9778/cmajo.20180058">Free HAART</a> for all HIV-positive people.</li>
<li>Free <a href="https://www.cdc.gov/hiv/risk/prep/index.html">pre-exposure prophylaxis (PrEP)</a> to all people at heightened HIV risk.</li>
<li>Free relevant laboratory monitoring for all those on HAART or PrEP. </li>
</ol>
<p>In addition, we must demand full transparency and accountability from our health-care system. That starts with PHAC annually reporting progress towards the UN 95-95-95 by 2025 target, HIV prevalence and AIDS-related mortality. </p>
<p>Finally, the federal government should sponsor a yearly independent summit of all relevant stakeholders to promote accountability and transparency, compare regional progress and share lessons learned in the process. </p>
<p>As a leader in treatment and prevention, Canada has a global responsibility to optimally implement a strategy to effectively combat HIV-AIDS. That will require a major commitment from the provinces given that health care is a provincial responsibility. </p>
<p>Canada knows how to end the HIV-AIDS epidemic. It is high time to get it done.</p><img src="https://counter.theconversation.com/content/195542/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julio Montaner has received support, paid to his institution, from the BC Ministry of Health, Health Canada, the Public Health Agency of Canada, Genome BC, Vancouver Coastal Health and the VGH Foundation. Institutional grants have been provided by Gilead, Merck and ViiV Healthcare.</span></em></p><p class="fine-print"><em><span>Viviane Dias Lima receives funding from the Canadian Institutes of Health Research (PJT-148595; PJT-156147), and the Canadian Foundation for AIDS Research (CANFAR Innovation Grant – 30-101). </span></em></p>Dec. 1 marks World AIDS Day. Canada has the tools and means to end the epidemic. The question remains, are we up to the task?Julio Montaner, Killam Professor, Department of Medicine, University of British ColumbiaViviane Dias Lima, Scientist, Senior Methodologist & Associate Professor, Department of Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1906842022-09-26T13:27:19Z2022-09-26T13:27:19ZHIV treatment in South Africa: how to help people stay on ARVs when life gets in the way<figure><img src="https://images.theconversation.com/files/484889/original/file-20220915-19-ihxxy3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Poor retention in health services is one of the most important reasons people interrupt HIV treatment. </span> <span class="attribution"><span class="source">Stephane de Sakutin/AFP via Getty Images</span></span></figcaption></figure><p>Antiretroviral therapy (ART) has turned HIV into a manageable chronic condition. When ART is working effectively, HIV cannot be transmitted. This allows people with HIV to live fuller lives without the fear of infecting others. It’s also led global HIV control efforts to focus on increasing ART coverage. The aim is to improve the health of people living with HIV, and to decrease and eventually halt the spread of the virus. </p>
<p>UNAIDS set 90-90-90 targets to measure global progress by 2020: 90% of people with HIV know their status, 90% of those with a known status are on treatment, and 90% of those on treatment are virally suppressed (a blood test result that means ART is working effectively). These targets have now been increased to 95-95-95, to be reached by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186775/">2030</a>.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/hiv-aids-and-90-90-90-what-is-it-and-why-does-it-matter-62136">HIV, AIDS and 90-90-90: what is it and why does it matter?</a>
</strong>
</em>
</p>
<hr>
<p>South Africa has <a href="https://www.spotlightnsp.co.za/2022/07/26/spotlight-on-hiv-six-graphs-that-tell-the-story/">achieved</a> the first 90 target but it <a href="https://www.thembisa.org/content/downloadPage/Thembisa4_5report">falls short</a> on the second 90.
Despite having more than <a href="https://www.unaids.org/en/regionscountries/countries/southafrica">5.5 million people</a> on treatment, only 75% of those with a known status are on ART. </p>
<p>Poor retention in health services is one of the most important reasons for this. People living with HIV need to be on ART for their whole lives. This is a tough ask, and although the pills are available free of charge in public health institutions, many people <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186775">interrupt treatment</a>. Modelling and programme <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00310-2/fulltext">data</a> <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00327-8/fulltext?dgcid=raven_jbs_etoc_email#articleInformation">suggest</a> that the number of people re-initiating ART is as high as, or higher than, the number of people starting treatment for the first time. </p>
<p>Interrupting treatment is a problem for two reasons. First, people who aren’t on treatment are likely to become sick and die. Second, without consistent treatment HIV can be transmitted, leading to additional infections. </p>
<p>At <a href="https://www.anovahealth.co.za/">Anova Health Institute</a> we support the Department of Health in providing HIV services in five districts of South Africa. In a <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0256540">recent study</a>, we wanted to know more about why people with HIV interrupt and return to treatment, and how we can support them to stay in care. </p>
<h2>Reasons for stopping treatment</h2>
<p>We surveyed 562 and interviewed 30 people returning to care after interrupting ART in three provinces in South Africa. We also explored service provider challenges in providing treatment and care.</p>
<p>Our <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0256540">analysis</a> showed that retention in care is influenced by multiple factors. These include individual, family, societal and healthcare service barriers. </p>
<p>Mobility or relocation was the most common reason for treatment interruption, reported by close to a third of respondents. It was followed by ART-related factors, including side effects, and feeling too sick to continue ART (15% of respondents); and time limitations due to work (10%). Participants who move around a lot said managing their ART was difficult because of administrative hurdles.</p>
<p><a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.2012019">Health service barriers</a> included negative service provider attitudes and providers insisting on transfer letters, which led to interruption of treatment and care. Feedback sessions conducted with 99 healthcare providers revealed that people returning to care were sometimes sent to the back of the queue or turned away if they did not have transfer letters. Both these practices are discouraged in national guidelines. Most providers <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.2012019">reported</a> they had seen or heard other providers act poorly towards recipients of care after interrupting ART. The poor behaviours and attitudes of providers were partly attributed to limited resources and work overload.</p>
<p>On the other hand, we <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.2012019">found</a> that clinics which had flexible and extended hours services were better able to keep people in care. This shows that health services need to be more responsive to different life circumstances.</p>
<h2>What must be done</h2>
<p>Health systems should be set up to allow people to change where they pick up their drugs. <a href="https://journals.sagepub.com/doi/full/10.1177/11786329211073386">Movement between provinces</a> is common in South Africa. Health services need to be more responsive to people moving within and between districts and provinces, as well as outside South Africa. A functional health information system is needed to link medical records and allow movement between clinics or drug pick-up points anywhere in the country. Healthcare providers should not insist on transfer letters. <a href="https://www.knowledgehub.org.za/elibrary/adherence-guidelines-hiv-tb-and-ncds-standard-operating-procedures-2020">The official policy</a> requires people to be assisted without a transfer letter, in practice many are turned away. Improved treatment literacy would also empower people to understand their own treatment and demand access to care.</p>
<p>ART and other services relating to HIV and other chronic diseases can be provided in <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00327-8/fulltext?dgcid=raven_jbs_etoc_email#articleInformation">many ways</a> inside and outside <a href="https://journals.sagepub.com/doi/full/10.1177/11786329211073386">health facilities</a>. In South Africa, ART and chronic medication can be provided through the <a href="https://www.health.gov.za/wp-content/uploads/2021/09/ccmdd-dablab-AnQ.pdf">Dablapmeds programme</a>. This allows people to collect three months’ medication at pick-up points closer to home or work. Models like this should be supported and strengthened.</p>
<p>People with HIV <a href="https://ritshidze.org.za/wp-content/uploads/2022/03/Peoples-COP22-South-Africa.pdf">told the Department of Health</a> they wanted prescriptions for 12 months, and ART refills of three to six months. A 12-month prescription was used during COVID-19 as an emergency measure, and Anova’s programmes reported no decrease in viral suppression. This policy should be expanded. </p>
<p>Healthcare providers need improved working conditions and support to improve their ability to provide empathetic, quality services. Overall, the country needs more patient-centred and responsive health services to improve retention on ART.</p>
<p>People on ART need <a href="https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-022-00722-x">comprehensive support</a> that covers medication-related issues, psychosocial support and socioeconomic support. Proactive strategies could include check-in phone calls or messages, appointment reminders, and pop-up sites to collect treatment in remote communities, and after-hours facilities. Task shifting allows different forms of treatment support to be offered and can promote <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00327-8/fulltext?dgcid=raven_jbs_etoc_email#articleInformation">ART adherence</a>.</p>
<h2>Why this matters</h2>
<p>Supporting people living with HIV to stay on treatment is the biggest challenge currently facing South African HIV services. </p>
<p>The needs and views of people with HIV must be heard and considered to protect and build on the health gains from the country’s antiretroviral programme. </p>
<p>Services that are flexible and take into account people’s changing life circumstances will improve health and decrease HIV transmission.</p><img src="https://counter.theconversation.com/content/190684/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melanie Bisnauth is employed at the Anova Health Institute, a South African-based NGO, that receives funding from the President's Emergency Plan for AIDS Relief (PEPFAR) through USAID. Some of the work discussed in this article was funded through this grant.</span></em></p><p class="fine-print"><em><span>Kate Rees is employed at the Anova Health Institute, a South African-based NGO, that receives funding from the President's Emergency Plan for AIDS Relief (PEPFAR) through USAID. Some of the work discussed in this article was funded through this grant.</span></em></p><p class="fine-print"><em><span>Cathrine Chinyandura is employed at the Anova Health Institute, a South African-based NGO, that receives funding from the President's Emergency Plan for AIDS Relief (PEPFAR) through USAID. Some of the work discussed in this article was funded through this grant.</span></em></p>When antiretroviral therapy is working effectively, HIV cannot be transmitted. This allows people with HIV to live fuller lives without the fear of infecting others.Melanie Bisnauth, Public Health Technical Advisor, Anova Health Institute and Doctoral Researcher, School of Public Health, University of the WitwatersrandKate Rees, Public Health Medicine Specialist, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1677472021-09-29T15:07:12Z2021-09-29T15:07:12ZCombining an HIV vaccine with immunotherapy may reduce the need for daily medication<figure><img src="https://images.theconversation.com/files/422472/original/file-20210921-13-csnsx2.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The estimated lifetime costs of antiretroviral therapy for someone who acquires HIV at age 35 is $358,380.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/therapy-pills-on-pink-background-royalty-free-image/1214095662">YakubovAlim/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p><a href="https://doi.org/10.1126/sciimmunol.abh3034">A new combination treatment for HIV</a> can strengthen a patient’s immune response against the virus even after they stop taking traditional medications, according to a study published in the journal Science Immunology we co-led at the <a href="http://www.yerkes.emory.edu/research/divisions/microbiology_immunology/amara_rama.html">Amara Lab at Emory Univeristy</a>.</p>
<p>People with HIV take a <a href="https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-treatment-basics">combination of HIV medications</a> to reduce the amount of virus they have in their body. When taken as prescribed, these medications, collectively called <a href="https://www.cdc.gov/hiv/risk/art/index.html">antiretroviral therapy</a>, can reduce the amount of virus in the body to undetectable levels. Antiretroviral therapy must be <a href="https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treatment/taking-your-hiv-medications-every-day">taken daily</a> so the virus is less likely to mutate and <a href="https://hivinfo.nih.gov/understanding-hiv/fact-sheets/drug-resistance">become resistant to the drugs</a>.</p>
<p>While reducing the amount of virus in the body to undetectable levels means it can <a href="https://www.niaid.nih.gov/diseases-conditions/treatment-prevention">no longer be transmitted</a>, however, the most effective antiretroviral therapy drugs are unable to completely eliminate the virus. This is because HIV hides in <a href="https://dx.doi.org/10.1084%2Fjem.190.9.1197">immune-privileged</a> areas of the body, such as certain parts of the lymphoid tissue, that are less accessible to the immune system to protect them from damage. <a href="https://doi.org/10.1038/nri819">Killer T cells</a>, which search for and eliminate infected cells, are unable to patrol these <a href="https://dx.doi.org/10.1097%2FCOH.0000000000000293">viral reservoirs</a> that harbor HIV.</p>
<p><a href="https://dx.doi.org/10.1097%2FQAD.0b013e32835ecb8b">Constant exposure</a> to the virus can push killer T cells into a <a href="https://doi.org/10.1097/qad.0000000000000314">state of exhaustion</a> in which they don’t work as well. Exhausted killer T cells display more of a protein called <a href="https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/immunotherapy/immune-checkpoint-inhibitors.html">PD-1</a>, which functions as an “off switch” to its killing activity.</p>
<p>One way to reverse killer T cell exhaustion is to <a href="https://doi.org/10.1038/cddis.2015.162">block the PD-1 off switch</a>, but this does not boost the immune system’s response to the virus. Conversely, an HIV vaccine can significantly boost immunity against the virus. </p>
<p>So we tested whether <a href="https://doi.org/10.1126/sciimmunol.abh3034">combining these two tactics</a> could enhance HIV infection control. We administered a vaccine for <a href="https://www.livescience.com/51972-hiv-related-virus-evolutionary-history.html">SIV</a>, a close cousin to HIV, with a drug that blocks PD-1 in SIV-infected rhesus monkeys treated with antiretroviral therapy. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram illustrating immune boosting outcomes of study." src="https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422492/original/file-20210921-17-1nmhbxx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Combining a vaccine with a PD-1 blockade led to three improvements in immune response.</span>
<span class="attribution"><span class="source">Bhrugu Yagnik/Created with BioRender.com</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<p>We found that our approach generated robust anti-viral response in multiple parts of the body, including immune-privileged sites in the lymph nodes, and allowed killer T cells to infiltrate and purge viral reservoirs. Most importantly, the monkeys maintained strong immunity against the virus even after they stopped antiretroviral therapy and significantly improved their survival. None of the seven monkeys in the combination treatment group developed AIDS through our six-month follow-up period, compared with half of the monkeys who received only the vaccine or antiretroviral therapy alone.</p>
<h2>Why it matters</h2>
<p>Around <a href="https://www.unaids.org/en/resources/fact-sheet">38 million people worldwide</a> were living with HIV in 2020. If left untreated, HIV can cripple the immune system and leave the body vulnerable to <a href="https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/opportunistic-infections">normally harmless infections</a>.</p>
<p>There are accessibility issues with the treatment that must be diligently taken every day for life. A 2015 study estimated that the lifetime antiretroviral therapy cost for someone who acquires HIV at age 35 is <a href="https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/cost-considerations-and-antiretroviral-therapy">US$358,380</a>. And many people don’t have access to daily antiretroviral therapy. Around <a href="https://www.unaids.org/en/resources/documents/2013/20131219_AccessARTAfricaStatusReportProgresstowards2015Targets">three-quarters of adults with HIV in sub-Saharan Africa</a> do not reach persistent <a href="https://clinicalinfo.hiv.gov/en/glossary/viral-suppression">viral suppression</a> due to lack of treatment availability. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram illustrating the challenges posed by HIV." src="https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422493/original/file-20210921-23-z98bip.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">HIV poses a number of challenges to both patients and researchers.</span>
<span class="attribution"><span class="source">Bhrugu Yagnik/Created with BioRender.com</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<p>Finally, even though antiretroviral therapy can thoroughly suppress HIV infection, it does not cure it. There is always a risk that the virus may mutate to <a href="https://www.who.int/news-room/fact-sheets/detail/hiv-drug-resistance">become resistant to existing drugs</a>.</p>
<h2>What still isn’t known</h2>
<p>Completely wiping out HIV from the body is one way to eliminate the need for daily antiretroviral therapy. But a more achievable strategy is to put the infected cells in check. </p>
<p>Currently, only <a href="https://www.massgeneral.org/news/press-release/Hiv-new-study-of-elite-controllers-offers-powerful-evidence-that-a-cure-is-possible">0.5% of HIV positive individuals</a> are considered “<a href="https://clinicalinfo.hiv.gov/en/glossary/long-term-nonprogressors-ltnp">elite controllers</a>” who are able to suppress infection without medication. </p>
<p>While our study showed a potential pathway to control HIV, it is still in development and not ready for human patients. More research is necessary to understand how viral reservoirs form and why certain cells respond differently to different immunotherapies.</p>
<h2>What’s next</h2>
<p>A single form of therapy may not result in complete HIV remission. Our team is currently testing other drug combinations to unleash the full potential of the immune system and overcome barriers to a cure.</p><img src="https://counter.theconversation.com/content/167747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rama Rao Amara receives funding from NIAID/NIH. </span></em></p><p class="fine-print"><em><span>Bhrugu Yagnik and Sheikh Abdul Rahman do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People with HIV need to take daily medication to keep the virus at bay. A study has found that a new treatment combination could boost immunity and control virus levels even after stopping medication.Sheikh Abdul Rahman, Postdoctoral Fellow in Microbiology and Immunology, Emory UniversityBhrugu Yagnik, Postdoctoral Fellow in Microbiology and Immunology, Emory UniversityRama Rao Amara, Professor of Microbology and Immunology, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1606382021-05-12T12:26:49Z2021-05-12T12:26:49ZTRIPS waiver: US support is a major step but no guarantee of COVID-19 vaccine equity<figure><img src="https://images.theconversation.com/files/400035/original/file-20210511-13-e00ped.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protesters gather in Cambridge to demand that AstraZeneca shares blueprints for its COVID-19 vaccine.</span> <span class="attribution"><span class="source"> Luciana Guerra/PA Images via Getty Images</span></span></figcaption></figure><p>In a momentous shift, the US recently agreed to <a href="https://ustr.gov/about-us/policy-offices/press-office/press-releases/2021/may/statement-ambassador-katherine-tai-covid-19-trips-waiver">support a waiver</a> of the Trade Related Intellectual Property Rights (TRIPs) agreement at the World Trade Organisation (WTO). The waiver backed by the US would suspend intellectual property rights on vaccines.</p>
<p>Until the announcement, the US, alongside the European Union, Norway, Canada, Australia, the UK, Switzerland, Brazil and Japan, had been steadfast in their position that stringent patent protection is key to vaccine supply and the global effort to tackle COVID-19.</p>
<p>But proponents of the waiver argued that the temporary suspension of intellectual property rights was key to achieving vaccine equity and global health security. India and South Africa, with the support of over 100 countries, have been passionately making this case from inside the WTO since October 2020. Their call is for a braoder waiver – one that would cover patents and trademarks on all products required to fight COVID-19 for the duration of the pandemic. </p>
<p>Beyond the WTO, members of global civil society view the waiver on vaccines as essential to securing a <a href="https://peoplesvaccine.org/">“People’s Vaccine”</a> which is universally available to all, free at the point of delivery. </p>
<p>Washington’s support for a TRIPs waiver may, therefore, seem like a substantive win. This is especially so when considered against the backdrop of the horrors unfolding in countries such as <a href="https://theconversation.com/what-indias-second-wave-means-for-its-vaccine-coverage-and-the-rest-of-the-world-159937">India</a>. </p>
<p>But this move marks the start of the battle, not the end of the war. Much remains to be resolved before the waiver is translated into increased vaccine supply.</p>
<h2>The devil is in the detail</h2>
<p>Five key areas remain fundamental to vaccine equity for COVID-19 and tackling any future pandemic.</p>
<p>First, the problem is less about permission and more about how the waiver may work. WTO rules already allow for the temporary suspension of intellectual property rights in situations of public health emergencies like the COVID-19 pandemic. The <a href="https://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm">2001 Doha Declaration</a> re-affirmed that states can issue compulsory licenses on patented drugs in order to produce generic versions at quicker and more affordable rates. The <a href="https://www.wto.org/english/tratop_e/trips_e/wtl641_e.htm">2005 TRIPs amendment</a> further clarified that countries without manufacturing capacity or insufficient demand can import generic versions of drugs with the cooperation of producing or exporting states.</p>
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Read more:
<a href="https://theconversation.com/the-global-approach-to-vaccine-equity-is-failing-additional-steps-that-would-help-158711">The global approach to vaccine equity is failing: additional steps that would help</a>
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<p>In other words, countries with surplus capacity could already be producing generic versions of COVID-19 vaccines. These could be for domestic use and for export to countries lacking domestic manufacturing capacity. </p>
<p>The question is how to translate rights under WTO rules into access to medicines on the ground. The 2005 TRIPs amendment has <a href="https://lawecommons.luc.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1067&context=lucilr">only ever been used once</a> in 2007 when Canada supplied generic antiretroviral drugs to Rwanda. Those involved subsequently criticised the amendment for being overly bureaucratic, <a href="http://www.ip-watch.org/2010/03/01/efficacy-of-trips-public-health-amendment-in-question-at-wto/">costly and complicated</a>. </p>
<p>The TRIPs waiver is only a progressive move if it helps to expedite the generic production and export of affordable vaccines (and related medical products), beyond what is already permissible under the existing rules.</p>
<p>Second, the details of the COVID-19 vaccine waiver are still to be worked out and require consensus among the WTO membership. This could take months, years, or even prove to be impossible. US support is a major step toward agreement. But other countries that see the intellectual property regime as part of the solution, not the problem, may yet hold out against the waiver. Momentum of support and effective trade and health diplomacy is key.</p>
<p>Third, the Biden administration has only indicated that it would be willing to waive patent protection for vaccines. This is insufficient. In line with the original <a href="https://docs.wto.org/dol2fe/Pages/SS/directdoc.aspx?filename=q:/IP/C/W669.pdf&Open=True">proposal</a> made by India and South Africa at the WTO, the waiver should apply to all medical products. These include treatments, diagnostic kits, ventilators, crucial manufacturing components, and protective gear. This is important if the waiver is to help combat COVID-19. </p>
<p>Fourth, the poorest countries will still be unable to produce vaccines. Even if WTO members approve it, the waiver will be more form than substance. Pharmaceutical companies may need to be incentivised to share knowledge and build capacity in developing countries to produce quality, generic versions of the vaccines. The TRIPs agreement mentions technology transfer numerous times, particularly to the least developing countries. It reads:</p>
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<p><a href="https://www.wto.org/english/docs_e/legal_e/trips_e.htm#ann1">…recognising</a> the desirability of promoting the transfer of technology and capacity building in the pharmaceutical sector in order to overcome the problem faced by Members with insufficient or no manufacturing capacities.</p>
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<p>However, as with all such “best endeavour” clauses in the WTO, nothing has been done to make this supposed aspiration a reality.</p>
<p>Finally, we need to ensure the waiver is progressive. Tampering with the TRIPs amendment risks rolling back existing flexibilities. The roll back will happen if there is a restriction on the types of products for which a compulsory licence can be issued. It will also happen if limits are placed on the export of generic versions of the vaccines to those countries with no manufacturing capacity. Time limitations will also roll back existing flexibilities. Emergency measures to respond to COVID-19 must not cause harm for long term flexibilities on patents and licensing.</p>
<h2>The next battle: technology and production</h2>
<p>A TRIPs waiver on its own will allow access to patents. But such patents are only a part of the barriers to countries beginning to expand manufacturing. </p>
<p>Making vaccines is complicated – much more so than many other pharmaceutical products – and technology and know-how <a href="https://www.ft.com/content/b0f42409-6fdf-43eb-96c7-d166e090ab99">will be crucial</a> to expand supply. This point is frequently raised by critics of the waiver. They argue that there is insignificant existing production capacity that can be brought online even if freed of patent obligations. </p>
<p>However, there is evidence that unutilised capacity is available. For example, the Canadian pharmaceutical company <a href="https://globalnews.ca/news/7743371/biolyse-covid-19-vaccines-health-canada-johnson-and-johnson/">Biolyse</a> has been seeking a compulsory licence to produce viral vector vaccines like the Johnson and Johnson vaccine for export to developing countries. Such a step would be compliant with both the TRIPs agreement and the Canadian Access to Medicines Regime.</p>
<p>If the necessary technology sharing does not take place, governments are going to need to provide greater incentives to bring it about. They are, in short, going to need to make good on some of the promises for technology transfer and capacity building made in the TRIPs agreement all the way back in 1995.</p><img src="https://counter.theconversation.com/content/160638/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erin Hannah receives funding from the Social Sciences and Humanities Research Council of Canada. </span></em></p><p class="fine-print"><em><span>James Scott receives funding from The British Academy. </span></em></p><p class="fine-print"><em><span>Silke Trommer receives funding from the Social Sciences and Humanities Research Council of Canada. </span></em></p><p class="fine-print"><em><span>Sophie Harman receives funding from The Leverhulme Trust. </span></em></p>Much remains to be resolved before the waiver is translated into increased vaccine supply.Erin Hannah, Department Chair/Associate Professor of Political Science, King's University College, Western UniversityJames Scott, Senior Lecturer in International Politics, King's College LondonSilke Trommer, Senior Lecturer Politics, University of ManchesterSophie Harman, Professor of International Politics, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1507782020-11-29T09:11:27Z2020-11-29T09:11:27ZWhy Uganda must recognise nurses for more than a decade of HIV care<figure><img src="https://images.theconversation.com/files/371259/original/file-20201125-21-vlcycx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many hospitals permit nurses to initiate and manage patients on ART.</span> <span class="attribution"><span class="source">Jean-Marc Giboux/Getty Images</span></span></figcaption></figure><p>In the years after the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673685901229">“slim disease” or HIV</a> was first recognised in southwestern Uganda in 1982, access to treatment was for a privileged few. At the time, only a handful of clinics such as the Joint Clinical Research Centre could offer any relief for those living with HIV. Because only a small number of patients could afford the prohibitive fees for HIV services, care was almost entirely provided by <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">medical doctors</a>. </p>
<p>Even when antiretroviral medicines such as <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">AZT</a> became available 14 years later in 1996, only a select few Ugandans such as top government officials and high-income individuals could afford them.</p>
<p>Many Ugandans with HIV died premature deaths as the virus ravaged their bodies with no medicines to stall it. Then the game-changer came in June 2004. The United States government, through the PEPFAR initiative, provided substantial external donor aid to enable the <a href="https://implementationscience.biomedcentral.com/articles/10.1186/s13012-017-0578-8">provision of free antiretroviral therapy</a> (ART) at national and regional referral hospitals across Uganda.</p>
<p>But then the “medicines without doctors” predicament emerged as a new challenge. From the 2,700 who were enrolled on treatment in 2004, there are currently <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">1.2 million Ugandans</a> accessing ART. </p>
<p>The giant leap in the number of people accessing HIV treatment would not have been possible without task shifting from medical doctors to less-specialised cadres such as nurses and midwives. Task shifting to <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">nurses</a> was, however, done informally without a guiding policy framework. There is still no such policy. </p>
<p>A national policy on task shifting is critical. Nurses need legal protection against litigation in the course of executing delegated tasks. This policy could also serve as a blueprint for overcoming Uganda’s <a href="https://academic.oup.com/inthealth/article/9/1/1/2433261">health workforce shortages</a> and help the country reach health-related sustainable development goals. </p>
<h2>Task shifting to nurses</h2>
<p>As the world commemorates 2020 as the International Year of the Nurse and Midwife, we reflect on findings from a <a href="https://pubmed.ncbi.nlm.nih.gov/31537365/">study</a> we conducted across Uganda that revealed the true extent of task shifting to nurses in <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">HIV care</a>. We found that in the nearly 200 hospitals we visited across Uganda’s 10 geographic sub-regions, 93% of them permitted nurses to initiate and manage ART. </p>
<p>Our <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">study</a> reveals for the first time that nurses have the highest representation in the leadership and governance of HIV clinics across Uganda. This trend was more pronounced in rural areas but was seen in both rural and urban settings.</p>
<p>The facility managers perceived nurses to be a more dependable cadre as they “tend to stick around for years”. There was a common perception that “higher grade” cadres, such as young doctors, tend to leave for further training and better-paying jobs. Because of the shortage of medical doctors, nurses were depended upon as the backbone of <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">HIV service delivery</a> in HIV clinics across Uganda. </p>
<p>Nurses were empowered to be “all-rounders” in HIV care, from testing to ensuring viral suppression. We were told that nurses could do “big things” if they receive regular training and supportive supervision. Over the past decade, several studies have demonstrated that <a href="https://jhu.pure.elsevier.com/en/publications/noninferiority-of-a-task-shifting-hiv-care-and-treatment-model-us-4">nurse-managed</a> HIV care and treatment is not inferior.</p>
<p>The dramatic expansion in access to <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00479-7">HIV treatment</a> in Uganda revealed the competence of nurses in managing more advanced roles in HIV disease management. But task shifting to nurses is still not yet formally recognised by policy. The official “scope of practice” of nurses has not been revised to reflect the extension in their roles in HIV service delivery.</p>
<p>Furthermore, pre-service training of nurses has not been revised to reflect their increased responsibilities in HIV disease management and hospital administration. </p>
<p>Although Uganda has lagged, other countries in Africa have not. In 2010, South Africa unveiled an <a href="https://pubmed.ncbi.nlm.nih.gov/24739661/">official policy</a> known as “Nurse Initiated and Managed Antiretroviral Therapy”, which permitted nurses into clinical HIV disease management.</p>
<h2>Way forward</h2>
<p>Task shifting to nurses should not only be about HIV but in response to the burgeoning <a href="https://www.ghdonline.org/uploads/Rabkin__El-Sadr_-_HIV_and_NCDs.pdf">noncommunicable diseases epidemic</a> as well. This is why policy reforms must be geared towards recognising what nurses are capable of as a cadre to achieve broader public health goals, including advancing progress towards <a href="https://ghrp.biomedcentral.com/articles/10.1186/s41256-019-0118-y">universal health coverage</a>.</p>
<p>Newer and more efficient forms of HIV <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-5069-y">service delivery</a> approaches known as “differentiated service delivery”, approved by the World Health Organisation in 2016, emphasise tailoring HIV care to patients’ individual needs instead of a “one size fits all” approach. For instance, whereas <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5136137/">patients</a> stable on ART can be managed by nurses, those with advanced HIV disease can be managed by clinicians.</p>
<p>Our study adds to an accumulating evidence base from across sub-Saharan Africa and the mounting calls for nurses to be sufficiently recognised for their prominent role in making HIV treatment more widely available over the past decade.</p><img src="https://counter.theconversation.com/content/150778/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Zakumumpa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The giant leap in the number of people accessing HIV treatment would not have been possible without task shifting from medical doctors to less-specialised cadres such as nurses and midwives.Henry Zakumumpa, Health Systems Researcher, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1500962020-11-17T14:00:08Z2020-11-17T14:00:08ZMillions of people are on treatment for HIV: why are so many still dying?<figure><img src="https://images.theconversation.com/files/369558/original/file-20201116-21-kumht.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Early diagnosis and treatment are key in the fight against HIV.</span> <span class="attribution"><span class="source">Peter Casaer</span></span></figcaption></figure><p>Twenty years ago treatment for HIV was a rare luxury in South Africa. Exorbitant costs and President Thabo Mbeki’s government’s fierce opposition to providing antiretroviral treatment (ART) kept it out of the public sector. </p>
<p>They were terrible days. Many lives were lost.</p>
<p>The environment has changed remarkably since then. The turning point came in 2004 when, after four years of struggle, led by the <a href="https://academic.oup.com/jhrp/article/1/1/14/2188684">Treatment Action Campaign</a>, the government begrudgingly agreed to start providing ART.</p>
<p>Antiretroviral coverage of people with HIV in South Africa has <a href="https://apps.who.int/gho/data/view.main.23300?lang=en">increased</a> from 0% in 2000 to 71% in 2019. The South African antiretroviral programme is now the largest in the world, with more than <a href="https://apps.who.int/gho/data/view.main.23300?lang=en">five million</a> people on treatment, and increasing. HIV-linked deaths decreased from <a href="https://apps.who.int/gho/data/view.main.22100?lang=en">150,000 in 2000</a> – peaking at around 300,000 in 2006 – to 72,000 in 2019. </p>
<p>But deaths have not decreased as much as was hoped. HIV remains a leading cause of death in <a href="http://www.statssa.gov.za/?page_id=1856&PPN=P0309.3&SCH=7914">South Africa</a>. Many people still present to health facilities with advanced HIV disease. And AIDS remains a major contributor to <a href="https://www.tandfonline.com/doi/full/10.3402/gha.v6i0.19090">hospitalisations and deaths</a> in Africa. </p>
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Read more:
<a href="https://theconversation.com/south-africas-remarkable-journey-out-of-the-dark-decade-of-aids-denialism-62379">South Africa's remarkable journey out of the dark decade of AIDS denialism</a>
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<p>Globally, <a href="https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics#:%7E:text=AIDS%2Drelated%20Deaths%E2%80%94AIDS%2D,%2D%20and%20middle%2Dincome%20countries.">690,000</a> people died from HIV in 2019.</p>
<p>Doctors Without Borders (MSF) supports hospitals in South Africa, Guinea, the Democratic Republic of Congo (DRC), Malawi and the Central African Republic that continue to treat large numbers of people with AIDS. Because people present with very advanced HIV disease, up to one in three dies during their hospital stay.</p>
<p>One of the main challenges remains that diagnostics and drugs aren’t readily available for people suffering from advanced HIV. This group of people is very vulnerable to deadly opportunistic infections such as tuberculosis (TB), meningitis and severe bacterial infections.</p>
<p>This all goes to show the world is very far from the end of AIDS.</p>
<h2>Gaps</h2>
<p>In the last ten years the focus has been on diagnosing people with HIV and starting them on treatment. Efforts around the test-and-treat approach have been mobilised around the <a href="https://www.unaids.org/en/resources/909090">UNAIDS 90-90-90 targets</a>: 90% of people with HIV to know their status; 90% of those whose status is known to be on antiretroviral therapy; and 90% of those on antiretrovirals to have an undetectable viral load.</p>
<p>This is necessary but it is not enough to address HIV-related mortality. Life-long treatment requires life-long support. Some people will interrupt treatment; some will struggle to take their tablets every day, risking developing drug resistance and treatment failure.</p>
<p>Today, most people with advanced HIV either are failing or have interrupted treatment. In two <a href="https://pubmed.ncbi.nlm.nih.gov/29514239/">MSF-supported studies</a> in the DRC and Kenya, only 20%-35% of inpatients with advanced HIV were ART-naïve (had never accessed treatment) and over half of those on ART had <a href="http://www.croiwebcasts.org/console/player/41323?mediaType=slideVideo&">treatment failure</a>.</p>
<p>The reality of treatment interruption and treatment failure requires a new approach.</p>
<p>This is why MSF piloted <a href="https://samumsf.org/sites/default/files/2019-06/Welcome%20services%20poster.pdf">Welcome Back Services</a> in Khayelitsha, Cape Town. The services focus on the needs of patients returning to care and those failing treatment. Stigmatisation and blaming patients for interrupting or failing treatment is common. This leads to delays in seeking care, and patients presenting as false-naïve – patients retesting for HIV and hiding the fact that they were previously on treatment. </p>
<p>This in turn leads to patients presenting in more advanced stages of the disease or on inadequate treatment.</p>
<p>This is one of the reasons why HIV still claims too many lives. Patients who present very late often have severe immune suppression, multiple concurrent life-threatening illnesses and significant organ damage due to HIV itself. Treatment is complicated by the need for many different medicines, with a higher risk of drug interactions and severe side effects. Even with intensive care, unavailable in most settings, many patients die.</p>
<p>TB is the leading cause of death among people with HIV in resource-limited settings. It is estimated that TB is responsible for around <a href="https://pubmed.ncbi.nlm.nih.gov/26266773/">50%</a> of deaths. Two other leading causes are cryptococcal meningitis, which is responsible for one in five HIV deaths, and severe bacterial infections. </p>
<p>Together, these infectious diseases cause more than two thirds of <a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(15)00137-X/fulltext">HIV-related deaths</a>. All three are preventable and treatable – if detected early enough.</p>
<h2>No time to lose</h2>
<p>There are immediate steps that can be taken.</p>
<p>There are more options than ever to prevent TB disease. New <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462706/">evidence</a> shows that shorter regimens of rifapentine and isoniazid, weekly for three months or daily for one month, are equally effective at treating latent TB and decreasing deaths compared to the older regimen of isoniazid for six to 36 months. And a <a href="https://www.aidsmap.com/news/oct-2020/four-month-tb-treatment-matches-six-month-standard-care">recent trial</a> demonstrated that a four-month treatment with a new regimen was as efficacious as the current six-month regimen to treat active TB disease. </p>
<p>When left untreated, the odds of surviving cryptococcal meningitis are zero. But <a href="https://theconversation.com/a-new-meningitis-screening-test-could-help-cut-south-africas-hiv-aids-deathtoll-69452">cryptococcal meningitis</a> can be prevented and there have been advances in treatment. Daily fluconazole is recommended in some countries for prevention of a first episode, and everywhere as secondary prophylaxis to prevent recurrent disease. Treatment with flucytosine and amphotericin B reduces mortality by 40%. Yet these medicines are still missing in many – if not most – health structures in Africa. </p>
<p>Steps can be taken to prevent death from advanced HIV. These include earlier detection at the primary care level – before patients develop disease so severe that they seek hospital admission. The longer the delay to diagnosis and treatment, the lower the chances of survival. </p>
<p>This is where CD4 tests and rapid tests for TB and cryptococcal meningitis are life-saving.</p>
<p>What is needed urgently to save lives is accelerated access to a package of care for the prevention, diagnosis and treatment of advanced HIV at the primary care and hospital level, along with strategies with clear targets to decrease AIDS mortality.</p><img src="https://counter.theconversation.com/content/150096/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gilles van Cutsem is affiliated with the Cryptococcal Meningitis Advocacy Group (CryptoMAG), a group of clinicians, researchers and policymakers advocating for increased access to diagnosis and treatment of cryptococcal meningitis. He is also the chair of the Flucytosine HIV-Crypto Project Advisory Committee of the European and Developing Countries Clinical Trials Partnership. </span></em></p>One of the main challenges remains that diagnostics and drugs for people suffering from advanced HIV aren’t readily available. This group of people is vulnerable to deadly opportunistic infections.Gilles van Cutsem, Honorary Research Associate, Centre for Infectious Disease Epidemiology and Research, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1500022020-11-15T07:57:32Z2020-11-15T07:57:32ZLarge Africa study makes important breakthrough in HIV prevention<figure><img src="https://images.theconversation.com/files/369092/original/file-20201112-17-ywbtm0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Long-acting cabotegravir injections once every eight weeks was better than the daily tablet used for HIV prevention.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Women make up more than <a href="https://www.unaids.org/en/resources/infographics/girls-and-women-living-with-HIV">half</a> of the people living with HIV around the world. Young women between the ages of <a href="https://www.unaids.org/en/resources/infographics/girls-and-women-living-with-HIV">10 and 24</a> are twice as likely to get HIV as young men in the same age group. In East and Southern Africa young women will acquire HIV on average five to seven years earlier than their male peers.</p>
<p>Researchers have been working hard to find effective <a href="https://theconversation.com/rings-and-things-other-ways-to-prevent-hiv-are-on-the-cards-69192">HIV prevention</a> measures.</p>
<p>Most notable is the pre-exposure prophylaxis (PrEP) pill known as <a href="https://theconversation.com/how-a-drug-can-help-prevent-5000-girls-being-infected-with-hiv-every-week-52539">Truvada</a>. This is a combination of two antiretroviral drugs – tenofovir and emtricitabine. This can be effective in preventing HIV acquisition. But taking a pill every day is not practical for many people. </p>
<p>Scientists from the HIV Prevention Trials Network <a href="https://www.hptn.org/news-and-events/press-releases/hptn-084-study-demonstrates-superiority-of-cab-la-to-oral-ftctdf-for">recently found</a> that a PrEP regimen of long-acting cabotegravir (CAB LA) injections once every eight weeks was better than the daily tablet used for HIV prevention. Ina Skosana spoke to Sinead Delany-Moretlwe, a research professor at the University of the Witwatersrand in South Africa and director of research at the Wits Reproductive Health & HIV Institute to find out more.</p>
<hr>
<h2>Can you tell us about the study?</h2>
<p>This study, known as <a href="https://www.hptn.org/research/studies/hptn084">HPTN 084</a> is the first one to compare the efficacy of two HIV prevention or pre-exposure prophylaxis regimens.</p>
<p>The first regimen consisted of an injection of the long-acting antiretroviral drug, cabotegravir given every eight weeks. The second regimen was the daily oral dose of Truvada. Truvada has been shown to be highly effective for HIV prevention when taken as prescribed in a variety of populations and contexts.</p>
<p>We enrolled over 3,200 sexually active, HIV-uninfected cisgender women at 20 sites in seven countries. Research took place in Botswana, Eswatini, Kenya, Malawi, South Africa, Uganda, and Zimbabwe between November 2017 and November 2020.</p>
<p>Our study randomised participants to one of two arms. One arm received active cabotegravir and a Truvada placebo. The other arm received active Truvada and placebos for cabotegravir. Cabotegravir was administered daily by mouth for 5 weeks and via intramuscular injection at 8-weekly intervals after an initial 4-week interval load.</p>
<h2>What did you find?</h2>
<p>Preliminary findings show that overall 1% of participants were infected with HIV during the study period. This suggests that both cabotegravir and Truvada are highly effective for HIV prevention in this population.</p>
<p>The 34 incident infections detected in participants assigned to Truvada is equivalent to an incident of 1.79%. And the four infections detected in the participants assigned to cabotegravir is equivalent to an incidence of 0.21%. This confirms a new prevention option for women that offers a significant advantage over existing oral PrEP which requires consistent daily use and is associated with significant adherence challenges.</p>
<p>We observed roughly 9 times the number of incident HIV infections in the Truvada arm compared to the cabotegravir arm. This finding suggests that cabotegravir is much more effective than Truvada in preventing HIV infection in women. And the threshold for early stopping of the trial was met. Based on these findings the independent data and safety monitoring board recommended that the blinded portion of the study be stopped early and the results released to the scientific and broader community.</p>
<p>An earlier sibling study in cisgender men and transgender women called <a href="https://www.hptn.org/news-and-events/press-releases/hptn-083-study-demonstrates-superiority-cabotegravir-prevention-hiv">HPTN 083 </a> showed similar results. A prep regimen containing long-acting cabotegravir injectable once every 8 weeks was superior to the daily oral Truvada in that population.</p>
<h2>What are the next steps?</h2>
<p>The study results are important and timely as more methods to prevent HIV among women at higher risk of HIV are urgently needed. These include methods that do not depend on daily or near-daily pill-taking, condom use or abstention from sex. The development of alternative methods to prevent HIV, and more adherence-friendly schedules than are currently available, will increase the HIV prevention choices and acceptability for women and reduce new HIV infections.</p>
<p>We have communicated with the research ethics committees and national drug regulators overseeing this study, and site investigators and study participants are being notified about the results as soon as possible. Participants will be able to learn about the medication that they were receiving. A protocol amendment will be submitted for regulatory review to allow participants to continue taking their assigned medication or to switch to cabotegravir if they choose. </p>
<p>Participants on Truvada will be offered cabotegravir as soon as the medication can be made available. All participants will be asked to continue on the study. And if they chose not to remain on the study, they will be referred for the best locally available HIV prevention services. We look forward to presenting these results in a peer-review setting at upcoming conferences as we finalise the primary analysis.</p><img src="https://counter.theconversation.com/content/150002/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This study is funded by the Division of AIDS (DAIDS) at the US National Institute of Allergy and Infectious Disease (NIAID), US National Institute of Mental Health (NIMH) and US National Institute of Health (NIH), the Bill & Melinda Gates Foundation, Viiv and Gilead donated the drug. </span></em></p>Our findings suggest that cabotegravir is much more effective than Truvada in preventing HIV infection in women.Sinead Delany-Moretlwe, Associate Professor and Director: Research at the Wits Reproductive Health and HIV Institute I, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1312422020-02-12T12:41:52Z2020-02-12T12:41:52ZHow nutrition education can make a difference to people with HIV in Nigeria<figure><img src="https://images.theconversation.com/files/313991/original/file-20200206-43123-1loe0jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>HIV and AIDS are still global health problems and sub-Saharan Africa remains the <a href="https://www.who.int/gho/hiv/en/">most affected</a> region. Globally, around <a href="https://www.unaids.org/en/resources/fact-sheet">770,000</a> people died from AIDS-related conditions in 2018, <a href="https://aidsinfo.unaids.org/">160,000</a> of them in West and Central Africa.</p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/29952786">standard treatment</a> for HIV consists of a <a href="https://www.ncbi.nlm.nih.gov/pubmed/29065165">combination</a> of at least three antiretroviral drugs. But <a href="https://www.ncbi.nlm.nih.gov/pubmed/23450554">providing</a> antiretroviral therapy without proper, nutritious diets may compromise the effectiveness of the treatment. </p>
<p>People with HIV have <a href="https://www.ncbi.nlm.nih.gov/pubmed/31108127">higher</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16477562">energy needs</a> than those of people without HIV. And the World Health Organisation <a href="https://extranet.who.int/rhl/topics/hiv-aids/food-insecurity-sexual-risk-behavior-and-adherence-antiretroviral-therapy-among-women-living-hiv">recommends</a> that antiretroviral medications be taken with food to avoid possible side effects such as headaches and stomach problems, which can lead to weakness and weight loss.</p>
<p>HIV infection has a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522867/">complex relationship</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/31668643">with nutrition</a>. </p>
<p>Because of the importance of good nutrition in the management of HIV, we <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2019.00030/full">aimed</a> to develop and test a nutrition education programme for adults living with HIV in the Nigerian context. We wanted to evaluate their knowledge of nutrition, their actual diets and the effect on their bodies – in short, the programme’s impact on their health and quality of life.</p>
<p>We <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0640-4">found</a> that the education programme helped people to choose healthy foods and this improved their physical well-being. This experience could contribute to other education programmes aimed at supporting people with HIV to have a better quality of life.</p>
<p>We started by studying the existing Nigerian nutrition guidelines for adults living with HIV. The nutrition information and recommendations were the same for all adults, whether they had HIV or not. The general premise of the <a href="https://nigeria.savethechildren.net/sites/nigeria.savethechildren.net/files/library/NPFN%20manual%20design%20%20v13.pdf">Nigerian national dietary guidelines</a> is to promote good dietary practices and to avoid alcohol consumption and smoking. </p>
<p>There are no details on key issues relating to HIV and nutrition such as how individuals can improve the variety of foods they eat, how they can get important vitamins and minerals, and how they can access clean drinking water despite limited resources. </p>
<p>In addition, there isn’t much appropriate nutrition information available to public health care staff and patients.</p>
<p>We wanted to design a programme that would plug this gap by teaching adults with HIV how to eat healthy foods with limited resources. </p>
<h2>The intervention</h2>
<p>Our <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2019.00030/full">research</a>, in the form of a nutrition education intervention, focused on outpatients receiving HIV treatment at two selected hospitals in Abeokuta, southwestern Nigeria. </p>
<p>First we conducted a needs assessment in a similar group, which revealed poor <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0640-4">quality of life</a>, high consumption of unvaried meals, poor nutrition knowledge and unhealthy eating behaviour. We used this information to develop contextualised nutrition education materials. Health care workers could use these materials to provide nutrition education specifically for patients with HIV, such as planning varied meals, the relationship between diet and medication, and dealing with barriers to healthy eating. </p>
<p>The content of the programme also covered the importance of hygiene and exercise, how to deal with problems like diarrhoea and anaemia, and how to shop for healthy food within a limited budget.</p>
<p>We developed a trainer’s manual, brochures, participant’s workbook and flipcharts. We also evaluated the impact of the education materials on the participants before and after the intervention. And we followed up with them for 12 weeks after the intervention.</p>
<h2>Better nutrition choices</h2>
<p>We <a href="https://www.ncbi.nlm.nih.gov/pubmed/31084656">found</a> that using the communication materials we developed could influence the participants’ decisions about healthy food choices and access. The nutrition education programme led to some significant improvements.</p>
<p>Participants were able to function better physically and their activities weren’t as limited by pain or weakness compared with the control group who didn’t receive nutrition education. Participants who received our nutrition education intervention had better nutrition knowledge, quality of life and dietary diversity scores compared to the control groups.</p>
<p>The intervention we designed showed that people don’t need to have more money to make better nutrition choices. They can and do improve their well-being when they have more knowledge. And our programme was effective in imparting this knowledge. We believe that our findings could be useful to improve programmes that help poor people living with HIV to access healthy food.</p><img src="https://counter.theconversation.com/content/131242/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Temitope Kayode Bello does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Providing antiretroviral therapy without incorporating quality diets may not help to reduce illness and death related to HIV.Temitope Kayode Bello, Postdoctoral Fellow, University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1297132020-02-06T11:45:38Z2020-02-06T11:45:38ZWhat the discovery of a new HIV strain means for the pandemic<figure><img src="https://images.theconversation.com/files/309642/original/file-20200113-103987-1fkdus0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's important for scientists to have the most thorough understanding of HIV. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The discovery of a rare new strain of HIV for the first time in nearly 20 years recently made <a href="https://edition.cnn.com/2019/11/06/health/hiv-new-strain-discovered/index.html">headlines</a> around the world. </p>
<p>The big question is what the discovery means for the overall response to the HIV epidemic.</p>
<p>A team of US researchers from Abbott, an American medical devices and health care company, led by Mary Rodgers and co-authors at the University of Missouri, announced the discovery in a <a href="https://journals.lww.com/jaids/Abstract/publishahead/Complete_genome_sequence_of_CG_0018a_01.96307.aspx">study</a> published in the Journal of Acquired Immune Deficiency Syndrome. The new subtype is the first strain to be identified since <a href="https://www.avert.org/professionals/hiv-science/types-strains">guidelines</a> for classifying new HIV strains were first established in 2000.</p>
<p>HIV has a multitude of different subtypes and, like other viruses, it changes (mutates) over time. This new strain is an important discovery, but it does not signify a new public health threat. It occurs rarely and can be effectively treated with existing antiretrovirals. Because antiretrovirals target characteristics of HIV that are common across all different subtypes, this new finding will not affect treatment and antiretroviral agents will still be effective as long as drug resistant mutations have not occurred. </p>
<p>The essence of the discovery is that it enhances scientists’ understanding of the complexity of the human immunodeficiency virus and its evolution and adds detail to the already comprehensive viral picture. </p>
<p>Having a thorough understanding of HIV is crucial in ensuring that HIV tests are effectively detecting the virus. Deeper insights could also have a bearing on vaccine development. </p>
<h2>Viral strains</h2>
<p>There are two main types of HIV. HIV-1 is the most common. HIV-2 is less common and accounts for fewer infections. The strains of HIV-1 can be classified into four groups – M, N, O and P. While N, O and P are quite uncommon, group M is responsible for most of the global HIV epidemic, accounting for roughly <a href="https://www.avert.org/professionals/hiv-science/types-strains">95%</a> of all infections worldwide. The newly discovered strain (also known as a clade) is part of group M and has been labelled as “subtype L”. </p>
<p>The prevalent strain found in South Africa is <a href="https://www.avert.org/professionals/hiv-science/types-strains">known</a> as a subtype of clade C.</p>
<p>One of the candidate HIV vaccine regimens <a href="http://www.samj.org.za/index.php/samj/article/view/5668/4223">currently</a> under investigation in South Africa is designed to be effective against subtype C. It is not yet known whether, if found to be effective in this region, it will be as effective in a region with a different prevalent strain. For example, in the US the predominant strain is subtype B.</p>
<p>The process of confirming a new strain of any virus can be long. Three separate cases need to be identified before a new subtype can be announced. The first two cases of this new strain were found in the Democratic Republic of Congo in 1983 and 1990 and the third case in 2001. So while the strain has been known to scientists for 18 years, the entire genome needed to be tested for confirmation. The technology to do this did not exist at the time.</p>
<p>The genome sequencing technology available today allows scientists and researchers to build entire genomes at a faster rate and lower cost than ever before. To use this next-generation technology successfully, the responsible scientists had to apply new techniques that focus on the virus portion of the collected sample in order to fully sequence the genome. </p>
<p>From a scientific point of view, the discovery helps us stay one step ahead of a virus. Furthermore, the role that new technology played in identifying the strain serves as an important reminder of how far we have come. The innovation and advancements in technology and molecular virology should be celebrated.</p>
<p>The fight against HIV has made some formidable gains in treatment and treatment outcomes with remarkable gains in longevity. </p>
<p>UNAIDS <a href="https://www.unaids.org/en/resources/fact-sheet">estimates</a> that new infections have decreased by 16% from 2,1 million in 2010 to 1,7 million in 2017. Undoubtedly one of the most promising achievements is the reduction in mother-to-child transmissions around the world. But the HIV response does not favour complacency. </p>
<h2>Emergency persists</h2>
<p>The notion that HIV is no longer an emergent threat is one that jeopardises the work of scientists and communities who continue to drive prevention of HIV and fight against the pervading stigma. The HIV emergency is not over. The epidemic still needs vigilant attention, especially as reduction rates stall. </p>
<p>The ultimate solution is a working cure and preventative vaccine. Trials were being held in South Africa – the <a href="https://desmondtutuhivfoundation.org.za/hiv-vaccine-trial-is-underway/">HVTN 702 studies</a> – into a HIV preventative vaccine in the hope that there would be an effective vaccine to prevent HIV. But they <a href="https://www.fredhutch.org/en/news/center-news/2020/02/hiv-vaccine-trial-africa.html">were halted</a> in early February 2020. This points to the need to refocus our energy on scaling up the effective treatment and prevention tools we have in hand to all those who need them.</p>
<p><em>This story was updated to reflect the fact that the HVTN 702 trials in South Africa were halted in February 2020.</em></p><img src="https://counter.theconversation.com/content/129713/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The discovery of a new strain of HIV gives scientists a better understanding of the virus.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1279552019-11-30T20:20:33Z2019-11-30T20:20:33ZThe social management of HIV: African migrants in South Africa<figure><img src="https://images.theconversation.com/files/304432/original/file-20191129-95230-17ww3hh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nowhere in South Africa is the migrant population as dense as in inner-city Johannesburg.</span> <span class="attribution"><span class="source">Supplied</span></span></figcaption></figure><p>HIV is the most common chronic illness in <a href="https://www.unaids.org/en/regionscountries/countries/southafrica">South Africa</a>. One in every five is infected and one in every 13 takes antiretroviral drugs daily. Managing HIV medically has become more of a part of normal life.</p>
<p>Amid this public health emergency, some <a href="https://africasacountry.com/2018/10/how-many-immigrants-live-in-south-africa">2.5 million</a> foreign-born <a href="https://africacheck.org/factsheets/geography-migration/">African immigrants</a> live in South Africa. They largely come from countries with the highest HIV prevalence rates in the <a href="https://aidsinfo.unaids.org/">world</a>, such as Lesotho. Yet their access to health care and services is limited, because they are vulnerable in various ways. Though entitled to inclusion and care in South Africa, they may face deportation, xenophobia, exploitation, language barriers, cultural estrangement and social isolation. </p>
<p>In spite of these challenges, migrants do <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5594-3">manage HIV medically</a>. But we do not really know how they manage socially in communities where the stigma of the disease affects all dimensions of life. HIV is often referred to today as a <a href="https://theconversation.com/how-hiv-became-a-treatable-chronic-disease-51238">“manageable” chronic illness</a>, but it is not just a medical condition. It is also very much a social condition as living with HIV comprises both clinical features of care and experiences of stigma and social angst.</p>
<p>Understanding how migrants manage this social dimension of their condition matters because it shapes the landscapes and outcomes of their care. It directly influences when and where people seek treatment, and how well they adhere to it if they do. This in turn affects critical issues such as drug resistance and prevention of transmission.</p>
<p>In a recent journal <a href="https://www.tandfonline.com/doi/full/10.1080/01459740.2019.1677646">article</a>, I unravel complexities of stigma and perceptions of HIV in Mozambican migrant communities. My research exposes layers and shades of stigma across different social networks and locations, which influence how HIV is managed socially. It shows how an individual’s HIV status determines how other community members are regarded and interacted with in daily life.</p>
<h2>Perceptual contrasts</h2>
<p>Nowhere in South Africa is the migrant population as dense as in inner-city Johannesburg. In their urban enclaves, community members inevitably lead lives entwined with those of people receiving care for HIV, whether aware of their infection or not.</p>
<p>HIV is spoken of here in ways that acknowledge, perpetuate and replicate stigma. For instance, Mozambicans may allude to HIV as “stepping on the mine”, as “being poisoned” or as “getting stung”. Open conversation about HIV is avoided, which in turn creates an anxiety that motivates secrecy. This is so because disclosure of HIV serostatus may put social life at risk.</p>
<p>I explore perceptions of HIV among two groups of Mozambican migrants in Johannesburg: one consisting of patients receiving care for HIV in a hospital; and the other of community members unaware of their own serostatus.</p>
<p>The contrast between how these two groups perceive of each other is staggering. The patients apprehensively conceal their status for fear of what others might think of them. But these others express mostly empathy and understanding for their condition. </p>
<p>I identify two reasons for such stark perceptual contrasts. The first lies in a transformation of identity, which results in a division between an “us” and a “them”, between the HIV-positive and the HIV-negative. </p>
<p>This process creates a schism between “patienthood” and “personhood”. When a person tests positive for HIV, fears of physical death in the future transform into fears of social disruption in the present. <a href="https://www.tandfonline.com/doi/abs/10.1080/13691058.2019.1571230?af=R&journalCode=tchs20&">Loneliness and isolation</a> then result from the person keeping her HIV status secret. </p>
<p>As the identity of a community member shifts from personhood to patienthood, as she receives counselling and care, she comes to associate disclosure with her own (and others’) social death. Her serostatus then becomes a secret in her life, while her notion of others’ perceptions of HIV becomes confined to the realm of the suspected and nervously anticipated. Expecting social misfortunes should others learn of her status, she opts for concealment as a strategy of survival in the community.</p>
<p>Secondly, I find that stigma is tied to location, because of the ways in which location is tied to social networks. In different social networks such as family at home, friends, work colleagues, acquaintances in the community or the nightlife, the stakes of disclosure vary considerably.</p>
<p>For instance, one focal point of stigma is the local HIV clinic. It is supposed to care for its patients, but at the same time it also estranges them, because others might recognise them there and so become antagonists rather than fellow patients.</p>
<p><a href="https://youtu.be/PTwvkqYH06k">Video abstract</a></p>
<p>In fact, Mozambicans largely prefer to avoid clinics in South Africa and go home to Mozambique for treatment. The stakes of disclosure, involving livelihoods, partners and identities, are far too high to risk being seen receiving care in South Africa. Disclosure may be less hurtful in certain locations where social networks are more sympathetic.</p>
<p>This may further complicate the therapeutic journey of migrants in terms of costs, retention in treatment or simply having to explain away the true purpose of one’s absence.</p>
<h2>Medicalised, not socialised</h2>
<p>HIV may have become easier to manage medically, but stigma continues to cause distress and remains severely challenging to manage. This is also a challenge for health care provision, as it sways choices of when and where to seek care: a South African clinic, for example, or a distant, socially safer treatment option.</p>
<p>HIV may have been medicalised, yes, but not socialised.</p><img src="https://counter.theconversation.com/content/127955/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bent Steenberg receives funding from the European Commission and the Mellon Foundation.</span></em></p>HIV is a condition that must be managed, not just medically, but also socially, tackling stigma, social anxieties and the risks of disclosure.Bent Steenberg, Medical Anthropologist, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1184932019-06-10T11:08:47Z2019-06-10T11:08:47ZAdherence is delaying HIV elimination targets. What’s needed to break the cycle<figure><img src="https://images.theconversation.com/files/278627/original/file-20190610-52762-vgzdye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa has the world's highest AIDS burden.
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As 2020 draws closer, the deadline to end AIDS by 2030 looms large. The aim is to achieve the ambitious targets of <a href="https://theconversation.com/hiv-aids-and-90-90-90-what-is-it-and-why-does-it-matter-62136">“90-90-90”</a>. That is, 90% of people living with HIV knowing their status; 90% of all those with HIV on antiretroviral therapy; and 90% of those on antiretroviral therapy with no HIV in their bloodstream.</p>
<p>So how has a country like South Africa, with the heaviest AIDS burden in the world, fared?</p>
<p>According to UNAIDS, South Africa achieved the first of the three 90s in 2017. This was driven largely by <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/south-africa#footnote107_3tf8dz2">two nationwide testing initiatives</a>. But success in achieving the two remaining targets has been slower. <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/south-africa#footnote107_3tf8dz2">As of 2018</a>, only two thirds of the 7.1 million people living with HIV were on antiretroviral therapy, of whom 78% percent were virologically suppressed. This equates to only 44% of all people with HIV being virologically suppressed.</p>
<p>People <a href="http://aidsinfo.unaids.org/">who are virologically suppressed</a> can’t transmit HIV, a major reason to push the 90-90-90 targets. If less than half of South Africans are suppressed, the country needs to work harder to get the missing half tested and treated appropriately. This is for their own health, and to stop further transmissions.</p>
<p>There are two main reasons these targets haven’t been met. The first relates to testing: people still don’t get tested, test late, or don’t make their way onto antiretroviral treatment.</p>
<p>The second is that people who do start their treatment often stop taking their medication. This has blunted the extraordinary way in which South Africa has enrolled millions of people onto safe and effective HIV treatment. Fifteen years ago, hardly anybody was on treatment and the disease killed almost everyone who had it. Today, most people with HIV have free access to a single, safe tablet a day in state clinics. As a result, people are living long healthy lives with HIV.</p>
<p>For South Africa to improve antiretroviral adherence, it needs a package of other interventions at a social, systemic and individual level. Innovative breakthroughs are also needed in the administration of the drugs.</p>
<h2>Why people don’t take their drugs</h2>
<p>The reasons that people don’t take their antiretrovirals are multi-faceted and extremely complex. </p>
<p>The side-effects of earlier antiretrovirals were one reason. But many of the newer antiretroviral medications are much better tolerated. People with HIV are therefore less likely to discontinue them. In fact, most of the reasons people don’t take their medication aren’t related to the antiretrovirals themselves. </p>
<p>Instead, they’re related to much broader and often social or systemic issues. These include the social chaos that surrounds people who have marginal or no employment; alcohol or substance use; family fragmentation and all the trappings of a society that often offers poor social support.</p>
<p>Treatment for most people with HIV consists of a single tablet taken once a day. Side-effects occur early on and resolve in the majority of cases within a few days or weeks. </p>
<p>In these terms, treatment for HIV is possibly well ahead of treatments for other chronic diseases, such as diabetes. It’s simple, convenient, effective, well tolerated and cost effective. And yet starting and staying on antiretroviral therapy remains a significant challenge.</p>
<p>Some of the myriad reasons for not taking antiretrovirals include complexity of the regimen; size of the pill; pill burden associated with treating other illnesses that people may have.</p>
<p>In addition, for many the issue is around access and availability of their antiretroviral medications. Many people don’t have the means to get to the clinic for their medications; they can’t afford time off work to go to the clinic; or the clinic does not have their antiretrovirals because of stock-outs.</p>
<p>Some people simply want to forget that they have HIV. Or they may feel so well that they forget to take their pills. For some, it’s simply a case of life happens and life is busy – it’s easy to forget to take one’s pills.</p>
<p>Stigma and non-disclosure of HIV status are further contributors, not to mention the impact of substance abuse and (often undiagnosed) mental health disorders like depression and anxiety.</p>
<p>So what’s the answer?</p>
<h2>Innovative approaches needed</h2>
<p>One answer is to come up with drugs that are easier to take. That goes without saying. In addition, however, we believe that the time is ripe to develop innovative approaches to improving adherence.</p>
<p>The theme of this year’s <a href="https://www.avac.org/event/9th-sa-aids-conference-2019">AIDS conference</a> in South Africa is “Unprecedented Innovations and Technologies: HIV and change”. Its focus is on the incredible scientific, social and digital innovations and technologies that could expand possibilities and opportunities towards controlling HIV/AIDS.</p>
<p>One example currently under development that may help overcome some of the challenges posed to antiretroviral adherence at social, systemic and individual level is new thinking around how antiretrovirals could be delivered.</p>
<p>What if they could be delivered as an injectable medication at monthly (or even less frequent) intervals instead of a daily pill? Or even better, what about implantable antiretrovirals that last not months but years? No pills for people to have to conceal in cases of non-disclosure; no daily pill that is easily forgotten in the chaos of daily life; less frequent clinic visits which benefits the individual as well as the health system.</p>
<p><a href="https://academic.oup.com/ofid/article/5/10/ofy247/5106902">Studies</a> have demonstrated that people with HIV prefer injectable antiretrovirals to pills, despite injection pain. If we look at the example of contraception, this isn’t surprising – the <a href="http://www.bioline.org.br/pdf?ep11043">preferred contraceptives</a> in sub-Saharan Africa are injectable contraceptives.</p>
<p>A decade ago, injectable and implantable antiretrovirals may have sounded like science fiction. But these technologies are increasingly within reach and may resolve many of the issues associated with poor adherence.</p><img src="https://counter.theconversation.com/content/118493/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Moorhouse has received speaker fees and honoraria from Gilead Sciences, AbbVie, Cipla, Johnson and Johnson, Sanofi, Pfizer, ViiV Healthcare, Mylan and Southern African HIV Clinicians Society; and conference sponsorship from Johnson and Johnson, BD, Gilead, Merck, Cipla and Mylan. She receives funding from from USAID, Unitaid and study drug donations from ViiV and Gilead and is part of ART optimisation collaborations.
</span></em></p><p class="fine-print"><em><span>Willem Daniel Francois Venter has received speaker fees and honoraria from Gilead Sciences, AbbVie, Cipla, Johnson and Johnson, Pfizer, ViiV Healthcare, Mylan and the Southern African HIV Clinicians Society; and conference sponsorship from Johnson and Johnson, BD, Gilead, Merck, Cipla and Mylan. He receives funding from from USAID, Unitaid and study drug donations from ViiV and Gilead and is part of ART optimisation collaborations.</span></em></p>Most of the reasons people don’t take their medication aren’t related to the antiretrovirals themselves, but rather social and systemic issues.Michelle Moorhouse, Senior Research Clinician, University of the WitwatersrandWillem Daniel Francois Venter, Deputy Executive Director, Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1111022019-02-21T14:17:27Z2019-02-21T14:17:27ZCancer drug pricing gets in the way of treatment in developing countries<figure><img src="https://images.theconversation.com/files/257024/original/file-20190204-193226-1kwfkjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Access to affordable medical treatment can save lives.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Most cancers can now be detected early. This hasn’t always been the case. The first big breakthrough came 80 years ago when the <a href="https://www.mayoclinic.org/tests-procedures/pap-smear/about/pac-20394841">pap smear</a> was introduced. Ten years later the <a href="https://www.pinkdrive.co.za/breast-health-info/mammograms/">mammogram</a> was created and then nearly half a century ago the <a href="https://www.mayoclinic.org/tests-procedures/fecal-occult-blood-test/about/pac-20394112">fecal occult blood test</a> was developed. </p>
<p>Advances in diagnosis have made a huge difference. When cancer is detected at an <a href="https://www.who.int/news-room/detail/03-02-2017-early-cancer-diagnosis-saves-lives-cuts-treatment-costs">early stage</a> – and when coupled with appropriate treatment – the chance of survival beyond five years is dramatically higher. Early diagnosis can also reduce the cost of treatment. </p>
<p>Despite this, millions of cancer cases are found late. This results in expensive and complex treatment options, diminished quality of life, and avoidable deaths. </p>
<p>The <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">global cancer burden</a> is estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018 up from 12.7 million new cases and 7.6 million deaths in <a href="http://governance.iarc.fr/SC/SC50/Biennial%20Report%202012-2013.pdf">2008</a>. One in 5 men and one in 6 women <a href="https://www.uicc.org/new-global-cancer-data-globocan-2018">worldwide</a> develop cancer during their lifetime, and one in 8 men and one in 11 women die from the disease. </p>
<p>Unless greater effort is placed into altering the course of the disease, this number is expected to rise to close to 30 million <a href="https://gco.iarc.fr/tomorrow/home">new cases</a> by 2040. </p>
<p>More than <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">70%</a> of the world’s total new annual cases occur in Africa, Asia, and Central and South America. These regions account for more than 60% of the world’s cancer deaths. Yet treatment for cancer is not widely available in these regions. Health systems are often not equipped to deal with detection and treatment of cancers. Prevention and early detection programmes are often weak or non-existent. </p>
<p>This situation is exacerbated by the <a href="https://www.healthpolicy-watch.org/cancer-drugs-unaffordable-for-millions-treatment-costs-exceed-other-diseases-who-reports/">high cost</a> of treatment and, in particular, the high cost of newer cancer medication. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834140/pdf/mdx521.pdf">Cancer medication pricing</a> has increasingly become a global issue creating access challenges in low-and middle-income countries. Death rates from cancer in wealthy countries are <a href="http://cebp.aacrjournals.org/content/cebp/early/2015/12/10/1055-9965.EPI-15-0578.full.pdf">declining slightly</a> because of early diagnosis and the availability of treatment.</p>
<p>But this isn’t the case in low- and middle-income countries. For example, over 80% of children diagnosed with cancer in high-income countries will be <a href="https://www.who.int/news-room/fact-sheets/detail/cancer-in-children">cured</a>. In low and middle-income countries the rate is as low as 10%. </p>
<h2>Massive disparities</h2>
<p>Only <a href="https://academic.oup.com/annonc/article/21/4/680/156750">5%</a> of global resources for cancer are spent in the developing world. Yet these countries account for almost <a href="https://www.sciencedirect.com/science/article/pii/S014067361061152X?via%3Dihub">80%</a> of disability-adjusted years of life lost to cancer globally. And developing countries, governments and individuals struggle to pay for products that are priced at several times the level of their per capita GDP. Buyers are at the mercy of a single provider, often the patent holder of the product, particularly where the product has no competitors. </p>
<p>In 2018 the <a href="http://apps.who.int/medicinedocs/en/m/abstract/Js21758en/">World Health Organisation</a> found that pricing of cancer drugs was disproportionately higher than other types of pharmaceuticals and therapies.</p>
<p>Nor is it just a question of price. Efficacy comes into the picture too. In 2017, estimated global expenditure on medicines for cancer and related supportive care amounted to <a href="https://www.iqvia.com/institute/reports/global-oncology-trends-2018">US$ 133 billion</a>. Despite these huge costs, a systematic evaluation of 68 cancer medicines approved by the European Medicines Agency in 2009–2013 showed that only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5627352/">35%</a> had established evidence of prolonged survival at the time of approval. Similarly, only 10% of the 68 medicines had evidence of improvement in the quality of life at the time of approval.</p>
<p>In addition, some medicines may present higher risk of toxicities to patients, with <a href="https://apps.who.int/iris/handle/10665/272962">evidence</a> of high rates of deaths related to treatment (toxic deaths) and high chances of patients discontinuing treatment due to intolerance. </p>
<h2>Some answers</h2>
<p>We often hear that efforts to expand cancer care aren’t affordable and will divert resources from higher priorities. A similar view was once held about HIV/AIDS. Yet we have seen remarkable success expanding access to services. Many lessons can be learnt from this experience. For example, generic drug competition in the HIV market has been essential in bringing the price of antiretroviral medicines down dramatically. </p>
<p>Developing countries should be encouraging the use of generic and biosimilar cancer medicines with a view to enhancing competition. This will certainly drive down cancer drug prices. <a href="http://ascopubs.org/doi/10.1200/JGO.2016.008607">For example</a>, in Norway, an infliximab biosimilar was discounted by nearly 70% and now represents more than 50% of drug sales. Similarly, in India and Peru, a rituximab biosimilar was introduced at a 50% lower price compared to the originator, illustrating the value they bring into oncology care.</p>
<p>In addition, governments must ensure that the application of patent law and rights for market exclusivity are not over compensating innovators and becoming barriers to access. Such activism has been found resonance in many countries as has been the case in <a href="https://www.fixthepatentlaws.org/wp-content/uploads/2016/09/MSF-FTPL-report-FINAL-VERSION.pdf">South Africa</a>.</p>
<p>These approaches are important to create platforms for engagement and the political momentum to strengthen health care for cancer patients at national level and take action globally to provide guidance for treatment and care, share knowledge about treatment cost and provide a legal framework to ensure treatment is available. </p>
<p>The cost of new drug development as an explanation for the high prices of new medicines is doubtful. Yet when it comes to health care and certainly in the case of potentially fatal diseases such as cancer, people are willing to bear a heavy burden even if the health benefits in reality turn out to be limited.</p>
<p>What’s important is that biomedical and technological advancements don’t introduce greater disparities and inequities when it comes to access to care and outcomes. The watch word must be affordability, not profitability.</p><img src="https://counter.theconversation.com/content/111102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vikash Sewram does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The global cancer burden especially in developing countries is exacerbated by the high cost of treatment.Vikash Sewram, Director of the African Cancer Institute, Faculty of Medicine and Health Sciences , Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1077652018-11-30T11:41:51Z2018-11-30T11:41:51ZAIDS treatment has progressed, but without a vaccine, suffering still abounds<p>I mentioned to a friend, a gay man nearing 60, that <a href="https://www.worldaidsday.org">World AIDS Day</a>, which has been observed on Dec. 1 since 1988, was almost upon us. He had no idea that World AIDS Day still exists. </p>
<p>This lack of knowledge is a testament to the great accomplishments that have occurred since World AIDS Day was created 30 years ago. It is also due to an accident in the timing of his birth that my friend escaped the devastation wreaked by AIDS among gay men in the U.S., before there was antiretroviral therapy. </p>
<p>Many people have forgotten AIDS, but there are consequences to forgetting. The fight against AIDS is at a tipping point. Increasingly, there are signs that we may be heading in the wrong direction.</p>
<h2>Many successes, yet the grand prize is elusive</h2>
<p>I am a social epidemiologist with more than 20 years of research experience in HIV and STD prevention. I am also the founder of <a href="https://www.youtube.com/c/TheBasicswithDrMo">The Basics with Dr. Mo</a>, a sex health communications project that translates prevention science directly for people who need it most.</p>
<p>It is true that global HIV/AIDS success stories abound: Mother-to-child transmission can be reduced to <a href="http://www.who.int/hiv/topics/mtct/en/">below 5 percent</a>, 75 percent of people living with HIV know their status and <a href="http://www.unaids.org/en/resources/fact-sheet">59 percent receive antiretroviral therapy</a>. </p>
<p>Most recently, Pre-Exposure Prophylaxis (PrEP) – the use of antiretrovial drugs to prevent HIV infection among those exposed – has proved to be a <a href="https://www.cdc.gov/hiv/risk/prep/index.html">successful prevention approach</a>.</p>
<p>Yet the prize – a vaccine that can prevent HIV infection – remains elusive, and makes impossible the use of the only known strategy to have ever eradicated an infectious disease: widespread vaccination. That disease was smallpox, in 1980.</p>
<h2>The seeds of unease</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A demonstration for AIDS advances in July 2018 in The Netherlands, with Princess Margaret Van Orange pictured at the center.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/amsterdamnetherlands-july-232018-princess-mabel-van-1140466079?src=dBNVXnXsHdBScshgvjTuTA-1-19">Paolo Amorim/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Despite the lack of a vaccine, in 2016 United Nations member states adopted a <a href="http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2016/june/20160608_PS_HLM_PoliticalDeclaration">political declaration</a> on ending the AIDS epidemic by 2030. </p>
<p>As part of the accountability framework, interim 2020 goals set a target of 500,000 new HIV infections for that year. A review of the most recent data estimated <a href="http://www.unaids.org/en/resources/documents/2018/unaids-data-2018">1.8 million new HIV infections</a> in 2017, exactly the <a href="http://www.unaids.org/en/resources/documents/2017/20170720_Core_epidemiology_slides">same number as in 2016</a>.</p>
<p><a href="https://www.bbc.com/news/health-44884593">Prominent scientists</a> have already begun to question the ability to eradicate AIDS by the 2030 deadline, and concede that the situation has stagnated. The attainment of eradication looks bleak, without the aid of either an effective vaccine or the immediate large-scale promotion and utilization of existing prevention tools (i.e., condoms, voluntary circumcision and potentially PrEP). Given that the vast majority of new HIV infections are sexually transmitted and that <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2015/july/20150702_condoms_prevention">condoms have played a decisive role</a> in the global control of HIV transmission, ongoing condom availability and use will be essential to future eradication.</p>
<p>Condoms – both male and female – remain a <a href="https://www.cdc.gov/std/hiv/stds-and-hiv-fact-sheet-press.pdf">highly effective mechanism</a> of HIV/AIDS prevention, as well as of other sexually transmitted infections that greatly enhance the risk of HIV transmission. </p>
<p>Condom use is also strongly advised by global public health institutions, including the <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">World Health Organization</a> and the <a href="https://www.cdc.gov/hiv/basics/prevention.html">U.S. Centers for Disease Control and Prevention</a>, in conjunction will all other HIV prevention tools including PrEP, because of their lower levels of effectiveness in preventing transmission. </p>
<p>Condom availability is a different matter and varies greatly from country to country. Countries with the highest levels of HIV often rely heavily on donor support. According to the most recent data, in sub-Saharan Africa in 2013, only <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">10 condoms were available</a> annually for every man aged 15 to 64 (as compared with the recommended 50 to 60), and, on average, there was one female condom available for every eight women. Funding required to maintain – let alone scale up – HIV commitments, particularly those dedicated to prevention, are <a href="https://www.avert.org/professionals/hiv-around-world/global-response/funding">increasingly uncertain.</a></p>
<h2>The hydra, sprouting new heads</h2>
<p>Even though condoms are an extremely effective barrier method, it is usage that makes condoms efficacious in preventing HIV transmission. Reported condom use varies considerably around the world, and ranges from 80 percent use by men in Namibia and Cambodia to less than 40 percent usage by men and women in other countries, including some highly affected by HIV such as Sierra Leone and Mozambique. </p>
<p>Age plays a role, too. Among young people aged 15 to 24, <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">condom use at last sex varies</a> from more than 80 percent in some Latin American and European countries to less than <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">30 percent in some West African countries</a>. In the U.S., condom use is at the lower end of the spectrum: Only one-third of the population uses condoms, a number that has not changed significantly over the past two decades.</p>
<p>The majority – 66 percent – of the <a href="https://www.avert.org/global-hiv-and-aids-statistics">world’s HIV/AIDS cases</a> are in sub-Saharan Africa, where there has been much progress, particularly with the provision of antiretroviral therapy.</p>
<p>However, there are worrying signs in other parts of the world. There has been <a href="http://www.unaids.org/en/resources/documents/2018/unaids-data-2018">little change in new HIV infections</a> in countries outside of sub-Saharan Africa between 1990 and 2017. </p>
<p>In fact, six of the 10 most populous countries in the world have experienced <a href="http://www.unaids.org/en/regionscountries/countries">10 percent to 45 percent increases in new HIV infections since 2010</a>: Russia, China, Brazil, Pakistan, Mexico and Bangladesh. Even in countries such as the U.S., where new HIV infections have decreased by 8 percent overall, the rates of change are unevenly distributed. For example, <a href="https://www.cdc.gov/hiv/statistics/overview/ataglance.html">young African-American men</a> who have sex with men show no decrease in new infections; African-American gay and bisexual men represent the largest percentage of new HIV infections: more than one-quarter. </p>
<p>The increased provision of antiretroviral therapy to people living with AIDS has had a huge impact on extending life and in preventing new HIV infections. However, there remains 25 percent of the population who live with HIV, about 9 million people, who do not know their status. </p>
<p>While we have been necessarily focused on the head of the hydra in sub-Saharan Africa, other hydra heads are beginning to make their presence known, many in countries ill-prepared to deal with increases in the number of new HIV infections. </p>
<p>In the absence of a vaccine, behavior change in the form of condom use promotion, acceptance and adoption, at a scale that many gay men utilized during the peak of the AIDS epidemic in the industrialized world, will need to occur. There are many challenges: continued stigma and gender inequality, not to mention issues of availability, distribution and proactive, nonjudgmental promotion. </p>
<p>We must not forget. Progress on reducing the rate of new HIV infection has been done before. It can be done again, but only if we take forceful, funded action now.</p><img src="https://counter.theconversation.com/content/107765/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Miller does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>World AIDS Day is Dec. 1. With many advances in preventing and treating the disease, the disease has fallen from top of mind for many. An epidemiologist explains why that could be dangerous.Maureen Miller, Adjunct Associate Professor of Epidemiology, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1005092018-11-28T12:57:34Z2018-11-28T12:57:34ZBabies born to mums with HIV face higher risks even though they’re HIV negative<figure><img src="https://images.theconversation.com/files/246685/original/file-20181121-161641-w8psje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The largest number of HIV-exposed but uninfected children are in South Africa.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>One of the most remarkable public health successes of the last decade in southern Africa has been the reduction in the number of babies born with HIV. This was achieved through the provision of antiretroviral therapy to pregnant and breastfeeding women living with HIV. For example, the number of new HIV infections in children in South Africa has come down from a peak of 70 000 in 2003 to 13 000 in <a href="http://aidsinfo.unaids.org">2017</a>.</p>
<p>Nevertheless, worldwide there are still an estimated <a href="http://aidsinfo.unaids.org">14.8 million</a> children under the age of 15 who were born HIV uninfected but have been exposed to their mother’s HIV during pregnancy.</p>
<p>The largest number of HIV-exposed but uninfected children – <a href="http://aidsinfo.unaids.org">3.2 million</a> – are in South Africa.</p>
<p>A staggering <a href="http://www.health.gov.za/index.php/shortcodes/2015-03-29-10-42-47/2015-04-30-08-18-10/2015-04-30-08-21-56?download=2584:2015-national-antenatal-hiv-prevalence-survey-final-23oct17">30%</a> of pregnant women in South Africa have HIV. Their infants are exposed to both HIV and antiretroviral drugs during pregnancy and breastfeeding. HIV-exposed but uninfected children don’t have HIV, so what’s the big deal?</p>
<p>It is a big deal because HIV-uninfected children born to mothers with HIV are prone to infections that are more severe, are at almost two times greater risk of dying before their first birthday, and are more likely to be born prematurely than children born to mothers without HIV. </p>
<p>In our <a href="https://www.ncbi.nlm.nih.gov/pubmed/30321432">recent study</a> we set out to try and quantify the contribution of deaths in HIV-exposed but uninfected infants to the overall infant mortality rates in Botswana and South Africa.</p>
<p>What we found was that because children born to mothers with HIV make up almost 1 in every 4 infants in Botswana and South Africa, and because they die more often than children born to mothers without HIV – even when they are HIV-uninfected themselves – this contributed to a higher infant mortality rate in both countries.</p>
<h2>The risks</h2>
<p>Even when they’re not HIV infected, children born to women with HIV experience a complex package of detrimental exposures. </p>
<p>For example, HIV-exposed but uninfected infants are still more often born <a href="https://www.ncbi.nlm.nih.gov/pubmed/29040569">preterm or of low birth weight</a>. This increases their risk for complications and death early in life. </p>
<p>They are also exposed to more infectious pathogens in the home such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/27393540">tuberculosis</a>. </p>
<p>There are other problems too. Breastfeeding has enormous nutritional and immunological benefits, but has often been avoided in infants born to women with HIV. Maternal access to antiretrovirals has made it safer but sustained breastfeeding is still low. One study in South Africa showed that, irrespective of HIV-status, women stopped <a href="https://www.ncbi.nlm.nih.gov/pubmed/29959720">breastfeeding</a> their babies on average when the infants were eight weeks old.</p>
<p>On top of this, HIV-exposed infants more often have mothers who are unwell or <a href="https://www.ncbi.nlm.nih.gov/pubmed/27091659">who have died</a>. And HIV-affected households experience challenging socioeconomic <a href="https://www.ncbi.nlm.nih.gov/pubmed/27392008">circumstances</a> that can make children more vulnerable. These exposures in the <a href="http://www.who.int/maternal_child_adolescent/child/nurturing-care-framework/en/">first 1000 days of life</a> can be detrimental to early childhood development and have life-long consequences. </p>
<p>In addition, infants born to women with HIV are subject to factors during pregnancy that unexposed infants aren’t. These include exposure to HIV particles, that may make their <a href="https://www.ncbi.nlm.nih.gov/pubmed/27049574">immune systems</a> develop differently. And these infants are exposed to at least three antiretroviral drugs given to the mother during pregnancy. </p>
<h2>What the research found</h2>
<p>To estimate the contribution of deaths in HIV-exposed but uninfected infants to the overall infant mortality rates we used previously published research comparing the mortality risk in HIV-exposed uninfected infants to risk of mortality in <a href="https://www.ncbi.nlm.nih.gov/pubmed/27456985">unexposed infants</a>, as well as United Nations estimates of infant mortality in Botswana and South Africa. </p>
<p>In Botswana, HIV exposed uninfected infants accounted for 26% of the infant population but 42% of all infant deaths. Similarly, in South Africa HIV exposed uninfected infants accounted for 23% of the infant population but 38% of all infant deaths. </p>
<p>Putting this into actual numbers, this extra mortality in HIV exposed uninfected infants increased the overall HIV-uninfected infant mortality rate in both Botswana and South Africa from around 30 deaths per 1000 infants to 35 deaths per 1000 in the year 2013. </p>
<p>Botswana and South Africa have adopted the World Health Organisation’s recommendation to provide lifelong antiretrovirals to all pregnant and breastfeeding women with HIV. But there’s a lack of research comparing the mortality of HIV-exposed to unexposed infants under these new guidelines. Our calculations are therefore based on the year 2013, the most recent year before policy shifts in both countries. There is emerging <a href="https://www.ncbi.nlm.nih.gov/pubmed/29272387">evidence</a> though of a persisting increase in mortality in HIV-exposed infants even with maternal antiretroviral therapy. </p>
<h2>What next</h2>
<p>With 1 in every 4 children in Botswana and South Africa being HIV and ARV-exposed, robust systems need to be put in place to monitor the long-term safety of these exposures during pregnancy. Countries need to invest in research to understand why HIV-exposed children still have an increased risk of dying. And countries need to ensure that routine child health interventions, such as immunisations and promotion of optimal durations of breastfeeding, are uniformly reaching HIV-exposed children.</p>
<p>Most critically, countries like South Africa and Botswana with high HIV infection rates need to find responsible, transparent and accurate ways of sharing what is known and being done about the risks of HIV-exposure with HIV-affected families and involve them in finding solutions.</p><img src="https://counter.theconversation.com/content/100509/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Slogrove receives funding from research funding agencies on a competitive funding basis including the US National Institutes of Health and the International AIDS Society. </span></em></p><p class="fine-print"><em><span>Kathleen M. Powis receives funding from the National Institute of Health and from the Collaborative Initiative for Pediatric HIV Education and Research. </span></em></p><p class="fine-print"><em><span>Mary-Ann Davies receives funding from research funding agencies on a competitive basis including the National Institutes of Health and the International AIDS Society.</span></em></p>HIV negative children born to women with HIV have a greater risk of dying before their first birthday.Amy Slogrove, Senior lecturer in Paediatrics and Child Health, Stellenbosch UniversityKathleen M. Powis, Assistant Professor, Harvard UniversityMary-Ann Davies, Associate Professor and Director of the Centre for Infectious Diseases Epidemiology and Research, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1044322018-10-22T14:17:13Z2018-10-22T14:17:13ZHow innovation can help end the AIDS epidemic by 2030<figure><img src="https://images.theconversation.com/files/241212/original/file-20181018-67188-12rs5mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The WHO recommends HIV viral load testing to monitor people on ARVs. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A United Nations <a href="http://www.unaids.org/en/resources/909090">initiative</a> backed by global experts has set its sights on an ambitious programme to bring an end to the AIDS epidemic by 2030. </p>
<p>The 90-90-90 strategy aims to do this by reaching three targets: 90% of all people with HIV must know their status, 90% of those diagnosed with HIV must receive antiretroviral therapy, and 90% of people receiving antiretroviral therapy must be virally suppressed. When a person is <a href="http://www.who.int/hiv/mediacentre/news/viral-supression-hiv-transmission/en/">virally suppressed</a> it means the virus in their blood is undetectable. The last goal is informed by <a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(17)30183-2/fulltext#%20">evidence</a> that people with a suppressed viral load are less likely to transmit HIV to others.</p>
<p>But a couple of steps still need to be taken before these goals can be met. The first is large scale community based HIV testing that aims to get people tested on an annual basis at the very least. The second is linking testing to care. This is critical because it addresses the gap between a person being diagnosed with HIV to when they start antiretroviral therapy. </p>
<p>The third step is the close monitoring of people taking antiretroviral medication. The World Health Organisation (WHO) recommends <a href="http://apps.who.int/iris/bitstream/handle/10665/255702/9789241512633-eng.pdf?sequence=1">viral load testing</a> as the primary method of monitoring people on antiretroviral therapy. Viral load is the measure of the amount of HIV in a person’s blood and is used as a measure of how well a person is responding to HIV treatment. The lower the viral load the better the health outcomes. </p>
<p>WHO guidelines advise that all patients on antiretroviral therapy receive a viral load test at six months and 12 months, and annually thereafter if the patient is stable. But very few patients receive that level of care. </p>
<p>The main barrier is the time it takes to get test results back from laboratories that are often situated great distances from clinics. One way round the problem is to enable viral load testing to take place at primary health care level – what’s known as point-of-care viral load testing. This would be a game changer. Results would be known immediately and health workers could intervene swiftly by evaluating antiretroviral treatments in real time. This would, in turn, improve treatment outcomes. </p>
<p>But achieving this requires innovation. A new approach is being piloted. The idea is to test if point-of-care viral load monitoring is in reach.</p>
<h2>Testing</h2>
<p>Monitoring the viral loads of people on antiretroviral therapy is an essential part of HIV management. Viral load testing helps doctors determine if a person is taking their medication as prescribed. It also helps to determine if patients are on the correct combination of antiretroviral drugs.</p>
<p>It’s a key part of the arsenal against HIV because research shows that people who are virally suppressed are less likely to pass on the virus to someone else. That makes it a key factor in breaking the cycle of transmission.</p>
<p>The most efficient way of doing this is through point-of-care testing sites. These are based within the community so that patients don’t have to travel long distances to get tests done as well as to receive treatment. This new model is being piloted with the aim of providing convenient access to care for patients.</p>
<p>Currently nearly all viral load testing is conducted in centralised and <a href="http://www.nhls.ac.za/?page=hiv_pcr&id=61">designated laboratories</a>. This means that there can be lags in getting results back to the field. Patients can wait for weeks. </p>
<p>Laboratory based viral load testing is also expensive. Point-of-care testing is also cheaper than lab-based viral loads: health care workers could do the test rather than highly paid technicians. </p>
<p>Small steps have been made in the direction of enabling viral load monitoring to be done at point of care.</p>
<p>But additional equipment is also needed. Pilots evaluating point-of-care viral load testing are ongoing. A pilot is being run using a portable testing machine – the m-PIMA HIV1/2 – that fits on a desk top and can provide an accurate reading of viral load in under 70 minutes. </p>
<p>The machine is being tested to establish whether it meets WHO standards. Once it is given the stamp of approval by the WHO, ministries of health can start the implementation at all sites. </p>
<h2>Closing the gap</h2>
<p>All countries still struggling to bring the HIV pandemic under control are focused on achieving the 90-90-90 goals. </p>
<p>South Africa, which still has the <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">biggest HIV epidemic in the world</a>, with 7.9 million people living with <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">HIV</a>, is no exception, and is making significant progress.</p>
<p>It is edging closer to the target of having 90% of people with HIV <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">knowing their status</a>. And it’s made significant progress on the second target that 90% of people with HIV should be on treatment. </p>
<p>But it has some way to go on the third. While the country is on track to meet the goal that 90% of people on treatment be virally suppressed, it’s advances on this front haven’t been uniform. Some regions of the country still lag behind others. Being able to roll out point of care testing would go a long way in helping close these gaps.</p><img src="https://counter.theconversation.com/content/104432/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Glenda Gray is the deputy chairperson of the Orange Babies Charity in South Africa, director of HCRISA, president and CEO of the South African Medical Research Council and a board member at the NRF. She is writing this article in her personal capacity.</span></em></p>Introducing viral load testing at health facilities can help South Africa reach the United Nations target to end AIDS.Glenda Gray, Research Professor, Perinatal HIV Research Unit and President, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1043472018-10-10T14:13:59Z2018-10-10T14:13:59ZWhy integrating HIV with non-HIV services in Uganda won’t work<figure><img src="https://images.theconversation.com/files/239340/original/file-20181004-52669-6xfbb9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A girl gets tested for HIV in Uganda where attempts to integrate HIV services with general health service have failed. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In many countries in sub-Saharan Africa, HIV services are still offered separately within health facilities. These HIV clinics have their own dedicated staff and infrastructure such as waiting areas, a separate patient flow system and they typically run on designated days of the week. This is known as a vertical model and was touted as a pragmatic emergency strategy to overcome sub-Saharan Africa’s weak health systems in the quest to rapidly enrol millions on HIV treatment.</p>
<p>Vertical HIV clinics are very common in sub-Saharan Africa. Studies conducted in <a href="https://www.tandfonline.com/doi/abs/10.1080/17441692.2011.621964?journalCode=rgph20">Kenya</a>, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126144">Swaziland</a> and <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0035479">Zambia</a> suggest that stand-alone HIV clinics are the rule rather than the exception in the region.</p>
<p>Stand-alone HIV clinics have depended substantially on donor aid especially from the US’s <a href="https://www.pepfar.gov/">President’s Emergency Plan for Aids Relief (PEPFAR)</a>. But over the past five years, there have been <a href="https://www.ncbi.nlm.nih.gov/pubmed/28376834">persistent reports</a> of declining international assistance to scale up HIV services in sub-Saharan Africa. This has been one of the main drivers of calls for integrating HIV services with non-HIV services to avoid duplication and promote long-term programme sustainability. </p>
<p>Numerous <a href="https://academic.oup.com/heapol/article/32/suppl_4/iv27/3925681">studies</a> have been done evaluating the integration of HIV services with other health services such as sexual and reproductive health service or those for non-communicable diseases. In addition, several policies, including <a href="http://www.who.int/hiv/pub/imai/operations_manual/en/">World Health Organisation</a> guidelines, have outlined ways in which HIV services can be integrated into general health services.</p>
<p>But, <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3500-4">research we conducted</a> across eight geographic sub-regions in Uganda shows that the country is not prepared for this integration. This is because general clinic staff don’t have specialist HIV knowledge, as well as the fact that sheer numbers of HIV clients will make it difficult. We argue that a more nuanced approach should be taken.</p>
<h2>Why not</h2>
<p>Our study identified a number of potential challenges in doing away with stand-alone HIV clinics.</p>
<p>Firstly, we found that HIV-related stigma was widespread among health workers. For example, we found that some health workers in the labour ward of a public health centre refused to touch HIV positive expectant women.</p>
<p>Secondly, we found that HIV-positive patients were discriminated against. In one large hospital we visited, the pharmacy prioritised patients who paid for their medication while HIV patients were treated last because they don’t pay. </p>
<p>Thirdly, health workers maintained that HIV disease management is a speciality skill. They argued that requiring all health workers to learn how to manage HIV treatment overnight was not feasible because of continuous updates in HIV treatment protocols. Also, the one-on-one touch by clinicians in HIV care would be hard to maintain in general clinics.</p>
<p>Fourthly, there’s the problem of numbers. HIV clinics in Uganda were described as “a hospital within a hospital” because of the large patient volumes. Uganda has 1.6 million people living with HIV with <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/uganda">898,200</a> enrolled on antiretroviral therapy in 2016. This suggests that the sheer volume of HIV clients at health facilities is too large simply to be merged with the general pool of patients. </p>
<h2>What we found</h2>
<p>Most <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5886169/">studies</a> evaluate integrating HIV with non-HIV services under experimental settings. Our study is different in that the majority of health facilities we surveyed had actually experienced having specialist HIV clinics, as well as been through the experience of integrated care. </p>
<p>Several hospitals we visited had reverted back to a stand-alone clinic model after failed attempts at integrating HIV with non-HIV services. Health workers and patients cited a number of reasons for this happening. These included:</p>
<ul>
<li><p>The chaos that ensued when all hospital laboratory services were brought under one roof. This included multiple accounts of HIV patient samples being lost. </p></li>
<li><p>The increased workload while implementing an integrated package of services.</p></li>
<li><p>A shortage of physical space. </p></li>
<li><p>The ability of health facilities to conduct HIV and non-HIV laboratory tests concurrently. </p></li>
<li><p>The absence of counselling rooms when facilities were integrated into general out-patient services. This affected the ability to offer HIV positive patients’ privacy. </p></li>
<li><p>Increased waiting times in integrated facilities. </p></li>
</ul>
<h2>What next</h2>
<p>Our study suggests that a wholesale switch to integrated health services is not feasible and a more incremental approach is advisable. From our findings it is clear that the health system in Uganda is unprepared for integrated care. </p>
<p>Retraining health workers, preparing people for the changes and shortages of space are among the issues that need to be addressed. Blanket integration policies are impractical and need to be tailored to country context.</p><img src="https://counter.theconversation.com/content/104347/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Zakumumpa received funding from The Wellcome Trust (UK) through the Consortium of Advanced Research Training in Africa (CARTA).</span></em></p>In Uganda stand-alone clinics for HIV treatment persist because of stigma and overcrowding.Henry Zakumumpa, Health Systems Researcher, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1003432018-07-24T14:20:04Z2018-07-24T14:20:04ZMen aren’t being tested for HIV. How health services can plug the gap<figure><img src="https://images.theconversation.com/files/229044/original/file-20180724-194131-to6c93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A community health worker conducting a HIV test in a mobile clinic in a remote part of KwaZulu-Natal. </span> <span class="attribution"><span class="source">Greg Lomas / Médecins Sans Frontières</span></span></figcaption></figure><p>Men make up slightly less than half of the adults living with HIV across the world. Yet they account for nearly 60% of the AIDS related deaths. </p>
<p>This is one of the observations from the <a href="https://www.thelancet.com/commissions/global-health-HIV">The Lancet Commission on HIV</a>, which looked at the global response to the pandemic. According to the <a href="https://www.thelancet.com/commissions/global-health-HIV">report</a>, the key driver of this gender difference in health outcomes between men and women is that men use health care services less than women. </p>
<p>This isn’t a new observation: for more than 10 years antiretroviral therapy (ART) programmes in sub-Saharan Africa have been reporting that a <a href="https://www.ncbi.nlm.nih.gov/pubmed/17459154">disproportionately higher</a> number of women are on treatment compared to men. </p>
<p>There’s a simple reason for this, which my work in the last decade highlights: men’s health is generally overlooked in HIV care. My studies show that women remain the focus of HIV testing and ART programmes, while men are disadvantaged in access to these. </p>
<p>In a <a href="http://journals.sfu.ca/jias/index.php/jias/article/view/21902/html">recent analysis</a> of long-term mortality in five large antiretroviral programmes in South Africa, I found that that over the last 12 years the proportion of men starting ART remained the same: between 2004 and 2006 only 31% of those enrolling in treatment programmes were men; by 2015, the figure was unchanged. </p>
<p>What this shows is that there needs to be a real mind shift towards men’s health issues. This, in turn, should lead to health care being provided in ways that encourage men to be tested so that they can get treatment earlier than is often currently the case. For example, <a href="https://www.ncbi.nlm.nih.gov/pubmed/25062091">research</a> shows that providing mobile clinics, or testing people at home, can make a difference.</p>
<p>So what are the obstacles to increasing men’s access to ART?</p>
<h2>Opportunities to access</h2>
<p>The largest obstacle is access to HIV testing. Most testing is done through health facilities, often with a strong focus on testing pregnant women. </p>
<p>The average woman will have a number of encounters with the health system in her lifetime. As a young girl, she will probably go to the local clinic for family planning. When she is pregnant she will go for antenatal care. When her child is small she will go to the local clinic for vaccinations. As mothers are generally still the main caregivers, she will take her child to the clinic when the child is ill. And if she has an elderly relative, there’s a chance she will accompany them to the clinic. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Community caregiver Nonhlanhla Ngema passes a long queue of patients at Eshowe Gateway Clinic to collect ARVs as part of a Medecins Sans Frontieres (MSF) to keep people on treatment.</span>
<span class="attribution"><span class="source">Greg Lomas / Médecins Sans Frontières</span></span>
</figcaption>
</figure>
<p>This means that there are several opportunities to be offered an HIV test and to start treatment. And if she starts treatment at a young age, she is likely to be healthy and have good survival prospects. So the health system seems to be doing well at engaging young women in HIV services. </p>
<p>In contrast there has been very little concerted effort from health services to go out and find the men. </p>
<p>The pattern of men’s engagement with the health system is totally different. There is no easy entry point into the health system for healthy young men. Primary health care clinics offer few services targeting men. This is generally limited to treating TB and sexually transmitted infections.</p>
<p>The fact that men are falling outside the net of health care systems is well illustrated in data on people knowing their HIV status. In 2012 nearly a third (31.9%) of men didn’t know their status compared with only 19% in the case of women. The greater proportion of men not knowing their status was particularly worrying given that the percentage of all adults with HIV who didn’t know their status <a href="https://www.ncbi.nlm.nih.gov/pubmed/26091299">dropped dramatically between 2000 and 2012</a> – from over 80% in the early 2000s to 23.7%. </p>
<p>This has important implications for men as well as their sexual partners. People with HIV who are undiagnosed are likely to have high viral loads. This means they have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/22313960">high risk</a> of sickness and death, and also that they are more likely to transmit HIV. </p>
<h2>Reaching men</h2>
<p>So how do we reach more men earlier?</p>
<p>Finding ways of testing men as early as possible will mean changes in the way our health system delivers services. </p>
<p>Preliminary findings show that there is higher testing uptake among men in services that fall outside the traditional facilities. For example, research shows that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25062091">providing mobile clinics</a>, testing people at home, self-testing and offering male-only or <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.12593">male-friendly services</a> can increase men’s uptake of HIV testing. </p>
<p>These and other strategies need to be tried in different settings, and where successful, rolled out across the sub-continent.</p>
<p>The good news is that a change in mindset seems to be happening. After years when it seemed that they were blind to the mounting evidence, international agencies and big donors are starting to discuss the absence of men from HIV programmes. At the end of 2017, UNAIDS produced a report on this blind spot in the response to HIV.</p>
<p>The World Health Organisation has recently established a working group on engaging men into HIV care. And most recently, at the 2018 International AIDS Conference, PEPFAR, the US President’s Emergency Plan for AIDS Relief, launched a global coalition <a href="https://www.pepfar.gov/press/releases/284176.htm">to increase testing and access for men</a>. </p>
<p>Given the huge influence that international agencies and donors have on the priorities of national programmes in sub-Saharan Africa, these are long overdue but extremely welcome new initiatives which could substantially increase access to testing and ART for men.</p><img src="https://counter.theconversation.com/content/100343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Morna Cornell receives salary funding from the National Institutes for Health, USA, under award number U01AI069924.</span></em></p>Women and children remain the focus of HIV while men are disadvantaged in accessing testing and treatment in Africa.Dr Morna Cornell, Senior Researcher, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1003742018-07-23T14:29:08Z2018-07-23T14:29:08ZThe HIV pandemic: time to recalibrate and target the weak spots<figure><img src="https://images.theconversation.com/files/228830/original/file-20180723-189310-pb058s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More than 15 000 researchers, activists and policymakers descend on Amsterdam this week for the 22nd International Aids Conference.</span> <span class="attribution"><span class="source">Marcus Rose/IAS</span></span></figcaption></figure><p><em>HIV remains a global challenge. Between 36.7 million and 38.8 million people live with the disease worldwide. And more than 35 million have died of AIDS related causes since the start of the epidemic in the mid-1980s. Two years ago the International Aids Society and The Lancet put together a commission made up of a panel of experts to <a href="https://www.thelancet.com/commissions/global-health-HIV">take stock</a> and identify what the future response to HIV should be. The report is being released to coincide with the <a href="http://www.aids2018.org/About">22nd International Aids Conference</a> in Amsterdam. The Conversation Africa’s Health and Medicine Editor Candice Bailey spoke to Head of the International AIDS Society Professor Linda-Gail Bekker, who also led the commission, about its report.</em> </p>
<p><strong>What have we learnt about the global HIV response in the last 30 years?</strong> </p>
<p>The world had an emergency on its hands 30 years ago with the arrival of HIV. A huge amount of effort was put into trying to find solutions. And there were some incredible breakthroughs. First was the miracle of lifesaving antiretroviral treatment, the biggest game changer over the last three decades. Great strides have been made in rolling out the treatment. UNAIDS tells us that <a href="http://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">22 million people</a> are currently on treatment. That’s truly remarkable.</p>
<p>But we’ve also learnt that relying on the current pace is insufficient. That’s clear from the figures. In some countries the incidence is rising, and in many parts of the world the incidence rate has stalled or plateaued. We are not seeing the downturn that we need to be able to reach the global goal of <a href="http://www.unaids.org/en/resources/campaigns/World-AIDS-Day-Report-2014">ending the HIV pandemic by 2030</a>. </p>
<p>The biggest lesson we’ve learnt is that we need to reinvigorate the prevention message especially since we have new tools to combat HIV transmission in many different settings. This includes <a href="https://theconversation.com/one-year-in-lessons-on-rolling-out-an-hiv-prevention-pill-in-south-africa-88255">Pre-exposure prophylaxis</a> (PrEP) – a daily antiretroviral that’s given to people who have a high risk of contracting HIV to lower their chances of getting infected – as well as treatment as prevention, which involves giving people living with HIV antiretrovirals to suppress their viral loads. </p>
<p>For a sustainable response and looking forward to the next era, it will be important to position our responses to HIV within the broader health agenda. Patients don’t only have HIV, they have other issues. There are mental health needs and there are sexual and reproductive health needs, so HIV treatment and care must fit into that broader agenda. This will enable a more sustainable response.</p>
<p>This is a challenge in many parts of the world where HIV is in a siloed response and people are only treated by HIV specific services. There needs to be a service delivery model that considers the broader health agenda. This goes beyond integration. We need to think about where can we take the lessons from HIV into other diseases. In the case of HIV, person centred and community-based care has become critical to ensure people get access to treatment. </p>
<p>The message is simple: the epidemic is far from over and it’s not time to disengage. We’re here for the long haul. To ensure we have a sustainable approach we need to recalibrate.</p>
<p>The commission is calling for a new way of doing business that will seek common cause with other global health issues. We understand that the HIV response will need resources. This will be a great way to get a double bang for the buck.</p>
<p><strong>What’s still going wrong?</strong></p>
<p>In many regions we have left whole sectors of the population behind. These include men who have sex with men, women who trade sex and people who inject drugs. They aren’t getting proper services because of policy, prejudice and stigma.</p>
<p>And different regional pockets need particular attention. One is in Eastern Europe and Central Asia where there has been a 30% increase in new infections since 2010. This is particularly concerning. Its clear that whole regions are being left behind because of politics, denial and stigma.</p>
<p>Here the administrations are not doing the evidence based thing – they are failing their people and the response. </p>
<p>Another pocket is West and Central Africa. These are countries that are not reducing rates of infection as quickly as we had hoped, often due to limited resources. Nigeria, for example, needs help with the reduction of mother to child transmission.</p>
<p>These are areas that are going to need attention, help and encouragement. </p>
<p>But we don’t want to put out the notion that we are in trouble across the world.</p>
<p>In East and South Africa, for example, we have made significant gains. There is still a lot to be done but the trends are going in the right direction. In many ways South Africa really is a good news story because its administration and politics favour an enthusiastic response to do the right thing. Domestic funding around HIV has increased. South Africa still has the biggest number of people in the world living with HIV – 7.9 million according to the <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">latest HSRC report</a>. But the country is beginning to turn the ship around. That’s something we can be incredibly proud of.</p>
<p>There are, nevertheless, still pockets that need attention. For example, adolescent girls and young women under the age of 25 in KwaZulu-Natal are roughly three times more likely than men younger than 25 to be living with HIV. We have had them in our sights but we now need a concentrated effort to tackle HIV in this cohort otherwise we will miss the target.</p>
<p>We need to look at the evidence and where can we make an impact with integrated care. This would be through HIV programmes that are part of sexual and reproductive health along with economic empowerment initiatives such as getting girls to stay in school and making sure they have opportunities to make autonomous decisions about sexual and reproductive health. </p>
<p>Doing everything for everyone is a waste of money and time. We need to sharpen the tip of our response. We must put our responses where we get the biggest bang for buck and call on those resources that offer prevention and treatment. </p>
<p><strong>What are the biggest challenges between now and 2030?</strong></p>
<p>Resources are the constant challenge globally. We live in a world where politics is unpredictable. We need to constantly advocate for funding while diversifying funding opportunities.</p>
<p>The second challenge is stigma and discrimination. Policy and ideology that is counter productive also feeds into stigma and discrimination. We need to do to something about laws that criminalise behaviour, like sex work, and stigmas towards intravenous drug users, gay people and men who have sex with men. Decriminalising sex work in South Africa, for example, would go a long way to reduce stigma, enable services and help the public health approach. </p>
<p>Continuing to understand how to reach young women and girls and protect them socially and medically; those are also big challenges. </p>
<p>Finally, in South Africa there is a challenge to find men who are not in the health services and get them into care and onto treatment. We know that a suppressed viral load means no HIV transmission and so this should be on its agenda.</p><img src="https://counter.theconversation.com/content/100374/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from various research funding agencies on a competitive funding basis.</span></em></p>The HIV epidemic is far from over and it’s not time to disengage, says International Aids Society President Linda-Gail Bekker.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/996882018-07-12T14:42:54Z2018-07-12T14:42:54ZHow health workers have adapted to South Africa’s breastfeeding policy<figure><img src="https://images.theconversation.com/files/227432/original/file-20180712-27036-908fah.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In the past 20 years there has been a massive global push for mothers to exclusively breastfeed their newborns for the first six months of their lives. The <a href="http://www.who.int/pmnch/media/news/2016/breastfeeding_brief.pdf">science</a> suggests this is a good way to improve their children’s later development. </p>
<p>There has also been a large body of research on the effects of formula milk, and other replacement foods, on the health of babies during their first six months. A great deal shows that they have <a href="https://www.scielosp.org/scielo.php?pid=S0042-96862005000600009&script=sci_arttext">negative effects</a>. </p>
<p>But for many years HIV positive mothers were <a href="http://apps.who.int/iris/handle/10665/78393">advised</a> to either exclusively breastfeed their babies, or only feed them formula. They could choose which they preferred – but not a mixture of the two.</p>
<p>This was very confusing for many mothers. Many fell back on mixed feeding. They started using both approaches as the same time – sometimes breastfeeding their babies, sometimes using commercial formula or other replacement liquids and foods. </p>
<p>In South Africa this practise was <a href="https://journals.co.za/content/healthr/2016/1/EJC189314?TRACK=RSS">very common</a> – <a href="https://journals.co.za/content/healthr/2016/1/EJC189314?TRACK=RSS">close to 90%</a> of the country’s babies were mixed fed in the early 2000s.</p>
<p>In 2010 this changed. The World Health Organisation took a stand and <a href="http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/">recommended</a> that governments should make a choice between the two options. They either had to encourage HIV positive mothers to exclusively breastfeed <em>or</em> to exclusively formula feed. They shouldn’t do both. </p>
<p>These guidelines prompted South Africa to end its free formula programme in public facilities. Instead, it <a href="https://nutritionconfidence.wordpress.com/tag/tshwane-declaration-of-support-for-breastfeeding-in-south-africa/">promoted exclusive breastfeeding</a> for all mothers. This meant that frontline health workers, including nurses and clinic staff, had to change they way they counselled mothers about feeding practises. </p>
<p>Seven years after the new policy was introduced we wanted to find out how well frontline workers had adjusted. Did they understand the new policy and its purpose? And did it make a difference to breastfeeding rates? </p>
<p>Our <a href="https://doi.org/10.1186/s13006-018-0164-y">findings</a> were surprising. When it came to HIV positive mothers, the frontline workers encouraged them to breastfeed their babies exclusively.</p>
<p>But when it came to HIV negative mothers, the workers didn’t highlight the importance of exclusive breastfeeding, nor did they discourage mothers from mixed feeding.</p>
<p>Our study suggests that South Africa could improve exclusive breastfeeding rates. The rate has improved in recent years – by <a href="https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf">2016</a> 32% of mothers were exclusively breastfeeding their babies. But there’s still a great deal of room for improvement. Kenya, for example, has achieved a rate of <a href="https://theconversation.com/how-a-breastfeeding-initiative-in-rural-kenya-changed-attitudes-78852">over 60%</a>.</p>
<p>The onus is with the South African government to engage health workers about the benefits of exclusive breastfeeding for babies born to HIV positive as well as HIV negative mothers. They need to provide clear communication tools and counselling skills that can help health workers address the barriers mothers face.</p>
<h2>Reliant on advice</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/19323863">Studies</a> have shown that new mothers rely heavily on the advice they get from health workers about infant feeding. </p>
<p>Mothers who get <a href="https://www.ncbi.nlm.nih.gov/pubmed/29026431">confusing or misleading advice</a> from health workers are less likely to exclusively breastfeed, or to do so for a shorter time. On the other hand, those who receive clear, <a href="https://www.ncbi.nlm.nih.gov/pubmed/16028656">positive messages</a> about exclusive breastfeeding from their health workers are more likely to breastfeed. </p>
<p>That’s why our study focused on health workers. We interviewed frontline health workers from four community health clinics in Soweto. They included nurses, ward-based outreach team members and staff seconded from non-governmental organisations. Each of them had counselled mothers about baby feeding before and after the policy change. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some mothers were breastfeeding their babies but not exclusively, they were using formula.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Few health workers understood the scientific rationale of the policy to promote exclusive breastfeeding. Many were under the impression that the formula programme had been stopped due to costs and most hadn’t been trained on the new policy. </p>
<p>The health workers believed that breastmilk was best for babies and were able to rattle off the nutritional benefits and other advantages such as allowing the mother and the baby to bond and the fact that it was cheaper. </p>
<p>But there were differences in the way they responded to HIV positive and negative mothers. They advised all mothers to breastfeed their babies. But they spent more time educating HIV positive mothers about the importance of exclusive breastfeeding rather than HIV negative mothers. The subtext was that mixed feeding was mostly a HIV related risk.</p>
<p>When they spoke to HIV negative mothers they spent more time warning them about HIV and advising them how to protect themselves. They did not emphasise the benefits of exclusively breastfeeding. </p>
<h2>What next?</h2>
<p>There are still structural barriers around exclusive breastfeeding that need attention. This includes maternity leave policies that fall short of the six month exclusive breastfeeding period, an absence of public and workplace spaces for breastfeeding and the idea that exclusive breastfeeding is only for HIV-exposed babies. On top of this, mixed feeding remains a cultural norm in many communities.</p>
<p>On the bright side, exclusive breastfeeding rates are increasing in South Africa and health workers have an important role to play in explaining the health and development benefits of exclusive breastfeeding for all babies. </p>
<p>South Africa’s health department should provide health workers with updated information on the benefits of exclusive breastfeeding and the risks of mixed feeding. This needs to include pre-tested materials that can be placed in public spaces like clinics.</p>
<p>In addition, they should continuously provide interactive content on the health workers’ cellphones through platforms like <a href="http://www.health.gov.za/index.php/mom-connect#nurseconnect">NurseConnect</a> which they could access during consultations. </p>
<p>Health workers also need training on how to navigate between health education and counselling that empowers mothers. To get the best outcome for both mother and baby, a single directive from above is less likely to result in behaviour change than a two-way conversation about overcoming barriers.</p><img src="https://counter.theconversation.com/content/99688/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sara Nieuwoudt is a Consortium for Advanced Research Training in Africa (CARTA) PhD fellow. CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No--B 8606.R02), Sida (Grant No:54100029), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) (Grant No: 107768/Z/15/Z) and the UK government. The statements made and views expressed are solely the responsibility of the fellow.</span></em></p>Health workers promote exclusive breastfeeding to HIV positive mothers more than they do to mothers who are negative.Sara Jewett Nieuwoudt, Lecturer, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/951632018-05-15T13:23:35Z2018-05-15T13:23:35ZProviding healthcare to men who have sex with men is complex but possible<figure><img src="https://images.theconversation.com/files/218244/original/file-20180509-34009-14z8zzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There needs to be a wide range of sexual health services for men who have sex with men.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Research has shown that addressing HIV in certain <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228373">key populations</a> is a priority in order to end the epidemic in the general population.</p>
<p>Key populations are groups identified by the World Health Organisation that warrant specific attention in health programmes because they face a particularly high risk of getting HIV and other sexually transmitted infections. They are also marginalised and do not have good access to health services. </p>
<p>One of these groups is men who have sex with men (MSM). It is critical to ensure that they are able to get access to HIV prevention and treatment services. </p>
<p>But in many parts of sub-Saharan Africa, including South Africa, men who have sex with men <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780345/">encounter stigma and prejudice</a> when they use health services. This often limits their access to healthcare. </p>
<p><a href="http://journals.lww.com/stdjournal/Abstract/publishahead/Utilization_of_Sexually_Transmitted_Infection.98418.aspx">Our research</a> shows that it’s possible to provide good quality care in the public sector to men who have sex with men.</p>
<p>We looked at health services specifically designed and provided at a set of South African government clinics. We found that men who accessed these services did well on antiretroviral regimens. </p>
<h2>South Africa’s reality</h2>
<p>An estimated <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">7.1 million people in South Africa are living with HIV</a>. That’s about 12.6% of the general population. </p>
<p>Among men who have sex with men, this figure <a href="https://www.cambridge.org/core/journals/epidemiology-and-infection/article/age-bias-in-survey-sampling-and-implications-for-estimating-hiv-prevalence-in-men-who-have-sex-with-men-insights-from-mathematical-modelling/A301257CE75A110D4BD61594764A8E98">may be as high as 34.6%</a>. </p>
<p>Providing health services to this group is challenging partly because of its diversity. Many men who have sex with men do not see themselves as gay. They may identify as bisexual or straight, or not label themselves in this way at all. This makes it difficult to find ways to reach out to them. </p>
<p>Their sexual practices also vary which can increase their risk of contracting HIV. For example, some men have anal sex without a condom, which is risky. But not all men who have sex with men have anal sex. </p>
<p>So sexual health services for men who have sex with men need to understand and meet the needs of a wide range of men. The challenge is that they usually have to access regular health services where they feel they are not understood and experience discrimination. They often feel unable to explain their sexual history to health workers. </p>
<p>Our study looked at how a health service targeted at men who have sex with men, <a href="http://www.health4men.co.za/sexual-health-services/">Health4Men clinics</a>, provided by an NGO in government run, primary care health facilities could help to solve these problems. </p>
<p>There are three Health4Men clinics in Johannesburg and one in Cape Town. They provide comprehensive sexual health services, including preventing and treating HIV and other sexually transmitted infections. </p>
<h2>Filling the gaps</h2>
<p>Of the gay and bisexual men who were tested for HIV at the clinics close to 40% were HIV positive. The figure was 14% for straight men. </p>
<p>We found that the clinics were very successful in helping men remain on antiretroviral treatment. More than 80% of the men who started antiretroviral treatment at the clinics were still taking their medication two years later. There was no difference in the retention patterns between gay and straight men. </p>
<p>People on antiretroviral therapy must take treatment for the rest of their lives. But keeping people on treatment is a challenge.</p>
<p>In addition, men who have sex with men are often unaware of their sexually transmitted infections because there often aren’t visible symptoms. This often means that they don’t seek treatment. Finding and treating these infections is important because untreated sexually transmitted infections increase the risk of contracting HIV. </p>
<p>Part of the reason that Health4Men services have been successful is the presence of male health care workers. They are specially trained to be sensitive to diversity in gender and sexuality, and to understand the specific needs and health problems affecting men who have sex with men. Their presence seems to make many men feel more comfortable discussing sexual matters. </p>
<p>And based on our research, the clinics attracted men who identified as gay, bisexual and straight, showing that they were considered safe spaces. </p>
<h2>Meeting the needs</h2>
<p>To stop the spread of HIV, South Africa needs to expand access to specialised health services for men who have sex with men. Services should also be provided in community spaces linked to health facilities. </p>
<p>Implementing these specialised services in rural areas is a bit more challenging due to limited resources. But in these areas health workers should be trained to understand diversity in gender and sexuality. Training health workers about diversity has been shown to reduce prejudicial <a href="https://www.ncbi.nlm.nih.gov/pubmed/27835058">attitudes toward men who have sex with men</a>.</p>
<p>In the end, what is important is that HIV prevention services – including regular testing, access to condoms and lubricant, treatment of sexually transmitted infections and PrEP (a pill taken daily to prevent HIV infection) – reach HIV-negative men who have sex with men. It’s also crucial for those who are already HIV-positive to have access to antiretroviral therapy to decrease the spread of HIV.</p><img src="https://counter.theconversation.com/content/95163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Rees works for Anova Health Institute. </span></em></p><p class="fine-print"><em><span>Remco Peters works for the Anova Health Institute</span></em></p>In many parts of sub-Saharan Africa men who have sex with men encounter stigma and prejudice when accessing health services.Kate Rees, Honorary Research Associate, Public Health Medicine, University of Cape TownRemco Peters, Extraordinary Professor in the Department of Medical Microbiology, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/882552017-12-01T12:33:07Z2017-12-01T12:33:07ZOne year in: lessons on rolling out an HIV prevention pill in South Africa<figure><img src="https://images.theconversation.com/files/197282/original/file-20171201-10147-184x2y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">NIAID</span></span></figcaption></figure><p>Last year South Africa became the first country on the continent to register the use of a drug that could be used as an oral pre-exposure prophylaxis for HIV prevention. Pre-exposure prophylaxis, referred to as PrEP, is the use of anti-retroviral drugs by people who do not have HIV to prevent them from becoming infected. </p>
<p>The idea behind PrEP has been to target high risk populations where new infections remain consistently high. This includes sex workers, men who have sex with men, injection drug users and young women.</p>
<p>Following a <a href="http://apps.who.int/iris/bitstream/10665/197906/1/WHO_HIV_2015.48_eng.pdf">recommendation</a> by the World Health Organisation to use the drug as an additional HIV prevention choice South Africa registered <a href="http://www.mccza.com/documents/2e4b3a5310.11_Media_release_ARV_FDC_PrEP_Nov15_v1.pdf">Tenofovir/Emtricitabine</a> last year.</p>
<p>By June this year South Africa’s PrEP programme was being implemented at 17 sites that were serving sex workers and men who have sex with men. The programme had also been expanded to provide the drug at nine clinics at seven tertiary institutions which serve more than 120,000 young people. </p>
<p>The PrEP rollout data shows that there is a relatively slow, but increasing, uptake of PrEP. There are concerns. One year after the licence was procured there are fears that the rollout isn’t sufficiently targeting one of the country’s most high risk populations: young women.</p>
<p>This is a critical cohort of people in the fight against new HIV infections. Studies show that young women in South Africa, aged between 15 and 24 years have the <a href="http://www.unaids.org/en/resources/campaigns/2014/2014gapreport/gapreport">highest HIV incidence</a>. About 1,745 new HIV infections occur among these young women every week. </p>
<p>An additional factor that makes the group so important in bringing down infections is that they represent a <a href="http://www.indexmundi.com/south_africa/demographics_profile.html">substantial section</a> – about 10% – of the population. </p>
<p>Unless this problem is solved the rates of new infections in South Africa are unlikely to be reduced. </p>
<h2>Great idea, challenging to deliver</h2>
<p>After South Africa procured the licence for the HIV prevention tablet, the National Department of Health launched a national policy and set of guidelines to rollout PrEP and provide test and treat services. Test and treat allows people to access antiretrovirals as soon as they test positive.</p>
<p>The government’s cost-effectiveness analyses suggested that the greatest impact of PrEP would be in populations that have a substantial risk for HIV infection. As a result the policy focused initially on providing PrEP at a limited number of sex worker sites. This would help them learn more about real world delivery prior to scale up. </p>
<p>But here lies the issue. There is a high level of political will and desire in the government to rollout PrEP to young women who are at risk, but the health system requirements are complex. Cost is also a consideration. There is a need to establish how best to identify young women at highest risk and how best to offer and retain young women on PrEP. </p>
<h2>Next steps</h2>
<p>PrEP is new technology that has the potential to alter the HIV epidemic particularly among women. But a narrow focus on a single technology alone is unlikely to solve health and social challenges associated with HIV. </p>
<p>South Africa needs to pay careful attention to access and service delivery issues and constraints, and to engage communities as PrEP is scaled up so that its potential is fully realised.</p>
<p>There are a number of small scale research projects mainly in and around Johannesburg and Cape Town that could help inform how best to deliver PrEP to young women. More than 500 adolescent girls and young women between the ages of 16-24 years are being enrolled in the projects. The aim is to to learn more about scalable models of PrEP delivery for adolescents in countries like South Africa which has limited resources. </p>
<p>Without an understanding of best practices and most cost effective scalable delivery models for young women, it will be challenging for South Africa to maximise the impact of core HIV prevention, treatment, and care interventions. </p>
<p>Another critical step to filling the gaps would be to generate greater community awareness about PrEP. Many people don’t know that there is an antiretroviral pill that, if taken every day, can reduce a person’s risk of being infected with HIV. Getting the message across is difficult because the legacy of concerns about antiretrovirals and their side effects persist in many communities. </p>
<p>This is not just about awareness but about the need for a broader conversation about how we address the underlying issues that continue to shape HIV risks in young women. Stigma, violence against women, judgemental attitudes about young people having sex all make it more difficult for people to accept PrEP and to use it effectively. </p>
<p>A broader conversation is needed to increase knowledge and awareness of PrEP, its potential to change the course of the epidemic, and where it fits in to a broader programme of HIV prevention.</p><img src="https://counter.theconversation.com/content/88255/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sinead Delany-Moretlwe has received a drug donation from Gilead Sciences for a demonstration project.</span></em></p><p class="fine-print"><em><span>Saiqa Mullick does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa’s data rollout of its pre-exposure prophylaxis shows that there is a relatively slow, but increasing, uptake. However, more needs to be done to target young women.Sinead Delany-Moretlwe, Associate Professor and Director: Research at the Wits Reproductive Health and HIV Institute I, University of the WitwatersrandSaiqa Mullick, Director of Implementation Science, Wits Reproductive Health & HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/879802017-11-30T21:07:00Z2017-11-30T21:07:00ZCould we safely reduce the frequency of treatments for HIV-positive people?<figure><img src="https://images.theconversation.com/files/195911/original/file-20171122-6027-ledcng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pillbox (illustration only).</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Most HIV-positive people under treatment take a daily dose of antiviral drugs for life. However, a major trial is currently underway in France that may confirm that patients could safely omit several days of treatment a week without risk to their health. Some 300 patients have already switched to a treatment mode called “Intermittent in short cycles”, taking their medication four days a week instead of the seven currently specified. The small protocol began several years ago and the patients are doing well.</p>
<p>A larger trial is currently underway, and if the initial findings are confirmed, it could have significant benefits around the globe. At the end of 2016, <a href="https://www.hiv.gov/federal-response/pepfar-global-aids/global-hiv-aids-overview">37 million people were living with HIV</a>, with 1.6 million new infections that year alone. The vast majority of those living with HIV are in lower-income countries, particularly in Sub-Saharan Africa. Globally, only 21 million of those infected have access to antiretroviral therapy. If only four days of treatment are necessary for many patients, however, the same supply of antiretroviral drugs would go much further – and in particular, out into the developing world. </p>
<p>In September 2017, the French Agency for Research on HIV/AIDS, <a href="http://www.anrs.fr/en">ANRS</a>, launched a <a href="https://clinicaltrials.gov/ct2/show/NCT03256422?term=quatuor&cntry1=EU%3AFR&rank=1">large clinical trial</a> called Quatuor (Quartet in English) of the four-day-a week protocol. It involves 640 volunteers recruited from 63 public hospitals in France and the Caribbean. <a href="https://www.youtube.com/watch?v=7SMiF9bIN7A">Dr. Pierre de Truchis</a>, at Raymond Poincaré Hospital in Garches (Hauts-de-Seine), is the principal investigator.</p>
<h2>Four-days-a-week treatment, in the making for 15 years</h2>
<p>We now have 15 years of experience concerning the safety of maintenance medicine treatments alleviated with short breaks. The primary experiment started in 2003 as part of a protocol called <a href="https://www.iccarre.net/">ICCARRE</a>, which stands for “intermittent in close cycles, antiretrovirals remain effective”. Led by Dr. Jacques Leibowitch of the Raymond Poincaré Hospital, a group of 48 patients went from seven to five days of treatment per week, and then to four. Their viral load remained below detection level, and the results were considered sufficiently robust by the international scientific community that they were published in 2010 by the <a href="https://www.fasebj.org/content/29/6/2223.full.pdf"><em>FASEB Journal</em></a>. Similar observations on 94 patients led to a <a href="https://www.fasebj.org/content/early/2015/04/01/fj.14-260315.full.pdf">second publication in 2015</a>.</p>
<p>In 2009, Assistance Publique-Hôpitaux de Paris (AP-HP) and Versailles Saint-Quentin University jointly filed for two international patents, one for “maintenance therapies under any standard triple combination” taken four days a week or less, the other for the use to that purpose of innovative quadruple combination therapies.</p>
<h2>A first nationwide clinical trial</h2>
<p>Convinced by the first results of the ICCARRE protocol, in 2014 ANRS launched its first clinical trial called 4D (four days) over two years at 17 medical centres in France. More applications to participate in the trial were received than could be accepted, indicated Professor Christian Perronne, the trial’s principal investigator. The results, presented at the 2016 International AIDS Conference in Durban, South Africa and <a href="https://academic.oup.com/jac/advance-article-abstract/doi/10.1093/jac/dkx434/4662829?redirectedFrom=fulltext">published in the <em>Journal of Antimicrobial Chemotherapy</em></a>, indicate that <a href="http://www.anrs.fr/en/presse/communiques-de-presse/328/short-cycle-antiretrovirals-road-treatment-4-days-week">96 of the 100 patients</a> who scrupulously followed the “four consecutive days out of seven” pattern were 100% successful. Early in the fourth week of the study three patients had a newly detectable viral load, which became undetectable upon the return to daily treatment. One patient left the study.</p>
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<img alt="" src="https://images.theconversation.com/files/200244/original/file-20171220-4995-11i0f7k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/200244/original/file-20171220-4995-11i0f7k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200244/original/file-20171220-4995-11i0f7k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200244/original/file-20171220-4995-11i0f7k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200244/original/file-20171220-4995-11i0f7k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200244/original/file-20171220-4995-11i0f7k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200244/original/file-20171220-4995-11i0f7k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sign in Simonga village, Zambia (2005).</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/london/75148497/">Jon Rawlinson/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>The results were sufficiently encouraging that the ANRS continued with the Quatuor test. To allow a comparison, it includes a “control” group consisting of patients who continue to take their treatment seven days a week for 48 weeks. This methodology meets the requirements of health authorities for the level of evidence to accumulate before a change in prescribing recommendations.</p>
<p>Experience has shown that daily treatments with anti-retroviral drugs can have substantial negative side effects, including nausea, diarrhoea and fatigue. Some patients consequently take their medication less consistently than they should – a problem that arises in many chronic diseases. Reducing the treatment frequency could reduce the negative side effects, and thus improve patients’ well-being. Indeed, a four-days-a-week regime is the equivalent of <a href="http://www.scientonline.org/open-access/reviewing-anti-hiv-maintenance-treatment-4-days-a-weeka-safe-ethical-slash-on-156-days-of-yearly-over-medication.pdf">five treatment-free months every year</a> the individual patient, a significant reduction.</p>
<h2>Where do we go from here?</h2>
<p>The full results of the Quatuor trial will be available at the earliest in 2019, at which time it may be possible in France to officially recommend the four-days-a-week treatment. Internationally, the results of the study will not necessarily be followed, even in the United States. Yet this is the country that in 2001 first opened the path to intermittence treatments, which was then followed by Dr. Leibowitch.</p>
<p>It’s worth asking why, more than 15 years later, the reduction of treatment still remains at the experimental level. In France, a number of HIV/AIDS associations have not yet fully grasped this issue. Instead, they have focused on preventive treatments, including as <a href="https://www.cdc.gov/hiv/basics/prep.html">pre-exposure prophylaxis</a> (PrEP). Under the impetus of artist Richard Cross, some of Dr. Leibowitch’s patients have created an association, <a href="https://fr-fr.Facebook.com/iccarre/">The Friends of ICCARRE</a> that aims to promote the possibility of a lightened treatment program.</p>
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<p>While the Quatuor trial is still underway, some AIDS clinicians in France have already begun to lighten their patients’ prescriptions. Such a possibility is consistent with Article 8 of the <a href="https://www.conseil-national.medecin.fr/node/1376">French Code of Medical Ethics</a> and was confirmed in May 2017 by the <a href="https://cns.sante.fr/about-the-cns/mission-organization/">National Council for AIDS and Hepatitis</a> (CNS). The organisations remained cautious, however: Any such change requires a rigorous medical follow-up, with close biological examinations of the patient.</p>
<p>The continuing dominance of the daily treatment regime may be explained by resistance to change – which is not unique to physicians – and by the difficulty of questioning established rules within the medical community. Other factors can play a role as well, including the caution of patients and physicians, as well as doctors’ fear of lawsuits.</p>
<p>Another factor is the influence of the pharmaceutical industry. After all, four days of treatment rather than seven represents 42 percent reduction in medication. If expanded throughout France, such a treatment program would result in a savings of some 500 million euros each year (based on 100,000 patients on treatment, with an average monthly cost per patient of 1,000 euros). Beyond reducing costs nationally, reduced treatment frequency could also increase the availability of antiretroviral treatments to those currently not being treated, particularly in the developing world.</p>
<p>An additional trial, called “big ICCARRE”, also led by Dr. Leibowitch, is exploring the possibility of that HIV treatment can safely be reduced to three, two or even one day per week, while maintaining a controlled viral load in patients. The objective is to find the medical dosage that is both necessary and sufficient for each patient, and is in accordance with the phrase often attributed to Hippocrates, <a href="https://en.wikipedia.org/wiki/Hippocratic_Oath#.22First_do_no_harm.22">“First do no harm”</a>.</p><img src="https://counter.theconversation.com/content/87980/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline Petit volunteers with the patient association "Les amis d'ICCARRE".</span></em></p>A clinical trial currently underway in France could confirm that that HIV treatment can be safely reduced to just four days a week, while maintaining the same efficacy.Caroline Petit, Biologiste, chargée de recherche au CNRS, chargée de mission à l'IHEST, École normale supérieure (ENS) – PSLLicensed as Creative Commons – attribution, no derivatives.