tag:theconversation.com,2011:/global/topics/antiretroviral-therapy-27171/articlesAntiretroviral therapy – The Conversation2024-02-18T07:07:22Ztag:theconversation.com,2011:article/2229542024-02-18T07:07:22Z2024-02-18T07:07:22ZHIV among older South Africans in rural areas: big study shows there’s a problem that’s being neglected<p>South Africa continues to have a high prevalence of HIV among all age groups. About 8.2 million people or <a href="https://link.springer.com/article/10.1007/s10461-023-04222-w">13.7%</a> of the population live with HIV, one of the highest rates in the world. </p>
<p>The country also has one of the world’s most impressive antiretroviral therapy programmes. Over <a href="https://www.phc.ox.ac.uk/blog/the-importance-of-primary-care-in-south-africa2019s-hiv-treatment-programme">5 million people</a> living with HIV are currently on chronic treatment. Widespread access to antiretroviral therapies since 2008 has led to millions of people <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9851406/#:%7E:text=The%20widespread%20roll%2Dout%20of,aging%20in%20the%20ART%20era.">ageing with chronic HIV infection</a>. Consequently, people with HIV are older on average than they were just a decade ago. </p>
<p>Most HIV prevention and treatment programmes and policies in South Africa remain focused on adolescents and young adults. A growing group of middle-aged and older adults with HIV, or at high risk, are being left behind. </p>
<p>To date, there has been little research about sexual behaviour, risk of HIV transmission, HIV stigma and HIV prevention for adults over 40 years old. </p>
<p>The <a href="https://haalsi.org/">Health and Aging in Africa: Longitudinal Studies in South Africa</a> study – or Haalsa as it is commonly known – is an exception to this trend. It seeks to better understand both the risk of getting HIV and the health of ageing adults with HIV in South Africa. </p>
<p>This project, a collaboration between the University of the Witwatersrand and Harvard University, has followed a cohort of over 5,000 adults older than 40 in the Agincourt region in north-east South Africa for more than 10 years. </p>
<p>Throughout this decade of research, the team has been gaining a deeper understanding of this “greying” HIV epidemic. Numerous important insights about HIV in older populations have already been achieved. Here we present some of the findings. </p>
<h2>Sexual activity is common</h2>
<p>Research conducted in 2017 uncovered a <a href="https://pubmed.ncbi.nlm.nih.gov/27926667/">high</a> prevalence of HIV in this older population. Nearly 1 in 4 people over 40 years old were living with HIV. </p>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/27926667/">study</a> found that 56% of respondents, across all HIV status categories, had had sexual activity in the past 24 months. Condom use was low among HIV-negative adults (15%), higher among HIV-positive adults who were unaware of their HIV status (27%), and dramatically higher among HIV-positive adults who were aware of their status (75%).</p>
<p>In another <a href="https://pubmed.ncbi.nlm.nih.gov/32516151/">investigation</a> in this cohort, the team found that over the period from 2010 to 2016 the incidence rate of HIV for women was <a href="https://pubmed.ncbi.nlm.nih.gov/32516151/">double</a> that of men.</p>
<h2>Feeling the stigma</h2>
<p>There are relatively few studies of HIV-related stigma among older adults, despite the <a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(22)00041-1/fulltext">increasing number</a> of older adults living with HIV.</p>
<p>The majority of research excludes, or ignores, age as a variable. Understanding HIV-related stigma in older adults remains crucial and can inform interventions to support their mental health and overall well-being. </p>
<p>Our <a href="https://pubmed.ncbi.nlm.nih.gov/38286975/">research</a> suggests that social stigma poses a significant barrier to testing behaviour among older adults. A quarter of our respondents reported social stigma related to HIV infection.</p>
<p>This stigma was found to have important implications for HIV care: those experiencing high social stigma were <a href="https://pubmed.ncbi.nlm.nih.gov/38286975/">less likely</a> to engage in HIV testing and less likely to be linked to treatment.</p>
<p>A recent pilot study examined home-based HIV testing options for older adults and showed a preference for <a href="https://pubmed.ncbi.nlm.nih.gov/37696252/">self-testing</a>. More privacy may encourage more adults to establish their HIV status.</p>
<h2>Treatment targets</h2>
<p><a href="https://haalsi.org">Haalsa</a> is uniquely positioned to understand how older adults with HIV are faring in terms of achieving HIV treatment targets, including viral <a href="https://pubmed.ncbi.nlm.nih.gov/31243144">suppression</a>. </p>
<p>In 2014-2015, 63% of older adults with HIV in the study were taking antiretroviral therapy and 72% of those on therapy were virally suppressed. More recent updates have suggested that as of 2018-2019, many more older adults with HIV were virally suppressed. </p>
<p>To further highlight the critical importance of viral suppression for healthy ageing, the Haalsa team explored the impact of viral suppression on <a href="https://pubmed.ncbi.nlm.nih.gov/36179754/">life expectancy</a> in older adults. </p>
<p>Here, they found large gaps in life expectancy based on viral suppression <a href="https://pubmed.ncbi.nlm.nih.gov/36179754/">status</a>: a 45-year-old man without HIV could expect to live about another 27 years; a man with virally suppressed HIV could expect to live 24 years. One with unsuppressed HIV could expect to live 17 years.</p>
<p>Similarly, a woman aged 45 without HIV could expect to live another 33.2 years compared with 31.6 years longer for a woman with virally suppressed HIV. A woman with unsuppressed HIV could expect to live a further 26.4 years. </p>
<h2>Looking to the future</h2>
<p>Taken together, these new insights are critically important to inform the design of interventions and policies to ensure healthy ageing in South African society, and particularly among those with or at high risk of HIV. </p>
<p>Tailored strategies to prevent new HIV infections, awareness programmes and support to ensure that more people living with HIV in older age groups achieve and maintain viral suppression are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.</p><img src="https://counter.theconversation.com/content/222954/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jen Manne-Goehler receives funding from the US National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Julia Rohr receives funding from National Institute on Aging of the National Institutes of Health (NIH). </span></em></p><p class="fine-print"><em><span>Till Bärnighausen for this work my institution has received a grant from the National Institutes of Health/National Institute of Aging (NIH/NIA), which is the HIV component NIH/NIA of the overarching NIH/NIA HAALSI
Unrelated to this work, I also receive funding from a wide range of public science funders, including the NIH (other institutes), the German National Research Foundation , the European Union (within the Horizon science funding programme, the Alexander von Humboldt Foundation, the Volkswagen Foundation, the German Federal Ministry of Education and Research, the German Federal Ministry of the Environment, Wellcome (the British Medical Research Foundation), and the Else Kröner Fresenius Foundation.</span></em></p><p class="fine-print"><em><span>Francesco Xavier Gomez-Olive Casas, Kathleen Kahn, and Nomsa Mahlalela do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A significant number of older adults in rural South Africa are HIV-positive. Awareness programmes and self-testing would reduce cases.Jen Manne-Goehler, Physician-scientist, Harvard T.H. Chan School of Public HealthFrancesco Xavier Gomez-Olive Casas, Research Manager at MRC/Wits Agincourt Research Unit, University of the WitwatersrandJulia Rohr, Research Scientist, Harvard UniversityKathleen Kahn, Professor: Health and Population Division, School of Public Health, University of the WitwatersrandNomsa Mahlalela, Researcher, University of the WitwatersrandTill Bärnighausen, Professor, University of HeidelbergLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2133102023-10-24T13:12:46Z2023-10-24T13:12:46ZHIV-positive parents in Zimbabwe struggle to manage their children’s education – study shows how<p>Over the past three decades researchers have explored various aspects of the impact of the HIV pandemic. One focus area has been children who have lost their parents to AIDS. Less attention has been given to children who are raised by parents living with HIV. This group has become much bigger as more people have <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2021/september/20210906_global-roll-out-hiv-treatment">access to antiretroviral therapy</a> and are therefore expected to raise their children. </p>
<p>Our research in Zimbabwe looked at the effects the HIV status of parents had on their children’s education. </p>
<p>In Zimbabwe, the current HIV prevalence rate among adults is about <a href="https://www.unicef.org/zimbabwe/hivaids">13%</a>. In 1997 it was at its peak at <a href="https://pubmed.ncbi.nlm.nih.gov/20406793/">29.3%</a>. Nevertheless, Zimbabwe still has the <a href="https://www.statista.com/statistics/270209/countries-with-the-highest-global-hiv-prevalence/#:%7E:text=Among%20all%20countries%20worldwide%20those,rate%20of%20almost%2026%20percent.%20**link%20is%20behind%20a%20paywall**">sixth highest HIV rate</a> in the world. Eswatini has the highest rate (19.58%) and South Africa ranks fourth (14.75%).</p>
<p>Our research focused on mothers in Harare, Zimbabwe’s capital city, who had access to treatment. We were interested in the impact of HIV on their investment in their children’s education. We conducted <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">interviews</a> at <a href="http://mashambanzou.co.zw/">Mashambanzou Care Trust</a>, a local non-profit organisation that provides care to about 5,000 HIV-positive low-income individuals in Harare. Thirteen HIV-positive mothers were interviewed to discuss the key reasons behind the disruption of their children’s schooling .</p>
<p>We found that the HIV status of low-income parents in Zimbabwe severely affected their children’s education, in four ways.</p>
<p>Firstly, HIV worsened the financial barriers parents faced when trying to get their children educated. Secondly, children missed school because they needed to take care of sick parents or siblings. Thirdly, sick parents were not involved with their children’s <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">academic achievement</a> because they were physically, mentally and emotionally incapable of helping. Lastly, children of HIV-positive mothers did not always have birth certificates, a major barrier to school and exam registration in Zimbabwe.</p>
<h2>Financial barriers</h2>
<p>The research showed that HIV in Zimbabwe is not only a health issue but also a socioeconomic problem that can force people into <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">poverty traps</a>. </p>
<p>HIV-positive women expressed the view that the Zimbabwean economy, their partner’s health and their own health affected how they supported their children’s educational needs. </p>
<p>We found children with parents who could not afford to pay school fees or buy school uniforms could be sent home until the payments were made. Other low income families experienced this too but parents with HIV could not work and so had more difficulty paying school fees.</p>
<p>HIV-affected families could also face the burden of raising other children from deceased or ill family members. Some of the mothers had siblings and close family members who had died of AIDS. In one case, a <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">single HIV-positive mother </a> had three biological children and three orphans from relatives.</p>
<h1>Missing school</h1>
<p><a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">Girls</a> were particularly affected because they were expected to care for siblings, help sick parents with daily activities such as eating and toileting, and make sure they had a place to live and food to eat. </p>
<p>Mothers spoke about the heavy burden their daughters had to <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">carry</a>. </p>
<blockquote>
<p>My eldest child was the one who took care of me and cooked for me. When I got sick, my daughter stopped going to school. She is the one who took the responsibility of taking care of me. </p>
</blockquote>
<p>Some children were forced to drop out of school to earn an income. </p>
<blockquote>
<p>He dropped out of school after finishing his Form 3. He is currently selling bananas at Mbare and the money he is getting is not enough. Most of the time he brings home some food after selling bananas. </p>
</blockquote>
<h2>No time to help</h2>
<p>Most HIV-positive mothers told us that they did not <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">spend time</a> with their children because they spent a lot of time on income-generating activities, attending to their own health, or their husband’s health. These tough conditions led to even more illness and stress.</p>
<blockquote>
<p>All my seven children stay at home as none of them is in school right now. Each day of their lives is difficult as in some cases we fail to get some food to eat. After having failed to get food for the family, it then stresses me more as the mother. Given my condition that I am HIV-positive I end up getting continuous headaches and sometimes I get sick as a result of the stress. </p>
</blockquote>
<h2>Birth certificates</h2>
<p>Some HIV-positive parents were too sick to obtain birth certificates for their <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">children</a>. Without birth certificates, children risk being sent home and cannot benefit from programmes that target poor children. One mother told of trying to get birth certificates for her children in Mutare, almost 300 kilometres away from Harare.</p>
<blockquote>
<p>I once went to Mutare to secure birth certificates for my children. I was told to bring my national identification card which was in Harare during that time. I am yet to go back to Mutare and collect birth certificates for my children. I am only being stopped from travelling because I am currently sick and receiving treatment. </p>
</blockquote>
<h2>Looking to the future</h2>
<p>Our research highlights a vulnerable group of children who should also benefit from social assistance programmes that target HIV-affected orphans, given that their parents are too sick to care for them. </p>
<p>They should be included in the <a href="https://www.ajol.info/index.php/ajsw/article/view/194113#:%7E:text=Zimbabwe%20adopted%20the%20National%20Orphan,social%20safety%20nets%20for%20OVC.">National Orphan Care Policy</a>, which seeks to provide basic care and protection to orphans and vulnerable children, and the <a href="https://www.unicef.org/esa/media/11846/file/Unicef_Zimbabwe_Education_Budget_Brief_2022.pdf">Basic Education Assistance Module</a>, which pays school fees for this group of children.</p><img src="https://counter.theconversation.com/content/213310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tatenda Zinyemba 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>Some children of HIV-positive parents drop out of school to look after their mothers and fathers. Others skip class to earn cash for the family by selling goods.Tatenda Zinyemba, Researcher in Economics, Health and Governance, Maastricht Economic and Social Research Institute on Innovation and Technology, United Nations UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2054992023-06-12T09:56:25Z2023-06-12T09:56:25ZHIV care for migrant women in South Africa: the gaps and 5 steps towards offering better services<figure><img src="https://images.theconversation.com/files/529106/original/file-20230530-19-44pgfi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa's healthcare system has gaps in providing HIV treatment to highly mobile women.
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Around <a href="https://www.statssa.gov.za/publications/P0302/P03022022.pdf#page=24">8.45 million</a> people in South Africa live with HIV – an estimated 13.9% of the population. Of South African women aged 15-49, approximately <a href="https://www.statssa.gov.za/publications/P0302/P03022022.pdf#page=25">24%</a> are HIV positive.</p>
<p>The roll-out of services to prevent mother-to-child transmission of HIV has been notably successful in <a href="https://www.hst.org.za/publications/District%20Health%20Barometers/DHB+2017-18+Web+8+Apr+2019.pdf#page=105">reducing</a> the rate of transmission. </p>
<p>But there are still gaps in the delivery of HIV treatment and prevention. A case in point is migrant women. <a href="https://theconversation.com/south-africas-healthcare-system-cant-afford-to-ignore-migration-120797">People who move</a> across national borders or between regions and provinces are particularly easy for healthcare systems to miss. And there’s no integrated system of tracking them. Nor is there any robust national data on how many migrant women, specifically pregnant migrant women, are on treatment and virally suppressed. </p>
<p>In 2020, it was <a href="https://www.statssa.gov.za/?p=14569">estimated</a> that there were 4 million migrants in South Africa, some of whom were women living with HIV. The public health system has <a href="http://www.samj.org.za/index.php/samj/article/view/8569">struggled to respond</a> yet alone integrate this mobile population.</p>
<p>The vulnerability of migrants was <a href="https://theconversation.com/covid-affected-access-to-hiv-treatment-the-stories-of-migrant-women-in-south-africa-show-how-195214">highlighted</a> during the COVID-19 pandemic when restrictions affected people’s ability to travel to access treatment as well as the delivery of healthcare.</p>
<p>In a recent <a href="https://journals.sagepub.com/doi/full/10.1177/11786329211073386">paper</a> we explored the challenges of the COVID-19 pandemic for HIV prevention services in Johannesburg, South Africa’s economic hub. We interviewed healthcare providers and stakeholders in policy and programming. The aim was to understand the gaps in ensuring adherence to lifelong antiretroviral therapy for mobile populations. </p>
<p>The information we gathered shone a light on the country’s overburdened healthcare facilities and the shortcomings in the network of referral clinics in Johannesburg and across Gauteng province. We went on to draw from these insights to understand the systemic gaps in the delivery of antiretroviral treatment (ART) to migrant women. We identified five in particular. And we then identified possible solutions, including how technology could improve access to healthcare.</p>
<h2>The gaps</h2>
<p>The pandemic created new problems in healthcare delivery and exposed existing shortcomings. Five main themes emerged from our qualitative study. </p>
<p>First, women living with HIV and who were highly mobile feared going to healthcare facilities because they were scared of getting COVID. This interrupted their treatment and increased their risk of falling ill. </p>
<p>Second, some healthcare workers told us they felt overwhelmed by the added burden of the pandemic on providing HIV prevention services to pregnant women. For example, many reported that there was a lack of infrastructural resources to follow social distancing protocols. This disrupted their provision of care. </p>
<p>Third, migrant women faced a number of logistical barriers:</p>
<ul>
<li><p>some who left Gauteng province and then tried to return to collect their medication couldn’t do so due to border and lockdown restrictions</p></li>
<li><p>some lost their jobs and income, and were unable to afford travel to collect their ART</p></li>
<li><p>some were denied care because they didn’t have documentation (though this <a href="https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/what-does-the-law-say-about-migrants-and-refugees-accessing-healthcare-in-south-africa/">should not have been a barrier</a>). </p></li>
</ul>
<p>These factors resulted in patients interrupting treatment. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-essential-reads-on-migrant-access-to-healthcare-in-south-africa-190257">5 essential reads on migrant access to healthcare in South Africa</a>
</strong>
</em>
</p>
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<p>Fourth, some individuals who sought treatment reported mistreatment and xenophobic <a href="https://theconversation.com/telling-the-complex-story-of-medical-xenophobia-in-south-africa-127040">attitudes</a> from healthcare providers. Even some healthcare providers reported that their colleagues behaved negatively towards <a href="https://theconversation.com/southern-africa-needs-better-health-care-for-women-and-girls-on-the-move-121151">migrant women</a>. </p>
<p>Time pressures were the fifth theme. Health workers said they needed more time to counsel patients. This helps build a rapport and strengthens the ability of patients to manage their health. </p>
<p>From these insights we drew up a list of interventions we think would improve antiretroviral services to migrant women in South Africa. </p>
<h2>What can be done?</h2>
<p>The first step is to dispense antiretrovirals for a longer duration of time to alleviate stress for individuals on the move and encourage retention in the ART programme.</p>
<p>Secondly, decentralise services and bring care to the community with pop-up delivery that can help remove logistical barriers like transport to clinics that are far away. </p>
<p>Thirdly, introduce virtual care platforms – like online HIV prevention of mother to child transmission services. It could help highly mobile individuals to interact with healthcare providers. This could help to improve the referral system between clinics and counsellors could follow up patients who had moved. The system could keep better patient records and send reminders for medicine collections. In addition, it should include translation services to help remove communication barriers between service providers and users. And it could better integrate communication of healthcare facilities – even those in other countries – so as to track patients.</p>
<p>Fourthly, healthcare providers need better opportunities to build closer relations with each other. This could create a better understanding of the changes in their work and the underlying issues that affect them. Greater understanding could help get to the root of where <a href="https://theconversation.com/migrants-in-south-africa-have-access-to-healthcare-why-its-kicking-up-a-storm-189574">negative attitudes</a> towards migrants stem from to improve behaviours towards patients. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-social-management-of-hiv-african-migrants-in-south-africa-127955">The social management of HIV: African migrants in South Africa</a>
</strong>
</em>
</p>
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<p>In addition, healthcare facilities often improvise to come up with strategies and solutions that meet the requirements and changes to programmes. If these were better documented they could then provide knowledge translation and learning opportunities on a larger scale for other healthcare providers, facilities and programmes.</p>
<p>Fifth, government should evaluate healthcare environments before changing policies and programmes. Platforms such as working groups should be provided for collaboration with researchers, service providers and mobile patients to help direct policy and practices. </p>
<p>South Africa needs to take a more pragmatic approach to the delivery of antiretroviral treatment. It needs a healthcare system that is migration-aware and offers a service that recognises mobility – one that speaks to the realities of migrant women living with HIV in South Africa.</p><img src="https://counter.theconversation.com/content/205499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melanie Bisnauth holds a PhD in Public Health at the University of Witwatersrand, South Africa and received funding from the Life in the City, School of Governance. Some of the work discussed in this article was funded through this grant.
</span></em></p>The vulnerability of migrants was highlighted during the COVID-19 pandemic when restrictions affected people’s ability to travel to access treatment.Melanie Bisnauth, Doctoral Researcher, School of Public Health and Public Health Technical Advisor, Anova Health Institute, University of the WitwatersrandLicensed 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>
<figure class="align-center zoomable">
<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>
<figcaption>
<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>
</figcaption>
</figure>
<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>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xaCk3-FG9Rw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">John Robert Engole was the first patient to receive HIV treatment under PEPFAR.</span></figcaption>
</figure>
<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/1952442022-11-29T12:29:54Z2022-11-29T12:29:54ZInjectable HIV prevention drug shows promise: we worked out how much South Africa should pay for it<figure><img src="https://images.theconversation.com/files/497226/original/file-20221124-21-w5xkkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Remembering to take a pill every day can be a barrier to good adherence.</span> <span class="attribution"><span class="source">Daniel Born/The Times/Gallo Images/Getty Images</span></span></figcaption></figure><p>Pre-exposure prophylaxis (PrEP) is an HIV prevention method. It is taken by people who are HIV negative, so that if they are unknowingly exposed to HIV, the drug will prevent the virus from infecting them. </p>
<p>The development of this method is important for South Africa because the country is the epicentre of the HIV pandemic. Around <a href="https://www.unaids.org/en/regionscountries/countries/southafrica">7.5 million</a> people in South Africa live with HIV – about a fifth of the global population of people living with HIV. </p>
<p>The current standard-of-care PrEP is a combination antiretroviral drug that must be taken orally, called tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). This tablet has be taken daily for it to be effective, as <a href="https://pubmed.ncbi.nlm.nih.gov/27149090/">research</a> has <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5175411/">shown</a>. It has been available in South Africa since 2016 as part of demonstration projects and implementation studies. </p>
<p>Since 2020, the National Department of Health has committed to rolling it out at every primary healthcare clinic for those who want it. The pricing of oral TDF/FTC has never been a problem. It’s part of first line HIV treatment, and given the large volumes required for South Africa’s successful HIV treatment programme and generic availability, South Africa buys it at low prices. </p>
<p>However, the effectiveness of oral PrEP is only as good as the adherence to it. And remembering to take a pill every day can be a barrier to good adherence.</p>
<p>Recently, two large clinical trials (<a href="https://www.nejm.org/doi/10.1056/NEJMoa2101016">HPTN 083</a> and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00538-4/fulltext">HPTN 084</a>), partly run in South Africa, showed that a two-monthly long-acting injectable antiretroviral, cabotegravir (CAB-LA), was even more effective than TDF/FTC at preventing HIV. </p>
<p>The benefit of an injectable product is that it avoids the problem of having to remember to take a pill daily. Moreover, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813716/">recent</a> acceptability <a href="https://pubmed.ncbi.nlm.nih.gov/32052214/">studies</a>, including ones <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7276-1">conducted in South Africa</a>, have shown that people strongly prefer injectable products over oral pills for HIV prevention. </p>
<p>The big question is: at what price would CAB-LA be affordable and acceptable for the South African government? We sought to answer it in our <a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(22)00251-X/fulltext">recent study</a>. </p>
<h2>Our study</h2>
<p>Currently CAB-LA is only offered in a few high-income countries and at high prices. For example, it costs <a href="https://jamanetwork.com/journals/jama/article-abstract/2789293">$22,200 per person per year in the US</a>. This price is prohibitive in South Africa. </p>
<p>South Africa is one of 90 countries that will be able to get a generic version of CAB-LA <a href="https://www.aidsmap.com/news/jul-2022/viiv-healthcare-allow-90-countries-access-generic-versions-hiv-prevention-shot">brokered through the Medicines Patent Pool</a>. But the price at which this version will be offered has not yet been set.</p>
<p>To find out what the optimal price level would be for South Africa, <a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(22)00251-X/fulltext">we ran</a> an established HIV transmission model used by the South African government for all HIV programme planning and budgeting, called Thembisa. </p>
<p>We compared the impact of CAB-LA over the next 20 years to that of the existing oral PrEP, while testing different price levels for CAB-LA. We assumed that everyone who is eligible for oral PrEP now would be able to have CAB-LA in the future. This included anyone between the ages of 15 and 24, female sex workers, and men who have sex with men. We assumed that more people would choose the injectable, and stay on it for longer than on the current oral preparation. </p>
<h2>What we found</h2>
<p><a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(22)00251-X/fulltext">Our analysis</a> found CAB-LA averted 15%-28% of new HIV infections compared to simply continuing with oral PrEP at the current low uptake levels. This is three times more than what maximising coverage with current oral PrEP would achieve. </p>
<p>Importantly, we found that the cost per CAB-LA injection needed to be less than twice that of a two-month supply of TDF/FTC to be at least as cost-effective. This means the acceptable price level for CAB-LA for South Africa would need to be somewhere between R160 and R260 (US$9 and US$14) per injection. </p>
<p>This range is towards the bottom end of the <a href="https://pubmed.ncbi.nlm.nih.gov/31855323/">minimum price range</a> currently discussed by international organisations and the manufacturer (US$16-US$270). We also found that an acceptable price level is easier to achieve if more people choose to start and continue using injectable PrEP, as higher guaranteed volumes will assist in negotiating lower prices.</p>
<h2>Why this matters</h2>
<p>Our findings come just in time for the decision-making process of the South African government. These findings are also likely relevant to governments in other low- and middle-income countries with a high HIV burden, as well as donor agencies worldwide. All of these players are currently contemplating whether, and how quickly, to replace or augment oral PrEP with CAB-LA. </p>
<p>Injectable PrEP has the potential to substantially change HIV prevention, and bring HIV control within reach, allowing a country like South Africa to spend tax money on other pressing health needs. But for implementation at a large enough scale, it would first need to be affordable, and this will require a multi-partner effort. </p>
<h2>Multi-partner effort needed</h2>
<p>What could this multi-partner effort look like? A successful roll-out would involve:</p>
<ul>
<li><p>lowering the drug’s price to a level possibly below the cost of production, and lowering the cost of production</p></li>
<li><p>harnessing, creating and sustaining demand for the product over the long term, wherever possible, in national programmes rather than single demonstration sites</p></li>
<li><p>establishing and maintaining manufacturing capacity, including local manufacture where possible, and supply chains. </p></li>
</ul>
<p>For this, all parties have to work together – including originator and generic manufacturers, donor organisations and other large funders, and the governments of low- and middle-income countries, in particular those with high HIV prevalence, such as South Africa.</p>
<p>For South Africa, the roll-out can only start in earnest if we have a commitment for injectable PrEP from the government, with or without donor organisation involvement. In turn, that commitment has to start with price negotiations with the current manufacturer. By adding the first precise estimate of the maximum drug price that a country like South Africa should accept, we hope to have set that ball rolling.</p><img src="https://counter.theconversation.com/content/195244/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lise Jamieson receives funding from United States Agency for International Development, and Bill and Melinda Gates Foundation. She is a member of the National Department of Health PrEP Technical Working Group.</span></em></p><p class="fine-print"><em><span>Gesine Meyer-Rath receives research funding from the United States Agency for International Development, FIND, WHO, the National Institutes of Health and the Bill and Melinda Gates Foundation. She is a member of the National Department of Health PrEP Technical Working Group, the National TB Think Tank, and WHO's Cost-Effectiveness of HIV testiNg Services Technical Working Group (CENTS).</span></em></p>The benefit of an injectable product is that it avoids the adherence issues related to taking a pill daily.Lise Jamieson, Senior Researcher, University of the WitwatersrandGesine Meyer-Rath, Research associate professor in Global Health, Boston UniversityLicensed 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>
<hr>
<p>
<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/1898672022-09-23T12:34:56Z2022-09-23T12:34:56ZHIV therapies currently need to be taken regularly for life – longer-lasting antibody treatments could one day offer an equally effective one-shot alternative<figure><img src="https://images.theconversation.com/files/485987/original/file-20220921-15282-mal6o3.jpg?ixlib=rb-1.1.0&rect=3%2C0%2C2236%2C1333&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Broadly neutralizing antibodies are able to recognize multiple strains of HIV at once.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/monoclonal-antibody-is-an-antibody-made-by-cloning-royalty-free-image/1302640944">Naeblys/iStock via Getty Images Plus</a></span></figcaption></figure><p><a href="https://www.verywellhealth.com/antiretroviral-therapy-5216107">Antiretroviral therapy</a> has had an enormous impact on treating HIV infections around the world. The <a href="https://www.unaids.org/en/resources/fact-sheet">millions of people</a> currently taking these treatments under medical supervision can reasonably expect to reduce their viral loads to <a href="https://www.niaid.nih.gov/diseases-conditions/treatment-prevention">undetectable levels</a>, eliminate the risk of transmission and live a normal life span. However, antiretroviral therapy is not without shortcomings. People need to take these medications regularly for life, and <a href="https://doi.org/10.1038%2Fs41598-018-21081-x">low compliance</a> can lead to drug resistance.</p>
<p>There is a promising new option on the horizon. I am a <a href="https://scholar.google.com/citations?user=LyV-cJVvSncC&hl=en">researcher who studies AIDS treatments</a>, and I believe that <a href="https://my.clevelandclinic.org/health/treatments/22246-monoclonal-antibodies">monoclonal antibodies</a> could become game-changers for the treatment of HIV infections.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BADDj82oces?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">HIV poses a challenge to the immune system.</span></figcaption>
</figure>
<h2>HIV presents challenges to antibodies</h2>
<p><a href="https://my.clevelandclinic.org/health/body/22971-antibodies">Antibodies</a> are proteins that serve as major players in the immune system’s response to pathogens, which cause disease, and allergens, which cause allergic reactions. Antibodies recognize specific markers, or antigens, on a potentially harmful substance and help the body eliminate it.</p>
<p>Over the past few decades, researchers have been able to isolate individual antibodies specific to the individual pathogen or allergen they are meant to attack. With this advance, <a href="https://my.clevelandclinic.org/health/treatments/22246-monoclonal-antibodies">monoclonal antibodies</a> made in the lab have become a <a href="https://www.pharmavoice.com/news/2018-09-biologics/612566/">major segment of the pharmaceutical industry</a>. You can see numerous ads on TV or in magazines promoting monoclonal antibodies to treat osteoporosis, autoimmune disorders and various types of cancers.</p>
<p>Antibodies can also be used to treat viral infections, including <a href="https://combatcovid.hhs.gov/what-are-monoclonal-antibodies">COVID-19</a>. But using antibodies gets more complicated with HIV, the virus that causes AIDS in people.</p>
<p>One reason is that HIV has an <a href="https://doi.org/10.1093/bmb/58.1.19">enormous number of variants</a> circulating across the world and even within a single infected individual. In fact, the genetic variation of HIV within a single patient exceeds the genetic variation of all circulating influenza strains worldwide during an entire flu season.</p>
<p>The immune system of an individual infected with HIV creates antibodies to neutralize the virus. However, because these antibodies can usually recognize only one particular strain, they are unable to neutralize other HIV strains circulating in the population. Furthermore, HIV can <a href="https://doi.org/10.1073%2Fpnas.0630530100">mutate within an infected individual</a> and escape antibodies specific to the variant causing the original infection.</p>
<p>This ability to mutate and escape ongoing immune responses is a critical factor in the virus’s ability to continuously replicate, a hallmark of AIDS. It also makes it difficult to design an antibody treatment that can account for HIV’s enormous genetic variability.</p>
<figure>
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<figcaption><span class="caption">Monoclonal antibodies are used to treat many types of cancer.</span></figcaption>
</figure>
<h2>Broadly neutralizing antibodies show promise</h2>
<p>The discovery of rare individuals who make anti-HIV antibodies that can be effective against <a href="https://doi.org/10.1186/s12977-018-0453-y">up to 80% of circulating strains</a>, however, has boosted prospects for antibody treatments for HIV.</p>
<p>These <a href="https://doi.org/10.1080%2F22221751.2020.1713707">broadly neutralizing antibodies</a>, or bnAbs, have seen impressive results. <a href="https://doi.org/10.1038/s41591-018-0001-2">Monkey</a> <a href="https://doi.org/10.1073%2Fpnas.1214785109">studies</a> have found that a single administration of bnAbs can prevent infection from SHIV, the nonhuman primate version of HIV. One study found that <a href="https://doi.org/10.1038/nature12744">two broadly neutralizing antibodies</a> were able to reduce viral loads to undetectable levels in infected monkeys.</p>
<p>In people, one study administering <a href="https://doi.org/10.1038/s41586-018-0531-2">two bnAbs</a> also saw suppression of HIV replication and nearly undetectable viral loads. One <a href="https://doi.org/10.1056/NEJMoa2031738">early-phase clinical trial</a> in 2021 showed that one bnAb could potentially offer protection against HIV infection.</p>
<h2>Long-term production of antibodies</h2>
<p>All the monkey and human studies mentioned above required re-administering the broadly neutralizing antibodies every three weeks or so to maintain effective concentrations. This runs into the same problem antiretroviral therapies face in terms of requiring the individual to retake the drug frequently for life. But researchers have found a potential solution.</p>
<p>Using a small virus that doesn’t cause disease, called an <a href="https://doi.org/10.1038/s41591-022-01762-x">adeno-associated virus</a>, to deliver broadly neutralizing antibodies into the body can stimulate muscle cells to continually produce these antibodies. Because muscle cells have a <a href="https://education.seattlepi.com/average-life-span-skeletal-muscle-cells-6414.html">prolonged life span</a> and can last on average 10 to 16 years, they can be turned into factories that produce the antibodies essentially for life. </p>
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<figcaption><span class="caption">Broadly neutralizing antibodies can target many HIV strains circulating around the world.</span></figcaption>
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<p>One study my colleagues and I conducted using adeno-associated virus found that one monkey was able to produce these antibodies for <a href="https://doi.org/10.3389%2Ffimmu.2020.00449">over six years</a> after a single injection. </p>
<p>Another monkey that researchers dubbed the “<a href="https://doi.org/10.1016/j.immuni.2019.02.010">The Miami Monkey</a>” is considered functionally cured, meaning its viral loads have been at undetectable levels for prolonged periods even without continuous antiviral drug therapy. <a href="https://doi.org/10.1016/j.immuni.2019.02.005">Two other monkeys</a> have also been cured of their AIDS virus infections with this approach.</p>
<p>Adeno-associated virus vectors for HIV antibody therapies still face one more hurdle: <a href="https://doi.org/10.1016/S2352-3018(19)30003-7">anti-drug antibodies</a>, or antibodies the body produces in response to the antibodies in the treatment. Anti-drug antibodies can result when the body registers an antibody treatment as foreign and mounts an immune response against it, negating the treatment. They have also have caused problems for antibody treatments in <a href="https://doi.org/10.1634%2Ftheoncologist.2016-0061">cancer</a> and <a href="https://www.uptodate.com/contents/tumor-necrosis-factor-alpha-inhibitors-induction-of-antibodies-autoantibodies-and-autoimmune-diseases">autoimmune disorders</a>. That may especially be the case for broadly neutralizing antibodies, which have unusual structures that deviate from what the body normally expects an antibody to look like.</p>
<p>Researchers are working hard to develop simple and accessible approaches to help patients build tolerance to broadly neutralizing antibodies. Some of these approaches include delivering treatments to other areas that have greater immune tolerance than the muscle, such as <a href="https://doi.org/10.1016%2Fj.omtm.2019.11.010">to the liver</a> and <a href="https://doi.org/10.1007%2Fs12016-018-8680-5">through the mouth</a>.</p>
<p>Stay tuned.</p><img src="https://counter.theconversation.com/content/189867/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald C. Desrosiers receives funding from the National Instituyes of Health. He receives no corporate/commercial/company support.</span></em></p>Antiretroviral therapies for HIV, while extremely effective, need to be taken daily for life. Designing antibody treatments that need to be taken only once could improve compliance and reduce drug resistance.Ronald C. Desrosiers, Professor of Pathology, Vice-chair for Research, University of MiamiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1887642022-09-05T18:36:09Z2022-09-05T18:36:09ZHIV patients in Botswana get adequate treatment but not all of them – one group is slipping through the cracks<figure><img src="https://images.theconversation.com/files/481068/original/file-20220825-14-j8bh53.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">Franco Volpato/Shutterstock</span></span></figcaption></figure><p>HIV remains a major public health challenge globally. Around <a href="https://www.unaids.org/en/resources/fact-sheet">38 million</a> people are estimated to be living with the infection. Sub-Saharan Africa bears the brunt of the HIV epidemic. Close to two thirds of the HIV cases are in the region. </p>
<p>But huge strides have been made in curbing the epidemic. One of the keys to this has been the introduction of antiretroviral therapy (ART). It’s resulted in people with HIV living long, productive lives and reducing the risks of HIV transmission. </p>
<p>HIV has a high mutation rate, however. As a result, there is evidence of HIV variants with resistance to almost all available antiretroviral drugs. The development of variants with drug resistant mutations is a major challenge to the success of ART – and therefore to efforts to achieve the UN goal of <a href="https://www.unaids.org/en/resources/campaigns/World-AIDS-Day-Report-2014">ending AIDS by 2030</a>.</p>
<p>In developing countries, screening for HIV drug resistant variants is done only when patients who are on treatment have high viral loads – over 1,000 copies/ml, as per the World Health Organization <a href="https://www.who.int/publications/i/item/9789241507196">guidelines</a>. This means drug resistant HIV variants in patients with low viral loads aren’t detected. This is the case in many countries in sub-Saharan Africa – including Botswana.</p>
<p>We <a href="https://www.researchgate.net/publication/358958674_HIV-1_drug_resistance_mutations_among_individuals_with_low-level_viraemia_while_taking_combination_ART_in_Botswana">set out to establish</a> three things.</p>
<p>Firstly, what percentage of patients on ART had low HIV viral loads. This is data that’s never been collected before. Secondly, we wanted to determine HIV drug resistant mutations in this cohort of patients. The third thing we set to establish is whether there’s a connection between patients with low viral loads and treatment failure. This is known as virologic failure.</p>
<p>Answering these three questions has given us a much deeper understanding of where a country like Botswana stands in its efforts to eliminate HIV. As a result of our research we have a better understanding of how many people with HIV have low viral loads, how serious a threat we face from drug resistant HIV variants and finally how many people with low viral levels are at risk of treatment failure. </p>
<p>We found that people with low viral loads were just as likely to harbour drug resistant HIV variants as people with high viral loads. This matters because it points to the need to change how people with HIV who are on ART are managed in developing countries. </p>
<p>We recommend that patients on ART with detectable viral loads above 50 copies/ml be further investigated to ensure that they don’t harbour drug resistant HIV variants. </p>
<h2>What we found</h2>
<p><strong>Number of HIV patients on ART with low viral load:</strong> Our study looked at a cohort of 6,078 people with HIV from across Botswana who were receiving combination antiretroviral therapy. We narrowed this down to 4,443 people who had been on ART treatment for at least six months. </p>
<p>Only 8% had viral loads of more than 50 copies/ml. Testing for mutations only happens on patients with viral loads of over 1,000 copies/ml, which means that this group isn’t being screened.</p>
<p>The figure of 8% may seem low. But it means that this cohort either has a resistant variant, or their treatment isn’t working.</p>
<p><strong>Prevalence of drug resistant mutations:</strong> We sequenced the HIV in the patients with low viral loads as well as those with viral loads above 1,000 copies/ml. We found no difference in the prevalence of HIV drug resistant mutations between the two patient groups. This indicates that patients with low HIV viral loads are just as likely to harbour HIV variants with drug resistance mutations as those with high viral loads.</p>
<p><strong>Treatment failure:</strong> A select group of the patients with low HIV viral loads were followed up for at least a year. We found that there was a statistically significant association of low level HIV viral load with subsequent virological (or treatment) failure. Our results show that patients with a low HIV viral load are more likely to experience virological failure.</p>
<p>Current treatment guidelines describe virologic failure as viral loads above 1,000 copies/ml. Our results challenge this. </p>
<h2>Going forward</h2>
<p>Our results echo the views expressed by others who have <a href="https://www.frontiersin.org/articles/10.3389/fmed.2022.939261/full">looked at this issue</a>. Like them, we recommend that the HIV treatment guidelines in developing countries be improved to ensure that patients with low HIV viral load while on ART get the necessary attention. </p>
<p>In developed countries, screening for drug resistant HIV variants is done when people start ART. Drug resistance screening is also done whenever a patient on treatment has a detectable viral load. </p>
<p>The same approach should be applied in developing countries. </p>
<p>Patients should also have a follow-up viral load test which – if the virus is still detectable – should lead to sequencing of the HIV variants they harbour. If found to have a drug resistant variant, the patient should be switched to an appropriate ART regimen. </p>
<p>If they are found not to harbour HIV drug resistant variants, the patient should undergo intensive adherence counselling because this could point to treatment failure. </p>
<p>Scientists and funders must invest time and resources to develop more sensitive HIV drug resistant assays that can sequence HIV in samples with low viral loads. This is currently a limiting factor as most of the available assays don’t work well with samples with low viral loads.</p><img src="https://counter.theconversation.com/content/188764/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simani Gaseitsiwe receives funding from : Wellcome Trust, NIH, EDCTP, Bill and Melinda Gates Foundation.
</span></em></p>Patients with low HIV viral loads are just as likely to harbour HIV variants with drug resistance mutations as those with high viral loads.Simani Gaseitsiwe, Principal Investigator and Research Associate at Botswana Harvard AIDS Institute Partnership, Sub-Saharan African Network for TB/HIV Research Excellence (SANTHE)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879242022-08-04T20:19:21Z2022-08-04T20:19:21ZNew Zealand’s plan to eliminate HIV transmission ignores deepening inequities in health outcomes for Māori women<figure><img src="https://images.theconversation.com/files/477520/original/file-20220803-17-j47fup.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">AIDS</span> </figcaption></figure><p>The New Zealand government plans to spend NZ$18 million on becoming the first country to <a href="https://www.beehive.govt.nz/release/government-sets-out-plan-eliminate-hiv-transmission-new-zealand">eliminate transmission</a> of the human immunodeficiency virus (HIV) within a decade. </p>
<p>In a <a href="https://www.health.govt.nz/have-your-say-aotearoa-new-zealands-hiv-action-plan">draft action plan</a> launched last week, associate health minister Ayesha Verrall set out key measures to increase prevention and testing, improve access to treatment and address stigma.</p>
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<p>These are ambitious targets, but the plan fails to take account of the changing pattern of the HIV pandemic. It does not reflect the <a href="https://pubmed.ncbi.nlm.nih.gov/24038370/">mounting evidence</a> that Māori, and Māori women in particular, have disproportionately high rates of HIV and are more likely to be diagnosed late. </p>
<p>If Māori women are not identified as a group at increased risk of HIV and progression to AIDS as a result of late diagnosis, the plan’s effectiveness in stemming the spread of HIV infection will be severely limited. This glaring omission could easily derail minister Verrall’s goal and instead exacerbate current HIV disparities.</p>
<p>Since national HIV surveillance was established in Aotearoa New Zealand in 1985, 5,430 people have been diagnosed with the virus and 757 have died of AIDS. The number of people diagnosed with HIV has <a href="https://www.otago.ac.nz/aidsepigroup/otago840423.pdf">declined</a> recently (from 195 in 2016 to 122 in 2021), but inequities in health outcomes are deepening.</p>
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Read more:
<a href="https://theconversation.com/hiv-40-years-on-four-action-points-to-end-aids-as-a-health-threat-162260">HIV 40 years on: four action points to end AIDS as a health threat</a>
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<p>The pattern of the HIV pandemic globally has changed dramatically with the advent of antiretroviral therapy (<a href="https://www.healthnavigator.org.nz/medicines/a/antiretroviral-therapy/">ART</a>) more than two decades ago. With timely access to ART, people with HIV can expect to enjoy the same health outcomes as everyone else. </p>
<p>ART has become a key plank in preventing the spread of HIV. But to be effective, ART must be initiated soon after a person becomes infected with the virus. If New Zealand is to achieve elimination of HIV by 2032, ART must be made readily available to everyone and we must remove the barriers caused by stigma, discrimination and racism. </p>
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<h2>HIV inequities are increasing</h2>
<p>At the recent <a href="https://aids2022.org/">24th International AIDS Conference</a> in Montreal, a consistent message was that the HIV pandemic is far from over, and that HIV inequities have increased. </p>
<p>The world will not eliminate HIV any time soon if governments and decision makers fail to recognise the adverse impact of HIV on disadvantaged populations such as Indigenous peoples, and especially Indigenous women. </p>
<p>At the conference, I presented five steps for developing action plans to prevent HIV transmission among Indigenous peoples. This provides a highly relevant framework for setting realistic and achievable goals for Māori living with HIV.</p>
<ol>
<li><p>Recognise the impact of colonisation and historical trauma</p></li>
<li><p>ensure access to culture</p></li>
<li><p>identify and resource protective factors such as whānau and family support</p></li>
<li><p>ensure health services are free from stigma and discrimination </p></li>
<li><p>understand and address the impacts of social determinants on health and wellbeing.</p></li>
</ol>
<p>UNAIDS leads the <a href="https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026">global effort to end AIDS</a> as a public health threat by 2030. It recently set a 95-95-95 target: 95% of people living with HIV knowing their HIV status; 95% of HIV-positive people receiving treatment; and 95% of people on treatment with suppressed viral loads.</p>
<p>New Zealand cannot ignore the fact we are part of the global community. If the international community fails to eliminate HIV within the next eight years, this will seriously hamper efforts in our country.</p>
<h2>Health reforms provide opportunity to enhance equity</h2>
<p>In 1994, more than a decade after the onset of the HIV pandemic, New Zealand’s ministry of Māori development Te Puni Kōkiri produced the first <a href="https://natlib-primo.hosted.exlibrisgroup.com/primo-explore/fulldisplay?vid=NLNZ&docid=INNZ7114110320002837&context=L&search_scope=INNZ">report</a> into the likely impact of HIV on Māori. </p>
<p>It warned Māori were vulnerable to HIV and the government needed to implement measures to prevent the spread of the virus among Māori. Just as has <a href="https://www.bmj.com/content/376/bmj.o180">happened with COVID-19</a>, the government paid scant attention to those warnings. </p>
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Read more:
<a href="https://theconversation.com/research-shows-maori-are-more-likely-to-die-from-covid-19-than-other-new-zealanders-145453">Research shows Māori are more likely to die from COVID-19 than other New Zealanders</a>
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<p>As we enter the fifth decade of the HIV pandemic, Māori continue to be adversely affected by HIV, with higher rates of late diagnosis increasing the <a href="https://pubmed.ncbi.nlm.nih.gov/22093231/">risk of poor health outcomes</a>. </p>
<p>Māori women have been rendered invisible in the draft action plan, despite the fact they have <a href="https://www.otago.ac.nz/aidsepigroup/otago840423.pdf">high rates of locally acquired HIV</a>.</p>
<p>Action plans play an important role in managing and controlling all manner of illnesses. This plan is no exception. But to be effective, plans need to be in tune with the needs of communities and based on consultation processes that engage with them respectfully. </p>
<p>New Zealand’s current <a href="https://www.rnz.co.nz/news/national/440988/health-system-reform-what-the-experts-are-saying">health reforms</a> are designed to lead to long overdue improvements in equity for Māori. But this is not reflected in this draft action plan, which may well undermine efforts to address HIV disparities. </p>
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Read more:
<a href="https://theconversation.com/with-closer-ties-to-gps-nzs-new-central-health-agency-could-revolutionise-treatment-of-major-diseases-159434">With closer ties to GPs, NZ's new central health agency could revolutionise treatment of major diseases</a>
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<p>The reforms require health services and professionals to put Te Tiriti o Waitangi and equity at the forefront of health policy and services. In its current form, the action plan fails to take advantage of the opportunities in the new health sector. </p>
<p>If New Zealand wants to stop the transmission of HIV among Māori, the HIV elimination action plan must set out strategies to address inequities. An overwhelming message from the AIDS conference was that affected communities, and especially people living with HIV, must be front and centre of efforts to prevent the transmission of the virus.</p><img src="https://counter.theconversation.com/content/187924/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clive Aspin has received funding from the Health Research Council of New Zealand. He is a founding member of the International Indigenous Working Group on HIV and AIDS. </span></em></p>The omission of growing evidence that Māori, and Māori women in particular, have worse health outcomes after HIV infection could derail New Zealand’s elimination plans and exacerbate disparities.Clive Aspin, Associate Dean Māori, Faculty of Health; Senior Lecturer in Health, Te Herenga Waka — Victoria University of WellingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1800492022-06-06T15:05:57Z2022-06-06T15:05:57ZHIV control approaches may not work for TB: lessons from South Africa and Zambia<figure><img src="https://images.theconversation.com/files/465313/original/file-20220525-26-biwo3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Chest x-rays are more sensitive for screening for TB.</span> <span class="attribution"><span class="source">PUNIT PARANJPE/AFP via Getty Images</span></span></figcaption></figure><p>Tuberculosis (TB) is one of the most deadly infectious diseases. Around <a href="https://www.who.int/publications/m/item/factsheet-global-tb-report-2021">9.9 million people</a> around the world fell ill with the disease in 2020 and an estimated <a href="https://www.who.int/publications/m/item/factsheet-global-tb-report-2021">1.5 million</a> people died. </p>
<p>The advent of <a href="https://theconversation.com/hiv-40-years-on-four-action-points-to-end-aids-as-a-health-threat-162260">HIV in the 1980s</a> unleashed large increases in TB, particularly in sub-Saharan Africa. In some countries, <a href="https://static1.squarespace.com/static/5aa93458b40b9d07675f0306/t/623b671611c14f1fae72d38c/1648060217506/TREATS+Final+Report+2022.pdf#page=7">the number</a> of people diagnosed with TB quadrupled every year. People with HIV are particularly susceptible to falling ill with TB. </p>
<p>My colleagues and I were part of a research project called <a href="https://static1.squarespace.com/static/5aa93458b40b9d07675f0306/t/623b671611c14f1fae72d38c/1648060217506/TREATS+Final+Report+2022.pdf">TREATS</a> – Tuberculosis Reduction through Expanded Antiretroviral Treatment and Screening for active TB. The project set out to see whether a “universal test and treat” approach in Zambia and South Africa could achieve steep reductions in HIV and TB. </p>
<p>This approach had been used in an HIV and TB intervention known as <a href="https://clinicaltrials.gov/ct2/show/NCT01900977">PopART (Population Effects of Antiretroviral Therapy to Reduce HIV Transmission)</a>. </p>
<p>We expected to find that screening everybody for TB would identify individuals with the disease who had not yet been diagnosed. We also thought treating them quickly would reduce the amount of TB in the community and reduce the infection risk to others.</p>
<p>But that’s not what we found. Screening everybody for TB had no impact on the prevalence or incidence of TB infection. The reasons are complex and our team is in the early stages of analysing the results to identify possible explanations.</p>
<h2>Double interventions</h2>
<p>The PopART intervention took place between 2013 and 2018. It delivered combined testing and treatment for HIV and TB to about 600,000 individuals in Zambia and South Africa. It was carried out by community health workers who visited every household in an entire community at least once a year. </p>
<p>The community health workers provided information on HIV and TB. In addition, they offered everyone an HIV test and screened everyone for TB using a simple symptom screen. </p>
<p>Individuals who had symptoms suggestive of TB were asked to provide a sputum sample which was taken to a health facility for testing for TB. </p>
<p>Any individual who tested positive for HIV was encouraged to access antiretroviral therapy (ART), which was provided to all regardless of CD4 count. </p>
<p>The PopART intervention was <a href="https://www.hptn.org/research/studies/hptn071#:%7E:text=What%20is%20HPTN%20071%3F,on%20community%2Dlevel%20HIV%20incidence.">found</a> to reduce HIV incidence by about 20% in the communities that received the intervention compared to those which did not. </p>
<p>The TREATS study then followed 2017-2021 to measure what effect the PopART intervention had had on TB. A key component of the TREATS study was measuring whether PopART had reduced the overall prevalence of active TB. There were 50,000 participants, aged 15 years and over. Community workers went door-to-door to explain the study and invite people to be tested for HIV and TB at mobile field sites. A mobile site was set up for screening and testing. It included a digital x-ray machine and portable laboratory for identifying TB in sputum samples.</p>
<p>The TREATS survey compared the prevalence of TB in communities that had received the PopART intervention with those that had not. We found no difference in prevalence of TB. TREATS also measured whether young people in communities which received the intervention had fewer new TB infections than those in communities that did not receive the intervention. Again we found no difference.</p>
<p>The TB screening used in the PopART intervention relied on symptom screening followed by sputum testing. It is likely that this screening method, while feasible and acceptable, is insufficient to reduce the burden of TB. We know that some people with TB do not have symptoms or do not consider their symptoms to be important to mention. Chest x-rays are more sensitive for screening for TB, but these are largely unavailable and unaffordable in places where TB disease is commonly found. </p>
<p>More sensitive tools for TB screening, that are feasible, acceptable and affordable, are urgently needed. </p>
<h2>Future directions</h2>
<p>Our study has highlighted the importance of addressing stigma around TB and HIV in encouraging people to come forward for diagnosis and treatment in these communities. Community health workers doing the PopART visits found that as the rounds of the intervention went on, the stigma broke down. People were happier to get tested for HIV and to be screened for TB. The numbers screening positive actually went up over time, which may be a reflection of people feeling more confident. </p>
<p>But TREATS has shown that improvements in the diagnosis and treatment of HIV do not easily translate into greater success against TB. Further research will be vital in building on the lessons of TREATS to find the best ways to fight this devastating disease.</p><img src="https://counter.theconversation.com/content/180049/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Ayles receives funding from EDCTP. </span></em></p>We expected to find that screening everybody for TB would identify individuals not yet diagnosed, and treating them quickly would reduce the prevalence of TB in the community.Helen Ayles, Professor Infectious Diseases and International health, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1797932022-03-24T14:26:49Z2022-03-24T14:26:49ZLeft to die: the fate of thousands of people living with HIV in Tigray<figure><img src="https://images.theconversation.com/files/453826/original/file-20220323-27-9phr1h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People receiving medical treatment at the entrance hall of Ayder Referral Hospital in Mekele, the capital of Tigray region, Ethiopia</span> <span class="attribution"><span class="source">YASUYOSHI CHIBA/AFP via Getty Images</span></span></figcaption></figure><p>People with human immunodeficiency virus (HIV) on regular treatment are now experiencing similar <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767138">life expectancy</a> to people without the virus. This is thanks to the innovation of <a href="https://pubmed.ncbi.nlm.nih.gov/25310317/">antiretroviral therapy</a> which can prevent the progression to AIDS. This is the late stage of HIV infection that occurs when the body’s immune system is badly damaged because of the virus. </p>
<p><a href="https://emedicine.medscape.com/article/211316-overview#a6">Evidence</a> shows that the survival period for HIV patients who progress to AIDS is usually less than two years in untreated patients. If patients do not have access to ART, the <a href="https://www.medscape.com/answers/211316-6065/what-is-the-prognosis-of-untreated-hiv-infection">prognosis</a> is poor, with an overall mortality rate of more than 90%.</p>
<p>A key factor that limits access to antiretroviral therapy is conflict or war. </p>
<p>For this reason, we are deeply concerned about people living with HIV in Ethiopia’s Tigray region, an area that’s been the focus of <a href="https://bmjopen.bmj.com/content/11/6/e043943">our work</a>. Currently, there’s <a href="https://www.hrw.org/tag/tigray-conflict">a conflict</a> between Ethiopia’s central government and the regional Tigrayan government. </p>
<p>We’ve <a href="https://www.researchgate.net/profile/Fisaha-Tesfay">carried out</a> <a href="https://www.researchgate.net/profile/Hailay-Gesesew">research</a> for over 12 years on HIV in Tigray. This includes <a href="https://pubmed.ncbi.nlm.nih.gov/28107430/">research</a> on the consequences of not taking antiretroviral therapy over short periods of time. </p>
<p>We believe that little attention is being given to HIV programmes or to the people who live on this medication. This is because the <a href="https://www.devex.com/news/opinion-in-tigray-we-are-demanding-food-and-medicine-not-bombs-102621">Ethiopian government</a> had imposed a siege and was withholding all basic services and blocking all forms of humanitarian assistance, including food aid and medical supplies. On March 24 2022 the Ethiopian government announced an indefinite humanitarian truce. A day later, the Tigray government <a href="https://www.aljazeera.com/news/2022/3/25/ethiopia-tigrayan-fighters-agree-to-cessation-of-hostilities">agreed</a> to the call for the humanitarian truce, calling on the federal government to take concrete steps to facilitate unfettered humanitarian access to Tigray.</p>
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Read more:
<a href="https://theconversation.com/decades-of-progress-gone-in-one-year-tigrays-healthcare-system-has-been-destroyed-170406">Decades of progress gone in one year: Tigray's healthcare system has been destroyed</a>
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<p>Patients receiving care for noncommunicable and communicable <a href="https://gh.bmj.com/content/6/11/e007328">chronic diseases</a> will be among the ones suffering due to lack of medical care. These include patients in HIV care.</p>
<p>Access to antiretroviral therapy is just one of the challenges. The war on Tigray will substantially impact the entire HIV care continuum, from diagnosis, enlisting for antiretroviral therapy and retention in HIV care. This is a great worry for those living with HIV in Ethiopia’s Tigray region. </p>
<h2>New HIV infections</h2>
<p>The starting point of positive outcomes of HIV care continuum is <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17051-7/fulltext">prevention</a> through a number of activities. These include condom use, prevention of <a href="https://apps.who.int/iris/handle/10665/96350">mother to child</a> transmission, and prevention of <a href="https://www.unaids.org/sites/default/files/media_asset/jc1601_policy_brief_criminalization_long_en.pdf">deliberate</a> transmission of HIV. </p>
<p>In Tigray, promotion of good health and disease prevention activities were provided through the health extension programme at health posts and through routine morning sessions at health centres and hospitals. But the region faced a <a href="https://rusi.org/explore-our-research/publications/rusi-newsbrief/international-community-struggles-address-ethiopian-conflict">full scale war</a> from November 2020 to June 2021. This was followed by a de facto blockade for ten months. Signs that it might be lifted came with the Ethiopian government’s announcement an <a href="https://www.aljazeera.com/news/2022/3/24/ethiopia-declares-truce-to-allow-aid-into-tigray">indefinite humanitarian truce</a>.</p>
<p>As a result, the health extension programmme was completely non-functional for more than a year, and about 70% of hospitals and 87% of health centres were <a href="https://gh.bmj.com/content/6/11/e007328">non-functional</a> within the first six months of the war. </p>
<p>Health facilities have run out of condoms and <a href="https://www.devex.com/news/tigray-the-deliberate-destruction-of-a-health-system-102252">pre-exposure medicines</a> used to prevent people from getting HIV. The Tigray health care system has <a href="https://gh.bmj.com/content/6/11/e007328">collapsed</a> because of the war. Reproductive health services – including HIV care services – have also collapsed. These potentially increase the rate of new HIV infections. The stories of sexual violence and wider and systematic gang <a href="https://www.telegraph.co.uk/global-health/women-and-girls/make-hiv-positive-hundreds-women-rush-tigray-hospitals-soldiers/">rape</a> involving deliberate HIV transmission are among the most heinous acts.</p>
<p>HIV in the <a href="https://pubmed.ncbi.nlm.nih.gov/30810344/">Ethiopian military</a> is high, and the rate of HIV among <a href="https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf">women</a> was already 1.2% (versus 0.6% in men) in Tigray. The Tigray regional health bureau showed that 7.3% of the women who have been raped have been diagnosed with various sexually transmitted infections and <a href="https://www.facebook.com/dimtsiweyane/posts/4853278724770265">5% have been infected with HIV</a>.</p>
<p>The fact that <a href="https://www.unhcr.org/refugeebrief/the-refugee-brief-5-november-2021/">over two million</a> Tigrayans were internally displaced also potentially increases the rate of new HIV infections in the region.</p>
<h2>HIV treatment linkage and retention</h2>
<p>Before the war, Tigray had <a href="https://bmjopen.bmj.com/content/11/6/e043943">147 health facilities</a> providing HIV care services, where 13 health facilities provided an oral HIV self-testing services. Each health facility had <a href="https://bmjopen.bmj.com/content/11/6/e043943">one to five peer educators</a> to promote ART adherence. </p>
<p>There were more than <a href="https://tigrayeao.info/tigray-health-bureau-tigray-health-sector-annual-bulletin-2021-january-2022/">43,000 HIV patients and 2,363 pregnant mothers</a> taking ART prophylaxis, with 867 HIV exposed infants in Tigray before the start of the war. These patients are at risk of AIDS related deaths because of the frequent interruption, and later, stoppage of antiretroviral therapy for more than ten months. This was due to the complete collapse of the HIV care system. </p>
<p>The war, and its aftermath, has had a devastating effect.</p>
<p>On January 2022, a group of health workers from Ayder Referral Hospital, the biggest specialised hospital in Tigray, reported <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00054-X/fulltext">running out of</a> basic medicines. Clinics have also run <a href="https://www.nasdaq.com/articles/doctors-say-lives-are-lost-in-hospitals-in-ethiopias-tigray-due-to-dwindling-supplies">out of stock</a>.</p>
<p>Up to <a href="https://www.theguardian.com/global-development/2022/mar/02/patients-dying-as-conflict-prevents-supplies-reaching-tigray-hospitals">half</a> of infants infected with HIV die within their first two years if they did not take ART. The survival status of women who were on ART prophylaxis is high likely to dwindle because of the high rate of malnutrition. The <a href="https://www.france24.com/en/africa/20211001-un-reports-unprecedented-malnutrition-in-tigray-amid-indications-of-siege">United Nations</a> has released data showing that 79% of 15,000 screened pregnant and lactating women in Tigray were diagnosed with acute malnutrition.</p>
<p>If the <a href="https://www.medscape.com/answers/211316-6065/what-is-the-prognosis-of-untreated-hiv-infection">mortality rate</a> of untreated HIV patients is more than 90%, the rate is even higher for HIV patients in Tigray.</p>
<h2>The transition</h2>
<p>In Tigray, 85% of the population are rural dwellers and rebuilding basic infrastructure such as road, water, and electricity will take the priority. Rebuilding the health infrastructure such as hospitals and health centres and replacing the <a href="https://www.reuters.com/article/ethiopia-conflict-health-idUSL1N2KE11S">90%</a> of lost ambulances will therefore take time. </p>
<p>This gap in the transition will result in further new HIV infections, delayed linkage to and interruptions of treatments, resistance to treatments, AIDS and deaths. </p>
<p>A preliminary report of damage assessment conducted by <a href="https://tigrayeao.info/tigray-health-bureau-tigray-health-sector-annual-bulletin-2021-january-2022/">Tigray Regional Health Bureau</a> between July to September 2021 showed that the rate of lost-to-follow up of people living with HIV and TB was 81% and 90%. </p>
<p>The existing inequity in poor HIV outcomes for rural dwellers and among women is an additional challenge to the unfolding tragedy as they make up the largest numbers of victims of war and conflicts.</p>
<p>Unless special attention is given to conflict and HIV the war will undermine the achievement of the 2030 goals to end AIDS, discrimination, and new infections.</p>
<p>The statements of global leaders for 2021 World AIDS Day contained messages of the ambitious goal of 2030. But they missed a core factor, namely the war or conflict that changes the likelihood of ending AIDS. </p>
<p>When the war is fought in one of the HIV prevalent areas, the goal of ending AIDS will simply be wishful thinking. </p>
<p>Access to HIV medicines is a basic human right and should not be denied, as experienced by the people with HIV in Tigray, especially in an era when the life expectancy of people with and without HIV is relatively <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767138">similar</a>. </p>
<p>We urge leaders of countries and influential HIV institutions such as the World Health organisation and UNAIDS to bring meaningful action and save those people living with HIV in Tigray who are left to die. </p>
<p><em>Dr Joanne Flavel from the Stretton Institute at The University of Adelaide, South Australia, contributed to the writing of this article.</em></p><img src="https://counter.theconversation.com/content/179793/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Hailay Abrha Gesesew is a principal investigator in a project sponsored by an Australian National Health and Medical Research Council (NHMRC) and is a Senior Research and Teaching Fellow at Research Centre for Public Health Policy at Torrens University Australia in Adelaide. The views expressed in this opinion piece are only the author, not necessarily the funder. </span></em></p><p class="fine-print"><em><span>Dr Fisaha Tesfay is a Postdoctoral Research Fellow at the Institute For Health Transformation, Deakin University Australia. The views expressed in this piece are only the author’s </span></em></p>Unless special attention is given to conflict and HIV the war will undermine the achievement of the 2030 goals to end AIDS, discrimination, and new infections.Hailay Gesesew, NHMRC Research Fellow (Public Health), Flinders UniversityFisaha Tesfay, Postdoctoral Research Fellow, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1729142021-12-02T11:10:57Z2021-12-02T11:10:57ZDonors have shifted their priorities when it comes to HIV: a look at the impact in Uganda<figure><img src="https://images.theconversation.com/files/435026/original/file-20211201-21-1vv49oy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cuts in donor funding stretch limited resources. </span> <span class="attribution"><span class="source">ISAAC KASAMANI/AFP via Getty Images</span></span></figcaption></figure><p>Some have dubbed it the collision of two pandemics. When the COVID pandemic hit two years ago, it was said that HIV was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194968/">“de-prioritised”</a> – in other words, forced to take a back seat. </p>
<p>The truth is that even before the advent of COVID, donors had begun to exit <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06316-4">HIV programmes</a> with increasing frequency. </p>
<p>I have been tracking decisions donors have been making around HIV programmes in Uganda, and conducting research on their impact for over seven years. The reason for this is that there has been limited research on understanding <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06316-4">the impact of loss</a> of donor support on HIV services in resource-limited settings. </p>
<p>The level of dependency on donor funding is very high in both low- and middle-income countries. For example, <a href="https://www.hiv.gov/federal-response/pepfar-global-aids/pepfar">Pepfar</a> the US government’s HIV and
AIDS response programme, can account for as much as <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2009-6">70% of national HIV spending</a> as is the case in Uganda. </p>
<p>In addition, Pepfar <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2009-6">often hires</a> additional personnel to help manage HIV medication supply chains in districts, frequently trains health workers in quality HIV care including on-site support supervision and invests in strengthening laboratory systems.</p>
<p>In Uganda, Pepfar is a major funder of HIV services. In a <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06316-4">recent paper</a> we looked at what happens to HIV services when countries heavily dependent on Pepfar lose some of this support. </p>
<p>Our findings indicate that basic services such as HIV testing and treatment were still available. But there were substantial reductions in the scope and quality of services provided. For example specialised peadiatric HIV services and nutrition support for people on antiretroviral therapy stopped. And patients felt that waiting times were longer and stock-outs more frequent. </p>
<p>HIV services must be comprehensive to ensure that people take their medication as prescribed and avoid onward transmission of the virus. Services such as child HIV care and ensuring medicine collection is seamless are a key part of ending HIV as a public health threat. </p>
<h2>What’s changed in the donor landscape</h2>
<p>Some of the biggest donors in health include Pepfar and the Global Fund to Fight AIDS, Tuberculosis and Malaria, an international <a href="https://www.theglobalfund.org/en/">funding mechanism</a>.</p>
<p>Over the past decade it’s become clear that global health organisations were scaling down on HIV funding, or changing how their money is dispersed. </p>
<p>The Global Fund has been systematically weaning off countries attaining middle-income status from its <a href="https://www.globalfundadvocatesnetwork.org/wp-content/uploads/2016/04/Aidspan-APMG-2016-Transition-from-Donor-Funding.pdf">HIV support programmes</a> in the belief that they have improved per capita income and that, ideally, this translates into more investments in their national HIV responses.</p>
<p>Pepfar cut support to countries described as <a href="https://www.tandfonline.com/doi/full/10.1080/09540121.2015.1051502">“middle income”</a> such as Vietnam, Nigeria and South Africa. In August 2012, it announced it would <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897549/">halve</a> its $500 million annual budget for South Africa.</p>
<p>Pepfar changed how it distributes HIV finances nationally in 15 focus countries. In Uganda, between 2015 and 2017, it implemented a policy known as “geographic prioritisation”. The aim was to use its aid more effectively. Instead of a generalised national response, it sought to align aid with HIV burden at sub-national level. The idea was that districts in Uganda that had a higher HIV burden would receive more support while those with lower HIV burden would receive significantly less support.</p>
<p>Some are predicting that the COVID-19 pandemic will further dent <a href="http://optimamodel.com/pubs/Jewell_2020.pdf">global HIV funding</a>.</p>
<h2>The Uganda experience</h2>
<p>Our <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223426">mixed-method study</a> explored the impact of Pepfar’s change in policy on HIV services in the country. Our research showed that policy shifts meant less dollars for HIV services in some parts of Uganda.</p>
<p>The change in policy resulted in 734 “low volume” health facilities losing site-level support while 10 districts in Northern Uganda with a relatively low HIV burden were meant to transition to Uganda government support. </p>
<p>In our qualitative arm of the <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06316-4">study</a>, we found that the change in the way Pepfar provided aid to Uganda had important effects.</p>
<p><strong>The scope of HIV services narrowed:</strong> The health workers and patients we talked to indicated that paediatric HIV services ceased, free HIV testing ceased at supported for-profit clinics. Patients decried the loss of nutrition support in food-insecure parts of Uganda.</p>
<p><strong>Quality of HIV care declined:</strong> Patients were unequivocal in relaying the notion that the quality of HIV care had progressively declined since Pepfar changed its policy. They talked of health workers being preoccupied with “medicines dispensing” rather than patient-centred care. The frequency of stock-outs of medicines increased with loss of supply chain experts.</p>
<p>Patients also indicated that waiting times were longer and HIV clinics were less organised. This was because Pepfar paid regular monetary allowances to “expert patients” to help plug severe staffing gaps at HIV clinics such as to help in managing triage systems.</p>
<p><strong>Community outreach activities:</strong> An important finding of our study was that community HIV outreach activities were heavily affected. Health workers and “expert patients” no longer received monetary allowances for making trips into communities for follow up of clients in their homes and for demand creation for HIV services, hence engagement in HIV care suffered. Pepfar’s changes meant that this was’t happening anymore.</p>
<p>Many of the effects described by health workers and patients were “negative”. But we also found that, in some cases, the loss of Pepfar support led to more integration of HIV with other services. For example, integrated community outreaches had combined immunisation and HIV testing. This prevents duplication and wastage inherent in disease-specific outreaches.</p>
<p>In addition, we <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2009-6">found</a> that a few districts in Uganda stepped up and increased funding for HIV such as providing fuel to transport samples to HIV labs. </p>
<p>But funding gaps remain. What’s clear is that further alternatives are needed. </p>
<p>Overall, the Uganda government hasn’t responded adequately, even though it knew that the cuts in funding were looming. </p>
<p>It is clear that increasing local ownership of HIV programmes is of paramount importance. In 2014, Uganda announced an “AIDS Trust Fund” to supplement donor aid to be financed through levies on soft drinks. This ought to be revived and fast tracked.</p><img src="https://counter.theconversation.com/content/172914/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Zakumumpa is supported by a research grant from Uppsala Monitoring Centre (UMC) in partnership with the Consortium for Advanced Research Training in Africa (<a href="http://www.cartafrica.org">www.cartafrica.org</a>). Henry Zakumumpa is also Principal Investigator for a research grant focused on understanding the effects of donor transition on health coverage in Uganda which is funded by WHO/Alliance for Health Policy and Systems Research.</span></em></p>HIV services must be comprehensive to ensure that people take their medication as prescribed and avoid onward transmission of the virus.
Even before the advent of COVID-19, donors had begun to exit HIV programmes with increasing frequency.Henry Zakumumpa, Health Systems Researcher, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1714092021-11-28T09:08:28Z2021-11-28T09:08:28ZSouth Africa isn’t doing enough to provide HIV prevention treatment for mothers: why it needs to<figure><img src="https://images.theconversation.com/files/431018/original/file-20211109-19-1ydmcp4.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>A <a href="https://www.unaids.org/en/keywords/pmtct">global target</a> for the elimination of mother to child transmission of HIV globally was set in 2015. The ambitious target of the Joint United Nations Programme (UNAIDS) was to reduce new infant HIV infections by <a href="https://www.unaids.org/sites/default/files/media_asset/start-free-stay-free-aids-free-2020-progress-report_en.pdf">75% by 2020</a>. This is equivalent to reducing new infections to under 1%. </p>
<p>South Africa has the <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/south-africa">largest number of people living with HIV</a> in the world: over 7.7 million. The country also has the largest HIV epidemic in pregnant women. Over one-third of pregnant women have HIV, contributing to one of the highest rates of vertical transmission (HIV from mother to infant), <a href="https://www.unaids.org/sites/default/files/media_asset/start-free-stay-free-aids-free-2020-progress-report_en.pdf#page=80">estimated</a> at 3.9% in 2020. </p>
<p>South Africa has been committed to achieving the elimination of maternal to child transmission of HIV since 2015. It introduced <a href="https://www.knowledgehub.org.za/system/files/elibdownloads/2019-10/PMTCT%20Guideline%2028%20October%20signed.pdf">policies</a> that give lifelong antiretroviral therapy to all pregnant women living with HIV. But, over six years later, new infections in pregnant women continue at a <a href="https://pubmed.ncbi.nlm.nih.gov/30932960/">high rate</a>.</p>
<p>Since 2017 the World Health Organisation (WHO) and several national HIV programmes have recommended offering daily oral preventive medication technically known as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948023/">pre-exposure prophylaxis (PrEP)</a> to pregnant and breastfeeding women at risk of getting HIV. PrEP is the use of antiretroviral therapy to prevent the acquisition of HIV in people who are not living with HIV. The recommendation is based on a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948023/">large body</a> of safety data from women living with HIV who used the same drugs as treatment during pregnancy and breastfeeding. </p>
<p>Not offering preventive treatment to women not living with HIV but who are at risk of HIV acquisition <a href="http://www.samj.org.za/index.php/samj/article/view/13421/9973">undermines the efficacy</a> of all of the South African efforts to eliminate mother to child transmission of HIV. It is urgent and overdue to implement PrEP in pregnancy and during breastfeeding. Failure to do so in the face of proven prevention interventions allows ongoing avoidable HIV infection among women in South Africa with the added high risk of transmission to their infants.</p>
<p>In the absence of PrEP, we estimate that over 90,000 infants will acquire HIV in the next 10 years. Our team’s <a href="https://pubmed.ncbi.nlm.nih.gov/30950882/">mathematical models estimate</a> that by providing PrEP to pregnant and breastfeeding women in South Africa, we could reduce maternal and infant HIV incidence by upwards of 136,000 in the optimistic scenario. This is similar to estimates of PrEP provision among female sex workers and men who have sex with men. </p>
<h2>Preventing new infections</h2>
<p>There are approximately 1 million live births in South Africa annually. Around 70% – representing 700,000 live births – involve women not living with HIV. Many of these women are at very high risk of HIV acquisition and infant HIV transmission due to a combination of biological and behavioural factors. These include having partners living with HIV, multiple partners and frequent condomless sex.</p>
<p>These women have the right to access PrEP to protect themselves against HIV during this high risk period. Currently, in South Africa, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0125525">around</a> one in three infant infections arise from mothers who acquire HIV during pregnancy or breastfeeding.</p>
<p>South Africa will continue to struggle to reach the elimination goals unless the government ensures that women at risk of HIV exposure can access an effective biomedical prevention option during their pregnancy and breastfeeding journey.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=295&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=295&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=295&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=371&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=371&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431479/original/file-20211111-21-gbxcsg.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=371&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Expected reductions in HIV incidence due to PrEP, 2020-2030, under different enhanced PrEP delivery scenarios.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Ongoing studies show a high receptiveness to PrEP among South Africans. This suggests that PrEP can be integrated into antenatal and postnatal care. A <a href="https://www.medrxiv.org/content/10.1101/2021.05.04.21256514v1">recent study</a> we did in Cape Town demonstrated that over 85% of women without HIV accepted PrEP at first antenatal care visit, and over 70% continued on PrEP at month one, and 60% at month three. </p>
<p>Those who were at higher risk of HIV acquisition were more likely to continue on and adhere to daily PrEP. The identifiers of higher risk are a sexually transmitted infection, a partner living with HIV, or having more than one sex partner. The Cape Town study also demonstrated the safety of providing PrEP in this population, in line with other studies in the region.</p>
<p>Antenatal care uptake in South Africa is high, reaching <a href="http://www.statssa.gov.za/publications/Report-03-06-03/Report-03-06-032020.pdf">over 95%</a>. This presents a perfect opportunity to offer PrEP to women seeking routine services. Expanding PrEP implementation to include pregnant and breastfeeding women will further support South Africa’s efforts to reach its ambitious goals of eliminating infant HIV.</p>
<h2>Expanding existing programmes</h2>
<p>Oral PrEP is <a href="https://pubmed.ncbi.nlm.nih.gov/31912985/">scaling up</a> among pregnant and breastfeeding women in <a href="https://pubmed.ncbi.nlm.nih.gov/32763221/">sub-Saharan Africa</a> with notable implementation successes in <a href="https://www.sciencedirect.com/science/article/abs/pii/S2352301819303352">Kenya</a> and <a href="https://sajhivmed.org.za/index.php/hivmed/article/view/1152">ongoing</a> demonstration projects in <a href="https://www.medrxiv.org/content/10.1101/2021.05.04.21256514v1">South Africa</a>, Lesotho, <a href="https://pubmed.ncbi.nlm.nih.gov/31584987/">Malawi, Zambia</a> and Zimbabwe. </p>
<p>The South African government should support the immediate training of healthcare providers and integration of PrEP into antenatal and postnatal care for all women at risk of HIV. All pregnant women who test HIV-negative at their first antenatal visit should receive the offer to start PrEP. This must be accompanied by comprehensive HIV prevention services, including counselling to support them to take daily PrEP while pregnant and breastfeeding. </p>
<p>Maternal HIV programmes that include primary prevention of HIV through the use of PrEP to pregnant and breastfeeding women at high risk of HIV are key to realising the goal of the elimination of HIV in infants.</p><img src="https://counter.theconversation.com/content/171409/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dvora Joseph Davey receives funding from the National Institute of Health (US).
</span></em></p><p class="fine-print"><em><span>Linda-Gail Bekker is director of a research organisation which receives funding from NIH (US), EDCTP and a number of other funding organisations. She also has received honoraria from Gilead, ViiV and MSD for advisory work. </span></em></p>It is urgent and overdue to implement PrEP in pregnancy and during breastfeeding. Failure to do so allows ongoing avoidable HIV infection among women in South Africa and their infants.Dvora Joseph Davey, Honorary Senior Lecturer in the Department of Biostatistics and Epidemiology, University of Cape TownLinda-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/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>
<figcaption>
<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>
<figcaption>
<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/1652672021-08-03T15:20:27Z2021-08-03T15:20:27ZFive ways Uganda’s health teams provided HIV care in lockdown<figure><img src="https://images.theconversation.com/files/414149/original/file-20210802-25-gnsgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">COVID-19 lockdowns have increased the need for ARV delivery in communities. </span> <span class="attribution"><span class="source">Jean-Marc Giboux/Getty Images</span></span></figcaption></figure><p>Uganda is currently in <a href="https://www.voanews.com/covid-19-pandemic/uganda-lifts-some-covid-19-restrictions">a partial</a> country-wide lockdown. The “second wave” of coronavirus infections has been especially <a href="https://www.bloomberg.com/news/articles/2021-06-07/uganda-imposes-second-lockdown-as-covid-19-cases-surge">unforgiving</a>. There is no household in Uganda I know of that has not been touched by the COVID-19 pandemic. Social media posts are awash with reports of death. Hundreds of lives cut short in their prime. It is no longer a story about the elderly. The frequency of death announcements in the national newspapers is truly unprecedented. </p>
<p>Earlier this year, the world watched as funeral pyres burned across India. At the time, the ravages of the virus appeared a little distant. But with daily flights from New Delhi, Uganda was to have its own cases of the dreaded Delta variant, which was soon confirmed by the <a href="https://www.uvri.go.ug/news/kampala-registers-indian-covid-19-varriant">Uganda Virus Research Institute</a>. Observers have also blamed Uganda’s recent presidential and parliamentary elections for the rise in infections, which had been initially admirably <a href="https://www.afro.who.int/news/who-supports-uganda-mitigate-risks-covid-19-transmission-during-election-period">controlled</a>.</p>
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Read more:
<a href="https://theconversation.com/what-uganda-has-got-wrong-and-right-in-its-struggle-to-contain-covid-19-163826">What Uganda has got wrong – and right – in its struggle to contain COVID-19</a>
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<p>Uganda announced its first total lockdown on <a href="https://www.sciencedirect.com/science/article/abs/pii/S0305750X20304459">20 March 2020</a>. Public and private transport was banned. Individual movement was restricted. People needed a special pass to travel about. The second 42-day lockdown was announced in mid-June 2021. This has now <a href="https://www.voanews.com/covid-19-pandemic/uganda-lifts-some-covid-19-restrictions">been eased</a>. It appears that lockdowns will continue to be a reality of life in Uganda, which has <a href="https://www.theguardian.com/global-development/2021/jun/15/vaccines-and-oxygen-run-out-as-third-wave-of-covid-hits-uganda">vaccinated</a> less than 1% of its population.</p>
<p>Much like March last year, people living with HIV are stuck in their homes and unable to visit their preferred health facilities to get their medication refills. Due to widespread HIV-related stigma, patients frequently seek HIV care at facilities <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4751409/">several kilometres away</a> from where they live. There are currently <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06607-w">1.2 million</a> Ugandans enrolled on antiretroviral therapy (ART) – they are especially affected by the lockdown.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/31343455/">Studies</a> suggest that people need to adhere strictly to antiretroviral therapy to suppress the virus. Interruptions in access to HIV medication can lead to treatment failure or drug resistance.</p>
<p>My colleagues and I conducted a <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06607-w">study</a> soon after the first lockdown in Uganda last year in eight districts from Eastern and Western Uganda. We found that HIV care providers used alternative ways to reach patients stuck in their homes by delivering HIV medications to their doorsteps. The identified innovations include decentralisation of ART distribution to community platforms, and six-monthly refills. These will be applicable beyond COVID-19. </p>
<h2>Five strategies for distributing ARVs</h2>
<p>Our <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06607-w">study shows</a> that districts and providers devised five key strategies to overcome lockdown restrictions in distributing antiretrovirals.</p>
<p><strong>Home-based deliveries</strong></p>
<p>Health facilities, supported by district health officers and organisations that implement <a href="https://www.hiv.gov/federal-response/pepfar-global-aids/pepfar">PEPFAR (US President’s Emergency Plan for AIDS Relief) programmes</a>, committed vehicle fleets to deliver medication refills door-to-door. These “mobile brigades” were frequently staffed by “expert patients” or HIV patients who serve as informal staff at the facilities they attend. They had the onerous task of locating homesteads deep in rural communities in Uganda.</p>
<p><strong>Extending ART refill periods</strong></p>
<p>Prior to the lockdown, the Uganda Ministry of Health was recommending that stable patients could be given three months’ supply of their medication at a time. During last year’s lockdown, dispensing was extended from three to six months for facilities with sufficient stock. The Ministry of Health also directed facilities to extend refills to “visitors” and not only to their registered patients.</p>
<p><strong>Community-based ART distribution</strong></p>
<p>Starting in <a href="https://aidsrestherapy.biomedcentral.com/articles/10.1186/s12981-015-0077-4">2017</a>, Uganda permitted outreach sites where people with HIV could collect their medication. These are known as community drug distribution points. The collection points are designated venues such as the community hall or even the private pharmacy nearest your home where patients pick up their HIV medication. The <a href="https://tasouganda.org/">AIDS Support Organisation</a>, an HIV care provider group in Uganda, reported that it routed most of its refills through community distribution points. </p>
<p><strong>Geospatial technologies</strong></p>
<p>Locating patients’ homes in the predominantly rural settings of Uganda can be daunting. There is limited coverage of modern physical addresses, and many settlements are informal. These obstacles stood in the way of “mobile brigades” distributing ART refills in remote outposts. Tertiary hospitals reported relying on geospatial technologies to pinpoint geographic locations that could be linked with their roving “mobile brigades”. Facilities used the available information about their patients such as phone numbers or physical addresses to locate geographical points where patients reside. Due to fears of involuntary disclosure of HIV status, some patients in Uganda provide false phone numbers to <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06607-w">care providers</a>. This complicated ART refill distribution. The use of geospatial technologies helped overcome this barrier. </p>
<p><strong>COVID-19 funding</strong></p>
<p>District health officers reported that they took advantage of the <a href="https://thinkwell.global/wp-content/uploads/2020/09/Uganda-COVID-19-Case-Study-_18-Sept-20201.pdf">funding</a> they received from the Uganda government as part of the COVID-19 response to distribute ART refills during their community outreaches. It was reported that the vehicle fleet and fuel used during COVID-19 outreaches deep in rural communities also offered them an opportunity to distribute ART refills for patients living along those routes. </p>
<h2>Beyond COVID-19</h2>
<p>One of the positives of the lockdown was the <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/jia2.25704">unprecedented demand</a> for community based ART delivery.</p>
<p>Before the pandemic, community-based ART models had registered relatively low uptake, mostly due to <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254214">HIV-related stigma</a>. These innovations in community ART distribution will continue to be important even beyond the COVID-19 pandemic, which may linger on in sub-Saharan Africa longer than in other parts of the world, due to delays in rolling out vaccines.</p><img src="https://counter.theconversation.com/content/165267/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Zakumumpa is supported by the Consortium for Advanced Research Training in Africa (CARTA) under the auspices of a post-doctoral research grant with funds provided by the Carnegie Corporation of New York. </span></em></p>There are currently 1.2 million Ugandans enrolled on antiretroviral therapy (ART). They are especially affected by the lockdown.Henry Zakumumpa, Health Systems Researcher, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1630292021-06-27T08:44:23Z2021-06-27T08:44:23ZStudy shows a huge burden of undiagnosed disease in a rural South African district<figure><img src="https://images.theconversation.com/files/407238/original/file-20210618-14443-83lsoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Healthcare worker, Boitsholo Mfolo, inside the digital x-ray truck at one of Africa Health Research Institute’s mobile screening camps in rural KwaZulu Natal, South Africa. </span> <span class="attribution"><span class="source">Samora Chapman/ Africa Health Research Institute</span></span></figcaption></figure><p>South Africa’s <a href="https://www.avert.org/news/hiv-testing-south-africa-rises-45-12-years">massive effort</a> over the years to test and treat people for HIV has drastically improved public health. But in that process, other diseases that are highly prevalent may have been neglected.</p>
<p>The country has been reporting lower rates HIV-related deaths. But more South Africans are presenting with noncommunicable diseases such as diabetes and hypertension. And tuberculosis (TB) remains the <a href="http://www.statssa.gov.za/?p=14435">leading cause of death</a> in people living with HIV.</p>
<p>We recently <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00176-5/fulltext">published the findings</a> of research we did in a rural area of northern KwaZulu-Natal, South Africa. It aimed to get a clearer picture of the state of health and disease in the area and to identify the prevalence and overlap of infectious and noncommunicable diseases.</p>
<p>The ultimate goal is to design better interventions to improve people’s health.</p>
<p>We set up mobile health camps and screened for diabetes, high blood pressure, HIV, TB, nutritional status (obesity and malnutrition), and use of tobacco and alcohol. </p>
<p>The detailed data allowed us to develop a profile of which diseases were being well managed, and which neglected, in the community. For example, we found that HIV was well treated relative to all other diseases. But TB, elevated blood glucose, and elevated blood pressure were poorly diagnosed and treated. </p>
<p>The study also allowed us to identify overlaps between disease patterns and their geographical location. For example, it was very interesting to see that the areas with the highest prevalence of TB and noncommunicable diseases were mostly in the remote parts of the district and did not overlap with those with the highest rates of HIV. </p>
<p>Our findings raise important questions about how healthcare and screening can most effectively be offered in rural and remote areas. One of our conclusions was that South Africa needs a public health response that expands the successes of the country’s HIV testing and treatment programme to provide multi-disease care targeted to specific populations.</p>
<h2>Key findings</h2>
<p>Our study drew on data collected over 18 months from 2018 to 2019 in uMkhanyakude district, a remote rural area in the east of the country. We screened 17,118 people aged 15 years and older by taking mobile camps into the community and providing screening within 1 km of each participant’s home. </p>
<p>The study provides an in-depth snapshot of the health of a rural population in South Africa.</p>
<p>It shows that:</p>
<ul>
<li><p>there are high and overlapping burdens of HIV, TB, diabetes and hypertension among men and women,</p></li>
<li><p>four out of five women over the age of 30 are living with a chronic health condition,</p></li>
<li><p>HIV-negative people and older people, particularly those over 50, bear a high burden of undiagnosed or poorly controlled noncommunicable diseases such as diabetes and hypertension.</p></li>
</ul>
<p>We found the highest burden of HIV in the vicinity of the main roads. This is similar to other <a href="https://academic.oup.com/ije/article/47/2/537/4781374">studies</a> and has been observed throughout the <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2011/july/20110711transporthiv">region</a> and world. </p>
<p>Just over half of all people 15 years or older (52%) were found to have at least one active disease, while 12% had two or more diseases. Over a third (34%) of people were living with HIV. This number was particularly high among 25 to 44-year-old women. The prevalence of HIV among them was 62%. </p>
<p>We attempted to measure the level of virus in every HIV-positive participant’s blood and found that 78% had no detectable virus, meaning that their antiretroviral therapy was working very well. </p>
<p>But the study also revealed that there are some demographic groups, including men in their 20s and 30s, who still have high rates of undiagnosed and untreated HIV and therefore have virus circulating in their blood. This means that they can pass HIV on to others. Our study highlights the importance of preventing new HIV infections, especially among young people.</p>
<p>In contrast to HIV, we found that most people with TB, diabetes or hypertension had disease which was previously undiagnosed or not well controlled. We found that 1.4% of the population had active TB, which is a <a href="https://www.who.int/news/item/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-associated-tb-and-drug-resistant-tb">very high rate</a> in national and global context. Of these only 30% were already diagnosed and on medication for TB. This meant that approximately 1 in 100 people in this community had undiagnosed TB. </p>
<p>Despite being a curable disease, TB remains one of the <a href="https://www.knowledgehub.org.za/elibrary/first-national-tb-prevalence-survey-south-africa-2018">leading causes of death</a> in South Africa. We found higher rates of TB in men with just under half of all men over age 45 having had TB in his lifetime. The high rates of undiagnosed TB and the finding that men in particular are affected by TB are echoed in South Africa’s recent national TB prevalence <a href="https://theconversation.com/first-ever-national-survey-shows-the-extent-of-south-africas-tb-problem-155153">survey</a> and are a huge cause for concern.</p>
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Read more:
<a href="https://theconversation.com/first-ever-national-survey-shows-the-extent-of-south-africas-tb-problem-155153">First ever national survey shows the extent of South Africa's TB problem</a>
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<p>We found that 8.5% of the population had high blood sugar (diabetes) and 23% had high blood pressure (hypertension). These conditions were mostly found in people older than 45 and were not well diagnosed or controlled. </p>
<p>Only 43% of people with high blood pressure and only 7% with high blood sugar had these conditions well controlled with medications. Women in particular bore a particularly high burden of disease with over 4 of 5 (80%) of those over 30 years old having at least one of these conditions.</p>
<p>When we asked participants about their experience in the study, they told us that they appreciated not having to travel long distances to receive <a href="https://pubmed.ncbi.nlm.nih.gov/33165556/">screening</a>.</p>
<h2>Next steps</h2>
<p>The data provide indicators for where the most urgent interventions are needed. It sets the stage for researchers to examine the biological, social and environmental determinants of disease in the area. It also provides detailed information to guide the Department of Health in development of decentralised models of rural healthcare that integrate management of HIV, TB and noncommunicable diseases.</p>
<p>This work has highlighted the immense burden of undiagnosed or untreated diabetes and hypertension in rural South Africa. As the country faces another surge of COVID-19, it is more important than ever to identify and treat people living with these diseases.</p><img src="https://counter.theconversation.com/content/163029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily B. Wong works for the Africa Health Research Institute and the University of Alabama at Birmingham. She and members of her research group receive funding from the National Institutes of Health, Bill and Melinda Gates Foundation, the African Academy of Sciences and the South African Medical Research Council.</span></em></p>South Africa needs a public health response that expands the successes of the country’s HIV testing and treatment programme to provide care for multiple diseases.Emily B. Wong, Assistant Professor, Africa Health Research Institute (AHRI)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1623512021-06-10T14:42:32Z2021-06-10T14:42:32ZEnding HIV in children is way off target: where to focus action now<figure><img src="https://images.theconversation.com/files/405297/original/file-20210609-6396-1lqv49h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Missing targets to end HIV in children represents nothing less than a global failure.</span> <span class="attribution"><span class="source">Sunil Pradhan/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>World leaders have recently, under the auspices of the United Nations, <a href="https://www.unaids.org/sites/default/files/media_asset/2021_political-declaration-on-hiv-and-aids_en.pdf">renewed</a> their commitment to ending AIDS. The new phase offers much needed hope for the future, provided the commitments made are fulfilled. </p>
<p>The adopted political declaration and its recommendations offer strategies for ending mother-to-child transmission of HIV and paediatric AIDS. They also address inequalities faced by adolescents living with HIV. The commitments include an interim target of suppressing the viral loads of 75% of all children living with HIV by 2023. Greater emphasis on innovative tools and strategies to locate and diagnose children of all ages living with HIV are very welcome. These include early infant diagnosis at the point of care, family testing and self-testing to find older children and adolescents who are not on treatment. </p>
<p>Looking back, children have been one of the most neglected groups affected by HIV. The paediatric targets for <a href="https://www.unaids.org/en/resources/909090">2020</a> were missed by a significant distance.</p>
<p>For example, the global target for the HIV treatment coverage rate for children by 2020 was 95%. But by 2019 only <a href="https://aids2020.unaids.org/chapter/chapter-2-2020-commitments/">53%</a> of children were on treatment. In 2020, an estimated <a href="https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">150,000 children acquired HIV globally</a>. The target was to reduce infections to 20,000. </p>
<p>Not meeting these targets represents a global failure. To make matters worse, in 2020, the COVID-19 pandemic <a href="https://www.unaids.org/sites/default/files/media_asset/start-free-stay-free-aids-free-2020-progress-report_en.pdf">disrupted</a> HIV services for children and pregnant women. </p>
<p>Failure to achieve these targets for children and adolescents in sub-Saharan Africa, home to <a href="https://www.unaids.org/en/resources/909090">90%</a> of the children living with HIV, means that new infections will continue to increase and HIV related mortality will be a reality for decades to come. </p>
<p>The June 2021 United Nations high level meeting was an opportunity to get the paediatric HIV response on track. The new political declaration is a result of extensive analysis of HIV data and consultation with member states, communities and partners from over 160 countries. In line with the 2021 political declaration, we emphasise that national governments should review their national strategies and commit resources to three key paediatric HIV issues. These are: prevention of mother-to-child transmission; HIV testing and treatment in children; and prevention and treatment of TB and HIV. </p>
<h2>1. Prevention of vertical transmission</h2>
<p>Programmes to prevent mother-to-child transmission of HIV have been scaled up. But this transmission <a href="https://www.sciencedirect.com/science/article/pii/S187603411830176X">is rising</a> in several African countries. Of equal concern, antiretroviral therapy coverage for pregnant women living with HIV is considerably lower in western and central African countries such as Nigeria and Angola (below 50%) than in southern Africa. South Africa and Botswana have coverage of <a href="https://www.avert.org/professionals/hiv-programming/prevention/prevention-mother-child">over 90%</a>. In 2017, an alarming <a href="https://www.avert.org/professionals/hiv-programming/prevention/prevention-mother-child">one in five children</a> born to mothers living with HIV in sub-Saharan Africa became HIV positive during childbirth or breastfeeding.</p>
<p>We advocate for better planning for comprehensive HIV prevention during pregnancy and breastfeeding, access to pre-exposure prophylaxis (PrEP) and other new prevention technologies. As per World Health Organisation <a href="https://www.who.int/publications/i/item/978-92-4-155058-1">guidelines</a>, pregnant women must be tested for HIV multiple times during pregnancy. And women who test positive for HIV should immediately be placed on antiretroviral therapy. </p>
<p>The efficacy of prevention of mother-to-child transmission practices needs to be reviewed and monitored closely in many African countries. Increasing access to viral load testing for pregnant and breastfeeding mothers living with HIV will also ensure the health of the mother and help to reduce vertical transmission.</p>
<h2>2. Paediatric HIV testing and treatment</h2>
<p>In 2020, <a href="https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">74,000 children were newly infected with HIV</a> in eastern and southern Africa. And 46,000 deaths among children younger than 15 in the region were due to AIDS. The <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview">treatment coverage rate</a> for children in eastern and southern Africa is 57% compared with 78% for adults. It is critical to ensure that all newborn babies exposed to HIV are tested between four and six weeks of age. Those living with HIV must start HIV treatment, because without treatment 50% will die before they reach two years of age.</p>
<p>This step is just the first of many in a process to ensure the health of HIV-exposed children as they grow older. We advocate for more resources to achieve the following:</p>
<ul>
<li><p>95% of HIV-exposed children tested by two months of age and again after cessation of breastfeeding;</p></li>
<li><p>95% of infants tested for HIV receive their test results no later than 15 days after blood sample collection;</p></li>
<li><p>95% of infants diagnosed with HIV infection initiate antiretroviral therapy no later than 15 days after receiving their test results;</p></li>
<li><p>85% of all children living with HIV on antiretroviral therapy must have suppressed viral load by 2023 and 95% by 2025;</p></li>
<li><p>scale up point-of-care early infant diagnostic testing, starting with areas that are hard to reach;</p></li>
<li><p>scale up efforts to actively track mother-baby pairs using a digital register of positive results;</p></li>
<li><p>greater use of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047763/#:%7E:text=Family%20testing%20is%20a%20type,can%20be%20adults%20or%20children.">family-based index testing</a> and use of HIV oral tests for children aged 2-11.</p></li>
</ul>
<h2>3. Childhood TB and HIV</h2>
<p>Tuberculosis (TB) is a major contributor to illness and death in children living with HIV, particularly in TB endemic settings. Children under 15 account for around <a href="https://apps.who.int/iris/bitstream/handle/10665/336069/9789240013131-eng.pdf">12%</a> of the 10 million TB cases globally. </p>
<p>TB preventive therapy is a proven and effective intervention, particularly in young children. But only <a href="https://theunion.org/our-work/tuberculosis/child-adolescent-tuberculosis">27% of the 1.3 million</a> eligible children under five received preventive therapy in 2018. For children (and adolescents) living with HIV, TB is the most common opportunistic infection. Those with severe immune suppression have a <a href="https://pubmed.ncbi.nlm.nih.gov/24564453/">five-fold higher risk of TB</a> compared to those with mild immune suppression. </p>
<p>National governments should therefore strengthen TB services for children with HIV so that 90% of them receive treatment for both conditions. TB and HIV health services need to be integrated. Family approaches to TB preventive treatment must be scaled up to include HIV-negative households. Access to short-course TB preventive therapy regimens must be expanded. <a href="https://www.paediatrichivactionplan.org/2020-tb-diagnostics">Innovative approaches</a> for TB diagnosis among children must be considered, including the use of <a href="https://academic.oup.com/jid/article/220/Supplement_3/S108/5583861">non-sputum biomarker-based</a> samples such as stools and urine.</p>
<h2>Getting back on track</h2>
<p>In view of the threat to paediatric HIV services posed by further waves of COVID-19, we highlight the need to eliminate vertical transmission and prioritise paediatric testing and treatment services to achieve the new commitments. </p>
<p>The commitment can be delivered through strong community-led responses in partnership with governments; maintaining and increasing domestic and donor funding for HIV and AIDS, particularly for low-income countries with limited fiscal ability and weak health systems; and ring-fencing resources for paediatric HIV and TB services.</p>
<p><em>Dr Stuart Kean, Co-Chair Advocacy Technical Working Group at the Eastern and Southern Africa Regional Inter-Agency Task Team on Children Affected by AIDS; Dephin Mpofu, Chair at the Eastern and Southern Africa Regional Inter-Agency Task Team on Children Affected by AIDS and Regional HIV and Gender Inclusion Lead, Southern Africa Region, World Vision International; and Anock Kapira, Programme Manager at Eastern and Southern Africa Regional Inter-Agency Task Team on Children Affected by AIDS, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/162351/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaymarlin Govender receives funding from the National Research Foundation and Sida</span></em></p><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>Not achieving the targets for children and adolescents in sub-Saharan Africa means that new infections will continue to increase and HIV related mortality will be a reality for decades to come.Kaymarlin Govender, Research Director at The Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-NatalLinda-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/1606152021-05-13T09:37:13Z2021-05-13T09:37:13ZPeople with HIV are still dying from a treatable, but neglected, disease: all it needs is a plan<figure><img src="https://images.theconversation.com/files/400238/original/file-20210512-24-1qps1l5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Political is necessary to lower deaths from cryptococcal meningitis.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Thembi Ngubane was a young woman who became famous through the American National Public Radio show <a href="https://www.comminit.com/hiv-aids-africa/content/thembi%E2%80%99s-aids-diary-year-life-south-african-teenager"><em>Thembi’s AIDS Diary: A Year in the Life of a South African Teenager.</em></a>. She was vibrant, punchy, full of life. She recorded the consultation when, as a doctor, I started her on antiretroviral therapy in 2005. Jo Menell’s documentary film, <a href="https://www.amazon.com/Thembi-Jo-Menell/dp/B07D5X77MN"><em>Thembi</em></a>, gives a sensitive and nuanced account of her fast rise to fame, culminating in meeting Barack Obama and addressing the US Congress, and then equally rapid fall into oblivion, loss from care, and death.</p>
<p>The disease that killed her was cryptococcal meningitis. It is a killer in the dark, responsible for an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818156/">estimated</a> 181,000 worldwide in 2014, of which 135,900 were in sub-Saharan Africa. Most were people who had been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818156/">living with HIV</a>. The cryptococcus fungus is everywhere in the environment and for people with a working immune system it causes no harm. But in people with HIV who have a weak immune system it can invade the lining of the brain and other organs, quickly leading to death unless treated.</p>
<p>Most people who <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818156/">die from cryptococcal meningitis</a> are under the age of 40. Yet, with early diagnosis and the best available treatment, mortality can be reduced to <a href="https://pubmed.ncbi.nlm.nih.gov/29539274/">30%</a> of what it is currently.</p>
<p>Why, then, do people still die? It is not because the lifesaving tools and treatments are unaffordable. The CrAg-LFA, a rapid finger-prick test to detect antibodies to cryptococcus in blood and spinal fluid, costs only US$2. The drug flucytosine, which if widely available would reduce deaths from cryptococcal meningitis by as much as <a href="https://pubmed.ncbi.nlm.nih.gov/29539274/">40%</a>, costs only US$100. The other key drug needed for treatment, amphotericin B, is affordable for health department budgets in its convential formulation, while the less toxic liposomal form of amphotericin B remains too expensive for most. </p>
<p>Saving lives does not require high tech tools, but simple point-of-care tests. The key medicines are decades old, generally simple to produce, and off-patent. The biggest part of the treatment cost is that of basic hospitalisation and medical staff. The real problem lies higher up, with a lack of political will to address this leading cause of HIV-related mortality. </p>
<p>In May 2021, a group of health organisations based in Africa, Europe and the US released the <a href="https://www.gaffi.org/special-webinar-announcement-ending-cryptococcal-meningitis-deaths-by-2030-a-new-global-initiative/">Strategic Framework for Ending Cryptococcal Meningitis Deaths by 2030</a>. It calls on the World Health Organisation, donors, governments, civil society organisations and industry to set clear targets, draw up plans and work together to drastically reduce deaths from cryptococcal meningitis.</p>
<h2>Preventable deaths</h2>
<p>Tens of thousands of people die unnecessarily because cryptococcal meningitis has been neglected. </p>
<p>There is a <a href="https://www.who.int/tb/strategy/end-tb/en/">global strategy</a> to end deaths from tuberculosis, but no strategy to end cryptococcal meningitis. A strategy is crucial for priority setting, resource allocation and planning. It focuses attention on the steps needed to end cryptococcal meningitis deaths and who should be responsible for addressing those steps.</p>
<p>Access to tests and optimal treatment remains extremely limited in clinics in sub-Saharan Africa. Flucytosine, the cornerstone medicine for treatment, isn’t registered in any country in Africa. Pharmaceutical companies rarely apply for registration if the market is not deemed to be profitable. Governments do not include unregistered drugs in national guidelines. In the case of flucytosine this catch-22 situation led to <a href="https://pubmed.ncbi.nlm.nih.gov/32126322/">market failure</a>.</p>
<p>There is reason to hope, however. </p>
<p>A few years ago the South African National Institute for Communicable Diseases, with support from the US Centers for Disease Control, scaled up systematic screening for cryptococcal meningitis of people with HIV with severe immune suppression. This helped to diagnose more people but without flucytosine the treatment was still suboptimal. A number of public sector doctors started treating patients with flucytosine after obtaining exemptions from the South African regulator to use an unregistered drug. </p>
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Read more:
<a href="https://theconversation.com/explainer-how-south-africa-regulates-medicines-and-vaccines-154843">Explainer: how South Africa regulates medicines and vaccines</a>
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<p>This inspired Doctors Without Borders to start a clinical access programme to donate flucytosine to one hospital in every province of South Africa. Early <a href="https://pubmed.ncbi.nlm.nih.gov/32126322/">results</a> already show much lower mortality in patients treated with flucytosine. The clinical access programme was taken over by the Clinton Health Access Initiative and expanded to provide supplies for advanced HIV disease to nine countries. </p>
<p>Spurred by the prospect of increasing demand, a large Indian manufacturer of generic medicines took over the production of flucytosine and applied for registration in a number of African countries, including South Africa. An increasing number of <a href="https://sahivsoc.org/Files/crypto%20guidelines.pdf">national guidelines</a> now include the treatment recommended by the World Health Organisation.</p>
<p>Yet, despite this progress, most people with cryptococcal meningitis remain without a diagnosis and without optimal treatment. This is why a global strategy is needed. The strategy must have clear targets and a roadmap to scale up access to tests and medicines. Transforming cryptococcal disease from a silent killer into a disease that is mostly cured is achievable at a modest cost.</p>
<h2>Call for action</h2>
<p>The last time I saw Thembi was in consultation days before she died in 2009. She was a shadow of the person I had started on antiretroviral treatment a couple of years earlier. </p>
<p>After interrupting treatment, she had gradually lost weight and was increasingly confused. My heart sank when I read the referral letter: cryptococcal meningitis. With late diagnosis and optimal treatment out of reach, I knew the prognosis was poor.</p>
<p>The call for attention to cryptococcal meningitis is a plea to bring this neglected cause of death out of the darkness. This can be done by ensuring that testing and treatment becomes available everywhere.</p>
<p><em>Dr Amir Shroufi, Medical Advisor at the CDC Foundation contributed to the article.</em></p><img src="https://counter.theconversation.com/content/160615/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gilles van Cutsem is affiliated with Doctors Without Borders, a member of the Cryptococcal Meningitis Advocacy Group, and Chair of the Patient Advisory Committee of the slow release flucytosine research project. </span></em></p>Cryptococcal ceningitis is one of the main causes of death of people with HIV. The tests and medicines to diagnose and treat it exist but remain inaccessible to most. A global strategy is needed.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/1555852021-03-01T14:24:17Z2021-03-01T14:24:17ZSmall things can save lives: coping with COVID-19 in resource-scarce hospitals<figure><img src="https://images.theconversation.com/files/386697/original/file-20210226-17-k1t0rz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">“We saw patients dying for avoidable reasons. They were dying because masks that came loose were not being replaced,” says MSF COVID-19 intervention nursing activities manager, Caroline Masunda.</span> <span class="attribution"><span class="source">Chris Allan</span></span></figcaption></figure><p>Everywhere, patients have died from COVID-19 when patient numbers exceeded the capacity of the health system. The number of doctors, nurses and oxygen points just wasn’t enough. </p>
<p>People died from a lack of oxygen because no one noticed that their oxygen mask wasn’t well positioned or that their oxygen saturation was dropping. They died of dehydration or kidney failure because they didn’t receive enough water. They died because there weren’t enough staff, or because new staff added in an emergency were inexperienced and poorly organised. </p>
<p>There are a number of things every hospital can do to prevent unnecessary deaths when the system is overloaded.</p>
<p>COVID-19 has exacerbated the global shortage of health workers, already estimated to be <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-019-0352-x#ref-CR10">over seven million before the pandemic</a>. Where there are not enough doctors and nurses to deliver medical care, one solution is to move certain tasks to less specialised health workers, <a href="https://www.who.int/workforcealliance/knowledge/resources/taskshifting_guidelines/en/">a process called task-shifting</a>. </p>
<p>There is extensive public health <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5390445/">experience</a> with task-shifting and substantial <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-8-8">evidence</a> that this can reduce costs and improve efficiency in the areas of HIV, tuberculosis (TB) and other diseases. </p>
<p>In January 2021, during the peak of the second wave of COVID-19 in South Africa, I coordinated a support intervention of Doctors Without Borders in a large hospital in the country’s KwaZulu-Natal province. Hospital staff were so overwhelmed that many patients died because of lack of the basics: oxygen, water and basic patient monitoring and support. Colleagues supporting interventions in other resource-limited settings reported similar experiences.</p>
<p>When there is a shortage of nurses, such as in the COVID-19 pandemic, task-shifting of basic care to less specialised cadres such as caregivers, nursing auxiliaries or community health workers can prevent unnecessary deaths. Hiring lower level workers and staff to manage them can be life-saving.</p>
<h2>Precedents</h2>
<p>Distribution of antiretroviral therapy has been successfully shifted <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60894-X.pdf">from doctors to nurses</a>, to <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0056088">lay counsellors or peer educators</a>, and even <a href="https://pubmed.ncbi.nlm.nih.gov/24889337/">to patients in the community</a>. </p>
<p>In Mozambique, task-shifting of tuberculosis logistic management services to hospital auxiliary workers <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7126367/">reduced delays</a> to tuberculosis treatment initiation and hospital mortality. In another study, triage <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6933270/">by lay staff</a> reduced child deaths in the emergency department of a rural hospital. </p>
<p>And there are examples of family members partially taking over some basic tasks in resource-limited hospitals. Research in Kenya has shown that to cope with difficult work conditions <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-019-0352-x#ref-CR18">nurses delegate tasks to family and support staff</a>. But family members aren’t allowed into COVID-19 wards and these tasks have fallen back to nurses. </p>
<p>Task-shifting can and should be used in COVID-19 wards.</p>
<p>Nursing assistants or caregivers can provide basic care and patient support. Volunteers or lay staff can be hired to function as runners and porters, and communicate with families. This leaves time for nurses to focus on more medical tasks. </p>
<p>In KwaZulu-Natal and in Lesotho, Doctors Without Borders hired enrolled nurses to monitor oxygen saturation, and lay caregivers or ward attendants to ensure oxygen masks and nasal prongs were in place, and help with proning, hydration, bedpans, feeding and mobilisation of patients. In addition, doctor and nurse activity managers ensured management, coordination and training. This led to rapid improvements in patient care.</p>
<h2>What needs to be done</h2>
<p>Where resources are limited, basic care and oxygen delivery save more lives than intensive care. Yet the basics are often neglected. To prepare for future waves of COVID-19, hospitals need to plan for sufficient oxygen delivery, be prepared to hire sufficient basic health staff, and organise task-shifting of basic care and support.</p>
<p>Emergency responses require a great deal of coordination. Attention is needed to ensure adequate managerial staff are added to coordinate teams of sometimes inexperienced or new staff to work coherently. For example, in Ngwelezana hospital in South Africa, addition of a nursing activity manager was essential to improve organisation and quality of care in the ward. </p>
<p>Special attention should also be given to the night shift. Most patients die at night. Ensuring increased attention to and sufficient staff for patient monitoring and support at night can save lives. </p>
<p>Then there’s the provision of basic materials such as water bottles, cups, straws, pillows for proning (which can increase oxygen saturation by up to 10%) and bedpans. Availability of these items in sufficient quantities can also make the difference between life and death.</p>
<p>Healthcare workers have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595707/">learned many things</a> from the fight against epidemics such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195084/">HIV</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404531/">Ebola</a> in Africa over the past twenty years. When doctors and nurses were overwhelmed, innovative ways of task-shifting allowed them to efficiently provide quality care to high numbers of patients. </p>
<p>Small things can prevent unnecessary deaths during the COVID-19 pandemic, even in the poorest countries with the weakest health systems. Investing in sufficient oxygen capacity and basic care by hiring entry level health staff may save more lives than ventilators and high care.</p><img src="https://counter.theconversation.com/content/155585/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gilles van Cutsem is a Senior HIV/TB Adviser and International HIV/AIDS Working Group Lead with the international medical humanitarian organisation Médecins Sans Frontières / Doctors Without Borders. </span></em></p>Where there are not enough health workers to deliver medical care, one solution is to move certain tasks to less specialised health workers, a process called task-shifting.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/1507532020-11-29T09:16:48Z2020-11-29T09:16:48ZWhy it’s important to keep diagnosing and treating HIV during the COVID-19 pandemic<figure><img src="https://images.theconversation.com/files/371007/original/file-20201124-13-79sos3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People relying on HIV prevention, care and treatment services have become even more vulnerable because of COVID-19.</span> <span class="attribution"><span class="source">Foto24/Gallo Images/Getty Images</span></span></figcaption></figure><p>Since 2013, global efforts have been made to gain control over the AIDS epidemic by 2020 through UNAIDS’ <a href="https://www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_en.pdf">90-90-90</a> targets. The focus has been to have 90% of all people living with HIV know their status; and of those, 90% initiated on antiretroviral therapy (ART); and of those, 90% reaching viral suppression through ART adherence. <a href="https://www.who.int/hiv/mediacentre/news/viral-supression-hiv-transmission/en/">Viral suppression</a> means that virus in their blood is undetectable and they cannot transmit HIV sexually.</p>
<p>Much ground has been made towards achieving these goals. To date, 14 countries have reached the 90-90-90 targets. However, <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/july/20200706_global-aids-report">missed targets</a> in other countries have allowed 3.5 million HIV infections and 820,000 AIDS-related deaths to occur since 2015. </p>
<p>One of the countries missing the mark is South Africa, which carries <a href="https://www.hsrcpress.ac.za/books/south-african-national-hiv-prevalence-incidence-behaviour-and-communication-survey-2017">20%</a> of the global HIV burden. By 2018, encouragingly 90% of all people with HIV in South Africa knew their status. However, only 68% who knew their status were on ART; and of those, 87% were virally supressed. This equated to 61% of all people with HIV in South Africa initiated on sustained ART and 53% of all people with HIV virally suppressed.</p>
<p>Then, by late 2019, COVID-19 emerged and has now swept the globe. This new pandemic has shifted the projected course of public health resources and existing HIV campaigns. The South African National AIDS Council worries that the progress of <a href="https://sanac.org.za/the-national-strategic-plan/">multi-year strategic plans</a> has been upended. This is a shared concern for many countries with a high burden of HIV.</p>
<p>COVID-19 has put a strain on the country’s already stretched health system. The measures taken to curb the spread have made it hard for people to access routine healthcare and medication for chronic noncommunicable disease as well as HIV. Strategies are needed to optimise health-related outcomes for all conditions, while still allowing the healthcare system to combat the novel pandemic.</p>
<h2>COVID-19 and health systems</h2>
<p>Hard national lockdowns around the globe, including <a href="https://mg.co.za/article/2020-03-23-ramaphosa-announces-21-day-lockdown-to-curb-covid-19/">South Africa’s</a>, were essential to slow the transmission of COVID-19 and allow healthcare systems to prepare for the impending wave of critically ill patients. </p>
<p>Unfortunately, these unprecedented country-wide shutdowns have had downstream effects on other aspects of the public healthcare systems. They’ve created a serious threat for countries with a high prevalence of HIV. People relying on HIV prevention, care and treatment services have become even more vulnerable.</p>
<p>People with HIV need ART to survive, because there’s no cure or vaccine. During lockdown, patients were afraid to leave their homes to <a href="https://theconversation.com/covid-19-promotes-innovative-hiv-service-delivery-in-cape-town-142583">collect medications</a>. The trepidation was brought on by the fear of contracting COVID-19, but also the threat of <a href="https://www.iol.co.za/news/politics/49-cases-of-police-brutality-reported-since-start-of-lockdown-says-bheki-cele-50160784">police brutality</a> or <a href="https://www.enca.com/news/summary-cele-briefs-media-covid-19-level-1-regulations">incarceration</a> through reinforcement of quarantine. For patients who did make it to ART dispensaries, many <a href="https://www.iol.co.za/the-star/news/south-africa-facing-arv-shortages-as-covid-19-fight-disrupts-supply-50741964">facilities experienced</a> – and are still experiencing – supply-chain management deficiencies causing medication stock-outs. Additionally, due to the influx of COVID-19 patients, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433230/">other services</a> (such as reproductive health services) may have been unavailable.</p>
<p>The World Health Organisation and UNAIDS <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/may/20200511_PR_HIV_modelling">projected</a> that a complete HIV treatment interruption of six months could lead to an excess of more than 500,000 AIDS-related deaths in sub-Saharan Africa over the next year. This is a major step backwards. In 2018, <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/may/20200511_PR_HIV_modelling">470,000 AIDS-related</a> deaths were reported in the region. </p>
<p>South Africa has one of the highest <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564522/pdf/main.pdf">numbers of HIV cases and people</a> on ART. The country would experience the largest changes in both HIV incidence and mortality due to ART interruptions. Treatment interruptions or delays will further compromise the immune systems of people with HIV. This could mean <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564522/pdf/main.pdf">disease progresses</a> to where the CD4 count is too low to be reconstituted or opportunistic infections become unmanageable. </p>
<p>These projections should scare everyone. As it stands, <a href="https://theconversation.com/how-covid-19-threatens-efforts-to-contain-hiv-aids-in-south-africa-142575">since April 2020</a>, 36 countries containing 45% of the global ART patient population have reported disruptions in ART provision. Twenty-four countries are combating stock-outs of first line treatment regimens. Other <a href="https://theconversation.com/how-covid-19-threatens-efforts-to-contain-hiv-aids-in-south-africa-142575">by-products</a> of a disrupted healthcare system are that 38 countries reported a substantial decrease in uptake of HIV testing. </p>
<p>South Africa is already seeing a nearly <a href="https://theconversation.com/how-covid-19-threatens-efforts-to-contain-hiv-aids-in-south-africa-142575">20% decrease</a> in ART collection in key provinces and a <a href="https://bhekisisa.org/multimedia/2020-06-09-standing-by-when-epidemics-collide-does-hiv-tb-cause-worse-covid-19/">10% decrease</a> in viral load testing of ART patients since the introduction of lockdown in March. Even shorter, sporadic treatment disruptions can yield additional complications. These include an increase in the spread of HIV drug resistance, which carries long-term consequences for <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/may/20200511_PR_HIV_modelling">future treatment success</a>.</p>
<h2>HIV and COVID-19</h2>
<p>Globally, scientists have focused mostly on the <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044">increased risk</a> of COVID-19-related illness and death associated with noncommunicable diseases such as hypertension and diabetes. </p>
<p>Sadly, the role other infectious diseases play in health-related outcomes is largely forgotten. Hits to established HIV programmes make people with HIV even more vulnerable to adverse health events. It is, therefore, also important to understand that this same population is at increased risk of COVID-19-related morbidity and mortality.</p>
<p>There’s an intersect between noncommunicable diseases and infectious disease, with HIV at the centre. The nature of the virus and the treatment required means that people with HIV are at <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044">increased risk</a> of inflammation and metabolic syndrome disease. This puts them at risk of chronic noncommunicable diseases – a <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html">risk-factor</a> for COVID-19. Furthermore, ART has allowed people with HIV to live longer and naturally develop these comorbidities through increased age. People with active tuberculosis (TB) are over <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044">2.5 times</a> more likely to die from COVID-19. In South Africa, the TB/HIV co-infection rate is above <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044">60%</a>.</p>
<p>The first study published on the effect of COVID-19 infection among people with HIV in sub-Saharan Africa was reported from the Western Cape, South Africa. People with HIV have a <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044">2.75 times</a> greater risk of dying from COVID-19 than those without HIV. Viral suppression did not seem to affect health outcomes, with HIV accounting for about <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044">8%</a> of all COVID-related deaths. There is increased cause for concern when considering the high levels of HIV comorbidity with noncommunicable diseases and TB.</p>
<h2>Way forward</h2>
<p>The projected models must be taken seriously and strategies are required to sustain all vital health services. </p>
<p>There is an urgent need for global and local differentiated <a href="https://sajhivmed.org.za/index.php/hivmed/article/view/1118/1942">service delivery</a> to ensure HIV service continuity – most critically uninterrupted ART supply – during the COVID-19 pandemic. These strategies could include a change in where HIV testing is provided and treatment is dispensed. Patients could be given longer treatment refills or bulk packs of treatment. </p>
<p>Community-based services could serve both pandemics. Such a strategy could relieve pressure on public healthcare facilities while protecting the most vulnerable populations who need to stay at home to minimise their risk of exposure.</p>
<p>With restricted global movement comes restricted imports of HIV tests and treatments. Countries must include <a href="https://sajhivmed.org.za/index.php/hivmed/article/view/1118/1942">locally manufactured</a> medications within their national ART regimens. Governments, suppliers and donors need to avoid excess HIV-related deaths by creating an <a href="https://www.thelancet.com/action/showPdf?pii=S2352-3018%2820%2930211-3">uninterrupted supply of ART</a>. </p>
<p>If the world is single-minded and focuses purely on combating one pandemic (COVID-19), forgetting others, the effects of other morbidity and mortality on healthcare systems will be seen for a long time to come.</p><img src="https://counter.theconversation.com/content/150753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathryn L Hopkins is affiliated with the Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. </span></em></p><p class="fine-print"><em><span>Glenda Gray receives NIH funding for HIV vaccine research and is employed by the SAMRC.</span></em></p>If the world is single-minded and focuses purely on combating one pandemic, forgetting others, the effects of other morbidity and mortality on healthcare systems will be seen for a long time to come.Kathryn L Hopkins, Perinatal HIV Research Unit, University of the WitwatersrandGlenda 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/1508502020-11-29T09:15:58Z2020-11-29T09:15:58ZNurses are playing a bigger role than ever in the fight against HIV – they deserve more support<figure><img src="https://images.theconversation.com/files/371268/original/file-20201125-23-dt2u0k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"> 2020 is the international year of the nurse and midwife.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The first cases of HIV were <a href="https://www.cdc.gov/mmwr/pdf/wk/mm5021.pdf">reported in 1981</a>. Since then, nurses all over the world have been at the forefront of the fight against the epidemic. They have stepped up to provide skilled care for those infected and affected by the virus. </p>
<p>The World Health Organisation marked 2020 as the <a href="https://www.who.int/campaigns/year-of-the-nurse-and-the-midwife-2020">year of the nurse and the midwife</a>. As this challenging year comes to a close, it is imperative to reflect on the resilience and impact of nurses in the fight against the HIV epidemic.</p>
<p>An inspirational documentary film <a href="https://5bfilm.com/">5B</a> testifies to the compassionate, committed responses of a nurse-led community in the early days of the HIV epidemic. In the film, nurses and other healthcare providers reflect on their experience and how they transformed care. </p>
<p>The film shows nurses taking extraordinary actions to comfort, protect and care for people living with HIV in the United States. But the resilience of nurses in the fight against HIV is the same across the world. Nurses in high and low-income countries continue to dedicate their lives to caring for those living with the virus.</p>
<p>Nurses <a href="https://www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery">represent 50%</a> of the global healthcare workforce. And they are often the sole healthcare providers in many low and middle-income countries. They are pivotal to efforts to end HIV, by helping people with testing, treatment and prevention. That is why nurses all over the world have moved to the forefront of the global efforts to achieve the <a href="https://www.unaids.org/en/resources/909090">90-90-90: Treatment for All</a> goals. These are the Joint United Nations Programme on HIV and AIDS’ (UNAIDS) goals to help end the AIDS epidemic by 2030. </p>
<h2>Expanding role</h2>
<p>As life-saving medications and prevention interventions have been discovered, nurses have continued to be champions in the fight against HIV and AIDS. The role of the nurse has expanded over the years beyond skilled care at the bedside to include clinical and behavioural research, education and training leadership, programme management, policy making, and patient advocacy and activism.</p>
<p>Nurses are <a href="https://www.sciencedirect.com/science/article/pii/S1055329014000430">initiating and managing</a> antiretroviral therapy (ART) in places where there are no or limited physicians. Key tasks include preparing patients for ART; determining medical eligibility; recommending first and second-line ART regimens; clinical monitoring; and managing side effects.</p>
<p>Nurses have also formed organisations such as the <a href="https://www.nursesinaidscare.org/i4a/pages/index.cfm?pageid=1">Association of Nurses in AIDS Care</a> (based in the US, with a chapter in Nigeria) and the <a href="https://www.nhivna.org/">National HIV Nurses Association</a> in the UK. </p>
<p>These organisations help provide education, professional development, networking, research and leadership support to nursing and allied health professionals working with people living with HIV. They also promote awareness of issues related to HIV through public policy and advocacy. </p>
<p>Since the announcement of the 90-90-90 targets by UNAIDS, the Association of Nurses in AIDS Care has underscored many ways in which nurses can lead. The association has developed several policies, including:</p>
<ul>
<li><p>Ensuring patients’ rights to equitable and accessible health care</p></li>
<li><p>Providing care for underserved and vulnerable populations</p></li>
<li><p>Providing care along the full spectrum of HIV services</p></li>
<li><p>Providing evidence-based and person-centred care</p></li>
<li><p>Committing to inter-professional collaboration</p></li>
</ul>
<p>Despite the COVID-19 pandemic’s serious impact on the most vulnerable communities worldwide and <a href="https://theconversation.com/how-covid-19-threatens-efforts-to-contain-hiv-aids-in-south-africa-142575">threat</a> to the progress of HIV care, nurses remain at the frontline of service. They have demonstrated incredible courage, selflessness and stoicism in this unprecedented year. They are applying the lessons learned during the early days of the HIV and AIDS epidemic in response to the COVID-19 pandemic.</p>
<p>It’s important to recognise all the nurses and midwives who have been lost to the fight against HIV and AIDS and now COVID-19.</p>
<h2>What next</h2>
<p>Nurses’ values and commitment alone are not enough to ensure success in ending HIV and AIDS by 2030. Nurses are often relegated to reduced practice roles and are sidelined. This is why the Association of Nurses in AIDS Care has declared a <a href="https://www.nursesinaidscare.org/i4a/pages/index.cfm?pageid=3300">call to action</a> to demand support for HIV nursing globally, seeking to:</p>
<ul>
<li><p>Advance nurse-led care through policies and legislation that support nurses’ true role in HIV prevention, care, and treatment</p></li>
<li><p>Expand resources, budget allocation, and staffing structures that reflect the central role of nursing to HIV care and achievement of global targets</p></li>
<li><p>Promote the equitable representation of nurses on healthcare and HIV decision-making bodies</p></li>
<li><p>Develop health systems that ensure strong inter-professional collaboration</p></li>
</ul><img src="https://counter.theconversation.com/content/150850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jerry John Nutor 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>Nurses represent 50% of the global healthcare workforce. And they are often the sole healthcare providers in many low and middle-income countries.Jerry John Nutor, Assistant Professor, Family Health Care Nursing, University of California, San FranciscoLicensed 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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<hr>
<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/1467002020-09-29T14:49:59Z2020-09-29T14:49:59ZZambian study points to why some mothers don’t carry on taking HIV drugs<figure><img src="https://images.theconversation.com/files/360255/original/file-20200928-16-78vutp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many factors influence how consistently women take their HIV medicine.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>There are more than <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/zambia">85,000 children</a> living with HIV in Zambia. The primary source of infection is from mother to child during pregnancy, childbirth or breastfeeding. Antiretroviral therapy (ART) is an <a href="https://www.avert.org/professionals/hiv-programming/prevention/prevention-mother-child">effective</a> strategy to eliminate these new infections. But it only works if women take their medications consistently.</p>
<p>Adherence to ART is still a major challenge in sub-Saharan Africa, especially among <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5651-y">pregnant and breastfeeding women</a>. In 2012, the World Health Organisation (WHO) introduced <a href="https://www.who.int/hiv/PMTCT_update.pdf#page=7">new guidelines</a> for the prevention of mother-to-child transmission of HIV. Women with HIV are provided with the antiretrovirals as soon as they become pregnant and have to take treatment for life. </p>
<p>The use of ART among pregnant and breastfeeding women in Zambia increased from 65% in 2012 to <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/zambia">80% in 2018</a> – but adherence has been problematic. </p>
<p>A <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111421">number of factors</a> can influence whether women take their HIV medicine consistently. They may forget or be too busy. They may fear stigma and discrimination in their communities. They might have difficulty paying for the medication or be unable to access healthcare. Adverse side effects of the drugs can also drive people to stop taking them. Sometimes women intend to take the medication, but circumstances like inadequate access to water or food get in the way. Some intentionally don’t take the drugs because of their attitudes and beliefs. </p>
<p>In a <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09505-8">recent study</a> we investigated whether attitudes or behavioural beliefs about ART influenced women’s intentions to adhere to antiretroviral drug regimens. We surveyed pregnant and breastfeeding women in Zambia. We found that the intention to adhere to ART differed significantly by income, knowledge about HIV transmission, attitudes, and behavioural beliefs. Older women with little knowledge about HIV transmission, and a more negative attitude towards ART, had the weakest intention to adhere to their medication. </p>
<p>Whatever the reason, poor adherence carries serious consequences. For the individual, it can mean increased risk of passing HIV to their children. For the community and the world, it can mean drug resistance and transmission of resistant mutations. </p>
<h2>Attitudes and beliefs about antiretrovirals</h2>
<p>It’s common for people living with HIV to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286200/">unintentionally lapse</a> in taking their drugs. But intentional lack of adherence has been on the rise in low-resource countries. </p>
<p>My colleagues and I launched the <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09505-8">first study in Zambia</a> to explore how attitudes and beliefs affect HIV-positive pregnant and breastfeeding women’s intention to take ART consistently. These attitudes and beliefs are influenced by education, religion and socio-cultural norms. People who believe ART improves health are more likely to adhere than those who doubt that HIV exists or the effectiveness of the drugs.</p>
<p>We surveyed women at hospitals and clinics in the urban Lusaka district and the rural Sinazongwe district. We assessed their attitudes by asking them to rate their agreement with statements like: </p>
<blockquote>
<p>Taking ART drugs is easy for me; and </p>
<p>It is tiresome to take ART drugs every day. </p>
</blockquote>
<p>Their beliefs were captured with statements such as: </p>
<blockquote>
<p>I am confident that I will take my ART drugs consistently as prescribed by my healthcare provider; and </p>
<p>I feel comfortable about talking to my healthcare provider about taking my ART drugs.</p>
</blockquote>
<p>We found a significant association between attitude towards ART and women’s intention to take it. Most of the women with a negative attitude towards ART had the weakest intention to adhere to their medication. And most women with a positive attitude had the strongest intention to adhere to their medication regimen. Similarly, those with negative beliefs were less likely to have a strong intention to adhere to their medication regimen. </p>
<p>After accounting for where people lived (rural vs urban) and other factors such as education, income, age and occupation, we found that attitude rather than belief was the key to adherence intention, regardless of where the women lived. </p>
<p>Older rural women with less knowledge about HIV transmission were less likely to plan to adhere to the medication. Positive attitudes about ART were linked with strong intention to adhere.</p>
<h2>What next</h2>
<p>These findings have implications for research, clinical care and policy. Researchers should design and test interventions that specifically target women’s negative attitudes and behavioural beliefs and follow them to see if their intention translates to adherence to ART.</p>
<p>Insights about attitude and beliefs may be useful in improving adherence intention by paying attention to rural communities where resources and knowledge about HIV transmission may be less available.</p>
<p>Health educators can use these findings to advocate for education programmes and materials that reach more vulnerable populations, especially in rural and low-resource areas. Information about HIV and transmission to infants should be presented to women prior to starting ART treatment, including those in rural areas. Women should be given sufficient time to acknowledge the importance of this information for their own health and the health of their entire families.</p>
<p>Interventions that specifically target women’s negative beliefs about ART should effectively increase their adherence to ART. Countries like Zambia, with a high HIV prevalence, urgently need to develop tailored approaches to foster more positive attitudes and beliefs towards ART.</p><img src="https://counter.theconversation.com/content/146700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jerry John Nutor 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 use of antiretroviral therapy among pregnant and breastfeeding women in Zambia has increased but adherence is a problem.Jerry John Nutor, Assistant Professor, Family Health Care Nursing, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.