tag:theconversation.com,2011:/uk/topics/world-aids-day-23075/articlesWorld AIDS Day – The Conversation2023-12-01T13:38:30Ztag:theconversation.com,2011:article/2189182023-12-01T13:38:30Z2023-12-01T13:38:30ZWho is still getting HIV in America? Medication is only half the fight – homing in on disparities can help get care to those who need it most<figure><img src="https://images.theconversation.com/files/562804/original/file-20231130-23-mq7ite.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Access to life-saving HIV prevention medications varies by race and other sociodemographic factors.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/aids-awareness-red-ribbon-royalty-free-image/1445701859">David Talukdar/Moment via Getty Images</a></span></figcaption></figure><p>As the globe marks another <a href="https://www.who.int/campaigns/world-aids-day/world-aids-day-2023">World AIDS Day</a> on Dec. 1, it’s crucial to both acknowledge the significant strides made in the global battle against HIV and recognize the persistent challenges that remain. While the United States had seen a <a href="https://www.cdc.gov/hiv/statistics/overview/ataglance.html">slow decline</a> in the overall number of new HIV infections from 2017 to 2021, a closer look at the data reveals <a href="https://www.cdc.gov/hiv/statistics/overview/in-us/incidence.html">persistent disparities</a> largely borne by LGBTQ people and <a href="https://theconversation.com/use-of-hiv-prevention-treatments-is-very-low-among-southern-black-gay-men-170794">communities of color</a>.</p>
<p>As a <a href="https://scholar.google.com/citations?user=DbZMkzUAAAAJ&hl=en">social epidemiologist</a> who proudly identifies as a gay Latino, I have a vested interest both personally and professionally in understanding and addressing the HIV disparities my communities face. It’s disheartening to realize that, despite available medical advances that can end the AIDS epidemic, these resources aren’t reaching those who need them the most.</p>
<h2>Tools in the HIV prevention arsenal</h2>
<p>When HIV/AIDS first emerged in the U.S. in the 1980s, <a href="https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/">condoms were the only prevention strategy</a> available other than behavioral changes like abstinence. Since then, the development of effective medications has made it possible to live with HIV.</p>
<p>In the 1990s, researchers adopted the model of “<a href="https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/arv-therapy-as-prevention">treatment as prevention</a>,” which recognized that an HIV-positive person with a reduced viral load from taking their antiviral therapy medications had a lower likelihood of passing the virus to their sexual partners. This messaging was changed in recent years to <a href="https://www.idsociety.org/science-speaks-blog/2021/u--u-the-evidence-is-in.-spreading-the-word-that-undetectable--untransmissable-is-the-next-crucial-step/">“undetectable = untransmittable,” or U=U</a>, when a landmark study concluded that people living with HIV who are virally suppressed, or undetectable, through medications are not able to pass the virus on to a sexual partner.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/8q21PG1CdNs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">People who have undetectable levels of the virus are deemed to have untransmittable HIV.</span></figcaption>
</figure>
<p>In 2005, researchers introduced <a href="https://www.hiv.uw.edu/go/prevention/nonoccupational-postexposure-prophylaxis/core-concept/all">non-occupational postexposure prophylaxis, or nPEP</a>, which aimed to prevent infection in someone exposed to HIV by initiating antiviral therapy. </p>
<p>In 2012, the U.S. Food and Drug Administration approved the first <a href="https://www.hiv.uw.edu/go/prevention/preexposure-prophylaxis-prep/core-concept/all">preexposure prophylaxis, or PrEP</a> drug, which is an antiviral therapy that someone who has not been exposed to HIV takes daily to prevent infection. In 2021, the FDA approved the use of a <a href="https://www.hiv.uw.edu/go/prevention/preexposure-prophylaxis-prep/core-concept/all#recommended-regimens-dosing-hiv-prep-long-acting-injectable-">long-acting, injectable form of PrEP</a>, providing an alternative to daily pills. </p>
<p>While medical advancements have enhanced the options to prevent HIV, many aren’t reaching the people they are intended to treat. Of the estimated <a href="https://www.cdc.gov/hiv/group/racialethnic/other-races/prep-coverage.html">1.2 million people eligible for PrEP in the U.S.</a>, only 30% received a prescription in 2021.</p>
<h2>Racial disparities</h2>
<p>Gay and bisexual men continue to comprise around <a href="https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics/">two-thirds of new HIV infections</a> in the U.S. <a href="https://www.cdc.gov/hiv/policies/data/transgender-issue-brief.html">Transgender people</a>, <a href="https://www.vice.com/en/article/pkgnny/homeless-hiv-treatment">people who inject drugs</a> and <a href="https://www.cdc.gov/hiv/group/sexworkers.html">sex workers</a> also have disproportionate new infection rates. But cases are not distributed evenly by race. </p>
<p>The Centers for Disease Control and Prevention’s 2021 HIV Surveillance Report on groups at risk of HIV in 13 U.S. cities found that <a href="https://www.cdc.gov/hiv/pdf/library/reports/cdc-hiv-surveillance-special-report-number-31.pdf">nearly 80% of gay and bisexual men</a> engaged in condomless anal sex, with higher rates among white men than among both Black and Latino men.</p>
<p>However, between 2015 and 2019, white gay and bisexual men experienced a <a href="https://www.cdc.gov/hiv/group/msm/msm-content/diagnoses.html">17% decrease in HIV cases</a>. Black and Latino gay and bisexual men experienced no significant reductions. This is likely due to disparities in access to HIV prevention medication. Among those who were HIV negative, <a href="https://www.cdc.gov/hiv/pdf/library/reports/cdc-hiv-surveillance-special-report-number-31.pdf">only a little over 40% had used PrEP</a> in the past 12 months, with white men reporting higher use than both Black and Latino men. Among those who were HIV positive, 95% were actively using antiviral therapy, and there was little variation by race.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Hand holding orange PrEP pills above a clothed table with an open pill bottle" src="https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.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">The first PrEP drug was approved in 2012, but access remains uneven across the U.S.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-latina-woman-taking-medicine-royalty-free-image/1320349143">Sara Jurado/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>Factors such as stigma, lack of access to and mistrust in health care, socioeconomic status, and cultural nuances that restrict access to PrEP likely contribute to the unchanging HIV burden <a href="https://www.cdc.gov/hiv/group/bmsm/prevention-challenges.html">Black</a> and <a href="https://www.cdc.gov/hiv/group/gay-bisexual-men/hispanic-latino/prevention-challenges.html">Latino</a> men, <a href="https://www.cdc.gov/hiv/policies/data/transgender-issue-brief.html#systemic-factors-that-contribute">trans people</a> and <a href="https://www.vice.com/en/article/pkgnny/homeless-hiv-treatment">people experiencing homelessness</a> face.</p>
<h2>Closing the PrEP access gap</h2>
<p>A recent systematic review of 42 different interventions to promote PrEP among gay and bisexual men in the U.S. found that the most promising involve addressing <a href="https://doi.org/10.1186/s12981-022-00456-1">various social and environmental factors</a> that restrict access and adherence. </p>
<p>Tackling access barriers at the community and health care levels can enhance public health initiatives to expand PrEP access, including addressing issues like stigma and medical mistrust. This can help effectively promote PrEP use among Black and Latino gay and bisexual men and reduce racial disparities in HIV infections.</p>
<p>It is also important to note that while HIV disproportionately affects certain groups, <a href="https://www.cdc.gov/hiv/group/racialethnic/africanamericans/diagnoses.html">people having heterosexual sex</a> are still at risk and need to be part of the HIV prevention solution.</p>
<p>World AIDS Day serves as a poignant reminder that the fight against HIV is not only a global endeavor but also one that requires a nuanced understanding of the unique challenges different communities face. Addressing disparities and tailoring interventions can help move humanity closer to a world where HIV is no longer a pervasive threat.</p><img src="https://counter.theconversation.com/content/218918/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angel Algarin receives funding from the National Institutes of Health. </span></em></p>Two-thirds of new HIV infections are among gay and bisexual men. Although cases have decreased among white men, they have stagnated among communities of color.Angel Algarin, Assistant Professor of Health Promotion and Disease Prevention, Arizona State 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/1729452021-12-20T11:47:33Z2021-12-20T11:47:33Z‘HIV Made Me Fabulous’ film relies on science and embodied storytelling to counter stigma and discrimination<figure><img src="https://images.theconversation.com/files/438226/original/file-20211217-15-11va8uv.jpg?ixlib=rb-1.1.0&rect=170%2C45%2C2667%2C1485&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need a new script about women and HIV. </span> <span class="attribution"><span class="source">(Allie Carter)</span>, <span class="license">Author provided</span></span></figcaption></figure><blockquote>
<p>“We can’t demonize the very stuff that sometimes has made us be the people that we are.” </p>
</blockquote>
<p>So says <a href="https://www.unitedagents.co.uk/juno-roche">Juno Roche</a>, <a href="https://uk.jkp.com/products/gender-explorers?_pos=2&_sid=7b3772f93&_ss=r">a writer, activist</a> and trans woman who has lived with HIV for over 25 years. Roche wrote and narrated the film <a href="https://www.lifeandlovewithhiv.ca/film"><em>HIV Made Me Fabulous</em></a>, a 10-minute piece that combines narrative and dance, and was directed and produced by filmmaker and dancer <a href="https://www.edmondkilpatrick.com/bio">Edmond Kilpatrick</a>. </p>
<p>As researchers who aim to improve responses to gender, social justice, sexual and reproductive health and rights and HIV, we co-produced the film, in collaboration with women living with HIV. We released it to commemorate <a href="https://www.worldaidsday.org/about/">World AIDS Day</a>, Dec. 1, a day to show support for people living with HIV and mourn those who have been lost. </p>
<p>We intend to promote hope and celebrate the lives and resilience of women living with HIV globally. Our research also seeks to understand the effect watching the film has on viewers, to consider future uses of film as a tool for combating stigma and discrimination and promoting empathy for women living with HIV.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CWjLhHjsfo-","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<h2>Extraordinary HIV advances</h2>
<p>This year, the world <a href="https://www.cdc.gov/museum/online/40yearsofprogress.html">marked 40 years</a> since the first five cases of what later became known as AIDS were officially reported. </p>
<p>Since that era, which began in illness, fear and death, science has yielded extraordinary HIV advances that would have been unthinkable <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4309625/">a few decades</a> ago.</p>
<p>With the right treatment and care, people living with HIV can expect to live a long and healthy life with zero risk of transmitting HIV to their sexual partners if their viral load <a href="https://www.cdc.gov/nchhstp/dear_colleague/2017/dcl-092717-National-Gay-Mens-HIV-AIDS-Awareness-Day.html">is undetectable</a> — meaning that the virus isn’t showing up on blood tests. </p>
<p>This finding underpins the stigma-reducing “<a href="https://preventionaccess.org/">Undetectable equals Untransmittable</a>” (U=U) campaign endorsed by more than 1,000 organizations in more than 100 countries.</p>
<p>Researchers, advocates and people living with HIV hope that medical advancements like this can be liberating for people living with HIV, offering more agency over <a href="https://doi.org/10.1111/1467-9566.12347">sexual choices</a> and turning outdated attitudes and beliefs about HIV on their head.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/QamnyGc0gtY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">‘HIV Made Me Fabulous.’</span></figcaption>
</figure>
<p>But not everyone knows the U=U message. And the benefits of this HIV prevention science <a href="https://doi.org/10.1007/s13178-020-00432-2">for women</a>, in a world where women still aren’t equal to men, is hindered by on-going <a href="https://doi.org/10.1371/journal.pmed.1001124">discrimination</a>, harassment and <a href="https://www.who.int/reproductivehealth/topics/violence/hiv/en/">violence</a>, particularly for groups already marginalized on the basis of sex, sexual orientation, gender identity or expression, racialization, Indigeneity, disability or experience as a sex worker.</p>
<h2>Evoking emotions, changing thinking with film</h2>
<p>Some public health researchers have documented a growing interest in drawing on <a href="https://doi.org/10.1177/1049732319871251">the capacity of film as a tool to evoke emotions, change thinking and transform society</a> for better health outcomes.</p>
<p>In creating <a href="https://www.lifeandlovewithhiv.ca/film"><em>HIV Made Me Fabulous</em></a>, we explore the question of whether combining science with art could do more than communicate the shift in scientific understandings of HIV infectiousness. </p>
<p>In <a href="https://doi.org/10.1075/sin.18.15hyd">embodied storytelling</a>, a storyteller uses the body as a communicative medium, and may also enable viewers and listeners to tap into sensations experienced in their bodies. By employing this approach, we are seeking to use the film to measure whether the artful telling of Roche’s experiences of stigma and HIV, using dance, can help <a href="https://doi.org/10.1080/19443927.2017.1327884">promote empathy and compassion by arousing felt emotions in viewers’ bodies</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2-h2B55qYu0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Collaborators involved in ‘HIV Made Me Fabulous’ discuss the film.</span></figcaption>
</figure>
<p>We hope the film allows viewers to engage with the information presented more fully, and expands viewers’ capacities to understand and relate to the experiences of women living with HIV. And in turn, we hope this alters people’s learned prejudices surrounding the disease. </p>
<h2>Reclaiming sexual pleasure</h2>
<figure class="align-right ">
<img alt="Black and white photo of a trans woman with medium length light hair looking up and smiling." src="https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Writer Juno Roche narrates both struggles and triumphs.</span>
<span class="attribution"><span class="source">(Allie Carter)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The film shares a story, often unheard, about the experiences of women living with HIV — both the struggles and the triumphs. Roche’s words are enacted by three performers (Jacky Essombe, Quanah Style and Joleen Mitton) who incorporate movement and dance. During the film, the women prepare to meet a potential lover, find the courage to knock on their door, and ride the ensuing emotional journey.</p>
<p>Kilpatrick, <a href="https://www.youtube.com/watch?v=ll66u0P_Uhc">whose work has explored dance as a vehicle for expressing life with HIV</a>, describes how he used movement, dance and storytelling in the film as a way to invite a physical and emotional response in the viewer, while hearing stories that may be associated with unconscious bias. “If Juno’s words are delivered with images that provide a visceral empathetic reaction,” he asks, “could old, embodied biases that lead to stigmatized reactions to people living with HIV be replaced by new, kinder ones?”</p>
<h2>Changing behaviours, attitudes</h2>
<p>To measure the impact of the film in addressing stigma, we’re inviting people to watch it and complete a <a href="https://forms.gle/HQYemm2HUPFKZEAd8">short, two-minute survey</a> sharing their reflections. The data we glean from surveys will inform the use of film in public health practice to change behaviours and attitudes toward sex and HIV — and ultimately improve people’s health.</p>
<p>We want communities to know that science has turned HIV into a treatable, chronic condition and that stigma has consequences to health and quality of life. We also want women to know that if they are HIV-positive, they still have the right to enjoy all aspects of life, including sexuality, on an equal basis to people without HIV.</p>
<p>We also invite people — from peer support workers and service providers to university professors, sex educators, people living with HIV and engaged citizens — to consider hosting a group screening and discussion using <a href="https://www.lifeandlovewithhiv.ca/wp-content/uploads/2021/11/HIV-Made-Me-Fabulous-Discussion-Guide_v1-Colour-Spreads.pdf">the film facilitation guide</a> and more <a href="https://www.lifeandlovewithhiv.ca/film">resources on our website</a>.</p>
<p>The arts can catalyze dialogue, <a href="https://theconversation.com/from-depression-to-parkinsons-disease-the-healing-power-of-dance-123748">awareness, action</a> and advocacy, while simultaneously contributing <a href="https://theconversation.com/how-theatre-can-help-young-nigerians-who-are-living-with-hiv-150378">to reducing stigma</a> and discrimination. These are essential features to end inequalities and also help end barriers that prevent people from getting treatment for HIV and living fuller lives.</p><img src="https://counter.theconversation.com/content/172945/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allie Carter has been awarded research funding from the Canadian Institutes of Health Research, the Michael Smith Health Research BC, the National Health and Medical Research Council, and the Australian Government Department of Health.</span></em></p><p class="fine-print"><em><span>Angela Kaida has been awarded research funding from CIHR, SSHRC, Grand Challenges Canada, and the Michael Smith Health Research BC. She does not work for, consult, own shares in or personally 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>Can a film’s artful telling of experiences of stigma and HIV, using dance, help promote empathy and compassion?Allie Carter, Adjunct Professor, Faculty of Health Sciences, Simon Fraser UniversityAngela Kaida, Associate Professor and Canada Research Chair in Global Perspectives in HIV and Sexual and Reproductive Health, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1728422021-12-06T13:41:58Z2021-12-06T13:41:58ZWhy addressing racism against Black women in health care is key to ending the US HIV epidemic<figure><img src="https://images.theconversation.com/files/435449/original/file-20211202-20099-1a4zath.jpg?ixlib=rb-1.1.0&rect=7%2C202%2C5184%2C2981&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When Black patients are treated by Black doctors, they have better health outcomes – but fewer than 6 in 100 American doctors are Black.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/smiling-senior-doctor-talking-to-patient-in-royalty-free-image/1309073221?adppopup=true">The Good Brigade/Digital Vision via Getty Images</a></span></figcaption></figure><p>Forty years into the HIV/AIDS epidemic, Black women continue to bear the highest burden of HIV among women.</p>
<p>Although Black women represent only <a href="https://www.census.gov/quickfacts/fact/table/US/LFE046219">13% of the female population</a>, they accounted for over half of HIV diagnoses among all females in the U.S. in 2018, according to <a href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/content/women.html">data from the U.S. Centers for Disease Control and Prevention</a>. White women, who are 62% of the female population, <a href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/content/women.html">accounted for 21%</a> of HIV diagnoses. </p>
<p>Black women are also <a href="https://doi.org/10.1371/journal.pone.0189973">less likely</a> than white women to <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6741a3.htm">receive the antiretroviral therapies</a> that are highly effective at preventing HIV infection and are more likely <a href="https://www.idsociety.org/news--publications-new/articles/2021/study-shows-black-women-with-hiv-had-highest-rates-of-premature-mortality-between-1998-2018/">to die of causes related to HIV</a>. </p>
<p>This year’s World AIDS Day theme included <a href="https://www.unaids.org/en/World_AIDS_Day">ending inequalities</a> in HIV and AIDS care. But in order to address the inequities, it will require examining the root causes of them. In the United States, the most prominent reasons for these disparities are <a href="https://doi.org/10.1056/NEJMms2025396">structural and systemic racism</a>. </p>
<p>I am the co-founder and director of a research center at Columbia University, <a href="https://sig.columbia.edu/content/get-involved">the Social Intervention Group</a>. In the past 30 years, more than a thousand Black women living with or at risk for HIV have participated in the center’s studies of the <a href="https://scholar.google.com/scholar?q=nabila+el+bassel&hl=en&as_sdt=0,39&as_vis=1">causes and dynamics of HIV, substance abuse and gender-based violence</a>. These include <a href="https://scholar.google.com/scholar?hl=en&as_sdt=0%2C39&as_vis=1&q=nabila+el+bassel+HIV&btnG=">intervention studies</a> to put new strategies into practice and evaluate their impacts.</p>
<p>We have identified three approaches that can help improve the health of this population of at-risk women, as well as their access to health care.</p>
<h2>Addressing life contexts and experiences</h2>
<p>Many women who participated <a href="https://doi.org/10.1001/jamanetworkopen.2021.5226">in our studies</a> told us that their health providers rarely pay attention to their life context.</p>
<p>Life context includes racism, discrimination, poverty, a history of homelessness, incarceration, partner violence, stigma and trauma. Black women often <a href="https://doi.org/10.1001/amajethics.2021.156">lack integrated health services</a> to address these co-occurring issues, and simultaneously <a href="https://doi.org/10.1073/pnas.1516047113">their needs are often ignored</a> by their health care providers, which means <a href="https://dx.doi.org/10.2105/AJPH.2008.140541">they do not receive the treatment they need</a>.</p>
<p>The data affirm these women’s personal experiences. Black women are almost <a href="https://www.americanprogress.org/article/basic-facts-women-poverty/">three times as likely to live in poverty</a> and to <a href="https://www.cdc.gov/healthequity/features/maternal-mortality/index.html">die from pregnancy-related causes</a> than white women. They are also more likely to <a href="https://www.nationalpartnership.org/our-work/resources/health-care/black-womens-health-insurance-coverage.pdf">hold low-wage jobs that do not provide health benefits</a>.</p>
<p>Black Americans overall remain more likely to <a href="https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/">lack health insurance</a> than their white counterparts. They often <a href="https://dx.doi.org/10.1007%2Fs11113-016-9416-y">lose insurance coverage more quickly</a>. </p>
<p>To help overcome these inequities, the Social Intervention Group has developed an intervention called “Empowering African American Women on the Road to Health,” <a href="https://sig.columbia.edu/research-projects/eworth">or E-WORTH</a>. This study was designed by and for Black women to decrease HIV transmission and improve access to care, and it evaluated whether its methods improve participants’ health outcomes in practice.</p>
<p>E-WORTH is a new cultural adaptation of an HIV intervention for Black women called <a href="https://doi.org/10.1371/journal.pone.0111528">Project WORTH</a>, which was selected as <a href="https://www.cdc.gov/hiv/pdf/research/interventionresearch/compendium/rr/cdc-hiv-worth_best_rr.pdf">a best practice by the CDC</a>. </p>
<h2>Culturally tailored HIV care</h2>
<p>A total of 352 women participated in <a href="https://dx.doi.org/10.1001/jamanetworkopen.2021.5226">our E-WORTH intervention study</a>, which started in November 2015 and concluded in August 2019. The intervention included a one-hour individual HIV testing and orientation session, and four weekly 90-minute group sessions. </p>
<p>These sessions included raising awareness about HIV and other sexually transmitted infection risks, proper condom use, sexual negotiation skills, risk reduction goal settings, increasing social support and linkage to services, intimate partner violence screening, safety planning and referral to violence prevention services. </p>
<p>The participants were provided with opportunities to discuss their experiences of barriers to health care and other services, and how racism affected their access to services. </p>
<p>These unique intervention components had a positive effect. We found at the 12-month follow-up that compared with women participating in a one-session HIV testing intervention, the women in the five-session E-WORTH intervention had 54% lower odds of testing positive for any sexually transmitted infection. They also reported 38% fewer acts of condomless vaginal or anal intercourse.</p>
<p>The findings suggest that implementing an HIV/sexually transmitted infection intervention that is culturally tailored and designed for Black women holds promise for reducing the disproportionate burden of these infections in this population.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A Black female doctor peers into the mouth of a patient." src="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Culturally tailored health care shows promise for improving health outcomes for Black women.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-receives-a-physical-the-daybreak-community-health-news-photo/540612512?adppopup=true">Gregory Smith/Corbis Historical via Getty Images</a></span>
</figcaption>
</figure>
<p>Research shows that Black women often don’t receive adequate care because <a href="https://doi.org/10.1073/pnas.1516047113">care providers frequently do not believe their pain is real</a>. Several participants in E-WORTH <a href="https://sig.columbia.edu/news/new-publication-protocol-prevent-hiv-and-violence-among-black-women">reported that</a> in their overall experiences with the health care system, “No one ever believes me.”</p>
<p>In contrast, because of the trust and respect shown by facilitators and study staff, women participating in E-WORTH reported <a href="https://sig.columbia.edu/news/new-publication-protocol-prevent-hiv-and-violence-among-black-women">feeling heard and believed</a>.</p>
<p>These same women have also told us that sometimes clinical staff blame them for contracting HIV and <a href="https://www.healthline.com/health-news/the-discrimination-black-americans-face-when-it-comes-to-pain-management#Racial-bias-in-medical-care">fail to discuss or offer treatment and care options</a>, which prevents them from accessing or staying in care. </p>
<p>To address life context, E-WORTH is interwoven with Afrocentric themes of trauma and resiliency. These draw on Black Americans’ historical and lived experiences, from slavery to Jim Crow to the mass incarceration of Black individuals. Multimedia sequences in the sessions are intentionally infused with conversations about historical oppression, race and culture as well as systemic issues such as the overpolicing of Black communities and <a href="https://www.sentencingproject.org/issues/racial-disparity/">disproportionate sentencing laws</a>. </p>
<p>The facilitators of the intervention sessions led discussions exploring how intersecting identities related to race and ethnicity are at the heart of the HIV epidemic for Black women. The scripts used by facilitators featured Afrocentric language, based on input from prior focus groups of Black women, including character names. Afrocentric graphics were used, such as purple for royalty. </p>
<h2>A need for Black doctors and structural racism training</h2>
<p>Researchers have found that <a href="https://www.scientificamerican.com/article/we-need-more-black-physicians/">the health outcomes of Black patients improve</a> when they are treated by Black doctors. Further, Black women are more likely to trust doctors who <a href="https://doi.org/10.1353/hpu.2018.0036">live in their communities</a>.</p>
<p>However, a <a href="https://doi.org/10.1007/s11606-021-06745-1">recent study</a> found that only <a href="https://www.usnews.com/news/health-news/articles/2021-04-21/little-progress-in-boosting-numbers-of-black-american-doctors">5.4% of American doctors are Black</a>, and only <a href="https://www.usnews.com/news/health-news/articles/2021-04-21/little-progress-in-boosting-numbers-of-black-american-doctors">2.8% of them are women</a>. </p>
<p><a href="https://doi.org/10.1001/jamanetworkopen.2020.15220">Another recent study</a> suggests that creating medical education programs at <a href="https://theconversation.com/us/topics/hbcus-38001">historically Black colleges and universities</a> could increase the number of Black doctors. This supports other studies confirming <a href="https://dx.doi.org/10.3934%2Fpublichealth.2017.6.579">the importance of these schools</a> in expanding America’s ranks of Black doctors.</p>
<p>Increasing the number of Black providers is only part of the solution, however. <a href="https://www.aamc.org/media/37286/download?attachment">Fewer than half of U.S. medical schools</a> provide some sort of instruction or training on addressing structural racism and racial disparities in medical care. </p>
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<p>Over the past few years, medical schools as well as schools for allied health professions have made greater commitments to <a href="https://www.aamc.org/news-insights/medical-schools-overhaul-curricula-fight-inequities">training the next generation of health professionals</a> to address racism. </p>
<p>While research has shown structural racism to be <a href="https://doi.org/10.1056/NEJMms2025396">a powerful driver of health disparities</a>, a <a href="https://doi.org/10.1016/S0140-6736(17)30569-X">wide gap exists</a> in the literature on the <a href="https://dx.doi.org/10.1007%2Fs40615-021-01137-x">impact of these trainings</a> on medical staff practices and their patients’ health outcomes. This underscores the need for more attention to <a href="https://doi.org/10.1177/0002764213487341">this type of research</a>. </p>
<h2>Underpinnings of racism in the medical system</h2>
<p>In late 2020, the American Medical Association declared <a href="https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health">structural racism a public health threat</a> and emphasized the urgent need to prepare the U.S. health care workforce to redress it.</p>
<p>“Without systemic and structural-level change, health inequities will continue to exist,” <a href="https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health">wrote AMA Board member Willarda V. Edwards</a>. “Declaring racism as an urgent public health threat is a step in the right direction toward advancing equity in medicine and public health.”</p>
<p>The Social Intervention Group continues to develop and evaluate solutions to curbing the HIV crisis among Black women. Our research findings suggest that when these women are actively engaged in all stages of their health care services and research, they can improve their health and lives. But this will require that medical professionals also address the health care system’s inherent structural racism.</p><img src="https://counter.theconversation.com/content/172842/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nabila El-Bassel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Black American women have disproportionate HIV infection rates – in part because of systemic and structural racism in the health care system.Nabila El-Bassel, Professor of Social Work, Director of Social Intervention Group, Columbia 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/1725502021-12-01T11:21:58Z2021-12-01T11:21:58ZCongo Basin’s vital clues to HIV’s behaviour: how we’re trying to crack its complex code<figure><img src="https://images.theconversation.com/files/434707/original/file-20211130-21-n0146o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">HIV prevalence in the Congo Basin is relatively low.</span> <span class="attribution"><span class="source"> Yannick Tylle/ GettyImages</span></span></figcaption></figure><p>There have been tremendous gains towards reaching the United Nations <a href="https://www.unaids.org/en/resources/documents/2017/90-90-90">90-90-90 targets</a> to end HIV as a public health threat. The aim was that, by 2020, 90% of people with HIV would know their status, 90% of those would be on treatment, and 90% would have suppressed viral loads. </p>
<p>But the epidemic is still far from over. One of the main reasons is the diversity that the HIV group M (HIV-1M) virus exhibits. This affects both vaccine and cure development. </p>
<p>Currently, there are four groups of HIV-1 (group M, N, O and P). Each originated from an independent transmission from a non-human primate to a human. HIV-1 group M (HIV-1M) is today responsible for the global AIDS pandemic. It can be divided into subtypes and numerous recombinant forms called clades or strains. </p>
<p>To design long term, globally relevant biological interventions, it is particularly important to fully understand the biological underpinnings of HIV-1M diversity: how it arose, spread and influenced the extents and duration of individual HIV-1 sub-epidemics.</p>
<p>I have spent <a href="https://pubmed.ncbi.nlm.nih.gov/26656688/">years</a> looking at the <a href="https://pubmed.ncbi.nlm.nih.gov/29484203/">different steps</a> that HIV-1M took when it first got into humans to become one of <a href="https://pubmed.ncbi.nlm.nih.gov/33918115/">the major circulating viruses</a> in the world. A lot of my work has focused on the <a href="https://www.worldwildlife.org/places/congo-basin#:%7E:text=The%20Congo%20Basin%20spans%20across,Congo%2C%20Equatorial%20Guinea%20and%20Gabon.">Congo Basin</a>. This is a region in the <a href="https://www.worldwildlife.org/places/congo-basin">centre of the continent</a> that spans six countries and is made up predominantly of equatorial rain forests.</p>
<p>This is where HIV-1M is most diverse, even though HIV prevalence in the region is low. Infections have shown to include almost all the main described HIV-1M lineages, in addition to unusual and rare non-M group strains. </p>
<p>The region is also the site of the cross-species transmission of all the HIV-1 groups and was the launchpad of the global HIV epidemic <a href="https://pubmed.ncbi.nlm.nih.gov/25278604/">around 1960</a>. </p>
<p>We do not currently know why there are up to 10 times as many different strains of HIV-1M in the Congo Basin region than are found in any other part of the world. This is an important line of inquiry, and one that has pre-occupied me the most in my work.</p>
<p>The primary goal of my research has been to assess what makes one strain survive and spread and another not. Why have so many of the unusual strains found in the Congo Basin never left the region? Is it possible that the widespread strains that triggered HIV epidemics around the world simply infected a person who, after moving to another part of the world, happened to be an effective transmitter? These are very important questions that the field has struggled to address. </p>
<p>Today, it is possible to use the function of the different HIV-1M proteins to assess the biological differences between different lineages. What my colleagues and I have found so far indicates that there are specific biological differences between HIV-1M clades that may explain their uneven spread around the world. </p>
<p>This is important because a successful vaccine or cure strategy must deal with the issues of HIV emergence and anticipate the factors governing emergence. To be effective, vaccine formulas need to cover all emergent strains.</p>
<p>But there are still plenty of unknowns. </p>
<h2>An ongoing search</h2>
<p>In our ongoing study, we used the function of one of the HIV-1M proteins, the Nef protein, to understand the <a href="https://pubmed.ncbi.nlm.nih.gov/29942655/">HIV epidemic in Cameroon</a>. </p>
<p>This <a href="https://pubmed.ncbi.nlm.nih.gov/25715106/">protein’s</a> optimal activity is to favour the efficient replication of the virus and make it more transmissible. We used samples from two distinct cohorts: individuals living in remote villages, including around the presumed site of the cross-species transmission; and those residing in the cosmopolitan city of Yaoundé. </p>
<p>Our preliminary data indicated that up to 18 distinct HIV-1M clades were circulating in Cameroon.</p>
<p>Despite this broad diversity, one clade accounts for about 50% of all the circulating viruses in the two cohorts. In addition, the HIV-1M Nef of the different clades found in Cameroon displayed different functional activities. This suggests that these clades have different capacities of enhancing HIV-1 transmission. </p>
<p>Furthermore, the function of Nef to enhance transmission of HIV-1M was higher in the cosmopolitan city compared to the remote cohort. This tells us that HIV-1M might be more transmissible in the city compared to the remote areas.</p>
<p>These data add more explanations of why some HIV clades have caused global pandemics while others have not. For instance, these data suggest that specific biological properties of the ancestral HIV-1M clades may have influenced their epidemiology spread. And therefore these clades were genetically predisposed to successfully establish the HIV epidemic in Cameroon and perhaps in other parts of the world. </p>
<p>In addition, these data also suggest that HIV-1M viruses in the two cohorts follow different evolutionary trajectories, possibly driven by sexual partner networks. These networks are likely to be much broader in the cosmopolitan city of Yaoundé, where the epidemic is still expanding, compared to the remote villages. It is possible that viruses circulating within large urban Cameroonian populations may have been selected for increased transmissibility.</p>
<h2>Going forward</h2>
<p>A vaccine and a cure can’t be developed without an understanding of the precise genetic underpinnings of the virus’s predisposition and evolution. Our research is filling in important pieces of this complex puzzle. Each new finding takes the world a step closer to the development of preventive strategies as well as our capacity to predict future HIV-1M emergence and dissemination events.</p><img src="https://counter.theconversation.com/content/172550/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marcel Tongo Passo 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>To be effective, vaccine formulas need to cover all emergent strains. But there are still plenty of unknowns.Marcel Tongo Passo, Principal Investigator based at Centre for Research on Emerging and Re-Emerging Diseases (CREMER), Sub-Saharan African Network for TB/HIV Research Excellence (SANTHE)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1725152021-11-28T09:08:44Z2021-11-28T09:08:44ZThe people most at risk of HIV in Kenya aren’t using preventive drugs: we asked why<figure><img src="https://images.theconversation.com/files/433692/original/file-20211124-19-1tp8spg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GettyImages</span> <span class="attribution"><span class="source"> Brent Stirton/Getty Images for the GBC</span></span></figcaption></figure><p>There has been a <a href="https://phia.icap.columbia.edu/wp-content/uploads/2020/04/KENPHIA-2018_Preliminary-Report_final-web.pdf">gradual decline</a> of new HIV cases overall in Kenya – from a high of <a href="https://aidsinfo.unaids.org/">230,000</a> new infections in 1992 to 33,000 in 2020. But there are particular population groups that are at higher risk of contracting HIV than the general population. In these groups, new HIV cases remain unacceptably high. </p>
<p>This is especially true among gender and sexual orientation minorities, including men who have sex with men and transgender women. Transgender women – individuals assigned male gender at birth, but who currently identify as female – have been documented to have the <a href="https://pubmed.ncbi.nlm.nih.gov/23260128/">highest risk</a> for HIV infection globally.</p>
<p>Data from sub-Saharan Africa on transgender women remain limited. But recent findings from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563853/">Kenya</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527771/">Nigeria</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/33000918/">South Africa</a> provide corroborating evidence of increased risk of HIV infection in transgender women.</p>
<p>The increased risk for HIV infection in transgender women is <a href="https://pubmed.ncbi.nlm.nih.gov/24322537/">driven</a> by a combination of factors. The mismatch between their current identity and government issued documents makes transgender women more likely to be unemployed, engage in sex work, and face violence from clients or even law enforcement. </p>
<p>Additionally, receptive anal sex has previously been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929859/">shown</a> to be an independent predictor of HIV acquisition. Stigma and criminalisation of same-sex relationships makes it difficult for either transgender women or men who have sex with men to seek preventive services in public healthcare facilities. This further <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929859/">compounds</a> their risk for <a href="https://pubmed.ncbi.nlm.nih.gov/23260128/">infection with HIV</a>.</p>
<p>Since 2017, the Health ministry in Kenya has been promoting use of pre-exposure prophylaxis (<a href="https://www.cdc.gov/hiv/basics/prep/about-prep.html">PrEP</a>) as part of HIV prevention efforts. These preventive medicines are recommended for use in both the general populations and those at increased <a href="https://www.who.int/news-room/fact-sheets/detail/hiv-aids">risk</a> for HIV acquisition. Transgender women and men who have sex with men would be ideal candidates for PrEP use.</p>
<p>However, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244226">recent data</a> from Kenya demonstrated subdued uptake and adherence to PrEP in men who have sex with men. Additionally, <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30285-6/fulltext">retention in PrEP</a> care for those who take it up is reduced with high rates of loss to follow-up.</p>
<p>In our <a href="https://pubmed.ncbi.nlm.nih.gov/33465090/">recent study</a>, my colleagues and I set out to explore the opinions of healthcare providers, leadership of community-based organisations and current PrEP users. We wanted to find out what they thought about Kenya’s PrEP programme. We sought to understand the perceived or experienced barriers to joining and staying on PrEP programmes. We were also interested in their views on how to improve PrEP provision.</p>
<h2>What we did</h2>
<p>Data were collected between February 2018 and April 2019 in coastal Kenya. Healthcare providers working in an HIV clinic at a public hospital were invited to participate in two focus group discussions, at the start of PrEP rollout at the facility and again a year later. The leaders of community-based organisations that have programmes for either men who have sex with men or transgender women were invited to separate focus group discussions. Finally, we invited transgender women and men who have sex with men to in-depth interviews. They were either currently on PrEP or had defaulted. </p>
<p>The discussions and interviews explored for PrEP knowledge, perceived or actual challenges to PrEP uptake and retention in care, and how to improve PrEP programming. Data from all three sources were used to paint a complete picture of the PrEP provision landscape in Kenya.</p>
<h2>What we found</h2>
<p>Four major themes emerged out of the analysis. </p>
<p>First, healthcare providers admitted to feeling ill-prepared for the massive PrEP roll-out in Kenya. They felt bombarded with targets without enough training or consideration of the increased workload. A year later they seemed less combative, but more passive about PrEP programming. Rather than proactively driving demand, they preferred that potential users present themselves to the facility and ask for PrEP. One said,</p>
<blockquote>
<p>While the research may have been done and it showed that PrEP works, we are lacking follow-up systems … I feel like we were not ready for the implementation.</p>
</blockquote>
<p>Second, we found differences in motivation for PrEP uptake between men who have sex with men and transgender women. Transgender women seemed to be strongly motivated by recognition of their increased risk for HIV infection and desire to remain HIV negative. A transgender woman said,</p>
<blockquote>
<p>I wish to remain HIV negative. I know that being a trans is putting me at risk for HIV. So, when I heard that PrEP was available here (hospital), I was among the first to ask for it.</p>
</blockquote>
<p>For men who have sex with men, the motivation to use PrEP was to facilitate condomless sex. One of the men remarked:</p>
<blockquote>
<p>… before I knew about PrEP, I had two partners. When I started using PrEP, I added two more (partners), as I felt protected (by PrEP). Now I have four partners. </p>
</blockquote>
<p>Third, healthcare providers did not consider transgender women to be at any increased risk for HIV infection. And they did not understand a need to give transgender women additional attention. This was reflected in the view of one healthcare provide:</p>
<blockquote>
<p>… they (transgender women) are just at the same level as anybody else exposed to HIV … They are not at a very high risk of acquiring HIV. </p>
</blockquote>
<p>Fourth, all respondents seemed to agree that the public hospital was not an ideal venue for PrEP provision. A leader of one community-based organisation felt PrEP uptake and retention would be better if there were additional incentives.</p>
<blockquote>
<p>There are some specific needs like those hormones, therapy, legal, because it is very expensive … that can be a plus for us.</p>
</blockquote>
<h2>Recommendations</h2>
<p>PrEP is available. But access continues to be limited. The limited access is due to a combination of healthcare provider attitudes and the sentiment among men who have sex with men and transgender women who feel unwelcome in public health facilities. There is an urgent need for alternative PrEP dispensing environments. These must be spaces where men who have sex with men and transgender women can feel free to access comprehensive HIV prevention services. </p>
<p>Healthcare providers need to be trained to accommodate the needs of these populations. Programming guidelines must recognise transgender women as an at-risk population.</p>
<p>Working with community-based organisations may help create tailor-made solutions that are available to the populations that most need them.</p><img src="https://counter.theconversation.com/content/172515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Makobu Kimani is a SANTHE (Sub-Saharan African Network for TB/HIV Research Excellence) Fellow.</span></em></p>Stigma and criminalisation of same-sex relationships makes it difficult for transgender women and men who have sex with men to seek preventive services. This compounds their risk for HIV infection.Makobu Kimani, Post-doctoral researcher, KEMRI-Wellcome Trust Research Program, Kenya Medical Research InstituteLicensed 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/1726242021-11-28T09:06:14Z2021-11-28T09:06:14ZHow inequality drives HIV in adolescent girls and young women<figure><img src="https://images.theconversation.com/files/433984/original/file-20211125-23-sn5vn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">To fight economic inequality, female dependency on relationships and gender-based violence, female education is critical.</span> <span class="attribution"><span class="source">GULSHAN KHAN/AFP via Getty Images</span></span></figcaption></figure><p>Despite the advances that have been made against HIV, the world has 37 million people living with HIV. And 680,000 people died from AIDS-related causes in <a href="https://www.unaids.org/en/resources/fact-sheet">2020</a>. While the prevention of mother to child transmission, and provision of treatment as prevention, are <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/july/20210714_global-aids-update">great successes</a>, there are still <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2021.306290?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed">gaps</a>. Over 1.5 million new HIV infections were recorded in <a href="https://www.unaids.org/en/resources/fact-sheet">2020</a>.</p>
<p>In 2020, adolescent girls and young women aged 15 to 24 accounted for <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/july/20210714_global-aids-update">25%</a> of new infections, while making up only 10% of the population. Six in seven <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/july/20210714_global-aids-update">new HIV infections</a> among adolescents (aged 15 to 19) were among girls, even though boys live in similar contexts. Young women aged 15–24 years old were <a href="https://www.unaids.org/en/resources/fact-sheet">twice</a> as likely to be living with HIV compared with men.</p>
<p>In addition to the difference in risk between the sexes, other risk and protective factors may have an influence. So, within the population of adolescent girls and young women, differences in their unique risk profiles mean that some may be at a higher risk of HIV infection than others.</p>
<p>Understanding risk profiles helps us realise that HIV is more than just a virus. These profiles highlight how HIV risk and HIV prevention uptake are influenced by biological, socio-behavioural and structural factors. So while new HIV prevention options may become available, adolescent girls and young women will weigh up the benefits of using them. They consider factors such as partner trust, the social value of relationships, their perceived risk and the economic and social consequences that occur as a result of using them. All this happens in the context of the structural inequalities that sustain risk – things that individuals can’t always control. </p>
<p>Risk profiles – the unique combination of factors that work to mediate HIV risk – should inform responses to the evolving pandemic. More nuanced and locally responsive approaches are required.</p>
<h2>Risk factors</h2>
<p>As the world aims for the <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/july/20210714_global-aids-update">90-90-90 goals</a>, it’s useful to see who is falling behind. Global <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2021/september/20210906_global-roll-out-hiv-treatment">data</a> suggests that in 2020, 84% of people living with HIV know their HIV status, 73% of those are accessing HIV treatment and 66% of those on treatment are virally suppressed. </p>
<p>Hidden in these successes are those who have still not been reached by HIV prevention and treatment efforts, who are put at risk by inequality, exclusion and social and economic vulnerability. What is the profile of those who have still not been reached? What factors within those profiles prevent us from reaching them? And how do we tailor interventions that respond to local contexts of risk? A large number of studies and programmes have already provided some of these answers. </p>
<p><strong>Power in relationships:</strong> Adolescent girls and young women who are sexually active are at the highest risk of HIV infection. Delaying sexual debut is a key goal of HIV prevention. But sexual relationships often start in adolescence. The <a href="https://www.tandfonline.com/doi/full/10.1080/17441692.2021.1969672">HIV transmission cycle</a> highlights that adolescent girls and young women in age-disparate sexual relationships, (i.e “sugar daddies”) are at higher risk than those in peer relationships. Age-disparate relationships often have social, emotional, economic and sexual value that may outweigh potential risks. But they are usually characterised by power dynamics that make discussions about sexual health difficult. In contexts of high female poverty and partner dependency, the power and gender inequalities of these relationships will <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/july/20210714_global-aids-update">increase the risk of HIV</a> infection and may limit the ability of adolescent girls and young women to negotiate <a href="https://viivhealthcare.com/en-gb/supporting-the-community/positive-action-programmes/hiv-a-virus-that-thrives-on-inequality/#unaids">safe sex practices</a>.</p>
<p><strong>Gender-based violence:</strong> Adolescent girls and young women who are victims of gender-based violence will have risk profiles that make them more vulnerable to HIV infection. In contexts where female poverty is high and retaining relationships is critical for survival, agency to make sexual health decisions may be difficult. In <a href="https://www.gov.za/speeches/minister-bheki-cele-quarter-one-crime-statistics-20212022-20-aug-2021-0000">South Africa</a>, home to the largest HIV pandemic, over 10,000 people were raped between April and June 2021. Many of these incidents took place at the home of the victim or the home of the rapist. In the same period, over 15,000 domestic violence assault cases were reported. These high rates of gender-based violence highlight that access to HIV prevention services are necessary but not sufficient to protect women from HIV infection. </p>
<p>To fight economic inequality, female dependency on relationships and gender-based violence, female education is critical. Additionally, changing gender norms in young boys and ensuring more equitable gender beliefs as men grow older will create an environment in which female agency is non-negotiable and respected.</p>
<h2>Services and interventions</h2>
<p>Use of HIV prevention services is influenced by inequalities in access and by social and gender norms. Access does not equate to uptake. A lack of knowledge about sexual health, inequitable gender norms around sex, and conservative social norms about adolescent sexual well-being contribute to poor uptake of sexual and reproductive health services among adolescent girls and young women. </p>
<p>Engaging their sexual partners, challenging social and gender norms, providing comprehensive sexual education, and creating sex-positive and egalitarian health services for adolescents are essential for fighting the HIV pandemic in young people.</p>
<p>Without understanding the social context in which adolescent girls and young women manage and negotiate sex, and tailoring interventions to break the transmission cycle, it will be a struggle to achieve epidemic control in adolescent girls and young women. </p>
<p>In sub-Saharan Africa, a more nuanced view of the risks faced by adolescent girls and young women will be essential for developing targeted and relevant interventions. These efforts will also help reduce inequalities and build societies more resilient to future pandemics.</p><img src="https://counter.theconversation.com/content/172624/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hilton Humphries receives funding from the South African National Research Foundation. </span></em></p>Adolescent girls and young women aged 15 to 24 accounted for 25% of new infections, while making up only 10% of the population.Hilton Humphries, Behavioural Scientist, Centre for the AIDS Program of Research in South Africa (CAPRISA)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1507862020-11-29T09:17:37Z2020-11-29T09:17:37ZBattles won – and lost – against AIDS hold valuable lessons for managing COVID-19<figure><img src="https://images.theconversation.com/files/371251/original/file-20201125-13-65tf7u.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"> Sonali Pal Chaudhury/NurPhoto via Getty Images</span></span></figcaption></figure><p>World AIDS Day this year finds us still deep amid another pandemic – <a href="https://theconversation.com/africa/covid-19">COVID-19</a>. </p>
<p>The highly infectious novel coronavirus has swept across the world, devastating health systems and laying waste to economies as governments introduced drastic measures to contain the spread. Not since the HIV/AIDS pandemic of the 1990s have countries faced such a common health threat.</p>
<p>This explains why UNAIDS has selected the theme “<a href="https://www.unaids.org/en/World_AIDS_Day">Global Solidarity, Shared Responsibility</a>” for this year’s World AIDS Day. </p>
<p>Infectious diseases such as these remain a major threat to human health and prosperity. Around <a href="https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">32.7 million people</a> have died from AIDS-related illnesses in the last 40 years. At the time of writing, <a href="https://coronavirus.jhu.edu/map.html">1.4 million people</a> had already died from COVID-19 in just one year. </p>
<p>These diseases take incredible expertise, collaboration and dedication from all levels of society to track, understand, treat and prevent.</p>
<p>The HIV/AIDS response played out over a much longer trajectory than COVID-19. But it is, in some respects, a shining example of what can be achieved when countries and people work together. The work of organisations such as the <a href="https://www.who.int/">World Health Organisation</a>, <a href="https://www.unaids.org/en">UNAIDS</a> and the <a href="https://www.iasociety.org/">International AIDS Society</a> help to coordinate rapid sharing of information and resources between healthcare providers and communities. </p>
<p>The <a href="https://www.theglobalfund.org/en/">Global Fund</a> and <a href="https://www.state.gov/pepfar/">PEPFAR</a> have mobilised resources that have helped to reduce morbidity and mortality in low- and middle-income regions. AIDS-related deaths have declined worldwide by <a href="https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">39% since 2010</a>. </p>
<p>These and other groups have also fought against high drug prices that would render medication inaccessible to many in the developing world. In South Africa, the epicentre of the HIV epidemic, a day’s supply of the simplest antiretrovirals <a href="https://www.internationalbudget.org/wp-content/uploads/AIDS-in-South-Africa-Report-on-Intergovernmental-Funding-Flows-for-Integrated-Response-in-the-Social-Sector.pdf">cost about R250 in 2002</a>. Today easier, more palatable treatment taken once per day <a href="https://www.spotlightnsp.co.za/2019/02/26/analysis-how-a-cutting-edge-medicine-made-it-to-sas-new-arv-tender/">costs</a> a few rands. </p>
<p>Collaboration and co-ordination has also meant that medications have been developed and tested in populations across the world. And once available, global guidelines and training opportunities ensure that healthcare provision and quality is standardised. </p>
<p>Many of these achievements did not come without a fight. Dedicated and sustained activism, at a political and community level were required to drive down drug pricing for the global South and is constantly required to ensure inclusive distribution of resources.</p>
<p>The corollary is also true – areas where the world continues to struggle arise predominantly where there’s a lack of solidarity and agreement. These include a lack of political support to implement evidence-based protection mechanisms for vulnerable or stigmatised populations. For example the legalisation of homosexuality. This results in continued but avoidable HIV infection and related mortality. </p>
<p>These lessons need to be taken on board as the world prepares for the next phase of managing COVID-19. All the interventions that helped contain and manage HIV and AIDS are critical in ensuring that no country, regardless of developmental status, and no population, especially those that face stigma and battle to access healthcare services, are left behind.</p>
<h2>Building on existing systems</h2>
<p>The lessons learnt from HIV and AIDS can be used to inform the COVID-19 response as the challenges are similar. </p>
<p>Many of the ongoing COVID-19 vaccine trials are taking place in multiple countries, including South Africa. The capacity to conduct these studies, including the clinical staff and trial sites, are well established as a result of decades of HIV/AIDS research. There are fears that developing nations might be excluded from accessing an effective COVID-19 vaccine. But global mechanisms are now in place to avoid this and to, instead, encourage and enable global solidarity, some of which were championed by the HIV/AIDS response. </p>
<p>The <a href="https://www.who.int/initiatives/act-accelerator">Access to COVID-9 Tools (ACT)-Accelerator,</a> established by the World Health Organisation in April 2020 in collaboration with many other global organisations, governments, civil society and industry, have committed through the pillar known as Covax, to equitable distribution of a COVID-19 vaccine as well as diagnostic tests and treatments. These global institutions and mechanisms require continued support.</p>
<p>With the deployment of an effective vaccine, an end to COVID-19 might soon be in sight. For HIV, vaccine development has been more complex and disappointing. The global community needs to remain committed to promoting access and support for the many incredible prevention and treatment options that are available. The unprecedented effort on the part of private industry in the COVID-19 vaccine response shines a light on what can be achieved when all interested parties engage. The HIV and TB vaccine endeavours need a similar effort.</p>
<p>These are not the only pandemics the world will face. In fact, there are strong predictions that the emergence of new pandemics will increase in the future. This is due to the effects of globalisation, climate change and proximity to wildlife. </p>
<p>The best hope for humanity is to not lose sight of what these pandemics cost us in terms of loved ones, in terms of freedom and economically. We must prepare now collectively across countries and across all levels of society. These preparations need to be grounded in the lessons learnt from HIV/AIDS and re-learnt from COVID-19. </p>
<h2>Social solidarity</h2>
<p>The success of the global response to current and emerging pandemics will rely on the ability of the less vulnerable to acknowledge their shared responsibility and respond to those calls.</p>
<p>An important truth of the HIV epidemic is that it doesn’t discriminate. No infectious disease acknowledges political borders and everybody is at risk of being infected or affected. If nothing else, because of this we need to continue to work together on a global scale knowing that “no one is safe, until everyone is safe”.</p>
<p><em>Carey Pike, Executive Research Assistant at the Desmond Tutu Health Foundation contributed to this article.</em></p><img src="https://counter.theconversation.com/content/150786/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from the National Institutes of Health, USA and other similar research funding agencies. </span></em></p>The HIV/AIDS response played out over a much longer trajectory than COVID-19. But it is, in some respects, a shining example of what can be achieved when countries and people work together.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/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/1277882019-11-27T19:03:23Z2019-11-27T19:03:23ZTreating HIV in the tiniest babies could have huge positive implications for their future<figure><img src="https://images.theconversation.com/files/303797/original/file-20191126-112522-6t9dkr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">World AIDS Day is observed annually in many countries to raise people's awareness in the fight against HIV.
</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/South-Africa-World-AIDS-Day/c7695c08ac48464aaa83baf08e113ef4/76/0">AP Photo/Themba Hadebe</a></span></figcaption></figure><p>Princess had a rough start in life. She was born HIV-infected. Her mother was often sick, and there was little family support for her own struggles with HIV. But Princess’ mother had recently started HIV treatment and planned to stay on it. She wanted to do everything possible for her daughter, so she made a decision that ultimately helped save Princess’ life: she enrolled her in a study to <a href="https://clinicaltrials.gov/ct2/show/NCT02369406">treat HIV infection just a few days after being born.</a> </p>
<p>HIV progresses rapidly in the first year of life, wreaking havoc on an infant’s developing immune system. Although treating HIV-infected women with three active drugs in pregnancy can prevent most transmission to babies, Princess is <a href="http://dx.doi.org/10.7448/IAS.17.1.18914">one of almost 500 children born each day in sub-Saharan Africa</a> who still become infected with HIV. The <a href="https://apps.who.int/iris/bitstream/handle/10665/208825/9789241549684_eng.pdf;jsessionid=99CDD75CD1C5DE39FCA4DE13341803C1?sequence=1">World Health Organization recommends</a> starting three-drug antiretroviral treatment in infected children as early as possible, yet this goal has proved elusive in most pediatric HIV treatment programs globally. </p>
<p><a href="http://doi.org/10.1093/cid/ciu432">Recent research in this field</a>, including our <a href="https://stm.sciencemag.org/lookup/doi/10.1126/scitranslmed.aax7350">new data from Botswana</a>, suggest that initiating treatment as close to birth as possible may be the best time to treat infants. Starting in the first week of life may reduce the total amount of virus in the baby’s body, it may improve favorable immune responses to the virus, and it may prevent rapid decline in health among children who are HIV infected – 50% of whom will die within two years if untreated. </p>
<p>Only a handful of exposed children are currently tested for HIV and started on treatment in the first week of life. South Africa has recently changed its <a href="https://sahivsoc.org/Files/ART%20Guidelines%2015052015.pdf">policy to test children at birth and 10 weeks</a>, but it is the only country in Africa to do so. All others have policies to test babies for HIV when they reach between four and six weeks old, by which time the viral burden in the body is high and signs of a weakened immune system may be apparent. </p>
<p>We are infectious disease doctors who work in Botswana and Boston and, since 2015, we have been conducting the <a href="https://clinicaltrials.gov/ct2/show/NCT02369406">Early Infant Treatment Study</a> in the Francistown and Gaborone regions of Botswana, a country with the third highest HIV-1 prevalence in the world. The study offers HIV testing and immediate initiation of treatment within days of birth. Given the mounting evidence that immediate treatment is good for HIV-infected children, we hope our research offers a road map for addressing barriers to newborn treatment.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303783/original/file-20191126-112522-1yvqz0s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A nurse in the Early Infant Treatment Study, Botswana, tests a baby to determine whether they are HIV positive.</span>
<span class="attribution"><span class="source">Early Infant treatment study team/Botswana-Harvard AIDS Institute Partnership</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Accurately diagnosing HIV in newborns</h2>
<p>The first barrier to early diagnosis and treatment is the way health providers diagnose newborns. The diagnostic test needs to be virtually perfect to establish that the baby is infected with HIV (and to start lifelong treatment). Children cannot be tested with standard antibody tests until they are at least 18 months old because they still have circulating antibodies from their mothers (including antibodies to HIV that would always lead to a positive test result). So tests that directly detect the HIV virus are needed. </p>
<p>Direct tests for HIV virus can be performed by a heel prick using drops of blood on filter paper, which can then be transported to a laboratory either at the same site or a distant location without refrigeration. These tests are commonly used, and highly accurate when children are at least four to six weeks old. But the accuracy of the test in newborns is not as well established, and the testing is less likely to be available at maternity wards, and even less likely if delivery occurs at home. In our study, we found that we could make a correct diagnosis in newborns as long as we tested a second sample for every child who initially screened positive or indeterminate. Since this does not happen often (less than 1% of tests in our setting), this repeat test strategy was feasible, and it provided enough diagnostic certainty to immediately offer treatment to infected newborns without fear of misdiagnosis.</p>
<h2>Limited drugs and misperceptions about treatment</h2>
<p>The next barrier is the limited number of antiretroviral drugs for use in newborns. <a href="https://www.who.int/hiv/pub/guidelines/paediatric020907.pdf?ua=1">Until recently only two drugs</a> – <a href="https://aidsinfo.nih.gov/contentfiles/lvguidelines/glchunk/glchunk_187.pdf">zidovudine and lamivudine</a> – have had adequate safety and dosing data from birth. Other drugs can only be used from when the child is two weeks old. But there are additional concerns, including medicines with a terrible taste that cannot be masked easily, or drugs with complex treatment formulations that make them difficult to use. With these limitations in mind, clinicians may delay starting treatment until later in infancy, believing the treatment is too difficult to administer for newborns. While the limited number of available drugs is a very real concern, our experience has been that newborns tolerate HIV treatment well, and can rapidly suppress the virus when the right supports are in place.</p>
<p>Another challenge that makes it difficult to initiate treatment at birth is rooted in perceptions about a baby’s ability to tolerate travel and treatment in the newborn period. Initiation of treatment often requires a referral to a pediatric HIV clinic. This transfer from one department to another – or in some cases one facility to another – can be complicated. These considerations may lead health providers to believe that HIV testing and treatment is best sorted out later in life when the infant is perceived as stronger. </p>
<p>However, we have found that this reasoning is misguided. Immediately after birth the child has suffered the least immune system damage from HIV. There are also opportunities for frequent contact with the health care system early in life, which can help a child stay on medications. In our study, we frequently partnered with nurses at postnatal care clinics to help with adherence counseling and even direct observation of dosing, and these partnerships helped improve treatment responses. </p>
<h2>Cost</h2>
<p>The final barrier to initiating testing and treatment at birth is cost. </p>
<p>Because not every infection can be detected at birth, testing at 4-6 weeks for virus in the blood, which may cost US$25 or more, is a “catch-all” for transmissions that occur in pregnancy, during delivery, or from early (but not later) breastfeeding. So birth testing adds a step to most infant diagnosis programs. However, the consequences of missed early diagnoses, and worse treatment outcomes with delay, are now better understood. </p>
<p>Targeted birth testing is also an option in cost-constrained settings. In the <a href="https://doi.org/10.1002/jia2.25111">Early Infant Treatment Study</a>, the vast majority of HIV-infected children had an easily identifiable risk factor for transmission – such as the mother being off treatment or having a history of detectable virus in her blood. Targeting babies at high-risk could be adopted to reduce cost, while still allowing us to identify nearly all the infected children and get them started on treatment. </p>
<p>Finally, in an attempt to find less costly diagnostic options, we piloted the use of facility-based, or “point-of-care,” testing for virus in the blood and demonstrated that it <a href="http://doi.org/10.1097/QAI.0000000000001384">identified almost all infant infections</a> in the first week of life. Point-of-care testing can offer less complexity and reduced cost, though at about $18 per test, we have not solved the cost issue entirely. </p>
<h2>Knocking down barriers</h2>
<p>There are both real and perceived challenges to diagnosing and treating HIV in newborns. While the resources of a study may not be available everywhere, our experiences in the Early Infant Treatment Study in Botswana suggest that this strategy works, and should become the standard of care everywhere. </p>
<p>We do not have a cure for HIV yet, but immediate testing and treatment of newborns offers a pathway forward so children like Princess can survive until we do.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/127788/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Roger L. Shapiro receives funding from the National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Gbolahan Ajibola does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Babies born with the HIV virus in their blood are at a turning point in the infection. With immediate treatment these children can develop much stronger immune systems to fight the virus.Roger L. Shapiro, Associate Professor of Immunology and Infectious Diseases, Harvard UniversityGbolahan Ajibola, Study Coordinator, Botswana-Harvard Partnership, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1077402018-11-30T15:36:11Z2018-11-30T15:36:11ZWhy nurses should take the HIV self-test<figure><img src="https://images.theconversation.com/files/248106/original/file-20181130-194935-1p6eu85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/133031549?src=8tO9cvRVCD6Y9ut5ZrWuPQ-1-2&size=medium_jpg">michaeljung/Shutterstock</a></span></figcaption></figure><p>The United Nations has set a goal that <a href="http://www.unaids.org/en/goals/unaidsstrategy">90% of people with HIV should know their status by 2030</a>. As a result, increasing numbers of people are expected to undertake self-tests to see if they may have HIV. </p>
<p>HIV testing can be done in a number of ways. Some clinics offer a simple blood test, with results provided in a few days. Others use saliva or a finger-prick sample of blood and offer results immediately. Home sampling kits, designed to be sent back to the clinic for results, are available in the UK through <a href="https://www.test.hiv/">this link</a>. Then there are home testing kits that provide results straight away, known as self-test. </p>
<p>For self-test, the person swabs their gums with a testing strip. The testing strip is then placed in a tube that analyses the strip for the presence of HIV antibodies. It looks similar to a pregnancy test – a window in the <a href="http://www.oraquick.com/what-is-oraquick/how-oral-testing-works">testing kit</a> shows lines to show a result of positive or negative.</p>
<p>Knowing an HIV status is essential for two reasons. One, HIV-positive people can take measures, such as practising safe sex, to avoid transmitting the virus to others. And two, HIV treatment increases a person’s T-cell count (important immune cells for fighting infection) and reduces levels of HIV in the body. Without treatment, <a href="https://www.nat.org.uk/we-inform/do-i-understand-hiv?gclid=EAIaIQobChMIr9-XlMH53gIVCbDtCh3p7wBoEAAYASAAEgLTKPD_BwE">HIV can turn into AIDS</a>, which is a life-threatening condition. </p>
<p>Although the test is physically easy – just a quick mouth swab – it can be emotionally difficult. Nurses who dispense these tests are often asked to support, guide and counsel the people taking the test – but their practice must be based on the most up-to-date information available. Consequently, nurse educators must find ways to promote learning in the most effective way possible. </p>
<h2>Valuable insights</h2>
<p>Learning by doing or through experience is called “<a href="https://theconversation.com/why-learning-from-experience-is-the-educational-wave-of-the-future-92399">experiential learning</a>”. It offers a great way to understand how people experience a situation. <a href="https://www.sciencedirect.com/science/article/pii/S0260691718304842">Our research</a> presents an overview of nurses’ experiences when we asked them to test themselves for HIV.</p>
<p>Our students revealed that they worried about their past sexual encounters and the test made them recall all of these encounters. And, despite their knowledge of health, some questioned non-risky behaviour – such as sharing cups with roommates. They then considered how their patients may feel when taking the tests. If they were concerned about “sharing cups”, then their patients might have similar worries. This suggested a need to consider what questions their patients may have.</p>
<p>All 30 participants of the study said they had experienced emotional fluctuations, worrying about the possibility of a positive test result. A few wanted to be alone when they were viewing the results of the test, they were nervous about waiting and some worried that they hadn’t done the test properly. All participants said they underestimated the significance of asking their patients to take such an “easy” test. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not as easy as it looks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/488256589?src=Lcaczd-NznsTITFtPUCvmw-1-0&size=medium_jpg">divasoft/Shutterstock</a></span>
</figcaption>
</figure>
<p>It motivated the nurses to learn more about HIV and HIV testing. Taking the test gave them insights into their patients’ experiences – they felt they understood why people may be reluctant to take the test. Taking part in the study meant they felt better able to give advice to their patients. This is important because, as patients, we trust those who have insight into our experiences. People who have experienced similar feelings will be more compassionate and understanding. </p>
<p>Nowadays, self-test kits are available in pharmacies and online, but the test is not all that is needed. People must be prepared for the result and, if they are HIV positive, they must be able to access treatment and support. This could be improved if it was guided by people who have been taken the test themselves. Nurses and other healthcare workers play an important role in process, and experiential learning is key to offering a more informed and humane test.</p><img src="https://counter.theconversation.com/content/107740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors 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>Taking the HIV self-test gave nurses valuable insights into what their patients go through.Amanda Lee, Associate Dean (International) Faculty of Health Sciences, University of HullMark Hayter, Professor of Nursing and Health Research/ Associate Dean Research, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1077652018-11-30T11:41:51Z2018-11-30T11:41:51ZAIDS treatment has progressed, but without a vaccine, suffering still abounds<p>I mentioned to a friend, a gay man nearing 60, that <a href="https://www.worldaidsday.org">World AIDS Day</a>, which has been observed on Dec. 1 since 1988, was almost upon us. He had no idea that World AIDS Day still exists. </p>
<p>This lack of knowledge is a testament to the great accomplishments that have occurred since World AIDS Day was created 30 years ago. It is also due to an accident in the timing of his birth that my friend escaped the devastation wreaked by AIDS among gay men in the U.S., before there was antiretroviral therapy. </p>
<p>Many people have forgotten AIDS, but there are consequences to forgetting. The fight against AIDS is at a tipping point. Increasingly, there are signs that we may be heading in the wrong direction.</p>
<h2>Many successes, yet the grand prize is elusive</h2>
<p>I am a social epidemiologist with more than 20 years of research experience in HIV and STD prevention. I am also the founder of <a href="https://www.youtube.com/c/TheBasicswithDrMo">The Basics with Dr. Mo</a>, a sex health communications project that translates prevention science directly for people who need it most.</p>
<p>It is true that global HIV/AIDS success stories abound: Mother-to-child transmission can be reduced to <a href="http://www.who.int/hiv/topics/mtct/en/">below 5 percent</a>, 75 percent of people living with HIV know their status and <a href="http://www.unaids.org/en/resources/fact-sheet">59 percent receive antiretroviral therapy</a>. </p>
<p>Most recently, Pre-Exposure Prophylaxis (PrEP) – the use of antiretrovial drugs to prevent HIV infection among those exposed – has proved to be a <a href="https://www.cdc.gov/hiv/risk/prep/index.html">successful prevention approach</a>.</p>
<p>Yet the prize – a vaccine that can prevent HIV infection – remains elusive, and makes impossible the use of the only known strategy to have ever eradicated an infectious disease: widespread vaccination. That disease was smallpox, in 1980.</p>
<h2>The seeds of unease</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247810/original/file-20181128-32197-1302x3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A demonstration for AIDS advances in July 2018 in The Netherlands, with Princess Margaret Van Orange pictured at the center.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/amsterdamnetherlands-july-232018-princess-mabel-van-1140466079?src=dBNVXnXsHdBScshgvjTuTA-1-19">Paolo Amorim/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Despite the lack of a vaccine, in 2016 United Nations member states adopted a <a href="http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2016/june/20160608_PS_HLM_PoliticalDeclaration">political declaration</a> on ending the AIDS epidemic by 2030. </p>
<p>As part of the accountability framework, interim 2020 goals set a target of 500,000 new HIV infections for that year. A review of the most recent data estimated <a href="http://www.unaids.org/en/resources/documents/2018/unaids-data-2018">1.8 million new HIV infections</a> in 2017, exactly the <a href="http://www.unaids.org/en/resources/documents/2017/20170720_Core_epidemiology_slides">same number as in 2016</a>.</p>
<p><a href="https://www.bbc.com/news/health-44884593">Prominent scientists</a> have already begun to question the ability to eradicate AIDS by the 2030 deadline, and concede that the situation has stagnated. The attainment of eradication looks bleak, without the aid of either an effective vaccine or the immediate large-scale promotion and utilization of existing prevention tools (i.e., condoms, voluntary circumcision and potentially PrEP). Given that the vast majority of new HIV infections are sexually transmitted and that <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2015/july/20150702_condoms_prevention">condoms have played a decisive role</a> in the global control of HIV transmission, ongoing condom availability and use will be essential to future eradication.</p>
<p>Condoms – both male and female – remain a <a href="https://www.cdc.gov/std/hiv/stds-and-hiv-fact-sheet-press.pdf">highly effective mechanism</a> of HIV/AIDS prevention, as well as of other sexually transmitted infections that greatly enhance the risk of HIV transmission. </p>
<p>Condom use is also strongly advised by global public health institutions, including the <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">World Health Organization</a> and the <a href="https://www.cdc.gov/hiv/basics/prevention.html">U.S. Centers for Disease Control and Prevention</a>, in conjunction will all other HIV prevention tools including PrEP, because of their lower levels of effectiveness in preventing transmission. </p>
<p>Condom availability is a different matter and varies greatly from country to country. Countries with the highest levels of HIV often rely heavily on donor support. According to the most recent data, in sub-Saharan Africa in 2013, only <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">10 condoms were available</a> annually for every man aged 15 to 64 (as compared with the recommended 50 to 60), and, on average, there was one female condom available for every eight women. Funding required to maintain – let alone scale up – HIV commitments, particularly those dedicated to prevention, are <a href="https://www.avert.org/professionals/hiv-around-world/global-response/funding">increasingly uncertain.</a></p>
<h2>The hydra, sprouting new heads</h2>
<p>Even though condoms are an extremely effective barrier method, it is usage that makes condoms efficacious in preventing HIV transmission. Reported condom use varies considerably around the world, and ranges from 80 percent use by men in Namibia and Cambodia to less than 40 percent usage by men and women in other countries, including some highly affected by HIV such as Sierra Leone and Mozambique. </p>
<p>Age plays a role, too. Among young people aged 15 to 24, <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">condom use at last sex varies</a> from more than 80 percent in some Latin American and European countries to less than <a href="http://www.who.int/hiv/mediacentre/news/condoms-joint-positionpaper/en/">30 percent in some West African countries</a>. In the U.S., condom use is at the lower end of the spectrum: Only one-third of the population uses condoms, a number that has not changed significantly over the past two decades.</p>
<p>The majority – 66 percent – of the <a href="https://www.avert.org/global-hiv-and-aids-statistics">world’s HIV/AIDS cases</a> are in sub-Saharan Africa, where there has been much progress, particularly with the provision of antiretroviral therapy.</p>
<p>However, there are worrying signs in other parts of the world. There has been <a href="http://www.unaids.org/en/resources/documents/2018/unaids-data-2018">little change in new HIV infections</a> in countries outside of sub-Saharan Africa between 1990 and 2017. </p>
<p>In fact, six of the 10 most populous countries in the world have experienced <a href="http://www.unaids.org/en/regionscountries/countries">10 percent to 45 percent increases in new HIV infections since 2010</a>: Russia, China, Brazil, Pakistan, Mexico and Bangladesh. Even in countries such as the U.S., where new HIV infections have decreased by 8 percent overall, the rates of change are unevenly distributed. For example, <a href="https://www.cdc.gov/hiv/statistics/overview/ataglance.html">young African-American men</a> who have sex with men show no decrease in new infections; African-American gay and bisexual men represent the largest percentage of new HIV infections: more than one-quarter. </p>
<p>The increased provision of antiretroviral therapy to people living with AIDS has had a huge impact on extending life and in preventing new HIV infections. However, there remains 25 percent of the population who live with HIV, about 9 million people, who do not know their status. </p>
<p>While we have been necessarily focused on the head of the hydra in sub-Saharan Africa, other hydra heads are beginning to make their presence known, many in countries ill-prepared to deal with increases in the number of new HIV infections. </p>
<p>In the absence of a vaccine, behavior change in the form of condom use promotion, acceptance and adoption, at a scale that many gay men utilized during the peak of the AIDS epidemic in the industrialized world, will need to occur. There are many challenges: continued stigma and gender inequality, not to mention issues of availability, distribution and proactive, nonjudgmental promotion. </p>
<p>We must not forget. Progress on reducing the rate of new HIV infection has been done before. It can be done again, but only if we take forceful, funded action now.</p><img src="https://counter.theconversation.com/content/107765/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Miller does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>World AIDS Day is Dec. 1. With many advances in preventing and treating the disease, the disease has fallen from top of mind for many. An epidemiologist explains why that could be dangerous.Maureen Miller, Adjunct Associate Professor of Epidemiology, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1056412018-11-28T21:56:53Z2018-11-28T21:56:53ZWorld AIDS Day: Let’s stop criminalizing HIV status<figure><img src="https://images.theconversation.com/files/247621/original/file-20181127-76752-1wsxaw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">MP Boissonnault attended World AIDS Day flag raising on Parliament Hill, Dec. 1 2017.
</span> <span class="attribution"><span class="source">Gov't of Canada/LGBTQ2 Secretariat</span></span></figcaption></figure><p>In Canada, people living with HIV can be charged with not disclosing their HIV status to their sexual partners. Since 2004, there has been a <a href="http://www.aidslaw.ca/site/hiv-criminalization-in-canada-key-trends-and-patterns/?lang=en">marked increase in the number of people who have faced charges related to HIV non-disclosure</a>. </p>
<p>In a 1998 landmark case, the Supreme Court of Canada ruled that a person who does not disclose their HIV status and expose other people to a <a href="http://www.aidslaw.ca/site/criminalization-confusion-and-concerns-the-decade-since-the-cuerrier-decision-hivaids-policy-law-review-141/?lang=en">“significant risk” of HIV transmission, could be found guilty of aggravated assault</a> (the Cuerrier decision). </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/247617/original/file-20181127-76767-1or2kuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/247617/original/file-20181127-76767-1or2kuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=793&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247617/original/file-20181127-76767-1or2kuc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=793&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247617/original/file-20181127-76767-1or2kuc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=793&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247617/original/file-20181127-76767-1or2kuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=996&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247617/original/file-20181127-76767-1or2kuc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=996&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247617/original/file-20181127-76767-1or2kuc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=996&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man kneels to look at the Canadian AIDS Memorial Quilt at the Canadian Museum of Civilization on World AIDS Day in Hull, Que. on Dec. 1, 1996.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/ Jim Young</span></span>
</figcaption>
</figure>
<p>In October 2012, <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/10008/index.do">a Supreme Court of Canada ruling (the Mabior decision) intensified the impact of criminalization of HIV non-disclosure</a>. </p>
<p>Clato Mabior was charged with nine counts of sexual assault for HIV non-disclosure for having unprotected sex (limited condom use) with female identified complainants who did not contract HIV and to whom he did not disclose his HIV status. </p>
<p>Mabior was living with a low viral load. The Supreme Court determined that low viral load with no condom use meets the test for <a href="http://www.pivotlegal.org/scc_hivdecision">“a realistic possibility of transmission of HIV.”</a> </p>
<p>This ruling impacted people living with HIV as the justice system utilized a punitive approach causing people to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689876/">live in fear and mental anguish. It also led to a decrease in rates of HIV testing and other health services</a>. </p>
<p>However, in a severe complication of the case, one of the complainants was a 12-year-old girl. Most of the decriminalization advocates failed to address this separate critical factor of the vulnerability of children and women. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532909/">The age of consent in Canada for sexual activity is 16 years old</a>. </p>
<p>Instead of treating this as a unique case, the <a href="http://www.hivjustice.net/case/canada-mabior-sentenced-to-14-years/">mainstream media narrative further stigmatized people living with HIV and characterized Black men as sexual predators</a>. (Mabior is a Black Sudanese immigrant.)</p>
<p>People living with HIV are not synonymous with sexual violence, as this case and the legal criminalization of non-disclosure suggests. </p>
<p>The current legislation <a href="https://www.tandfonline.com/doi/abs/10.1080/09581596.2015.1052731">increases stigma and discrimination against people living with HIV and spreads misinformation</a>. Given the preexisting <a href="http://policyoptions.irpp.org/magazines/april-2018/doing-justice-by-black-canadians/">criminalization of Black people</a> in Canada — including experiences of historical and contemporary <a href="https://robynmaynard.com/">racial profiling and incarceration</a> — the criminalization of Black people living with HIV is not surprising. </p>
<h2>The stigma of HIV + racism</h2>
<p>Black people represent <a href="https://www.cpha.ca/sites/default/files/uploads/resources/stbbi/webinar-17-02-07.pdf">approximately 2.5 per cent of Canada’s population and 13.6 per cent of people living with HIV</a>. Data shows that among non-disclosure cases, where the race of the defendant is known, <a href="https://www.publicimpactpr.com/images/clients/can/callous_cold_report_final.pdf">only 36 per cent are Black, while 50 per cent are white</a>. Yet this study of media representation found that since 1989, 62 per cent of all newspaper articles about HIV non-disclosure cases have focused on Black defendants.</p>
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<img alt="" src="https://images.theconversation.com/files/247652/original/file-20181128-32197-92y8u9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/247652/original/file-20181128-32197-92y8u9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247652/original/file-20181128-32197-92y8u9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247652/original/file-20181128-32197-92y8u9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247652/original/file-20181128-32197-92y8u9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247652/original/file-20181128-32197-92y8u9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247652/original/file-20181128-32197-92y8u9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Graffiti with capital letters: HIV.</span>
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<p>Moreover, since 2012 <a href="http://www.accho.ca/Portals/3/documents/resources/ACCHO_Criminals_and_Victims_Nov2010_LoRes.pdf">the majority of high profile cases of persons <em>convicted</em> under HIV criminalization legislation in Canada were African/Black men</a>. </p>
<p>There is a direct correlation <a href="https://theconversation.com/racism-impacts-your-health-84112">between racism and the health of Black communities</a>. Yet the majority of HIV research <a href="https://www.accho.ca/en/Links-Resources">does not mention the “R” word (racism), or the implications of colonialism and other forms of violence in the lives of Black people living with HIV/AIDS</a>. </p>
<p>The Black Coalition for AIDS Prevention (<a href="http://www.blackcap.ca/">Black CAP</a>) and Africans in Partnership Against AIDS (<a href="http://www.apaa.ca/">APAA</a>) are two AIDS organizations supporting African/Black/Caribbean peoples and communities living with HIV — by linking resistance, racism, homophobia, anti-immigration and other forms of intersectional violence as part of their service and research agendas to dismantle HIV stigma. </p>
<h2>More research needed</h2>
<p>In some good news, last year on World’s AIDS Day, both the Canadian federal and Ontario provincial governments released a statement to address what they call the over-criminalization of HIV non-disclosure. They said science-based knowledge along with advancements in medical treatment showed that individuals living with HIV with a suppressed viral load over six months <a href="https://www.halco.org/2014/news/canadian-scientists-consensus-statement-on-hiv-and-its-transmission-in-the-context-of-criminal-law">do not present a risk of spreading the virus</a>. The Ontario government said <a href="https://www.thestar.com/news/gta/2017/12/01/ontario-will-limit-its-prosecution-of-hiv-non-disclosure-cases.html">Crown attorneys will no longer prosecute such cases</a>.</p>
<p>How will this new limitation impact African/Black community members who have been charged or are being charged with HIV non-disclosure? It remains to be seen. Will it help to decrease the stigma of people living with HIV? </p>
<p>Since the perspectives of Black women and men living with HIV on the criminalization of HIV disclosure have not been extensively examined in Canada, there has been an effective silencing of their voices, experiences and knowledge. </p>
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<span class="caption">A flurry of red hearts in recognition of World AIDS Day.</span>
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<p>My research hopes to fill this gap by exploring the impact of criminalization of HIV positive Black people in Greater Toronto Area. I use interviews and art-based methods. I have spoken with mental health practitioners and lawyers and judges working on the decriminalization of HIV. </p>
<p>My preliminary research findings indicate that those living with HIV have experienced increased surveillance and criminalization after the Supreme Court decisions. <a href="http://conference.ohtn.on.ca/past-conferences/2013/PDFs/147.pdf">This increased surveillance has made the HIV stigma worse and increased perceptions of anti-Black racism — leading to health vulnerabilities and insecurities, including mental and physical health impacts</a>. Housing and employment are significant challenges. It’s also important to remember the violence of criminalization of HIV non disclosure <a href="http://www.aidslaw.ca/site/wp-content/uploads/2013/04/Women_crim-ENG.pdf">impacts women living with HIV</a> in unique ways, increasing <a href="http://www.consentfilm.org/about-the-filmmakers/">violence and vulnerability</a> in their lives. </p>
<p>What I also observed is the continued mobilization and resistance in African Diasporic communities. </p>
<p>As a health researcher, health practitioner and community activist who has family and loved ones impacted by HIV, <a href="https://www.worldaidsday.org/about/">World’s AIDS Day</a> on Dec. 1 brings mixed emotions. Now in its 30th year, activists remember who we have lost and unite for the continued fight to eradicate HIV/AIDS. It is a day to demand better health treatment and resources for all those living with HIV.</p><img src="https://counter.theconversation.com/content/105641/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Roberta K. Timothy 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>In Canada, people living with HIV can be charged with not disclosing their HIV status to their sexual partners. There is evidence that Black men suffer the most under this criminalization.Roberta K. Timothy, Assistant Lecturer Global Health, Ethics and Human Rights School of Health, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1073682018-11-28T12:57:36Z2018-11-28T12:57:36ZOvercoming the real – and perceived – barriers to HIV testing<figure><img src="https://images.theconversation.com/files/246891/original/file-20181122-182059-1aqwx1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The WHO recommends testing for HIV every 6 to 12 months.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There was a time when HIV was untreatable, heavily stigmatised, and the benefits of testing weren’t as clear as they are now. But that was 25 years ago. </p>
<p>HIV testing remains the crucial entry point for all HIV services, including both prevention and treatment. </p>
<p>When someone tests and learns that they are HIV positive, there is an opportunity to access life-saving treatment, ensure their own well-being and that of their intimate partners. When someone tests and learns they are HIV negative, there is an opportunity to evaluate their risk and assess which HIV prevention options are the best fit for them.</p>
<p>UNAIDS <a href="http://www.unaids.org/sites/default/files/media_asset/Global_AIDS_update_2017_en.pdf#page=100">estimates</a> that 76% of people living with HIV in eastern and southern Africa know their status. While an HIV-positive diagnosis can still provoke fear among some, <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">85% of people with HIV</a> in South Africa know their status. </p>
<p>The goal is that by 2020, 90% of people with HIV should know <a href="https://www.spotlightnsp.co.za/2018/07/18/new-estimates-of-sas-progress-toward-90-90-90/">their status</a>. Increasing the uptake of testing is an essential first step in this quest, which is part of a package of goals aimed at ending the epidemic.</p>
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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>
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<p>Many people still struggle to overcome real and perceived barriers to testing. These include access to testing and the stigma related to testing. However many of the hurdles still in place might not be as big as once thought.</p>
<h2>What’s standing in the way of 90%</h2>
<p><strong>Access:</strong> HIV testing is free in South Africa in all public clinics and health facilities, but for many people just getting to the clinic can seem like a major barrier. Whether this is because of long walking distances, the need to take time off work, or simply not prioritising or having the time to build testing into their health care routine.</p>
<p>One solution lies in the advent – and increasing availability – of <a href="https://sajhivmed.org.za/index.php/hivmed/article/view/775/1030">HIV self-testing</a> kits. Now getting an HIV test can be as simple as going to the pharmacy and following the instructions.</p>
<p><strong>Being judged:</strong> A common concern is around confidentiality and being judged. This is especially evident among young people who are at risk of HIV infection, but may feel as if they would be judged for being sexually active. It’s estimated that <a href="https://www.gov.za/sites/default/files/nsp%20hiv%20tb%20sti_a.pdf">2000</a> adolescent girls and young women in South Africa are infected every week. </p>
<p>This problem needs to be tackled by helping young people access testing. This can be done by providing <a href="http://opensaldru.uct.ac.za/bitstream/handle/11090/813/201604_SaldruPolicyBrief_02.pdf?sequence=1">youth friendly services</a> where health care professionals are friendly, non-judgemental and supportive. Testing must be normalised and seen as an appropriate, responsible and acceptable thing to do. Many clinics already undergo training and accreditation for the provision of adolescent and youth friendly services. But it’s not universal.</p>
<p><strong>Stigma:</strong> Aside from stigma around HIV, many <a href="http://www.unaids.org/en/topic/key-populations">high-risk groups</a> (such as sex workers, men who have sex with men, and injecting drug users) still face enormous barriers to accessing traditional services due to stigmatisation, discrimination and even criminalisation. This is especially true in sub-Saharan Africa where <a href="https://www.iasociety.org/The-latest/News/ArticleID/209/Condemning-Tanzania%E2%80%99s-anti-gay-initiatives">anti-LGBTI laws</a> are rife and few protective mechanisms exist.</p>
<p>The way this can be solved is by ensuring that testing campaigns and environments encourage everyone to test. More work must be done to combat bad laws and policies, stigma and discrimination. The fight should be against the virus, and not the people it targets.</p>
<p><strong>Low risk perception:</strong> The World Health Organisation and the South African government recommend testing every six to 12 months. But most people only test when they feel they have been at risk. Risk perception is highly subjective and sometimes incorrect. In a South African context, where the prevalence of HIV is so high – <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">20.6%</a> of adults aged 15 to 49 years have HIV – everyone is at risk and should get tested every year.</p>
<p>To encourage people to test more frequently, campaigns should continue to focus on the fact that HIV doesn’t discriminate. HIV testing also increases the opportunity to screen for multiple conditions, such as tuberculosis and other sexually transmitted infections, at the same time. This integration of HIV testing services with other health services is seen as a way of reducing stigma, increasing access, and is a move towards achieving universal health care.</p><img src="https://counter.theconversation.com/content/107368/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from various research agencies both local and international. She is the immediate past president of the International AIDS Society. </span></em></p>Knowing your HIV status is key to accessing life-saving treatment or evaluating the best prevention options.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1005092018-11-28T12:57:34Z2018-11-28T12:57:34ZBabies born to mums with HIV face higher risks even though they’re HIV negative<figure><img src="https://images.theconversation.com/files/246685/original/file-20181121-161641-w8psje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The largest number of HIV-exposed but uninfected children are in South Africa.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>One of the most remarkable public health successes of the last decade in southern Africa has been the reduction in the number of babies born with HIV. This was achieved through the provision of antiretroviral therapy to pregnant and breastfeeding women living with HIV. For example, the number of new HIV infections in children in South Africa has come down from a peak of 70 000 in 2003 to 13 000 in <a href="http://aidsinfo.unaids.org">2017</a>.</p>
<p>Nevertheless, worldwide there are still an estimated <a href="http://aidsinfo.unaids.org">14.8 million</a> children under the age of 15 who were born HIV uninfected but have been exposed to their mother’s HIV during pregnancy.</p>
<p>The largest number of HIV-exposed but uninfected children – <a href="http://aidsinfo.unaids.org">3.2 million</a> – are in South Africa.</p>
<p>A staggering <a href="http://www.health.gov.za/index.php/shortcodes/2015-03-29-10-42-47/2015-04-30-08-18-10/2015-04-30-08-21-56?download=2584:2015-national-antenatal-hiv-prevalence-survey-final-23oct17">30%</a> of pregnant women in South Africa have HIV. Their infants are exposed to both HIV and antiretroviral drugs during pregnancy and breastfeeding. HIV-exposed but uninfected children don’t have HIV, so what’s the big deal?</p>
<p>It is a big deal because HIV-uninfected children born to mothers with HIV are prone to infections that are more severe, are at almost two times greater risk of dying before their first birthday, and are more likely to be born prematurely than children born to mothers without HIV. </p>
<p>In our <a href="https://www.ncbi.nlm.nih.gov/pubmed/30321432">recent study</a> we set out to try and quantify the contribution of deaths in HIV-exposed but uninfected infants to the overall infant mortality rates in Botswana and South Africa.</p>
<p>What we found was that because children born to mothers with HIV make up almost 1 in every 4 infants in Botswana and South Africa, and because they die more often than children born to mothers without HIV – even when they are HIV-uninfected themselves – this contributed to a higher infant mortality rate in both countries.</p>
<h2>The risks</h2>
<p>Even when they’re not HIV infected, children born to women with HIV experience a complex package of detrimental exposures. </p>
<p>For example, HIV-exposed but uninfected infants are still more often born <a href="https://www.ncbi.nlm.nih.gov/pubmed/29040569">preterm or of low birth weight</a>. This increases their risk for complications and death early in life. </p>
<p>They are also exposed to more infectious pathogens in the home such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/27393540">tuberculosis</a>. </p>
<p>There are other problems too. Breastfeeding has enormous nutritional and immunological benefits, but has often been avoided in infants born to women with HIV. Maternal access to antiretrovirals has made it safer but sustained breastfeeding is still low. One study in South Africa showed that, irrespective of HIV-status, women stopped <a href="https://www.ncbi.nlm.nih.gov/pubmed/29959720">breastfeeding</a> their babies on average when the infants were eight weeks old.</p>
<p>On top of this, HIV-exposed infants more often have mothers who are unwell or <a href="https://www.ncbi.nlm.nih.gov/pubmed/27091659">who have died</a>. And HIV-affected households experience challenging socioeconomic <a href="https://www.ncbi.nlm.nih.gov/pubmed/27392008">circumstances</a> that can make children more vulnerable. These exposures in the <a href="http://www.who.int/maternal_child_adolescent/child/nurturing-care-framework/en/">first 1000 days of life</a> can be detrimental to early childhood development and have life-long consequences. </p>
<p>In addition, infants born to women with HIV are subject to factors during pregnancy that unexposed infants aren’t. These include exposure to HIV particles, that may make their <a href="https://www.ncbi.nlm.nih.gov/pubmed/27049574">immune systems</a> develop differently. And these infants are exposed to at least three antiretroviral drugs given to the mother during pregnancy. </p>
<h2>What the research found</h2>
<p>To estimate the contribution of deaths in HIV-exposed but uninfected infants to the overall infant mortality rates we used previously published research comparing the mortality risk in HIV-exposed uninfected infants to risk of mortality in <a href="https://www.ncbi.nlm.nih.gov/pubmed/27456985">unexposed infants</a>, as well as United Nations estimates of infant mortality in Botswana and South Africa. </p>
<p>In Botswana, HIV exposed uninfected infants accounted for 26% of the infant population but 42% of all infant deaths. Similarly, in South Africa HIV exposed uninfected infants accounted for 23% of the infant population but 38% of all infant deaths. </p>
<p>Putting this into actual numbers, this extra mortality in HIV exposed uninfected infants increased the overall HIV-uninfected infant mortality rate in both Botswana and South Africa from around 30 deaths per 1000 infants to 35 deaths per 1000 in the year 2013. </p>
<p>Botswana and South Africa have adopted the World Health Organisation’s recommendation to provide lifelong antiretrovirals to all pregnant and breastfeeding women with HIV. But there’s a lack of research comparing the mortality of HIV-exposed to unexposed infants under these new guidelines. Our calculations are therefore based on the year 2013, the most recent year before policy shifts in both countries. There is emerging <a href="https://www.ncbi.nlm.nih.gov/pubmed/29272387">evidence</a> though of a persisting increase in mortality in HIV-exposed infants even with maternal antiretroviral therapy. </p>
<h2>What next</h2>
<p>With 1 in every 4 children in Botswana and South Africa being HIV and ARV-exposed, robust systems need to be put in place to monitor the long-term safety of these exposures during pregnancy. Countries need to invest in research to understand why HIV-exposed children still have an increased risk of dying. And countries need to ensure that routine child health interventions, such as immunisations and promotion of optimal durations of breastfeeding, are uniformly reaching HIV-exposed children.</p>
<p>Most critically, countries like South Africa and Botswana with high HIV infection rates need to find responsible, transparent and accurate ways of sharing what is known and being done about the risks of HIV-exposure with HIV-affected families and involve them in finding solutions.</p><img src="https://counter.theconversation.com/content/100509/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Slogrove receives funding from research funding agencies on a competitive funding basis including the US National Institutes of Health and the International AIDS Society. </span></em></p><p class="fine-print"><em><span>Kathleen M. Powis receives funding from the National Institute of Health and from the Collaborative Initiative for Pediatric HIV Education and Research. </span></em></p><p class="fine-print"><em><span>Mary-Ann Davies receives funding from research funding agencies on a competitive basis including the National Institutes of Health and the International AIDS Society.</span></em></p>HIV negative children born to women with HIV have a greater risk of dying before their first birthday.Amy Slogrove, Senior lecturer in Paediatrics and Child Health, Stellenbosch UniversityKathleen M. Powis, Assistant Professor, Harvard UniversityMary-Ann Davies, Associate Professor and Director of the Centre for Infectious Diseases Epidemiology and Research, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1073882018-11-28T12:57:31Z2018-11-28T12:57:31ZLiver transplant from HIV+ living donor to negative recipient: the unanswered questions<figure><img src="https://images.theconversation.com/files/247683/original/file-20181128-32230-1q19ef7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More than a year after a groundbreaking liver transplant doctors still can't say if the recipient is HIV-positive or not.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A lifesaving partial liver transplant from an HIV-infected mother to her uninfected child – the first of its kind – was conducted last year at the University of the Witwatersrand’s <a href="http://www.dgmc.co.za/">Donald Gordon Medical Centre</a> in Johannesburg. More than a year later, both mother and child are doing well. </p>
<p>But the crucial question of the child’s HIV infection status remains unanswered. And we don’t expect to have a definitive answer any time soon.</p>
<p>Despite this uncertainty, the story of the transplant is inspiring. To date there have been no published reports of a living organ donation by a person with HIV, or of an intentional transplant from an HIV-positive to HIV-negative individual. The operation was driven by a number of factors. These included life-threatening liver failure in the child, no available deceased or suitable live HIV-uninfected donors, and an HIV-positive mother’s continued pleas to be allowed to save her child.</p>
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<p>We’ve learned a great deal from the operation and during the subsequent year. Most importantly, the success of this transplant provides a new therapeutic option for similar cases in high burden HIV countries where deceased donor organs are limited in number, or where access is limited. </p>
<p>But there are still gaps in our knowledge. The biggest is what the long term effect of the transplant will be on the child, and particularly whether the mother’s virus was transferred with the liver.</p>
<h2>The journey</h2>
<p>The child was 13 months old when the transplant happened. The liver has a remarkable ability to regenerate and grows back to its normal size in the donor in about six weeks.</p>
<p>Although born to an HIV-positive mother, the child did not have HIV. The mother was on antiretroviral therapy during pregnancy, and the child received standard preventative treatment. </p>
<p>The mom had an undetectable virus ahead of the transplant. The child also received antiretrovirals ahead of the transplant to try and prevent infection. Both mom and child are still on HIV treatment today. The child is also on immunosuppressive therapy to prevent liver rejection.</p>
<p>After the transplant, the child was tested for HIV. No virus was detected. Very sensitive tests also couldn’t detect traces of the virus within cells. This means that, one year on, there is no direct evidence of virus in the blood or blood cells. </p>
<p>But there is a caveat. Just because we can’t detect the virus doesn’t mean it isn’t hiding in very small amounts.</p>
<p>There’s another reason we can’t conclusively say whether the child is infected or not: 43 days after the operation HIV antibodies were detected in the child using standard diagnostic tests. But these antibodies have since decreased in amount. Normally, the presence of HIV antibodies means a person has been infected. But in this case, we can’t tell if these antibodies belong to the child or the mother (or both) because of the donor cells in the liver. </p>
<p>Because of these uncertainties, treatment is being continued for the moment. Whether this will be lifelong remains one of many open and unanswered questions.</p>
<h2>Unanswered questions</h2>
<p>The operation, and subsequent events, have put us on the cusp of new insights and understanding about HIV and its transmission.</p>
<p>We’ve been able to get some insights from previous events. For example, the transfer of <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/lt.21534">HIV through liver transplantation</a> has accidentally happened where deceased donors unknowingly had HIV. In all cases there was clear evidence of HIV infection in the recipient. </p>
<p>There are lots of other examples – not HIV related – of the transfer of specific immune responses from a donor to the recipient. An interesting one is the transfer of an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5716392/pdf/jaa-10-307.pdf">allergic reaction to peanuts</a> in cases where the recipients had no prior history of peanut allergy but developed reactions following transplantation. Such transfer of donor immune responses is why we can’t use our standard HIV antibody tests for a conclusive diagnosis of recipient HIV infection in the setting of transplantation.</p>
<p>Two factors make the situation we find ourselves in unique: it’s the first time that liver tissue from an HIV positive living person has been transplanted to a HIV-negative person. The second is that the liver is very different to other organs. </p>
<p>The liver is the major draining organ for substances passing through the gut. Because of its role in metabolism, nutrient storage and detoxification it needs to distinguish foreign particles that are good (food) from those that are bad (pathogens). That’s what makes it immunologically tolerant. Tolerance means the immune system is geared to prevent an overreaction to good molecules. </p>
<p>It’s not known how this tolerance might affect the risk of HIV infection. <a href="https://ac.els-cdn.com/S0042682213004467/1-s2.0-S0042682213004467-main.pdf?_tid=e43f8179-6c5c-4179-b987-73993a086539&acdnat=1543316015_bbbc31f6c2e624b1937f3ad5276edd61">Studies</a> on monkeys have shown an absence of actively infected cells in the liver compared with other organs. The presence of antiretrovirals in our transplant mom-child case would make the presence of actively infected cells even less likely. </p>
<p>On the other hand, latent or “silently” infected cells which are very difficult to detect could be present in small numbers and pose a potential risk of sparking an infection if antiretroviral treatment were ever stopped.</p>
<h2>The way forward</h2>
<p>There are still many gaps in our knowledge. For example, we need to understand HIV in the liver of patients who are on antiretrovirals and virally suppressed. </p>
<p>We also need to have a better understanding of this novel type of HIV exposure so that we can inform best practice in the setting of HIV-positive donor liver transplants. </p>
<p>Studies of this case and of further transplants of this nature will help us to fill in these knowledge gaps. </p>
<p>The ultimate aim is to have the best of both worlds – a life-saving intervention together with successful prevention of HIV infection in the transplant recipient.</p><img src="https://counter.theconversation.com/content/107388/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline T. Tiemessen receives research funding from the South African Medical Research Council (MRC) Strategic Health Innovation Partnerships (SHIP) programme, Department of Science and Technology/National Research Foundation (DST/NRF) South Africans Chair Initiative (SARChI) programme, Poliomyelitis Research Foundation (PRF), and the US National Institutes of Health (NIH).</span></em></p>A liver transplant from an HIV-positive living donor to an HIV-negative recipient is possible, but there are still gaps in our knowledge.Caroline T. Tiemessen, Head: Cell Biology, Centre for HIV and STIs, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1076222018-11-28T12:57:30Z2018-11-28T12:57:30ZSelf-testing: a potentially powerful tool for fighting HIV<figure><img src="https://images.theconversation.com/files/247721/original/file-20181128-32208-fqhl7g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The theme for World Aids Day is "know your status". </span> <span class="attribution"><span class="source">EPA</span></span></figcaption></figure><p>In recent years, more emphasis has been placed on testing for HIV. The idea behind this drive is that if people know their status, they’ll be able to seek treatment and support. One approach that’s become fairly common is self-testing, or <a href="http://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf;jsessionid=4368C00514D95782E3718B5D1599966D?sequence=1">self-screening</a>.</p>
<p>This is when a person collects their own specimen (blood or oral fluid), performs a rapid diagnostic test and interprets the result themselves. This type of test can also be done by a health provider or peer educator. The blood is obtained by pricking one’s finger; the oral fluid is swabbed from the inside of your cheek.</p>
<p>The rapid diagnostic test detects HIV antibodies in the blood or oral fluid. If the result is positive, people are encouraged to go and get their blood tested by a professional for confirmation.</p>
<p>Self-screening for HIV has been touted as a disruptive innovation: one that can help to close the HIV testing gap by reaching key and under-tested populations who won’t necessarily want to visit a doctor or clinic for testing. These under-tested populations include sex workers, men who have sex with men and young women aged between 15 and 24.</p>
<p>Research shows that HIV self-screening yields <a href="https://www.ncbi.nlm.nih.gov/pubmed/28530049">highly accurate results</a> even when carried out by untrained lay people. Two years ago the World Health Organisation published <a href="http://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf;jsessionid=4368C00514D95782E3718B5D1599966D?sequence=1">guidelines</a> recommending that self-screening be included in countries’ existing testing services. So far, 59 countries have implemented HIV self-screening policies and 53 others developing these policies. </p>
<p>Access to HIV testing is an important factor in reaching the United Nations’ “90-90-90” goal: by the year 2020, 90% of people with HIV must know their status, 90% of people with HIV must be on antiretroviral treatment, and 90% of people on treatment must be virally suppressed.</p>
<p>It’s estimated that <a href="http://www.who.int/hiv/topics/self-testing/en/">only 75%</a> of people around the world know their HIV status. This figure is higher in South Africa where an estimated <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">85% of people</a> with HIV know their status. </p>
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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>
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<p>To help South Africa reach this first “90”, my colleagues and I at the <a href="http://www.wrhi.ac.za/">University of the Witwatersrand, Wits Reproductive Health and HIV Institute</a> are collaborating with a number of organisations to scale up HIV self-screening among under tested populations. These include men, who have lower testing rates than the general population, young people, sex workers and their networks (clients, partners and peers).</p>
<h2>Self-screening</h2>
<p>From November 2017 to September 2018, we distributed HIV self-screening kits to primary recipients (clients directly receiving the kit) and secondary recipients (people related to primary recipients, for example their sexual partners). These were distributed in four of the country’s nine provinces. </p>
<p>The kits were handed out in a number of different places including existing HIV testing mobile services, and selected spaces in communities such as shopping centres. HIV self-screening kits were also distributed in workplaces, taxi ranks, and at health facilities for partners of pregnant women and people living with HIV. Participants in our <a href="http://www.wrhi.ac.za/uploads/files/Wits_RHI_Annual_Review_2017.pdf">sex worker programmes</a> were also given self-screening kits to share with their networks. </p>
<p>As part of the initiative, follow-ups were done telephonically with a randomly selected and representative sample of people who received kits in communities, workplaces and taxi ranks. We also followed up with everybody who received self-screening kits at health facilities and through our sex worker programmes.<br>
The aim is to encourage people to use the HIV self-screening kits and interpreting the results themselves. If the results are positive, the person must have the results confirmed by a health professional. If the results are still positive, the person should start HIV treatment immediately. </p>
<p>By the end of September 2018, we had distributed 505 836 kits. A majority – 62% – went to men; 12% were received by people who had never tested for HIV before; and 45% of the recipients had not tested in the last year. The WHO recommends testing for HIV every six to 12 months. </p>
<p>In less than a year we were able to reach the target populations. Our project is ongoing and forms part of a Unitaid-funded <a href="http://hivstar.lshtm.ac.uk/news/">HIV self-testing Africa initiative</a>, which is evaluating HIV self-screening around the continent.</p>
<p>Our findings, is informing the implementation of HIV self-testing in South Africa, and other countries. The findings will also be published in open access journals early next year. </p>
<p><em>Mohammed Majam, technical head of HIV Self-Testing at the Wits Reproductive Health and HIV Institute contributed to this article.</em></p><img src="https://counter.theconversation.com/content/107622/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joel Msafiri Francis received funding from HIV Research Trust, UK, THRiVE consortium, Global Fund Round 8 (HIV-Initiative), HIV Implementation Science fellowship, NIH grant through Harvard School of Public Health, Global Health Department.</span></em></p>Access to HIV testing is an important factor in reaching UN goals that 90% of people with HIV must know their status by 2020.Joel Msafiri Francis, Epidemiologist, Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/700052016-12-14T14:49:44Z2016-12-14T14:49:44ZHIV has no borders, but its treatment does. Why this needs to change<figure><img src="https://images.theconversation.com/files/149830/original/image-20161213-1608-1an6hv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Zimbabweans living with HIV who come to South Africa often have challenges remaining on their antiretroviral treatment regimens. </span> <span class="attribution"><span class="source">Henk Kruger</span></span></figcaption></figure><p>Panashe is a 26-year-old Zimbabwean woman living with HIV. She works in a restaurant on the western peripheries of Johannesburg. </p>
<p>She has known she is HIV positive since she was 20 years old living in Harare, Zimbabwe. This is where she started her antiretroviral treatment. She takes her antiretrovirals religiously and without problems. But this was not always the case. </p>
<p>When Panashe moved from Zimbabwe to South Africa in 2012 as an asylum seeker, she encountered problems with her treatment. Continuing treatment in the new country was a challenging and disorienting affair.</p>
<p>Antiretroviral treatment has been freely available in South Africa since 2007 and asylum seekers and refugees are eligible for treatment. But when Panashe arrived in South Africa, she was forced to change her treatment regimen. Antiretroviral regimens are the drug combinations people living with HIV are put on. The specific regimen depends on the antiretrovirals that the country makes available.</p>
<p>The forced regimen change meant that she had severe side effects which made her sick and nearly made her stop taking medication – a move which would have compromised her health. After a few weeks she adapted to the change, but her challenges reveal a wider problem.</p>
<p>The change happened because there are no regionally implemented and adopted treatment guidelines or referral systems for cross-border migrants who need antiretrovirals.</p>
<p>South Africa and Zimbabwe have made significant strides rolling out antiretroviral programmes. But Panashe’s story shows that the regional expansion of antiretroviral programmes still needs much work and needs to integrate migration. </p>
<p>This requires the regional harmonisation of treatment regimens and protocols and for regional referral systems to be developed. These systems should provide information about the possibilities of HIV treatment across borders at a clinic level and inclusion of foreign nationals into local support groups.</p>
<h2>Crossing the border</h2>
<p>Our ongoing research has been looking at the links between health and migration across borders in the southern Africa region. As part of our research we have spoken to government officials, researchers, funders and non-governmental organisations. </p>
<p>We found that despite the economic and political challenges in Zimbabwe over the past two decades, it has a relatively well functioning and expansive antiretroviral programme. There are some challenges, in particular delays in starting treatment. </p>
<p>But more than 1500 sites offer antiretrovirals and treatment for the prevention of mother to child transmission of HIV.</p>
<p>There are about 1.4 million people living with HIV in Zimbabwe, compared to around seven million in South Africa. About <a href="http://aidsinfo.unaids.org">62% of people who are eligible for treatment</a> take antiretrovirals. This is better than South Africa where only 48% are on medication.</p>
<p>There is no reliable data on migrants accessing or needing antiretrovirals in South Africa or the countries in the <a href="http://www.sadc.int/">Southern African Development Community</a>. But there are both Zimbabweans going to South Africa and Zimbabweans returning home. These migrants encounter three main challenges with cross border treatment. </p>
<p>Firstly, there is no standardised referral system. This means that cross-border migrants are sometimes unable to continue with the same treatment and are forced to change treatment regimes. They may risk missing treatment while registering in a new system. </p>
<p>Missed treatment or poor adherence and management of treatment can lead to the development of <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2016/february/20160208_Drug_resistance">drug resistant strains of HIV</a> which contributes to treatment failure. </p>
<p>This relates to the two other problems: changes in treatment and a lack of information.</p>
<p>Regimen changes are possible but can be daunting for people living with HIV on treatment. Treatment regimens in the region are very similar and changes can be managed effectively. But regimen changes can <a href="https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/16/regimen-switching-in-the-setting-of-virologic-suppression">produce changes</a> in side effects, and ordinarily require intensive monitoring.</p>
<p>Ordinarily, treatment regimen change is made in cases where there is viral resistance to a particular regimen, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716274/">or when side effects are particularly severe</a>.</p>
<p>Thirdly, information provided to patients about moving treatment sites across borders is scarce. Often providing additional pills in case of mobility is left to the discretion of doctors, and little information is provided about how to go about transfers.</p>
<p>Cross-border migrants often do not know how to negotiate foreign systems, <a href="http://www.scielo.org.za/scielo.php?pid=S0256-95742016000100007&script=sci_arttext&tlng=en">and sometimes have to deal with xenophobia in clinics</a>.</p>
<h2>Some progress</h2>
<p>The Southern African Development Community is yet to harmonise treatment protocols which could improve HIV services for migrants. </p>
<p>In the last 10 years there have been ongoing regional policy discussions. There has been a <a href="http://www.scielo.org.za/scielo.php?pid=S0256-95742016000100007&script=sci_arttext&tlng=en">significant movement</a> towards regional harmonisation but there are still challenges.</p>
<p>There is the <a href="http://www.arasa.info/files/6613/7574/3254/SADC_Policy_Framework_FINAL.pdf">2009 Policy Framework for Population Mobility and Communicable Diseases in the SADC Region</a>. It calls for coordinated cross-border referral services and mechanisms for continuity of care for patients with communicable diseases. Diseases which require prolonged treatment such as TB and HIV are recognised as particularly important.</p>
<p>But these guidelines have not been adopted and implemented at a regional level. </p>
<p>South Africa’s national Department of Health has been working on a new internal referral policy which would also address cross-border referrals, but is also yet to be implemented.</p>
<p>The policy should ensure that patients don’t miss treatment when travelling or migrating and that migrants are supported with treatment continuation when, and if, they return home. </p>
<p>For Panashe, this would make decisions about her future far easier. For now, however, she fears having to change her treatment again and lacks information on how she would transfer her treatment back to Zimbabwe.</p><img src="https://counter.theconversation.com/content/70005/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Wilhelm-Solomon receives funding from The Wellcome Trust. He is a fellow with Migration and Health Project Southern Africa which is based at the African Centre for Migration and Society.</span></em></p>South Africa and Zimbabwe have made significant strides to roll out antiretrovirals. But the regional expansion of treatment programmes still needs work.Matthew Wilhelm-Solomon, Writing fellow at the African Centre for Migration Studies, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/694992016-12-06T14:30:27Z2016-12-06T14:30:27ZWhat can be done to turn the tide of HIV among young girls in sub-Saharan Africa<figure><img src="https://images.theconversation.com/files/148596/original/image-20161205-19399-1hbqxjo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A young woman performs at an HIV prevention campaign during the International Aids Conference 2016.</span> <span class="attribution"><span class="source">International AIDS Society/Abhi Indrarajan</span></span></figcaption></figure><p>There’s a lot of good news about HIV/AIDS. Worldwide there has been a <a href="http://www.unaids.org/en/resources/campaigns/get-on-the-fast-track">steady decline</a> in the number of people between the ages of 15 and 24 being infected with HIV. The decline has been linked to behaviour changes such as waiting longer to become sexually active, having fewer multiple sex partners and using condoms in multiple partnerships. </p>
<p>In South Africa, however, this is not the case. The drop in the number of adolescent girls and young women becoming HIV positive is too slow and too little. In 2012 11.4% of young women aged 15 to 24 were HIV positive compared to <a href="http://www.hsrc.ac.za/uploads/pageContent/4565/SABSSM%20IV%20LEO%20final.pdf">2.9% of young men</a>. Four years earlier, this figure sat at 13.9% for young women compared to <a href="https://www.health-e.org.za/wp-content/uploads/2013/05/2966e129fc39e07486250fd47fcc266e.pdf">3.6% of young men</a>. </p>
<p>And when you put this in the context of the global picture it is equally as startling: <a href="http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview">42% of new HIV infections</a> occur in people aged between 12 and 24. Nearly 80% of these young people live in sub-Saharan Africa. And more than 70% of these infections occur in adolescent girls and young women.</p>
<p>Not only do these adolescent girls and young women have higher rates of HIV, they also acquire infection between five and seven years earlier than their male peers. </p>
<p>The quest to stem these infections is an important part of reducing the high rates of HIV among adolescent girls and young women in sub-Saharan Africa. Knowing your HIV status is an important part of this. But in South Africa this knowledge remains very low. Less than 50% of young people know their status. South Africa is worse off than many other countries. </p>
<p>So how can the country ensure that more adolescent girls are able to test for HIV and, where necessary, start taking antiretrovirals?</p>
<p>The answer lies in implementing extensive combination prevention programmes in high-prevalence settings for both men and women. This needs to include early antiretroviral treatment, provision of pre-exposure prophylaxis and medical male circumcision. There also needs to be a concerted effort to promote knowledge of HIV status, comprehensive age appropriate education in schools, economic empowerment and easy access to sexual and reproductive health services. </p>
<h2>Why are women so vulnerable</h2>
<p>The persistently high gender imbalance of HIV among young people has led to an increase in research to understand the disparate burden and associated risks facing adolescent girls and young women. </p>
<p>A number of contributory factors have been identified. </p>
<p>Part of the disconnect among women about their HIV status and their vulnerability relates to their perceptions that they have a low risk to HIV. This in turn perpetuates vulnerability to HIV, particularly in situations of high household poverty levels and unemployment.</p>
<p>Living in a society where patriarchy is embedded and gender inequality is rife also plays a major role. In these settings young women and girls are often limited from reaching their full potential because they do not finish school. Studies have shown that premature school leavers are more disadvantaged and that women who finish school have better job opportunities and the ability to make better life decisions.</p>
<p>Much attention has been paid to the role that age-disparate heterosexual relationships may play in this gender imbalance. <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159162">Several studies</a> show when there are larger age differences among sex partners, there is a higher chance of condoms not being used. This in turn leads to higher rates of sexually transmitted infections among adolescent girls and young women. </p>
<h2>Cycle of HIV transmission</h2>
<p>A <a href="http://link.springer.com/article/10.1007%2Fs11904-016-0314-z">recent study</a> involving women living in areas where HIV prevalence is as high as 66% among women in their 30s shows that the greatest difference in HIV prevalence is among men and women in the younger age groups. This reinforces the notion that women on average acquire HIV at a younger age than men.</p>
<p>The study helped explain a continuous “cycle of HIV transmission” between older men and younger women. But this transmission heightens the vulnerability of adolescent girls and young women to HIV. </p>
<p>This is because most younger women (aged 15 to 25) had male partners on average up to nine years older than them. Adolescent girls and young women in these age-disparate relationships are generally unable to negotiate safer sex practices involving the use of condoms, increasing the chance of them contracting HIV.</p>
<p>These women who acquire HIV, over time once they reach the age of 25, also have relationships with men of their own age who in turn acquire HIV. These men then have new relationships with younger women aged 15 to 25, spreading the virus and contributing to the cycle of HIV transmission. </p>
<h2>Programmes that work</h2>
<p>South Africa has made substantial progress in the large scale roll-out of HIV prevention and treatment programmes and has the <a href="https://africacheck.org/reports/yes-south-africa-has-the-worlds-largest-antiretroviral-therapy-programme/">largest antiretroviral programme</a> in the world. But young women are uniquely vulnerable to infection, and preventing HIV acquisition in this key population is a public health imperative.</p>
<p>Understanding the cycle of transmission and the sexual networks that drive HIV transmission could help design programmes to reduce HIV infection in adolescent girls and young women.</p>
<p>There are many <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2015/november/20151117_dreams">programmes</a> which could help adolescent girls and young women making an informed decision. These programmes also increase and retain their attendance in schools, reduce teenage pregnancies and gender-based violence and increase economic opportunities for young people. Most importantly they interrupt the cycle of transmission and decrease new HIV infections. </p>
<p>While these programmes exist, in many instances they are not delivered in the most appropriate way that ensures they influence young women’s thinking.</p><img src="https://counter.theconversation.com/content/69499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ayesha BM Kharsany 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>Stemming high HIV rates among adolescent girls and young women in sub-Saharan Africa has become a challenge due to the cycle of transmission.Ayesha BM Kharsany, Senior Scientist at CAPRISA, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/692702016-12-04T18:20:04Z2016-12-04T18:20:04ZMale circumcision in Uganda will only improve if local beliefs are considered<figure><img src="https://images.theconversation.com/files/147947/original/image-20161129-10945-10lk4rv.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">Reuters/Simphiwe Sibeko</span></span></figcaption></figure><p>For the past 10 years voluntary medical male circumcision has been recommended as a way of reducing female-to-male transmission of HIV. Estimates show that it could <a href="http://dx.doi.org/10.1080/17441692.2014.989532">reduce infections by 60%</a>. Several sub-Saharan African countries with high rates of HIV prevalence but low rates of male circumcision have rolled out the procedure as part of their HIV prevention initiatives.</p>
<p>Since 2007 more than 9 million circumcisions have been performed in <a href="http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/">eastern and southern Africa</a>. But to cover more than 80% of men on the continent by 2025, about 20 million more men need to be circumcised. If this happens about <a href="http://dx.doi.org/10.1371/journal.pmed.1001132">3.4 million new HIV infections</a> could be averted, reducing the number of people who would need HIV treatment and care.</p>
<p>While circumcision has been encouraged there are <a href="http://dx.doi.org/10.1016/j.socscimed.2015.04.020">many places</a> where it has <a href="http://dx.doi.org/10.1080/13557858.2013.772326">faced challenges</a>. This is linked to misconceptions about the purpose of circumcision as well as religious and cultural concerns which prevent men from getting circumcised. </p>
<p>Uganda is a case in point. By the end of 2015 the country’s health ministry aimed to circumcise 80% – <a href="http://health.go.ug/docs/UAIS_2011_KEY_FINDINGS.pdf">or 4.2 million</a> – men aged between 15 and 49. But between 2008 to 2013 the country only managed to <a href="http://www.aidsuganda.org/resource-center/downloads/%20doc_download/3-consolidated-q-3-supervision-report-may-2014">circumcise 50% of this population</a>. Most of these were young boys.</p>
<p><a href="http://dx.doi.org/10.2989/16085906.2016.1179652">Our research</a> found that religious and cultural beliefs compete with the messages about the purpose of circumcision. We found that this got in the way of men deciding whether or not to be circumcised medically and also affected the way they behaved afterwards. </p>
<p>When medical circumcision is introduced in settings where there are high rates of HIV, it must take into account local beliefs about circumcision. And local religious and social group leaders and women must be involved in the roll-out.</p>
<h2>Conflicts of belief</h2>
<p><a href="http://dx.doi.org/10.1016/j.socscimed.2015.04.020">Several studies</a> have compared uptake of circumcision in societies where there is a tradition of circumcision and those where there are not. </p>
<p>When circumcision is not part of religious or cultural practices, introducing voluntary male circumcision can be problematic because it is associated with ethnic and religious identities. This is the case in <a href="http://dx.doi.org/10.1080/17441692.2015.1006241">Zimbabwe</a>, <a href="http://dx.doi.org/10.1080/09540120220097919">Kenya</a>, and parts of <a href="http://dx.doi.org/10.1080/13691058.2013.807519">South Africa</a> where there are both social and cultural barriers to circumcision. </p>
<p>In Uganda, only <a href="http://www.who.int/bulletin/volumes/88/12/09-072975/en/">20% of men practice traditional male circumcision</a> for cultural and religious reasons. This is considerably lower than Kenya (80%) or Tanzania (70%) but similar to many other southern African countries.</p>
<p>We conducted a study of the beliefs and perceptions about circumcision in fishing villages on the shores of Lake Victoria, Uganda. The villages were part of an HIV combination prevention pilot study. </p>
<p>The overall aim of the trial was to investigate factors limiting access to HIV prevention interventions and to determine the feasibility of conducting an HIV combination prevention effectiveness trial to reduce HIV incidence among fishing communities in Uganda. </p>
<p>HIV combination prevention packages would include male circumcision along with access to antiretrovirals, prevention of mother to child transmission, condom promotion, counselling and testing, and health education. </p>
<p>We looked at the influence that different understandings and beliefs about male circumcision may have on voluntary male circumcision in the fishing communities, which are ethnically mixed and have high HIV prevalence. </p>
<p>In Uganda just over <a href="http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/uganda">7% of the population</a> is living with HIV. </p>
<h2>How the men felt</h2>
<p>We found that even when men opted for voluntary medical male circumcision, they followed practices afterwards that were informed by traditional beliefs. This at times involved engaging in unsafe sexual behaviour. While men understood the health benefits of medical circumcision, these messages were sometimes mixed with beliefs drawn from traditional circumcision practices. </p>
<p>For example, several respondents believed that vaginal fluids helped them heal after being circumcised. Some also believed that vaginal fluids could heal wounds from cuts and snake bites as a form of first aid. In these villages it was reported that women also used vaginal fluids to treat themselves and their children’s injuries. </p>
<p>They also believed that having sex with a non-regular partner could chase away spirits and that circumcision offered them protection from sexually transmitted infections. These encouraged unsafe sexual practices.</p>
<h2>Changing the mindset</h2>
<p>Both personal and community-wide misconceptions need to be improved if the uptake of male circumcision is going to be improved, and if post-procedure behaviour is going to be changed. This can only be done if local knowledge systems in the community are engaged. </p>
<p>Engagements must include local religious and community leaders and must involve both men and women. And this must happen during the roll out of the circumcision procedures but also afterwards.</p>
<p>Key local actors such as traditional and religious leaders from different ethnic groups could help provide support for an approach that takes into account local beliefs about circumcision.</p><img src="https://counter.theconversation.com/content/69270/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Seeley receives funding from British Medical Research Council </span></em></p><p class="fine-print"><em><span>Martin Mbonye and Monica Kuteesa 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>Medical circumcision in settings where there are high rates of HIV will only be successful if these interventions take into account local beliefs about circumcision.Martin Mbonye, Social scientist, MRC/UVRI Uganda Research Unit on AIDSJanet Seeley, Professor of Anthropology and Health, London School of Hygiene & Tropical MedicineMonica Kuteesa, Senior scientist, MRC/UVRI Uganda Research Unit on AIDSLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/689932016-11-30T10:09:54Z2016-11-30T10:09:54ZLeading African academics quiz Bill Gates on HIV/AIDS and the role of philanthropy<figure><img src="https://images.theconversation.com/files/147782/original/image-20161128-22735-17wkblz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Philanthropist Bill Gates addresses delegates at the 2016 Aids Conference in Durban.</span> <span class="attribution"><span class="source">Masimba Sasa</span></span></figcaption></figure><p>Philanthropist Bill Gates is the founder and co-chair of the Bill and Melinda Gates Foundation. It has committed more than <a href="http://www.gatesfoundation.org/What-We-Do/Global-Health/HIV#OurStrategy">US$3 billion</a> in HIV grants to organisations around the world and more than US$1.6 billion to the <a href="http://globalfund.org">Global Fund</a> to fight AIDS, tuberculosis and malaria. Gates answers questions from several African academics about HIV/AIDS on the continent. (Disclosure: The Gates Foundation is a strategic partner of The Conversation Africa).</p>
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<p><strong>Professor Francois Venter, Deputy Director of the Reproductive Health Institute in South Africa</strong> - <em>HIV prevention continues to be a mixture of biomedical interventions, such as pre-exposure prophylaxis (PrEP), male circumcision and treatment as prevention, as well as so-called behaviour change interventions. Some, such as condoms and reductions in partner numbers, get mired in a messy moral debate about sex. How do we get these behavioural interventions better tested, and the policymakers to listen to the evidence?</em></p>
<p><strong>Bill Gates:</strong> The truth is we still don’t know enough about the underlying dynamics that put people at risk of HIV. Social barriers – such as discrimination, stigma and structural inequality – work against biomedical efforts to address the epidemic. We have to better understand these barriers in order to develop more effective solutions.</p>
<p>And there are efforts around the world to do just that. For example, the <a href="http://www.pepfar.gov/documents/organization/247602.pdf">PEPFAR DREAMS initiative</a> should help us learn more about why adolescent girls and young women often face heightened risk of HIV infection. DREAMS programmes aim to deliver evidence-based tools that address barriers like poverty, gender inequality, sexual violence and lack of education. </p>
<p>It’s also important to learn more about the market factors – including supply and demand for new tools – that affect how people seek and use prevention options. Organisations like <a href="http://www.avac.org/">AVAC</a> and the <a href="http://www.clintonhealthaccess.org/">Clinton Health Access Initiative</a> are working to understand how to reach people with products and services they will be most empowered to use.</p>
<p>Large-scale change will ultimately only be successful if it is driven from within communities that face the greatest burden of the HIV epidemic. Civil society and local advocacy groups are key to developing and implementing solutions that match needs on the ground. We can help expand access to evidence-based tools, but it will take community ownership and leadership to ensure people can use them.</p>
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<p><strong>Professor Adam Habib, Vice-Chancellor of the University of the Witwatersrand, South Africa</strong> - <em>Philanthropists like yourself have been enormously generous contributors to addressing societal challenges, including HIV/AIDS, in recent years. There is a criticism that philanthropy, while demonstrating generosity, suffers from the weakness of pouring resources into the projects of individual philanthropists. The net effect is that the resources are not deployed in a systematic manner that could have far more effect on the lives of the disadvantaged. How do you work with governments and other organisations to ensure your strategy is aligned with the needs of the people in the countries that you are working with?</em></p>
<p><strong>Bill Gates:</strong> Solving the complex problems that affect the world’s poorest will only be possible with close collaboration between governments, NGOs, academic institutions, businesses and philanthropy. As only one part of this diverse community, we centre our approach on strong partnerships. We want to be sure that our work is informed at every stage by a broad group of experts, from high-level government officials and community leaders to local grantees and advocates.</p>
<p>One great example is our work with the Global Fund, which collects resources in a centralised pool that is then allocated based on local needs. Every project is planned, implemented and monitored with the guidance of a committee of local stakeholders, including local civil society and affected populations. We also work directly with a number of grantees in each country and depend on their invaluable on-the-ground insights and perspective.</p>
<p>While we’re proud of our contributions in the fight against HIV/AIDS, our resources represent only a small portion of worldwide funding to combat HIV. As a foundation, we can take on risks that governments and private institutions may be unable to take themselves. That’s why we concentrate our resources on areas where existing funds are insufficient or where our support can have potentially game-changing impact. This freedom lets our local and multilateral partners do their most ambitious work.</p>
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<p><strong>Dr Nelly Mugo, Principal Investigator at the Kenya Medical Research Institute</strong> - <em>Your foundation has done tremendous work in working with communities with high burdens of disease to find novel solutions and innovative delivery tools. There are often fairly simple interventions which, if implemented, would make differences in maintaining healthy populations, but are unattractive to funding institutions. The gap in access often lies in service delivery. What top five strategies would you advise countries such as mine to implement to improve service delivery and health outcomes?</em></p>
<p><strong>Bill Gates:</strong> There aren’t necessarily five specific approaches that will work in every country. It’s up to national governments and local communities to figure out what will work best for their specific needs. But there are some important general lessons that policymakers and health leaders can apply.</p>
<p>One lesson we’ve learned is that delivery of treatment and prevention is really important, and needs to be personalised. Not all patients require the same type of care. Tailoring delivery of services for people with different needs can improve outcomes, while saving health providers’ time and resources. This approach is called differentiated care.</p>
<p>Using data to reach at-risk populations faster and more effectively is also crucial. We’re excited to see this at work in Kenya, where the government is partnering with <a href="https://www.jhpiego.org/kenya/">Jhpiego</a> to develop new and creative ways to expand access to PrEP among adolescent girls, young women and other populations at risk. </p>
<p>Kenya’s HIV Prevention Road Map is also a great model for these types of efforts. The road map is a comprehensive, efficient government-led model for rolling out evidence-based programmes that reflect the needs of local populations. It also includes provisions to hold individuals and government agencies accountable.</p>
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<p><strong>Professor David Serwadda, former Head of the School of Public Health at Makerere University in Uganda</strong> - <em>Many have made the point that South to South collaboration, in which countries get to understand each other’s problems and how they have solved them (or not), will do much more good for innovation, development and shared responsibilities. Do you agree? If so what is your organisation doing to facilitate that?</em></p>
<p><strong>Bill Gates:</strong> I believe that South-South collaboration will lead to some of the most transformative changes in how we address global health challenges. Successful locally-driven programmes can serve as important models for communities that face similar challenges. The global reach of our foundation means that we can help ensure that lessons learned and best practices from one geography or issue can be adapted and applied to another.</p>
<p>Take for example, the Avahan programme in India. The programme provides services to almost 300,000 female sex workers, men who have sex with men and injecting drug users. It was developed to be driven by the communities it serves. We’re now seeing lessons from Avahan applied to a similar programme in Kenya.</p>
<p>We also know that one of the barriers to South-South collaboration is access to information. We now require that all research we support is made free for other scientists to find and build on. This approach, called “open access”, aims to reduce the hurdles that successful South-South partnerships must overcome, like paywalls and restrictions on the use of data. And we’re optimistic that it could help accelerate the development of game-changing innovations.</p>
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<p><strong>Professor John Idoko, Professor at the University of Jos, Nigeria</strong> - <em>What can other global health issues learn from the impact of political leadership on goals – national and global – in the HIV response?</em></p>
<p><strong>Bill Gates:</strong> Throughout the HIV response, we’ve really seen the power of an engaged and informed global community. Advocacy efforts that began during the early years of the HIV epidemic and continue today have been vital in expanding access to treatment and driving relatively rapid innovations in both prevention and treatment.</p>
<p>And national governments and donors responded to the passion of advocates. PEPFAR and the Global Fund, for example, have helped coordinate efforts and ensure that resources are used efficiently. Investment in research and development led to the development of revolutionary tools such as simplified antiretroviral treatment, voluntary medical male circumcision and PrEP.</p>
<p>But passion and funding alone are not enough. When I was in Durban for the AIDS conference in July I was reminded of how forward thinking national policies can change millions of lives. In South Africa, more than three million people now have access to treatment and far fewer babies are born with HIV each year. South Africa is also a leader on prevention, with its recent approval of PrEP and ongoing investment in the search for new tools.</p>
<p>The HIV response, beginning with the leadership of early advocates, has always been nimble and driven by evidence. Other global health movements can learn from this, and so can the current HIV/AIDS community. We know that reaching ambitious global targets will require us to be faster, smarter and more innovative, especially as we’ve seen the rate of new infections plateau. We’ll need to continue to be agile and let evidence guide our decisions.</p><img src="https://counter.theconversation.com/content/68993/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors 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>Bill Gates, who has been identified as the world’s most significant donor in the fight against AIDS, shares his thoughts on the pandemic with Africa’s most prominent HIV/AIDS academics.Bill Gates, Honorary doctorate, Addis Ababa UniversityLicensed as Creative Commons – attribution, no derivatives.