tag:theconversation.com,2011:/africa/topics/hiv-677/articlesHIV – The Conversation2024-02-09T13:35:58Ztag:theconversation.com,2011:article/2063752024-02-09T13:35:58Z2024-02-09T13:35:58ZLack of access to health care is partly to blame for skyrocketing HIV rates among gay Black men<figure><img src="https://images.theconversation.com/files/573871/original/file-20240206-20-wvuls8.jpg?ixlib=rb-1.1.0&rect=453%2C91%2C3636%2C2624&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man takes a free HIV test during the Harlem Pride parade in New York City.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/man-takes-a-free-hiv-test-during-the-harlem-pride-parade-in-news-photo/1152819582?adppopup=true">Kena Betancur/AFP via Getty Images)</a></span></figcaption></figure><p>Over the past 20 years, people living with HIV in the United States have seen a drastic improvement in their overall <a href="https://www.thebodypro.com/article/hiv-life-expectancy-in-u-s-matches-general-population-with-some-differences">quality of life</a>. But the medical achievements that have made those lives better and created longer <a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(23)00028-0/fulltext">life expectancies</a> have not benefited all communities. </p>
<p>In fact, some communities still have higher rates of new cases of HIV, the virus that causes AIDS. This is especially true for <a href="https://www.cdc.gov/hiv/group/msm/bmsm.html">Black gay and bisexual men</a>. Black queer men are <a href="https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=21">six times more likely</a> to die as a result of HIV-related complications when compared with queer men of different races.</p>
<p>In addition, in the <a href="https://www.cdc.gov/hiv/group/msm/bmsm.html">most recent available data</a>, Black queer men made up 26% of all new cases of HIV in 2019 despite making up <a href="https://williamsinstitute.law.ucla.edu/publications/black-lgbt-adults-in-the-us/">less than 3% of the total</a> U.S. population. </p>
<p>Finally, <a href="https://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html">data released in 2016</a> revealed that if the rates then of new HIV cases persisted, an estimated 1 in 2 Black queer men would acquire HIV in their lifetime. </p>
<p>For comparison, those rates mirror the <a href="https://www.prb.org/resources/the-status-of-the-hiv-aids-epidemic-in-sub-saharan-africa/">prevalence of HIV in sub-Saharan Africa</a> in 2003 when the international community began sending help, including then-<a href="https://www.cgdev.org/page/overview-president%E2%80%99s-emergency-plan-aids-relief-pepfar">President George W. Bush</a>, who approved and implemented his <a href="https://www.npr.org/sections/goatsandsoda/2023/02/28/1159415936/george-w-bushs-anti-hiv-program-is-hailed-as-amazing-and-still-crucial-at-20">Emergency Plan for AIDS Relief</a> program.</p>
<p>To this day, sub-Saharan Africa is still considered the epicenter of the AIDS crisis and accounts for <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2023/july/unaids-global-aids-update">nearly 70%</a> of the world’s HIV infections.</p>
<p>The <a href="https://doi.org/10.1353/hpu.2023.a903345">prevalence of HIV</a> in the Black queer community has been well documented in <a href="https://doi.org/10.1080/09540121.2023.2189223">academic research</a>, including <a href="https://doi.org/10.1177/00027642221145027">my own</a>, which demonstrates that when patients’ <a href="https://doi.org/10.5744/rhm.2023.6012">treatment plans</a> include access to health care and other social services, the patients stay healthy longer. </p>
<h2>The question of risky behavior</h2>
<p>The wide reach of HIV in the Black queer community is not due to members of that community having more sex, or using protection less, or having more partners than queer people of other racial or ethnic backgrounds.</p>
<p>In fact, long-standing studies have shown that when Black queer men have access to appropriate health care, they use condoms more often, and test themselves for HIV more often, than queer men of other races.</p>
<p>For example, <a href="https://www.contagionlive.com/view/hiv-rates-in-young-black-gay-men-strikingly-higher-despite-fewer-risk-behaviors">a study</a> conducted in 2018 found that young Black gay men reported lower rates of sexual risk behaviors, fewer sexual partners and more lifetime HIV tests, but still maintained the highest number of new cases.</p>
<figure class="align-center ">
<img alt="A Black man sits at a table surrounded by a group of other men at a large gathering." src="https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Black man sits among the audience at the annual World AIDS Day commemoration on Dec. 1, 2023, in Long Beach, Calif.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/long-beach-ca-the-audience-was-deeply-moved-by-the-singing-news-photo/1825635482?adppopup=true">Brittany Murray/Long Beach Press-Telegram via Getty Images</a></span>
</figcaption>
</figure>
<p>Studies published in <a href="https://doi.org/10.2105/AJPH.2012.301003">2012</a>, <a href="https://doi.org/10.1007/s10461-014-0842-8">2015</a>, <a href="https://doi.org/10.1007/s10461-018-2270-7">2019</a> and <a href="https://doi.org/10.1007/s10461-021-03430-6">2021</a> have shown that the increase in HIV infections in the Black queer community is not about the number of sexual encounters.</p>
<p>According to those studies, Black queer people have a higher risk of contracting HIV than those others because their communities are more tightly knit – despite behaving more safely than others.</p>
<p>As a result of social stigma and discrimination, Black queer men are more likely to have sexual relationships within their own racial group. Given the already high prevalence of HIV in this group, this concentration increases the likelihood of encountering a partner living with HIV and increases the risk of HIV infection.</p>
<h2>A perfect storm of racism and homophobia</h2>
<p>Preventive measures such as preexposure prophylaxis, or <a href="https://www.cdc.gov/hiv/basics/prep.html">PrEP</a>, have completely revolutionized the field of HIV treatments.</p>
<p>Available as an <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention">injection</a>, a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935218/">daily pill</a> or <a href="https://endinghiv.org.au/blog/prep-on-demand-dosing-guide/">on-demand dosage</a>, PrEP is known to be 99% effective in reducing the risk of acquiring HIV when taken as prescribed.</p>
<p>But in order to receive PrEP, for instance, one must first locate a provider who is willing to prescribe the medicine. <a href="https://www.nbcnews.com/feature/nbc-out/unequal-hiv-prevention-pill-use-puts-minority-men-higher-risk-n1059016">There are examples</a> of doctors simply refusing to prescribe it out of fear of “<a href="https://sph.cuny.edu/life-at-sph/news/2018/07/31/prep-perception-promiscuity/">increased promisciuty</a>.”</p>
<p>This sentiment is often rooted in racism and homophobia.</p>
<p>Even if one locates a provider, there is also the ever-looming issue of insurance and affordability. A <a href="https://www.webmd.com/hiv-aids/how-much-truvada-for-prep-costs">month’s supply</a> of Truvada, one of the two FDA-approved PrEP drugs, is nearly $2,000 without insurance, while a generic version costs $30 to $60 per month. </p>
<p>Though HIV care and <a href="https://www.healthaffairs.org/content/forefront/new-guidance-prep-support-services-must-covered-without-cost-sharing">PrEP</a> are broadly covered under the Affordable Care Act, that often means only the cost of the prescriptions. Patients are frequently surprised to learn that the lab costs of blood tests and analysis of PrEP are <a href="https://kffhealthnews.org/news/article/prep-hiv-prevention-costs-covered-problems-insurance/">not always covered</a>, nor are additional tests for other medical conditions, such as diabetes or high blood pressure. </p>
<p>This is problematic because in order to stay on PrEP, you must engage in quarterly check-ins and bloodwork. </p>
<h2>Lowering the risks</h2>
<p>HIV prevalence is highly <a href="https://www.mdpi.com/1660-4601/18/18/9715">concentrated in the South</a>, which accounts for over 50% of new HIV cases. The region also has the highest fatality rate for Black queer men.</p>
<p><a href="https://doi.org/10.3389/fcomm.2020.00026">My research</a> typically uses interviews of Black queer men to better understand how Black gay men experience and face structural barriers such as access to testing and <a href="https://health.gov/healthypeople/priority-areas/social-determinants-health">adequate housing</a>.</p>
<p>Most men I interview are living with HIV and offer insights on their lived experiences and professional expertise with great vulnerability and power.</p>
<p>For example, Travis – a pseudonym – is from Little Rock, Arkansas, and is living with HIV. “If I’m worried about where I’m going to sleep or how I’m going to afford medicine, I don’t care about getting tested,” he explained. “I am not gonna come to my appointment to get poked with needles.” </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509742/#:%7E:text=For%20example%2C%20Peterson%20and%20Jones,reduce%20HIV%2Drelated%20racial%20disparities.">Research</a> shows Travis is not an outlier. </p>
<p>Issues such as <a href="https://www.hud.gov/program_offices/comm_planning/hopwa">housing</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716244/">employment</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/23876086/">transportation</a> and concerns <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305389">about costs</a> of health care are major obstacles in staying healthy.</p>
<p>Another man I interviewed lives in Los Angeles and pointed out that the younger generation has had limited education about the risks of <a href="https://www.cdc.gov/hiv/group/msm/brief.html">Black gay life</a>. </p>
<p>“We don’t even think about the fact that so many young Black gay men were never taught about HIV and condoms in school,” he said. “We don’t learn that.”</p><img src="https://counter.theconversation.com/content/206375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deion Scott Hawkins 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>When appropriate care is available, several studies have shown, gay Black men are more likely to test themselves for HIV and engage in less risky sexual behaviors than gay men of other races.Deion Scott Hawkins, Assistant Professor of Argumentation & Advocacy, Emerson CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2191012023-12-20T14:00:34Z2023-12-20T14:00:34ZHIV drugs might help prevent multiple sclerosis, large new study suggests<figure><img src="https://images.theconversation.com/files/566642/original/file-20231219-27-rn9zv6.jpg?ixlib=rb-1.1.0&rect=46%2C37%2C6183%2C4100&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/white-orange-antiretroviral-therapy-pills-treatment-1860806827">Showtime.photo/Shutterstock</a></span></figcaption></figure><p>Over the last decade, <a href="https://link.springer.com/article/10.1007/s13365-014-0288-9">several case studies</a> have reported that people with multiple sclerosis (MS) who started antiretroviral therapy for HIV (to keep the virus in check) subsequently found that their MS symptoms had either disappeared completely or the disease progression had slowed considerably.</p>
<p>These findings compelled researchers to ask whether HIV or antiretrovirals could influence the risk of developing MS. According to our <a href="https://onlinelibrary.wiley.com/doi/10.1002/ana.26840">latest study</a>, published in Annals of Neurology, the answer is yes. </p>
<p>It’s very difficult to be certain if HIV or antiretroviral drugs might affect MS because large groups of people living with HIV, with detailed medical information on both HIV and MS, must be followed for a long period. </p>
<p><a href="https://link.springer.com/article/10.1186/s42466-019-0030-4">Three studies</a> previously asked this question but had either too few patients or no access to information on antiretroviral treatment. Consequently, earlier studies have not provided definitive answers.</p>
<p>For this study, we used large population-based health databases and clinical HIV and MS registries. They included virtually every person in British Columbia, Canada and Sweden who was medically recognised as HIV-positive dating back to 1992 in Canada and 2001 in Sweden. </p>
<p>We followed people with HIV from the first date that their HIV infection was recognised until the end of the study period (2020 in Canada and 2018 in Sweden). New diagnoses of MS during this period were searched for using data from hospitals and doctors, as well as information captured from specialist MS clinics. </p>
<p>The rate of new MS cases among people with HIV was compared to the rate of new cases in the general population within each region to determine if there truly was a different risk of MS in people with HIV.</p>
<p>We identified over 29,000 people with HIV and followed them for an average of nearly ten years. Over this period, only 14 HIV-positive people developed MS, which was 47% fewer cases than expected based on numbers in the general population. </p>
<p>When we looked specifically at people who had taken antiretroviral drugs (nearly everyone in the study), and only after they started antiretroviral therapy, we found 45% fewer MS cases than expected. In other words, we found a reduced risk among people who were HIV-positive and had used antiretroviral therapy.</p>
<p>The risk of MS was most significantly reduced for women, with a reduction of 72%. There were also fewer men developing MS in the HIV population than expected, but the difference in risk was less pronounced in men than in women.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/yzH8ul5PSZ8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Multiple sclerosis explained.</span></figcaption>
</figure>
<h2>Possible biological explanation</h2>
<p>From the results of this study alone, it is not possible to tell whether the virus or the antiretroviral therapy might be responsible for the reduction in MS risk. However, there are biological reasons to support both theories. </p>
<p>HIV leads to a progressive loss of immune cells called CD4+ T cells. These same cells are implicated in MS, as they initiate the cascade of events that leads to inflammation of the brain and spinal cord. By reducing CD4+ T cell counts, infection with HIV could reduce the likelihood of a person developing MS. </p>
<p>The finding that MS risk was lower when the HIV virus is presumably suppressed by antiretroviral drugs, though, might offer some hope that it is the treatment rather than the virus that plays a role. </p>
<p>Possible mechanisms for the effectiveness of antiretrovirals in reducing MS risk and disability include the inhibition of the Epstein-Barr virus. More and more research is accumulating to highlight the <a href="https://theconversation.com/multiple-sclerosis-the-link-with-earlier-infection-just-got-stronger-new-study-169314">important role</a> of <a href="https://theconversation.com/multiple-sclerosis-new-evidence-for-the-role-of-glandular-fever-virus-205904">Epstein-Barr in MS</a>. </p>
<p>The antiviral properties of HIV therapy might limit Epstein-Barr virus activity, thereby minimising both the risk of getting MS and of the disease progressing in those who have it. </p>
<p>The finding that HIV infection or antiretrovirals confer a protective effect against MS holds the potential to broaden our understanding of the causes of MS and how the disease damages the body. </p>
<p>Although treatments are available for the relapsing form of MS, none can halt the persistent progression seen later in the disease. Findings from this study might encourage a more concerted effort to determine whether antiretroviral drugs could slow MS disease progression. </p>
<p>With limited research resources, this approach could yield a more immediate benefit, addressing the major unmet need to develop better treatments aimed at preventing or slowing the progression of MS.</p><img src="https://counter.theconversation.com/content/219101/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kyla McKay has received research funding from the Swedish Research Council for Health, Workling Life and Welfare and StratNeuro. </span></em></p><p class="fine-print"><em><span>Elaine Kingwell has received funding from the Canadian Institutes of Health Research and MS Canada. </span></em></p>People who take antiretroviral drugs have a much lower risk of getting multiple sclerosis – especially women.Kyla McKay, Assistant Professor of Neuroepidemiology, Karolinska InstitutetElaine Kingwell, Senior Research Fellow, Primary Care and Population Health, UCLLicensed as Creative Commons – attribution, no derivatives.tag: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/2155102023-11-02T09:59:22Z2023-11-02T09:59:22ZThe future of medicine: 50-year forecast offers hope for HIV and cancer patients and predicts climate change to increasingly set agenda<p>The Covid-19 pandemic has changed the way we think about health and revealed significant flaws within our health care systems. It has also raised questions about the role of technology, as well as ethical concerns about the distribution of wealth and its impact on global health. How will this collective awakening that we have experienced influence the coming years and decades? This was the subject of our <a href="https://www.sciencedirect.com/science/article/pii/S0016328723000010">research on the future of medicine</a>.</p>
<p>We utilised the Delphi method in a three-round study involving 22 experts from seven European countries. Participants included physicians, academics, and industry professionals. Despite a slight reduction in panel size in later rounds, study validity remained intact. Data were collected through audio or video responses and analysed using <a href="https://en.wikipedia.org/wiki/NVivo">NVivo</a> 12. The research focused on updating current medical trends, identifying key drivers for future development, and making health care foresights. Data were coded independently to minimise bias and formed the basis for questions in subsequent rounds.</p>
<h2>1 to 2 years: beta and data</h2>
<p>While we remain in “eternal beta” – a state in which products or drugs are tested through active use by a wide audience – sales of portable smart electronic devices will continue to grow thanks to advances in sensors, artificial intelligence (AI) and the proliferation of 5G technology. Data generated by personal devices will also increasingly be transferred to professional devices. This will enable doctors to treat their patients more holistically and better inform their prescriptions.</p>
<h2>2 to 5 years: the private sector strikes back, climate-related tensions</h2>
<p>Rising strains on public health care are likely to bolster the role of private entities. Innovations in this sector will likely hinge on smart sensors, the blockchain, and digital health records. Over the same period, climate change will exacerbate health issues such as malnutrition and water scarcity, especially in vulnerable regions, necessitating a broader health care response.</p>
<h2>5 to 10 years: innovations leading to inequalities</h2>
<p>Advancements in genomics are accelerating personalised medicine, enabling better prediction and treatment of genetic diseases. Technologies like drug-gene interaction studies allow for optimised drug dosing, while nanotechnology permits targeted micro-dosing, reducing complications. However, the high cost of these innovations will exacerbate health care disparities, potentially fuelling social conflict, especially as climate change imposes additional health burdens.</p>
<h2>10 to 30 years: climate change takes centre stage</h2>
<p>Global warming, which according to the World Health Organisation could claim the lives of around 250,000 people a year by 2030, risks exacerbating inequalities in access to health care. Various disasters (floods, heat waves, etc.) disproportionately affect disadvantaged populations who do not have the resources to cope. This could put a strain on existing health care infrastructures, leading to disparities in access to care.</p>
<p>In addition, global warming could lead to forced migrations, placing an additional burden on health care systems in regions receiving climate migrants and creating difficulties in accessing health care due to social, economic, and linguistic barriers.</p>
<p>Experts predict that, within 10 to 15 years, technological advances could be less effective in meeting the needs of racial- and ethnic-minority patient groups. Indeed, the lack of diversity in clinical trials, a widely debated topic in medical research today, could contribute to the reduced effectiveness of drugs on a broad population.</p>
<p>However, experts anticipate that this trend will gradually fade over the next 20 to 30 years. They believe that health care companies will gradually adapt their treatments for people from lower socio-economic backgrounds and minority ethnic groups.</p>
<h2>30 to 50: a quantum leap</h2>
<p>Finally, looking ahead half a century, experts predict the emergence of highly effective treatments and even cures for diseases such as HIV and hepatitis C. There is no doubt that considerable progress has been made in the prevention, diagnosis, and treatment of diseases, particularly cancer.</p>
<p>The experts in our study predict a significant leap forward in these areas. They do not necessarily envisage a complete cure for all types of cancer or the eradication of major diseases, but do foresee progress in diagnostic and therapeutic methods that will enable a higher percentage of patients to be successfully treated at an early stage.</p>
<p>Against this backdrop of progress, they nevertheless stress that antibiotic resistance remains a real challenge. It is true that the development of new antibiotic molecules is still relatively slow. Our experts draw our attention to certain initiatives that focus on modifying existing antibiotics to overcome resistance, while others are exploring the use of bacteriophages, or studying entirely new classes of antibiotics.</p>
<p>Technological advances and a faster pace of life will continue to take their toll on our mental health, perhaps even increasingly so, with mood disorders becoming widespread. We could also see an increase in depression and certain personality disorders. This would force patients and doctors to resort to preventive medication, or even a “magic pill”, to cure mental disorders.</p>
<p>In addition, the problem of chronic metabolic diseases such as cardiovascular disease, diabetes and obesity is set to worsen. Contributing factors include the increasing prevalence of sedentary lifestyles, unhealthy diets, and an ageing population.</p>
<p>The incidence of pancreatic cancer, for example, has risen sharply in recent years. Researchers attribute this not only to lifestyle factors such as smoking, obesity and poor diet, but also to long-term exposure to certain environmental pollutants. Understanding and addressing these links between health and the environment is therefore becoming crucial to the future of health care.</p>
<h2>The ageing challenge</h2>
<p>Finally, the ageing of the population represents another major challenge that will have a considerable impact on health care systems, and not just on Western systems. The prevalence of age-related diseases such as neurodegenerative disorders, osteoporosis and certain types of cancer is set to increase.</p>
<p>This trend will not only place a considerable burden on health services, but will also require major changes in the way health care is delivered. Emphasis will need to be placed on preventive measures, early detection and management of chronic diseases, as well as health care environments and services adapted to the elderly.</p>
<p>In short, as we move forward in time, we imagine progress in the use of technology. While some of us will be offered the means to extend our longevity and improve our quality of life, others may suffer significant health disadvantages, particularly as a result of climate change.</p>
<p>General practitioners will have a cross-sectional view of a patient’s overall state of health, while specialists will be able to provide more targeted treatments. Personal care will become an even hotter topic, as lifestyle choices will reflect a person’s financial resources and social status. This will allow a commercial industry to thrive on the challenges of modern life.</p><img src="https://counter.theconversation.com/content/215510/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>Climate change, inequality, the evolution of knowledge… Experts have been surveyed, and a consensus is emerging on what to expect from the effects of these factors in the medical field.René Rohrbeck, Professor of Strategy, Director EDHEC Chair for Foresight, Innovation and Transformation, EDHEC Business SchoolAhmed Khwaja, Professor of Marketing, Business & Public Enterprise, Head of the Marketing Subject Group, Cambridge Judge Business SchoolHeikki Karjaluoto, Professor of Marketing, University of JyväskyläIgnat Kulkov, Postdoctoral researcher, EDHEC Business SchoolJoel Mero, Associate professor of marketing, University of JyväskyläJulia Kulkova, Adjunct professor, University of TurkuShasha Lu, Associate Professor in Marketing, Cambridge Judge Business SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2153142023-10-12T13:39:33Z2023-10-12T13:39:33ZJerry Coovadia remembered - a champion of science, children and compassionate public health<p>Deeply saddened as we in the South African health community were by the loss of Professor Jerry Hoosen Coovadia on 4 October 2023, I reflected on what he had come to mean in my medical career and in my life. </p>
<p>“Prof Jerry”, as we called him, was an internationally renowned South African paediatrician, public health and justice activist and clinician scientist. He made a lasting impact on child health, the response to HIV in South Africa and the region. He died, aged 83, at his home in KwaZulu-Natal, leaving his wife, Dr Zubeida “Zubie” Hamed. </p>
<p>What stands out for me is his principled, pragmatic and compassionate approach to paediatrics and child health. And then how these principles were brought to bear in response to the HIV epidemic. </p>
<h2>Earlier years</h2>
<p>In 1988 I found myself working to repay a government bursary at the quaint but very busy Eshowe Provincial Hospital in northern KwaZulu-Natal. There were three of us fresh new medical officers who, guided by a few key and wonderfully committed specialists, worked day and night in the emergency unit, outpatients and wards of this bustling public sector hospital serving rural communities. </p>
<p>Those “bush doctoring” days were some of my most fulfilling and exciting. It was satisfying to be carrying out emergency medicine or administering anaesthetics on two out of three nights. At the same time it was terrifying to put the mostly theoretical information we had gained in the last seven years to urgent and critical, practical use.</p>
<p>Paediatrics was no less terrifying than surgery or obstetrics. But we had the wonderful duo of Jenny Chapman guiding us in paediatrics and John Larson in obstetrics and gynaecology, and a library of important manuals and textbooks in the hospital boardroom. </p>
<p>Jenny, who was one of the most dedicated and caring paediatricians I have ever met, simply swore by Prof Jerry, his books and his teaching. I had not yet met Professor Coovadia in person, but I certainly came to intimately know his textbook (as I recall mine was a green version, much dog-eared and underlined) and his teachings not only at medical school but then under Jenny’s tutelage. </p>
<p>What set this book, <a href="https://global.oup.com/academic/product/coovadias-paediatrics-and-child-health-a-manual-for-health-professionals-in-developing-countries-9780199053940?cc=za&lang=en&">Paediatrics and Child Health</a>, apart was how it so practically but compassionately spoke to our setting and the African child. It dealt with the dilemmas and quandaries we faced daily in getting the best care to every child with our constrained resources. Jenny also taught me that it was wise to call and consult when the dilemma needed more than one opinion. And no opinion was more important than Prof Jerry’s.</p>
<p>When I later had the great good fortune to meet Prof Jerry in the 1990s as the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2754430/">HIV epidemic was taking off in KwaZulu-Natal</a>, I was thrilled to discover the author was just as I had imagined him from his book: principled, passionate and pragmatic. </p>
<p>Throughout the next decade, our paths crossed frequently as we all took up the business of getting lifesaving HIV treatment to Africa. This meant building clinical evidence, writing guidelines and taking to the <a href="https://assets.publishing.service.gov.uk/media/57a08cc840f0b6497400143c/long_live_zackie.pdf">streets and courtrooms</a> as activists. His resolute and strong stance against <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61581-6/fulltext">AIDS denialism</a> was critical and inspiring. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/jerry-coovadia-the-south-african-doctor-who-led-the-fight-against-hiv-in-children-215080">Jerry Coovadia: the South African doctor who led the fight against HIV in children</a>
</strong>
</em>
</p>
<hr>
<p>With the <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2009/november/20091101southafrica">end of the denialist era</a>, from 2008 onwards, Prof Jerry’s wisdom continued to be greatly valued. I always enjoyed hearing his opinion or proposed solution to a challenge. True to his nature, the proposal first and foremost had the child, the patient, their family and their community at the heart. </p>
<p>Thereafter, it was carefully considered with the known current evidence available and finally it was pragmatic and feasible in our setting and considerate of the primary health system. </p>
<p>That opinion was always delivered with a quiet but firm voice and his active eyebrows and ready smile providing the right amount of emphasis and exclamation. A recent interview that captured Prof Jerry so wonderfully quoted him as saying <a href="https://www.dailymaverick.co.za/article/2021-05-30-be-true-to-science-and-kind-to-patients-says-healthcare-giant-jerry-coovadia/">“be true to science and kind to patients”</a>, an instruction that should be given to every healthcare professional as they embark on their careers. </p>
<p>Prof Jerry was, and remains, an inspiring model.</p><img src="https://counter.theconversation.com/content/215314/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>His teaching spoke practically but compassionately to the needs of the African child.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/2150802023-10-05T15:50:48Z2023-10-05T15:50:48ZJerry Coovadia: the South African doctor who led the fight against HIV in children<p>South African-born Professor Hoosen “Jerry” Coovadia, renowned academic and prominent anti-apartheid activist, passed away on <a href="https://www.news24.com/news24/southafrica/news/hivaids-expert-professor-jerry-coovadia-dies-aged-83-leaves-behind-an-immeasurable-legacy-20231004">4 October</a>. As a paediatrician I was privileged to know and work with him over two decades. Prior to that I knew him when we were both health activists in apartheid South Africa.</p>
<p>In 2019 Coovadia was <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61581-6/fulltext">profiled</a> in the leading health academic journal, The Lancet, as an icon in South African health. The profile described him as the “Nelson Mandela of health”. This was in tribute to his dedication to ameliorating the diseases that afflicted children of South Africa, like malnutrition, measles and HIV, and his role in health activism. </p>
<p>In 2014, in my capacity as the president of the South African Medical Research Council, I was honoured to award him the <a href="https://www.samrc.ac.za/about-us/2014-scientific-merit-awards">SAMRC Presidential Award</a> in recognition of his life-long work in child health, his impact in the area of preventing mother-to-child transmission of HIV and the huge influence he had on health in South Africa. </p>
<p>Jerry was pivotal in proposing the use of maternal antiretroviral therapy to prevent breast milk transmission, which has now become the norm at a global level. His role in research that led to the control of HIV infection in children was so great that, in my view, it cannot be quantified in any meaningful way.</p>
<h2>Who was Jerry Coovadia?</h2>
<p>Jerry was born in Durban, on the east coast of South Africa, <a href="https://www.sahistory.org.za/people/professor-hoosen-mahomed-jerry-coovadia">in 1940</a>.</p>
<p>He knew instinctively from a young age that he would become a doctor. He did some of his medical training in India, and then returned to South Africa, where he was exposed to the atrocities of a two-tiered health system under which black South Africans bore the brunt of poor healthcare.</p>
<p>As a paediatrician, he excelled academically, training in immunology and eventually heading the Department of Paediatrics and Child Health at the University of Natal. </p>
<p>During his time as an academician he became prominent in the anti-apartheid movement. </p>
<h2>The AIDS fight</h2>
<p>I began working with Jerry in the mid 1990s. His path and mine would intertwine over the next 20 years as we bore witness to the <a href="https://academic.oup.com/ije/article/31/1/37/655915">explosion of HIV</a> in children. He was working at the King Edward Hospital in KwaZulu-Natal while I was at the Chris Hani Baragwanath Academic Hospital in Soweto. </p>
<p>Over the next decade we would “cross horns” on the various interventions to prevent mother-to-child transmission of HIV. </p>
<p>We didn’t always agree on interventions to prevent<a href="https://www.ncbi.nlm.nih.gov/books/NBK555904/"> post-partum</a> transmission through breastfeeding. </p>
<p>Even though our strategies differed, we were completely aligned in our common goal of trying to mitigate the scourge of HIV in the children we were trained to care for. </p>
<p>His textbook <a href="https://global.oup.com/academic/product/coovadias-paediatrics-and-child-health-a-manual-for-health-professionals-in-developing-countries-9780199053940?cc=za&lang=en&">Paediatrics and Child Health</a> was my Bible. My colleagues and I revered him as the doyen of child health in South Africa. </p>
<p>It was a huge privilege to collaborate with him on research to deliver antiretroviral therapy as an intervention to prevent mother-to-child transmission of HIV. </p>
<p>We worked together on studies seeking the most cost-effective way of preventing paediatric HIV using the least amounts of antiretrovirals at a time when these were prohibitively expensive. The two biggest were the <a href="https://pubmed.ncbi.nlm.nih.gov/11955535/">PETRA</a> study, evaluating various short courses of <a href="https://www.britannica.com/science/AZT">AZT</a> and <a href="https://www.news-medical.net/drugs/3TC-Tablets.aspx">3TC</a> to interrupt perinatal transmission, and the <a href="https://jamanetwork.com/journals/jama/fullarticle/199058">SAINT</a> trial, which evaluated the role of <a href="https://www.ncbi.nlm.nih.gov/books/NBK554477/#:%7E:text=Nevirapine%20is%20a%20drug%20used,antiretroviral%20therapy%20(ART)%20medications.">Nevirapine</a> for preventing mother-to-child transmission. </p>
<p>Over the years, we would co-publish on these studies and the effect of these various interventions to minimise breast milk transmission. </p>
<h2>Activist years</h2>
<p>Before I worked with Jerry as a young doctor, we were both health activists. I belonged to the Health Workers Association, which later became the South African Health Workers Congress; he was a member of the National Medical and Dental Association and was a leader in the talks to merge these two organisations.</p>
<p>I appreciated his activism and his vision for an equitable health system which he channelled into his work as a paediatrician and his work as a scientist.</p>
<p>He demonstrated to us as young doctors the role of social activism in health and that ill health is inextricably linked to socio-economic and political factors. If we were to be meaningful in our role as doctors, we had to address these factors with the same vigour as we demonstrated in the wards where we treated sick children.</p>
<p>Jerry encompassed what it means to be a doctor. He always lived by the Hippocratic Oath, basing his practice in medicine on the principles of beneficence, non-maleficence, justice and respect. </p>
<p>I am deeply grateful to have brushed shoulders with this great man. Go well Jerry, a life well lived, and many thanks to your family for sharing you with us.</p><img src="https://counter.theconversation.com/content/215080/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Glenda Gray receives funding from USAID and the NIH</span></em></p>A Lancet profile of Jerry Coovadia described him as the ‘Nelson Mandela’ of healthcare. Glenda Gray pays tribute to a legendGlenda Gray, Research Professor, Perinatal HIV Research Unit and President, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2137262023-10-02T12:38:37Z2023-10-02T12:38:37ZHIV self-test kits are meant to empower those at risk − but they don’t necessarily lead to starting HIV treatment or prevention<figure><img src="https://images.theconversation.com/files/550089/original/file-20230925-29-kvx1ps.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3058%2C2000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Regular testing for HIV protects you and those around you.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/focus-on-an-hiv-self-test-with-seronegative-result-royalty-free-image/930075664">pixinoo/iStock via Getty Images Plus</a></span></figcaption></figure><p>HIV self-test kits were developed to make it easier for people to access HIV testing. However, <a href="https://scholar.google.com/citations?user=7RB_bZUAAAAJ&hl=en">our</a> <a href="https://scholar.google.nl/citations?user=weevnFsAAAAJ&hl=en">research</a> <a href="https://www.researchgate.net/profile/Oluwaseun-Badru">team</a> has found that many people who use self-test kits <a href="https://doi.org/10.1007/s10461-023-04162-5">do not go on to receive needed HIV treatment</a> or start preexposure prophylaxis, or PrEP, to prevent future infection.</p>
<p>In 2016, the World Health Organization <a href="https://www.who.int/publications/i/item/WHO-CDS-HIV-19.36">recommended HIV self-test kits</a> as a way for people to confidentially test for HIV in their homes or other private places. Each kit contains detailed instructions on how to administer the test and read the results without the help of a clinician. However, the instructions advise confirming results in a health facility to improve access to care, especially for those with a positive reading.</p>
<p>Our team conducted a systematic review and meta-analysis of published research and data to understand how HIV self-testing influences access to HIV care and sexual behavior. Specifically, we looked at whether a positive test result led someone to seek care in a hospital or health facility to start treatment and whether a negative test result led someone at risk of contracting HIV to take preventive measures. We also looked at whether test results affected the number of sexual partners, engagement in anal sex without a condom and frequency of condom use.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/D_IHm3p8RW0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">HIV self-test kits provide quick results.</span></figcaption>
</figure>
<p>Based on the 15 studies that met our criteria, we found that while HIV self-testing increased a person’s chances of finding an HIV clinic or doctor by 8%, many people <a href="https://doi.org/10.1007/s10461-023-04162-5">did not initiate HIV treatment or PrEP</a> following self-testing.</p>
<p><a href="https://doi.org/10.1007/s10461-023-04162-5">Female sex workers</a> who used HIV self-test kits were 47% more likely to seek medical care, but this did not reduce the number of clients they saw per night.</p>
<p>For <a href="https://doi.org/10.1007/s10461-023-04162-5">men who have sex with men</a>, using HIV self-test kits may have increased the amount of condomless anal sex they have, according to <a href="https://doi.org/10.1097/QAI.0000000000001709">one U.S. study</a>. Those who use HIV self-test kits were more likely to have condomless anal sex with HIV-positive and HIV-negative partners, as reported by <a href="https://doi.org/10.1007/s10461-022-03804-4">one Chinese study</a>.</p>
<h2>Why it matters</h2>
<p>Many people are living with HIV and receiving treatment. However, some HIV-positive people are unaware of their HIV status and are at risk of infecting other people. Routinely checking your HIV status is important to prevent the spread of HIV.</p>
<p>Unfortunately, HIV testing is low in many regions of the world. Researchers from <a href="https://doi.org/10.4102/sajhivmed.v22i1.1273">South Africa</a>, the <a href="https://doi.org/10.1136/bmjopen-2015-009480">Netherlands</a> and the <a href="https://doi.org/10.1080/09540121.2020.1766663">United States</a> have reported a lack of HIV testing among different parts of the population, including <a href="https://theconversation.com/men-who-have-sex-with-men-originated-during-the-hiv-pandemic-to-focus-on-behavior-rather-than-identity-but-not-everyone-thinks-the-term-helps-189619">men who have sex with men</a>. There are many barriers to HIV testing, including <a href="https://doi.org/10.1186/s12905-021-01590-0">lack of knowledge about HIV</a> and <a href="https://doi.org/10.1080/09540121.2020.1742867">fear of</a> <a href="https://theconversation.com/people-living-with-hiv-face-harmful-stigma-daily-dababys-rant-was-just-more-public-than-most-165443">stigma and discrimination</a>. </p>
<p>Despite the availability of HIV test kits, many people at heightened risk have never been tested for HIV. As our research shows, some of those who test positive don’t receive treatment. Nor do all those who test negative but are at risk of infection receive preventive treatment or change their sexual behavior.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Clinician handing patient condoms" src="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Public health officials recommend talking to a doctor about HIV self-test results.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/the-doctor-advised-the-young-man-to-prevent-royalty-free-image/1210961713">Wasan Tita/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>What still isn’t known</h2>
<p>We found only one study that looked at how HIV self-testing influences PrEP use among men who have sex with men. </p>
<p>More research is needed to better understand the link between HIV self-testing and HIV prevention.</p>
<h2>What’s next</h2>
<p>Our next step is to understand why people did or did not receive care following HIV self-testing. We plan on interviewing HIV self-test kit users about their experience using the self-test and whether they went on to receive care.</p>
<p>We hope the results of this study will help us build an intervention to increase access to care following an HIV self-test. This will contribute toward the national plan to <a href="https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview/">end the HIV epidemic by 2030</a> in the U.S.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/213726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adeagbo Oluwafemi Atanda receives funding from University of Iowa and National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Engelbert Bain Luchuo and Oluwaseun Abdulganiyu Badru do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many people at heightened risk for HIV have never been tested. Those who have self-tested for HIV often don’t go on to receive care or change their sexual behavior.Oluwafemi Atanda Adeagbo, Assistant Professor of Public Health, University of IowaEngelbert Bain Luchuo, Senior Research Associate, University of JohannesburgOluwaseun Abdulganiyu Badru, Ph.D. Candidate in Community and Behavioral Health, University of IowaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114382023-09-28T14:16:45Z2023-09-28T14:16:45ZSouth African men are much more likely to die from TB than women – here’s why<p>Around the world, <a href="https://academic.oup.com/jid/article/209/suppl_3/S100/2192832">men</a> are more likely to get TB and to die from it than women. </p>
<p>We recently conducted <a href="https://www.nature.com/articles/s41598-023-36432-6#:%7E:text=PAFs%20for%20tuberculosis%20incidence%20due,17.5%25">research</a>
to establish the various factors that explain higher rates of TB among men in South Africa. South Africa is ranked among the top six countries contributing to <a href="https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22ZA%22">60%</a> of the global burden of TB. </p>
<p>Our main finding was that men are 70% more likely to develop TB and die from the disease, compared to women. We estimated that in 2019, 801 per 100,000 adult men developed TB while among women the rate was 478 per 100,000. </p>
<p>Current TB interventions focus on biomedical approaches emphasising preventive TB medication, diagnosing TB patients and treating them with anti-TB drugs. </p>
<p>Our research demonstrates, however, that dealing with socioeconomic conditions and other determinants of TB is also important. </p>
<p>Men’s access to health facilities needs to be improved and there needs to be more effort to encourage men to seek medical care.</p>
<h2>Our maths model</h2>
<p>We used our Thembisa TB model, recently developed at the Centre for Infectious Disease Epidemiology and Research at the University of Cape Town. </p>
<p>This mathematical model simulates the South African adult TB epidemic over time. </p>
<p>Because HIV is the most significant risk factor for TB and the primary driver of the epidemic, the TB model is combined with an existing <a href="https://www.thembisa.org">Thembisa HIV model</a>. </p>
<p>Approximately 60% of individuals with active TB are also <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266082">living with HIV</a>. </p>
<p>The model showed that between 1990 and 2019, South African men developed TB and died at consistently higher rates than women. </p>
<p>We estimated that in 2019 there were 1.6 times more new TB cases and 1.7 times more TB deaths in men than in women. </p>
<p>Our results are all the more startling because HIV is more <a href="https://www.unwomen.org/en/what-we-do/hiv-and-aids/facts-and-figures">prevalent in women</a> than men. The expectation would then be that women should have a higher TB incidence. </p>
<h2>Some of the risks</h2>
<p>Other <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/uhc-tb-determinants/6-3-tb-determinants">factors</a> contributing to the high TB epidemic among men included excessive alcohol use, smoking, diabetes and undernutrition.</p>
<p>We estimated that of the 801 per 100,000 adult men who developed TB in 2019, 51% were attributable to heavy alcohol use, 30% to smoking, and 16% to undernutrition. </p>
<p>The numbers for women were much lower. Of the 478 per 100,000 adult women who developed TB in 2019, 30% were attributable to heavy alcohol use, 15% to smoking, and 11% to undernutrition. </p>
<h2>Low testing rates</h2>
<p>We showed that lower testing rates and delays in starting TB treatment among men contributed to 7% higher mortality.</p>
<ul>
<li><p>Previous research has found that men are more likely to have <a href="https://www.statssa.gov.za/?p=15668#:%7E:text=In%20South%20Africa%2C%20the%20labour,actually%20used%20by%20the%20economy">jobs</a> and it was more difficult to take time off to go to the clinic or secure treatments as it would affect their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223013">earnings</a>. </p></li>
<li><p>Men were also often <a href="https://www.thelancet.com/article/S1473-3099(22)00149-9/fulltext">older and sicker</a> when they sought health care and were more likely to stop treatment. </p></li>
</ul>
<p>Our analysis showed that women benefited more from accessing HIV healthcare services, including HIV testing and antiretroviral therapy initiation. This significantly reduced TB incidence and mortality. </p>
<ul>
<li><p>We estimated that in 2019, mainly due to treatment for HIV, TB cases dropped by 38% in women. There was also a 52% reduction in deaths.</p></li>
<li><p>In contrast, TB cases among men dropped by 18% and there was a 29% reduction in deaths.</p></li>
</ul>
<h2>Next steps</h2>
<p>The higher tuberculosis incidence and mortality in men highlights the need to make health services more accessible to men and address the structural barriers to their retention in tuberculosis and HIV care. <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004237">Mobile clinics</a> could be circulated at places of work to provide testing for TB, HIV and other potential co-morbidities. </p>
<p>Additionally, there is a need for effective socioeconomic interventions. </p>
<ul>
<li><p>A review of studies conducted across the world has shown that <a href="https://doi.org/10.5588/pha.18.0006">anti-smoking</a> programmes driven by health practitioners and family members have achieved success rates of up to 82%.</p></li>
<li><p>Self-help programmes to stop excessive alcohol consumption need to be complemented by structural interventions such as increased <a href="https://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=7E7CD2AC1ED80FF1DF410FE748AEAA19?doi=10.1.1.476.1974&rep=rep1&type=pdf">alcohol taxation</a> and stricter enforcement of the laws <a href="https://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=7E7CD2AC1ED80FF1DF410FE748AEAA19?doi=10.1.1.476.1974&rep=rep1&type=pdf">restricting</a> the sale of alcohol.</p></li>
<li><p>A recent trial conducted in India showed that providing households with food baskets to improve nutrition could <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01231-X/fulltext">reduce TB</a> by 50%. </p></li>
</ul>
<p>Although biomedical approaches have led to declines in the TB epidemic, South Africa still remains classified as a <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/high-tb-burden-country-profiles">high TB burden</a> country.</p>
<p>Medical treatment needs to be complemented with measures to tackle socioeconomic conditions. Only then will we make real progress in reducing the TB epidemic in South Africa.</p><img src="https://counter.theconversation.com/content/211438/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mmamapudi Kubjane received funding from the Fogarty International Center of the National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health & Human Development (D43 TW010559), the South African Centre of Excellence in Epidemiological Modelling and Analysis, and the International epidemiology Databases to Evaluate AIDS (UO1AI069924). She currently works at the Health Economics and Epidemiology Research Office. She is a co-chair of the South African TB Think Tank, Epidemiology, Modelling & Health Economics Task Team.</span></em></p><p class="fine-print"><em><span>Dr Leigh Johnson receives funding from the Bill and Melinda Gates Foundation (award 019496). </span></em></p>In South Africa men are 70% more likely to die from TB than women. Tackling social factors such as smoking and high alcohol consumption could save more lives.Mmamapudi Kubjane, Researcher, Wits Health Consortium, University of the WitwatersrandLeigh Johnson, Associate professor, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2130852023-09-24T12:02:25Z2023-09-24T12:02:25ZYoung people with sexual or gender diversity are at higher risk of stopping their HIV treatment because of stigma and harsh laws<p>Ending the AIDS pandemic – particularly in eastern and southern Africa – cannot be achieved unless more resources are channelled to meet the needs of key vulnerable populations.</p>
<p>This is one of the themes that emerged during an <a href="https://www.samrc.ac.za/event/11th-sa-aids-conference-2023-20-23-june-2023-durban">AIDS conference in June</a> in South Africa. Prejudice against particular groups – such as men who have sex with men (MSM) and transgender communities – interferes with treatment regimes and people’s adherence to treatment. These groups are also at higher risk from HIV due to increased levels of stigma, discrimination, violence and criminalisation. </p>
<p>Our research is part of a three-year <a href="https://www.heard.org.za/wp-content/uploads/2023/06/SADC-Symposium-Report_final.pdf">project</a> on HIV-related stigma linked to young people with sexual or gender diversity. The research, conducted in Malawi, Zimbabwe and Zambia, involved 156 participants.</p>
<p>The research identified three main findings:</p>
<ul>
<li><p>Criminal laws and strongly negative socio-cultural and religious beliefs produced deeply rooted intolerance around sexual or gender diversity. </p></li>
<li><p>Participants spoke about repeated experiences of verbal harassment, being gossiped about and physical violence.</p></li>
<li><p>Other population groups with HIV said their lives had become more tolerable as social awareness and acceptance of HIV had increased over time. However HIV-related stigma regained its potency when linked to sexual or gender diversity, with adverse effects for adherence to antiretroviral treatment. </p></li>
</ul>
<p>Our research provided novel evidence on the deeply rooted fears and anxieties around multiple forms of stigma among young MSM and transgender women in southern Africa. </p>
<h2>Criminalising sex</h2>
<p>Across 13 countries in east and southern Africa, laws and policies criminalise same-sex sexual relations and facilitate the process of stigmatising gay and transgender individuals.</p>
<p>Recently, Uganda passed the Anti-Homosexuality Act of 2023, which punishes same-sex conduct with life imprisonment. Several acts considered as “aggravated homosexuality” are liable to the death penalty. </p>
<p>Our study also noted that young people had developed various strategies to manage their lives. For example choosing when to disclose or identify as a person living with HIV or as a member of the sexual minority community in others, but rarely being both at once. </p>
<p>The constant worry and stress of living with HIV, and the fear of being stigmatised, could have a significant impact on health and wellbeing. </p>
<p>The burden of concealing their identities resulted in a range of mental, emotional and physical vulnerabilities. Signs of depression as well as frequent alcohol use were evident.</p>
<p>Overall 42% of participants had contemplated suicide at least once. According to one participant, an 18-year-old:</p>
<blockquote>
<p>I feel like I am nothing, I am useless. In the community, looking at HIV, I am a gay, people they isolate me. So, I don’t feel comfortable, even failing to go to work and finding some money, whatever. And, sometimes, I decide if I can die today, I can rest. So, a lot of things come into my mind when I am disturbed … Sometimes my parents try to comfort me but, internally, I am really disturbed.</p>
</blockquote>
<p>As well as signs of depression, frequent alcohol use was evident. </p>
<p>There were few services available to assist in coping with these multiple stigmas, with those that came closest being provided by “sexual minority friendly” organisations or led by sexual minority peers themselves.</p>
<h2>Fear of being found out</h2>
<p>Being seen taking antiretroviral therapy or having it found in one’s possession signalled that one was living with HIV. Some individuals preferred to miss doses, occasionally or over more prolonged periods, rather than endure actual or feared stigma linked to being “found out” as someone living with HIV.</p>
<p>A 24-year-old told us:</p>
<blockquote>
<p>What made me to delay taking medication is when my partner wants me to visit his home because he stays in Zomba, and I haven’t disclosed my HIV status to my partner yet, and I can’t take the ARVs with me there. As a result, I go there without the ARVs.</p>
</blockquote>
<p>A 19-year-old said:</p>
<blockquote>
<p>It affects me sometimes because, if people reject you, you feel like stopping to take the medication. ‘Maybe am just wasting my time, let me just die.’ It affects me a lot.</p>
</blockquote>
<p>Other findings we made were that:</p>
<ul>
<li><p>Many participants had had their status disclosed by LGBTIQ+ peers without their consent. HIV-related stigma is still highly prevalent within the LGBTIQ+ community and has many negative impacts. </p></li>
<li><p>Participants continued to experience or fear stigma related to their sexual orientation at health facilities, which also affected their access to healthcare and retention in care.</p></li>
<li><p>Tailored HIV services for key populations, including young MSM and transgender women, were not reaching everyone; rural areas were the least included.</p></li>
<li><p>Through their experiences, gay young men and transgender women were familiar with the harmful consequences of stigma and yet they were often ostracised from planning and decision-making roles. </p></li>
</ul>
<h2>The way forward</h2>
<p>Key populations in our study faced inequalities in three main areas: access to HIV services; justice and human rights; and investments in programmes geared towards them.</p>
<p>There were few services available to assist in coping with these multiple stigmas. Those that came closest were provided by “sexual minority friendly” organisations or led by sexual minority peers themselves.</p>
<p>There need to be more community-based organisations that are run by members of these key populations. In Cameroon, for example, the <a href="https://www.usaid.gov/cameroon/health/hiv-aids">CHAMP</a> programme supports grassroots advocacy to mitigate stigma and violence and trains peers to offer counselling, </p>
<p>We can only achieve progress if we treat everyone as equal partners in fighting this pandemic.</p><img src="https://counter.theconversation.com/content/213085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaymarlin Govender receives funding from the National Research Foundation and Sida</span></em></p><p class="fine-print"><em><span>Patrick Nyamaruze receives funding from HIV/AIDS Special Fund Round III initiative of the Southern African Development Community. </span></em></p>Stigmatised people living with HIV often suffer from fear, depression and abuse. It’s sometimes easier to stop a treatment regime than risk being ostracised or assaulted by the community.Kaymarlin Govender, Research Director at The Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-NatalPatrick Nyamaruze, Post-doctoral research fellow, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2121772023-09-08T12:25:59Z2023-09-08T12:25:59ZAnemia afflicts nearly 1 in 4 people worldwide, but there are practical strategies for reducing it<figure><img src="https://images.theconversation.com/files/546721/original/file-20230906-33614-a4o8yh.jpg?ixlib=rb-1.1.0&rect=15%2C7%2C5126%2C3484&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Anemia symptoms include shortness of breath, dizziness and fatigue.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-holding-blood-in-test-tube-royalty-free-image/1180192054?phrase=anemia&adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p>Anemia is a major health problem, with <a href="https://doi.org/10.1016/S2352-3026(23)00160-6">nearly 2 billion people</a> affected globally. It afflicts more people worldwide than low back pain or diabetes – or even anxiety and depression combined. </p>
<p>Despite this, investments in reducing anemia have failed to substantially reduce the massive burden of anemia globally over the last few decades.</p>
<p>People <a href="https://www.ncbi.nlm.nih.gov/books/NBK499994/">become anemic</a> when their blood lacks enough healthy red blood cells to carry oxygen throughout the body. This decreased oxygen delivery causes many of the most <a href="https://www.nhlbi.nih.gov/health/anemia/symptoms">common symptoms of anemia</a>, including fatigue, shortness of breath, lightheadedness, difficulty concentrating and challenges with work and daily life tasks. </p>
<p>In addition to its direct health effects, anemia can <a href="https://doi.org/10.1111/nyas.14105">inhibit brain development and fine motor skills</a> in children and heighten the <a href="https://doi.org/10.3390/jcm10122556">risk of stroke</a>, <a href="https://doi.org/10.1681/ASN.2005030226">cardiovascular disease</a>, <a href="https://doi.org/10.1212/WNL.0000000000008003">dementia</a> and other chronic illnesses in older adults. <a href="https://doi.org/10.1111/nyas.14093">Anemia during pregnancy</a> can lead to increased rates of anxiety and depression, early labor, postpartum hemorrhage, stillbirth and low birth weight. Infections for both mother and baby are also more likely when the mother is anemic.</p>
<p>We are <a href="https://scholar.google.com/citations?user=LbtdQcsAAAAJ&hl=en">global</a> <a href="https://scholar.google.com/citations?user=0kfiPK8AAAAJ&hl=en">health</a> <a href="https://www.healthdata.org/about/people/nicholas-kassebaum">researchers</a> with expertise in epidemiological modeling of anemia alongside other maternal, neonatal and nutritional disorders. </p>
<p>Our work is part of the <a href="https://www.healthdata.org/research-analysis/gbd">Global Burden of Disease Study</a>, a large research study comprehensively estimating health loss due to hundreds of diseases, injuries and risk factors around the globe. Through our analysis, we have produced annual estimates of anemia prevalence by underlying cause for 204 countries and territories, by age and sex, from 1990 to the present. We have collected thousands of data points across hundreds of sources to produce the most comprehensive picture of anemia burden.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/z0Z1QMouVgE?wmode=transparent&start=29" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Anemia is often measured by the amount of hemoglobin – an oxygen-carrying protein within red blood cells – that a person has in their blood.</span></figcaption>
</figure>
<h2>Anemia is a widespread problem</h2>
<p>Anemia is diagnosed by a simple blood test and can be caused by a number of underlying conditions. </p>
<p>Decreases in healthy red blood cells can occur due to excessive loss of existing red blood cells, such as through bleeding or destruction by the body’s immune system. Anemia can also occur due to decreased production of new red blood cells or changes in the normal structure or lifespan of red blood cells that make them less effective.</p>
<p>Globally, anemia is the third-largest cause of disability: Our recent study found that <a href="https://doi.org/10.1016/S2352-3026(23)00160-6">nearly 1 in 4 people has anemia</a>. This burden is concentrated among children younger than 5 years and adolescent girls and women, one-third of whom are anemic. Anemia rates are particularly high in sub-Saharan Africa and South Asia, where we estimated that 40% – or two out of every five people – have anemia.</p>
<p>Reductions in anemia rates have been slow and uneven, dropping from 28% to 24% globally from 1990 to 2021. Adult males have fared better, with young children and adolescent girls and women – who bear the highest burden of anemia – showing the least progress. On the positive side, there has been a shift toward milder forms of anemia, which result in much less disability compared to severe anemia.</p>
<h2>Reducing anemia means tackling underlying causes</h2>
<p>Substantially reducing anemia globally is complicated by its many underlying causes. Dietary iron deficiency is the <a href="https://doi.org/10.1016/S0140-6736(15)60865-0">most common cause</a> across the globe. But other important drivers of anemia include blood disorders such as <a href="https://www.cdc.gov/ncbddd/sicklecell/index.html#">sickle cell disease</a> or <a href="https://www.cdc.gov/ncbddd/thalassemia/facts.html">thalassemias</a>, infectious diseases like <a href="https://theconversation.com/locally-transmitted-malaria-in-the-us-could-be-a-harbinger-of-rising-disease-risk-in-a-warming-climate-5-questions-answered-208726">malaria</a> and <a href="https://theconversation.com/parasitic-infections-hit-the-health-of-low-income-black-communities-where-states-have-neglected-sewage-systems-205616">hookworm</a>, gynecologic and obstetric conditions, <a href="https://theconversation.com/what-is-inflammation-two-immunologists-explain-how-the-body-responds-to-everything-from-stings-to-vaccination-and-why-it-sometimes-goes-wrong-193503">inflammation</a> and chronic diseases. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three-dimensional illustration of human artery anatomy, showing normal red blood cells and sickle-shaped blood cells flowing away from the heart." src="https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sickle cell disease – characterized by crescent or sickle-shaped red blood cells that can block blood flow to the rest of the body – is a well-recognized cause of anemia.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sickle-cell-cardiovascular-royalty-free-image/1130415446?phrase=sickle+cell+disease&adppopup=true">wildpixel/iStock via Getty Images</a></span>
</figcaption>
</figure>
<p>Anemia in adolescent and adult women often occurs due to loss of blood from menstruation and increased needs for blood for the developing baby during pregnancy. Much of the anemia burden in this group is <a href="https://doi.org/10.3390/nu13082745">likely related to</a> <a href="https://theconversation.com/the-us-lacks-adequate-education-around-puberty-and-menstruation-for-young-people-an-expert-on-menstrual-health-explains-187501">lack of menstrual education</a>, inadequate options for effectively managing menstrual problems in those who have them, and unmet needs for family planning services. These are also important drivers among transgender men and nonbinary people who menstruate. </p>
<p>Young children <a href="https://doi.org/10.1016/j.jpeds.2015.07.014">have increased requirements</a> for iron as their bodies grow, and malnutrition is a common cause of anemia in this group globally.</p>
<p>Iron supplementation has historically been the primary form of treatment and prevention of anemia. This includes large-scale addition of iron to foods such as flour, rice or milk, as well as providing oral iron tablets and intravenous iron, depending on the context and severity. </p>
<p>Some research has suggested that less than half of people with anemia will <a href="https://doi.org/10.1111/nyas.14175">fully respond to supplemental iron</a> if the underlying causes of iron deficiency remain untreated. For example, cells in our bodies <a href="https://doi.org/10.1016/j.beha.2004.08.020">sequester iron</a> as part of the immune response to some infections. Supplementing with iron without treating the underlying infection will do little to solve the iron deficiency in the long run, and it <a href="https://doi.org/10.1016/S0140-6736(06)67962-2">may even be harmful</a>.</p>
<p>Additional interventions include <a href="https://www.cdc.gov/hiv/risk/art/index.html">HIV treatment and prevention</a>, with <a href="https://theconversation.com/long-acting-injectable-prep-is-a-big-step-forward-in-hiv-prevention-190225">pre-exposure prophylaxis</a> and <a href="https://www.cdc.gov/hiv/basics/livingwithhiv/treatment.html">anti-retroviral therapy</a>. Preventing initial infection with HIV or suppressing the effects of the virus once infected will reduce the anemia burden related to HIV/AIDS.</p>
<p>Other strategies include malaria control methods, such as insecticide-treated bed nets and vaccination, and monitoring and prevention of chronic illnesses such as <a href="https://www.cdc.gov/kidneydisease/basics.html#">chronic kidney disease</a> and <a href="https://www.niehs.nih.gov/health/topics/conditions/inflammation/index.cfm">inflammatory conditions</a>. In combination with a robust supplementation program, these interventions could meaningfully reduce the global burden of anemia.</p>
<p>Anemia makes it hard for nearly 2 billion people worldwide to learn in school, perform at work and take care of their families. We hope our findings will allow for more comprehensive intervention and treatment plans, especially for the most vulnerable – adolescent and adult women, children and the elderly.</p><img src="https://counter.theconversation.com/content/212177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Kassebaum receives funding from the Bill & Melinda Gates Foundation. </span></em></p><p class="fine-print"><em><span>Theresa A McHugh and William Gardner do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Among young children, adolescents and adult women, anemia strikes 1 in 3 globally. Most cases are driven by dietary iron deficiency, red blood cell disorders and untreated tropical diseases.William Gardner, Researcher in Neonatal and Child Health at the Institute for Health Metrics and Evaluation, University of WashingtonNicholas Kassebaum, Adjunct Professor in Health Metrics Sciences and Professor of Anesthesiology and Pain Medicine, University of WashingtonTheresa A McHugh, Researcher and Scientific Writer at the Institute for Health Metrics and Evaluation, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1923382023-08-30T13:39:00Z2023-08-30T13:39:00Z‘Motherhood is hard’: young, HIV-positive mums in South Africa open up about regret and anger<figure><img src="https://images.theconversation.com/files/489318/original/file-20221012-22-szjlec.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women aren't often given space to discuss the difficult aspects of motherhood.</span> <span class="attribution"><span class="source">fizkes/Shutterstock</span></span></figcaption></figure><p>For any woman, pregnancy and giving birth are major life-changing experiences. Becoming a mother brings with it a range of emotions and, in <a href="https://www.africaknowledgeproject.org/index.php/jenda/article/view/92">many African cultures</a>, positive emotions are centred when talking about motherhood. </p>
<p><a href="https://scholar.google.com/scholar_lookup?hl=en-US&publication_year=2016&author=O.+Oyewumi&title=What+gender+is+motherhood%3A+Changing+Yoruba+ideals+of+power%2C+procreation%2C+and+identity+in+the+age+of+modernity">Scholarship</a> from the eastern, western and southern parts of the continent has <a href="https://www.africaknowledgeproject.org/index.php/jenda/article/view/92">emphasised</a> how motherhood is linked to <a href="https://doi.org/10.1017/CBO9781139344333">notions</a> of continuity, strength and sacrifice, unconditional love, consecration and spirituality, family ties, loyalty and happiness.</p>
<p>In many African cultures, mothers are expected to be resilient, happy and tenacious. But what about the often “silenced” aspect of motherhood? Generally, mothers are not expected or encouraged to share any <a href="https://doi.org/10.1086/678145">negative emotions about their experiences and role</a>. Those who defy this expectation are <a href="https://doi.org/10.1177/0743558420945182">frequently stigmatised</a> and labelled “bad mothers”. </p>
<p>These responses often arise from the belief that motherhood is life’s key purpose. Seen through this societal lens, becoming a mother ought to be fulfilling and overwhelmingly positive.</p>
<p>But human emotions are complex. People can experience joy and sadness simultaneously. This is underscored by <a href="https://journals.sagepub.com/doi/abs/10.1177/2158244019848802">our study</a> among HIV-positive mothers in South Africa about their experiences of motherhood. These young women, aged between 16 and 24, told us how they grappled with harsh realities and daily challenges. </p>
<p>They expressed regret about their unplanned experience of motherhood and wished their circumstances were different. It was clear they were experiencing conflicting internal emotions as they considered the roles, responsibilities and difficulties of motherhood. </p>
<p>Such negative emotions – especially regret – are seldom expressed when talking about motherhood. This leaves little room for African mothers to be vulnerable. To change this ideology and practice, safe space must be created for these feelings. </p>
<p>Doing so can promote open, honest and non-judgmental discussions that will lead to changes in the narratives surrounding motherhood, influence practices and boost emotional, mental and physical health. It can allow mothers and their children to thrive and be better equipped with the necessary skills to face life, irrespective of their challenges.</p>
<h2>Motherhood is hard</h2>
<p>We conducted one-on-one, in-depth interviews with ten HIV-positive mothers in Johannesburg, South Africa. The women all became mothers when they were adolescents. Their children’s ages ranged from two months to seven years old. We also interviewed three key stakeholders who, through their work as academics and researchers and in the healthcare field, engaged closely with adolescent mothers and HIV-positive individuals in South Africa.</p>
<p>None of the young mothers had planned to become pregnant. They were dealing with intersecting psychological, socioeconomic, health, cultural and physiological dynamics. They were stepping into new, unknown realities: as young mothers, some still had school responsibilities. Others were unemployed, <a href="https://data.worldbank.org/indicator/SL.UEM.1524.FE.ZS?locations=ZA">as is the case</a> for most adolescent girls and young women aged between 15 and 24 in South Africa. They depended financially on others such as their grandmothers, the government’s monthly child support grant, or transactional sex partners. </p>
<p>Their HIV status created another layer of complexity due to the attached health responsibilities, stigma and shame. Apart from the <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791450#:%7E:text=In%202019%2C%20an%20estimated%2070,aged%2020%20to%2024%20years.">high susceptibility</a> of adolescent girls to unplanned pregnancy and HIV infection in South Africa, another important reason for working with this group of mothers was to give voice to their experience and to possibly inform relevant policies.</p>
<h2>No judgment</h2>
<p>We created a safe, non-judgmental space in which the young women could share their feelings, both positive and negative. At least half of the participants told us that this was the first time they’d felt able to freely narrate their experiences, especially negative feelings about the experience of motherhood. Away from the pressure of cultural beliefs and expectations, they opened up. </p>
<p>The most prominent emotions they expressed were negative: specifically, they felt regret and anger. Their reflections were sometimes painful. One said:</p>
<blockquote>
<p>I will always feel like I robbed myself of my childhood, and at times I will resent my child. I would hit my child so badly, and even though she couldn’t hear what I was saying but I will always tell her that I regret being with her.</p>
</blockquote>
<p>Another told us:</p>
<blockquote>
<p>I don’t know whether it was worth it, but I know maybe I could have prevented it … I wish I had known how difficult it was to actually be a mother.</p>
</blockquote>
<p>This is a powerful negation of society’s notion that the moment a woman becomes a mother, she has access to knowledge and systems that enable her to maintain the image of <a href="http://dx.doi.org/10.1086/678145">“the good mother”</a>. The notion that the fear and doubt will be pushed aside and only positive emotions will dominate is simply false.</p>
<p>Most of the mothers also shared the joy and rewarding feelings of having their children. One stated that: </p>
<blockquote>
<p>… at first I was scared, but now I am happy because I look at her and she inspires me a lot … now I am seeing life in another way … with the support of my aunt and friends, I feel better.</p>
</blockquote>
<p>Another said:</p>
<blockquote>
<p>… it is good to see my baby laughing, happy, playing, very nice … like it is very (long pause) … it is beautiful … I like him smiling cos I’m like I can no longer imagine my life without my son (laughs).</p>
</blockquote>
<h2>Freedom and support</h2>
<p>It’s time to shift the conversation from conventional and rigid constructions of motherhood to a more open, inclusive picture across Africa. </p>
<p>This will do more than just give mothers the freedom to express the full range of their emotions about motherhood: it can also contribute to more inclusive, tailored policies and programmes that take into account the many complexities and dilemmas our participants spoke about. </p>
<p>These might include access to need-specific, supportive, non-judgmental counsellors and therapists, and increased peer mentorship programmes, as well as access to sexual and reproductive health information and career support programmes.</p><img src="https://counter.theconversation.com/content/192338/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Morolake Josephine Adeagbo 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>Negative emotions, especially regret, are seldom expressed when talking about motherhood.Morolake Josephine Adeagbo, Senior Research Associate, University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2099442023-07-24T12:15:09Z2023-07-24T12:15:09ZMassachusetts is updating its sex education guidelines for the first time in 24 years<figure><img src="https://images.theconversation.com/files/537922/original/file-20230717-232909-qmmoii.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5472%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A dozen U.S. states still do not mandate sex education in schools.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/happy-young-group-of-multiracial-students-hanging-royalty-free-image/1415841874?phrase=high+school+classroom+students&adppopup=true">Xavier Lorenzo/Moment via Getty Images</a></span></figcaption></figure><p>In June 2023, the Commonwealth of Massachusetts shared with the public a draft of a new framework that will guide <a href="https://www.doe.mass.edu/sfs/healthframework/">how elementary, middle and high schools in the state approach sex education</a>. </p>
<p>The <a href="https://www.doe.mass.edu/frameworks/health/1999/1099.pdf">last time Massachusetts issued guidelines</a> that specify expectations for what Massachusetts students learn about sex in schools was 24 years ago, when most U.S. homes were not yet internet-connected. </p>
<p>The new guidelines are part of a larger framework that addresses many aspects of health, including physical education, nutrition and hygiene. They include important improvements over the 1999 version, including standards that pertain to the well-being of gender and sexual minority populations. That’s noteworthy, given that other U.S. states have recently <a href="https://www.usatoday.com/story/news/nation/2023/04/19/florida-bans-teaching-gender-identity-sexuality-through-12-th-grade/11695779002/">prohibited classroom education about gender identity and sexual orientation</a>.</p>
<p>The draft Massachusetts framework has been in development since 2018 but is not yet final. After a public comment period, which is open until Aug. 28, the framework is subject to approval by the commonwealth’s Board of Elementary and Secondary Education and could be adopted as early as the fall of 2023.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A teenager lies on his bed while looking at his laptop." src="https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537923/original/file-20230717-184356-u9hkhb.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">For information about sex, young people turn to online pornography more often than talking to friends or parents.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/teenage-boy-in-his-bedroom-using-a-laptop-royalty-free-image/1097875056?phrase=high+school+students+watching+disturbing+images+online&adppopup=true">Richard Bailey/Corbis via Getty Images</a></span>
</figcaption>
</figure>
<p>I’m a public health researcher who <a href="https://scholar.google.com/citations?user=BgjSYDgAAAAJ&hl=en&oi=ao">focuses on sex education and healthy relationships</a>. I have co-developed and tested a new sex education module for high school students in Massachusetts with funding from the National Institutes of Health, so I read the part of the framework that deals with sex education with great interest. </p>
<p>I’ll provide some more detail on the Massachusetts framework below, but first it is important to understand the state of sex education in the U.S.</p>
<h2>Sex education and pornography</h2>
<p>Many young people in the U.S are not getting the sex education that they need. Currently, only 38 U.S. states and the District of Columbia mandate any kind of sex education. As a result, it isn’t surprising that <a href="https://www.guttmacher.org/fact-sheet/adolescents-teens-receipt-sex-education-united-states">fewer than half</a> of U.S. adolescents say that they have received information about where to get birth control before having heterosexual intercourse for the first time. And the racial disparities are concerning: Black and Hispanic teens are less likely than white teens to receive education about prevention of sexually transmitted infections or HIV, or <a href="http://doi.org/10.1016/j.jadohealth.2021.08.027">where to get birth control</a>. </p>
<p>So where do teenagers and young adults go to get information about sex, in the absence of comprehensive sex education at school? </p>
<p>According to a nationally representative <a href="http://doi.org/10.1007/s10508-020-01877-7">study that my team published in 2021</a>, young adults in the U.S. are more likely to turn to pornography than to their friends, parents, doctors or any other source. That’s a problem, because pornography isn’t designed to relay medically accurate or helpful information about sex — it’s designed to get clicks or likes, make money and entertain the viewer.</p>
<p>Massachusetts is not one of the states that mandates sex education. However, <a href="https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXII/Chapter71/Section1">state law does require</a> all public schools to teach health education. As a local control state, Massachusetts issues frameworks and guidance and allows local school districts boards to decide how to implement them. This approach will continue with the new framework once adopted.</p>
<p>Importantly, the new Massachusetts framework recognizes the prevalence of pornography, and it addresses other critical sex education topics for the modern world. </p>
<p>For example, the framework specifies that in grades 6 to 8, adolescents should learn about laws related to sexual digital imagery. This is important because otherwise they may not realize that possessing or sending nude digital photos of people younger than 18 years old is a crime even if the sender is also a minor. </p>
<p>The framework also suggests that adolescents should be able to analyze similarities and differences between friendships, romantic relationships and sexual relationships, and discuss various ways to show affection within each. It expects them to be able to define sexual consent and describe factors, such as drug and alcohol use, that can influence capacity to give consent. It recommends teaching strategies to help students recognize when someone is grooming or recruiting a young person for possible commercial sexual exploitation like human trafficking.</p>
<p>While these points are strong, I would like to see a recommendation that schools tell youth that mainstream online pornography is not a good source of information about sexual behavior.</p>
<h2>A series of online games</h2>
<p>Our research team, which includes <a href="https://www.bu.edu/sph/profile/kimberly-nelson/">Kimberly Nelson of Boston University,</a>, <a href="https://sph.unc.edu/adv_profile/julia-campbell/">Ph.D student Julia Campbell of the University of North Carolina</a> and BU <a href="https://www.linkedin.com/in/tomeka-frieson/">masters student Tomeka Frieson</a>, has been working on new sex education teaching materials for Massachusetts high schools for <a href="https://reporter.nih.gov/search/2sD11hHbEka-FPXly3o0yw/project-details/10406366">the past two years</a>. As researchers, we endeavored to create an online sex education module that reflected the best available evidence and feedback that we got from young people. </p>
<p>Our teaching materials are in the form of short, online games that students engage with on their own time, and then come back to the classroom to discuss. One of the games has students order the effectiveness of 11 different contraceptive methods. Another provides them with information about ways pornography can provide unhelpful expectations about sex and sexuality. A third game invites students to act as an advice columnist to solve relationship problems for peers. </p>
<p>When we tested the materials with 54 teens ages 14-18 years old in Massachusetts in 2022, we found a statistically significant positive impact on a range of outcomes, from increased condom use to fewer experiences of abuse by a dating partner. We will partner with a number of Massachusetts high schools in the next several years to continue testing the impact of our module. </p>
<h2>Reading the framework</h2>
<p>In reading the new Massachusetts guidelines, our team noted several strengths of its approach. </p>
<p>First, the framework is evidence-based. In other words, the recommendations reflect the latest and best available research about how adolescents develop, learn and behave with regard to sex and sexuality. </p>
<p>Second, the guidance is developmentally and age-appropriate, with different recommendations for different grade levels, and with careful attention to diverse perspectives, cultural differences, and the importance of delivering material in a way that would not traumatize students.</p>
<p>Third, the framework encourages youths’ critical thinking, reasoning, decision-making and problem-solving. </p>
<p>It is my hope that Massachusetts will strengthen the guidance on pornography. If it does, the new framework will be well positioned to serve as a national model.</p><img src="https://counter.theconversation.com/content/209944/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily Rothman receives funding from the National Institutes of Health. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health. </span></em></p>Twelve states do not require sex education of any kind.Emily Rothman, Professor and Chair, Occupational Therapy; and Professor of Community Health Sciences, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2078362023-07-13T11:46:33Z2023-07-13T11:46:33ZFungal infections in the brain aren’t just the stuff of movies – Africa grapples with a deadly epidemic<figure><img src="https://images.theconversation.com/files/532417/original/file-20230616-19-tunqcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The fungus Aspergillus fumigatus. This fungus can cause a number of disorders in people with compromised immune function or other lung diseases.</span> <span class="attribution"><span class="source">Kateryna Kon/Science Photo Library/GettyImages</span></span></figcaption></figure><p>In the 2023 American post-apocalyptic drama television series <a href="https://www.hbo.com/the-last-of-us">The Last of Us</a>, humans are plunged towards extinction as a fungal infection of the brain zombie-fies most of the species. This may seem far-fetched but fungi can, and do, infect human brains.</p>
<p>Fungi are present everywhere in our environment: in the air, in the soil, in decaying plant material, on our skin, and even in the gut as part of our natural flora.</p>
<p>Microscopic, disease-causing fungi can invade various parts of the body, leading to a range of symptoms and health problems. In fact, fungal infections contribute to <a href="https://doi.org/10.3390%2Fjof7050367">about 1.5 million deaths</a> every year. </p>
<p>I am a neurobiologist who has been studying fungal infections of the brain for 10 years. I was part of a team that recently <a href="https://doi.org/10.1111/pim.12953">published a review</a> discussing the emergence, and re-emergence, of fungal infections in Africa, especially in sub-Saharan Africa. We conclude that Africa is suffering from a silent, but costly, epidemic of fungal infections. We found that the emergence of deadly fungal infections in the region is primarily driven by a high burden of HIV infections, lack of access to quality healthcare, and unavailability of effective antifungal drugs.</p>
<h2>What are fungal infections?</h2>
<p>For the greater part of the history of humankind, fungal infections were never a threat to human health. This is mainly because most fungi cannot survive the warm human body temperature of 37°C. However, climate change and other environmental pressures <a href="https://doi.org/10.1016/j.joclim.2022.100156">have led</a> to the emergence of species of fungi that are capable of surviving at human body temperatures. </p>
<p>Even then, our immune systems are quite capable of fighting against fungal infections. For instance, our bodies can create localised acidic environments, limit micronutrient availability and release antimicrobial agents. </p>
<p>However, when the immune system is weakened, fungi are able to evade the body’s defences and avoid detection. They can generate bioactive agents which help them evade or adjust to the host immune response. Some adapt to survive in hostile, low-nutrient and low-oxygen environments. </p>
<p>Immunocompromised people are at risk of developing serious or life-threatening fungal diseases. Africa accounts for <a href="https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">67%</a> of the global burden of HIV, and opportunistic fungal diseases <a href="https://doi.org/10.1111/pim.12953">are on the rise</a>.</p>
<h2>Some examples</h2>
<p>One example of opportunistic fungal diseases is <a href="https://www.ncbi.nlm.nih.gov/books/NBK525986/">cryptococcal meningitis</a>, which emerged with the HIV pandemic in the late 1980s. Today, sub-Saharan Africa contributes about <a href="https://doi.org/10.1016/s1473-3099(17)30243-8">73%</a> of all global cases and deaths resulting from the disease. Cryptococcal meningitis is caused by the fungus <em>Cryptococcus neoformans</em>, which is found in soil and bird droppings. Infection by the fungus occurs when someone inhales fungal spores. It first leads to the development of a lung infection and later a fatal brain infection. Cryptococcal meningitis is a leading cause of adult meningitis in sub-Saharan Africa and it’s associated with <a href="https://doi.org/10.1016/S1473-3099(22)00499-6">almost 20%</a> of all AIDS-related deaths. </p>
<p>Effective treatments for cryptococcal meningitis are unaffordable and inaccessible for most affected people. Costs <a href="https://doi.org/10.1093/cid/ciy971">range between</a> US$1,400 and US$2,500 per patient for a full two-week antifungal treatment course. </p>
<p>The development of cheaper drugs has been hindered by a limited understanding of how the fungus causes such extreme damage in the brain. </p>
<p>Another example of an HIV-related opportunistic fungal disease is pneumocystis jirovecii pneumonia. It’s caused by a ubiquitous, airborne fungus <em>Pneumocystis jirovecii</em>, which is passed on from person to person. Pneumocystis hardly causes trouble in people with healthy immune systems, but they act as reservoirs and pass the infection to those with poor immune systems, who may develop serious symptoms including fever, a dry cough and trouble with breathing. Pneumocystis jirovecii pneumonia occurs in <a href="https://doi.org/10.1186/s12879-016-1809-3">15%-20%</a> of HIV patients who present with respiratory problems. </p>
<p>The diagnosis of pneumocystis jiroveci pneumonia is expensive and requires a well-equipped laboratory. In Africa’s poor urban and rural healthcare facilities this will be a challenge. The fungus, <em>P. jirovecii</em>, is also extremely difficult to culture, which limits diagnosis and research. </p>
<h2>Growing burden</h2>
<p>In our review, <a href="https://doi.org/10.1111/pim.12953">we found</a> various factors driving the emergence and reemergence of fungal threats. They include climate change, the spread of immunosuppressive diseases, medical advances such as organ transplants (the immune system is suppressed to minimise rejection), the use of immunosuppressants to manage inflammatory diseases, and the use of antibiotics. </p>
<p>While these factors are not unique to Africa, the burden of fungal diseases and the number of people who succumb to them is much greater. </p>
<p>The COVID pandemic seems to have made the global fungal burden worse. For instance, <a href="https://doi.org/10.1016/j.gr.2021.12.016">recent studies</a> have <a href="https://doi.org/10.4103%2Fijd.ijd_17_22">shown</a> that people who were infected with COVID and have recovered are vulnerable to infection with a fungus called mucormycosis, also known as the black fungus. COVID-induced lung damage, high blood sugar, and the steroids often used to treat it are all predisposing factors to black fungus infection. With a reduced capacity to clear fungal spores and a reduced immune response, thanks to the steroids, the fungus can gain entry and infect the sinuses and facial bones, eventually moving to the brain. </p>
<h2>But don’t we have antifungal drugs?</h2>
<p>Most of the population affected by fungal infections live in rural or poor urban settlements. </p>
<p>With poorly funded and overburdened healthcare systems, many African countries are not well prepared to deal with fungal infections. Additionally, some of the WHO-recommended antifungal drugs – such as flucytosine – are <a href="https://gaffi.org/antifungal-drug-maps/">unavailable</a> in most African countries. Ineffective and even rather toxic drugs are sometimes used instead. </p>
<p>The emergence of drug-resistant fungal strains is also a growing threat. Of great concern is the rise in multi-drug resistant Candida species, <a href="https://doi.org/10.1007/s11908-019-0702-9">azole-resistant Aspergillus</a> species and clinically resistant <a href="https://doi.org/10.1007/978-1-60327-595-8_20">Cryptococcus</a>. </p>
<h2>Management strategies</h2>
<p>Fungal threats are adding pressure to overburdened health systems with a limited arsenal of treatment options. </p>
<p>Healthcare professionals, scientific researchers, policymakers and governments must address the gaps in the diagnosis and management of fungal infections. This will help to improve capacity to deal with them.</p><img src="https://counter.theconversation.com/content/207836/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Dangarembizi is a scientific researcher in the field of neuroscience and medical mycology and her research is funded by several funding bodies including the Gabriel Foundation and the UK Medical Research Council. </span></em></p>Africa is suffering from a silent, but costly, epidemic of fungal infections.Rachael Dangarembizi, Neuroinfections Researcher, Neuroscience Institute, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2054992023-06-12T09:56:25Z2023-06-12T09:56:25ZHIV care for migrant women in South Africa: the gaps and 5 steps towards offering better services<figure><img src="https://images.theconversation.com/files/529106/original/file-20230530-19-44pgfi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa's healthcare system has gaps in providing HIV treatment to highly mobile women.
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Around <a href="https://www.statssa.gov.za/publications/P0302/P03022022.pdf#page=24">8.45 million</a> people in South Africa live with HIV – an estimated 13.9% of the population. Of South African women aged 15-49, approximately <a href="https://www.statssa.gov.za/publications/P0302/P03022022.pdf#page=25">24%</a> are HIV positive.</p>
<p>The roll-out of services to prevent mother-to-child transmission of HIV has been notably successful in <a href="https://www.hst.org.za/publications/District%20Health%20Barometers/DHB+2017-18+Web+8+Apr+2019.pdf#page=105">reducing</a> the rate of transmission. </p>
<p>But there are still gaps in the delivery of HIV treatment and prevention. A case in point is migrant women. <a href="https://theconversation.com/south-africas-healthcare-system-cant-afford-to-ignore-migration-120797">People who move</a> across national borders or between regions and provinces are particularly easy for healthcare systems to miss. And there’s no integrated system of tracking them. Nor is there any robust national data on how many migrant women, specifically pregnant migrant women, are on treatment and virally suppressed. </p>
<p>In 2020, it was <a href="https://www.statssa.gov.za/?p=14569">estimated</a> that there were 4 million migrants in South Africa, some of whom were women living with HIV. The public health system has <a href="http://www.samj.org.za/index.php/samj/article/view/8569">struggled to respond</a> yet alone integrate this mobile population.</p>
<p>The vulnerability of migrants was <a href="https://theconversation.com/covid-affected-access-to-hiv-treatment-the-stories-of-migrant-women-in-south-africa-show-how-195214">highlighted</a> during the COVID-19 pandemic when restrictions affected people’s ability to travel to access treatment as well as the delivery of healthcare.</p>
<p>In a recent <a href="https://journals.sagepub.com/doi/full/10.1177/11786329211073386">paper</a> we explored the challenges of the COVID-19 pandemic for HIV prevention services in Johannesburg, South Africa’s economic hub. We interviewed healthcare providers and stakeholders in policy and programming. The aim was to understand the gaps in ensuring adherence to lifelong antiretroviral therapy for mobile populations. </p>
<p>The information we gathered shone a light on the country’s overburdened healthcare facilities and the shortcomings in the network of referral clinics in Johannesburg and across Gauteng province. We went on to draw from these insights to understand the systemic gaps in the delivery of antiretroviral treatment (ART) to migrant women. We identified five in particular. And we then identified possible solutions, including how technology could improve access to healthcare.</p>
<h2>The gaps</h2>
<p>The pandemic created new problems in healthcare delivery and exposed existing shortcomings. Five main themes emerged from our qualitative study. </p>
<p>First, women living with HIV and who were highly mobile feared going to healthcare facilities because they were scared of getting COVID. This interrupted their treatment and increased their risk of falling ill. </p>
<p>Second, some healthcare workers told us they felt overwhelmed by the added burden of the pandemic on providing HIV prevention services to pregnant women. For example, many reported that there was a lack of infrastructural resources to follow social distancing protocols. This disrupted their provision of care. </p>
<p>Third, migrant women faced a number of logistical barriers:</p>
<ul>
<li><p>some who left Gauteng province and then tried to return to collect their medication couldn’t do so due to border and lockdown restrictions</p></li>
<li><p>some lost their jobs and income, and were unable to afford travel to collect their ART</p></li>
<li><p>some were denied care because they didn’t have documentation (though this <a href="https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/what-does-the-law-say-about-migrants-and-refugees-accessing-healthcare-in-south-africa/">should not have been a barrier</a>). </p></li>
</ul>
<p>These factors resulted in patients interrupting treatment. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-essential-reads-on-migrant-access-to-healthcare-in-south-africa-190257">5 essential reads on migrant access to healthcare in South Africa</a>
</strong>
</em>
</p>
<hr>
<p>Fourth, some individuals who sought treatment reported mistreatment and xenophobic <a href="https://theconversation.com/telling-the-complex-story-of-medical-xenophobia-in-south-africa-127040">attitudes</a> from healthcare providers. Even some healthcare providers reported that their colleagues behaved negatively towards <a href="https://theconversation.com/southern-africa-needs-better-health-care-for-women-and-girls-on-the-move-121151">migrant women</a>. </p>
<p>Time pressures were the fifth theme. Health workers said they needed more time to counsel patients. This helps build a rapport and strengthens the ability of patients to manage their health. </p>
<p>From these insights we drew up a list of interventions we think would improve antiretroviral services to migrant women in South Africa. </p>
<h2>What can be done?</h2>
<p>The first step is to dispense antiretrovirals for a longer duration of time to alleviate stress for individuals on the move and encourage retention in the ART programme.</p>
<p>Secondly, decentralise services and bring care to the community with pop-up delivery that can help remove logistical barriers like transport to clinics that are far away. </p>
<p>Thirdly, introduce virtual care platforms – like online HIV prevention of mother to child transmission services. It could help highly mobile individuals to interact with healthcare providers. This could help to improve the referral system between clinics and counsellors could follow up patients who had moved. The system could keep better patient records and send reminders for medicine collections. In addition, it should include translation services to help remove communication barriers between service providers and users. And it could better integrate communication of healthcare facilities – even those in other countries – so as to track patients.</p>
<p>Fourthly, healthcare providers need better opportunities to build closer relations with each other. This could create a better understanding of the changes in their work and the underlying issues that affect them. Greater understanding could help get to the root of where <a href="https://theconversation.com/migrants-in-south-africa-have-access-to-healthcare-why-its-kicking-up-a-storm-189574">negative attitudes</a> towards migrants stem from to improve behaviours towards patients. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-social-management-of-hiv-african-migrants-in-south-africa-127955">The social management of HIV: African migrants in South Africa</a>
</strong>
</em>
</p>
<hr>
<p>In addition, healthcare facilities often improvise to come up with strategies and solutions that meet the requirements and changes to programmes. If these were better documented they could then provide knowledge translation and learning opportunities on a larger scale for other healthcare providers, facilities and programmes.</p>
<p>Fifth, government should evaluate healthcare environments before changing policies and programmes. Platforms such as working groups should be provided for collaboration with researchers, service providers and mobile patients to help direct policy and practices. </p>
<p>South Africa needs to take a more pragmatic approach to the delivery of antiretroviral treatment. It needs a healthcare system that is migration-aware and offers a service that recognises mobility – one that speaks to the realities of migrant women living with HIV in South Africa.</p><img src="https://counter.theconversation.com/content/205499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melanie Bisnauth holds a PhD in Public Health at the University of Witwatersrand, South Africa and received funding from the Life in the City, School of Governance. Some of the work discussed in this article was funded through this grant.
</span></em></p>The vulnerability of migrants was highlighted during the COVID-19 pandemic when restrictions affected people’s ability to travel to access treatment.Melanie Bisnauth, Doctoral Researcher, School of Public Health and Public Health Technical Advisor, Anova Health Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2050252023-06-08T20:07:07Z2023-06-08T20:07:07ZLong COVID could be caused by the virus lingering in the body. Here’s what the science says<figure><img src="https://images.theconversation.com/files/530286/original/file-20230606-29-9qrejq.jpg?ixlib=rb-1.1.0&rect=58%2C226%2C5540%2C3505&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/cfKO58M1QpY">Alexander Grey/Unsplash</a></span></figcaption></figure><p>While most people survive and recover from COVID, for some people symptoms can <a href="https://www.nature.com/articles/s41586-021-03553-9">persist for months</a> or years. When symptoms last longer than 12 weeks, the condition is known as <a href="https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html">long COVID</a>. </p>
<p>Long COVID encompasses up to <a href="https://www.nature.com/articles/s41579-022-00846-2?utm_source=substack&utm_medium=email">200 different symptoms</a>. To determine evidence-based treatments for these symptoms, we need to understand the causes. One factor that may be associated with long COVID is that the virus hasn’t fully cleared from the body after the initial infection. </p>
<p>We know from other viruses that viral fragments can remain in different tissues for months or even years. This could be the case with SARS-CoV-2, the virus that causes COVID. Here’s what the science says so far. </p>
<h2>Other viruses lurk in the body</h2>
<p>Herpesviruses (such as Epstein-Barr virus, the cause of glandular fever), as well as HIV (human immunodeficiency virus) can exist in a “latency state” for life. This means the virus conceals itself within cells and remains dormant. </p>
<p>HIV, in particular, can remain dormant in infected cells throughout the body. Even though it’s inactive, it can still promote immune activation and inflammation. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hiv-latency-a-high-stakes-game-of-hide-and-seek-49665">HIV latency: a high-stakes game of hide and seek</a>
</strong>
</em>
</p>
<hr>
<p>Other viruses such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728251/">Zika</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492426/">measles</a> and <a href="https://bmjopen.bmj.com/content/6/1/e008859">Ebola</a> have been found in tissues of infected people months or years after initial infection. This viral persistence can <a href="https://www.ahajournals.org/doi/10.1161/circulationaha.105.548156">cause chronic illness</a>.</p>
<p>Several studies have shown COVID can also reactivate the Epstein-Barr virus, which has remained in the body in a latent state. Research shows this has been <a href="https://www.jci.org/articles/view/163669">linked to</a> fatigue and problems with thinking and reasoning in <a href="https://www.mdpi.com/2076-0817/10/6/763">people with long COVID</a>. </p>
<figure class="align-center ">
<img alt="Man looks at laptop, confused" src="https://images.theconversation.com/files/530287/original/file-20230606-15-u0ykc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/530287/original/file-20230606-15-u0ykc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/530287/original/file-20230606-15-u0ykc8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/530287/original/file-20230606-15-u0ykc8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/530287/original/file-20230606-15-u0ykc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/530287/original/file-20230606-15-u0ykc8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/530287/original/file-20230606-15-u0ykc8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Latent viruses can cause fatigue and problems with thinking and reasoning.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/4-EeTnaC1S4">Wes Hicks/Unsplash</a></span>
</figcaption>
</figure>
<h2>How do we know COVID stays in the body?</h2>
<p>Several studies have identified the genetic sequences of SARS-CoV-2 (RNA) as well as SARS-CoV-2 proteins in tissues and stool (poo) samples months following infection. </p>
<p>These studies include multiple autopsy reports that <a href="https://www.nature.com/articles/s41586-022-05542-y">found viral RNA and protein in a variety of tissues</a> from people who died up to seven months after infection. SARS-CoV-2 RNA was detected in at least half the samples of heart, lymph glands, eye, nerve, brain and lung tissue tested. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/long-covid-puts-some-people-at-higher-risk-of-heart-disease-they-need-better-long-term-monitoring-202596">Long COVID puts some people at higher risk of heart disease -- they need better long-term monitoring</a>
</strong>
</em>
</p>
<hr>
<p>In people who survived, <a href="https://www.nature.com/articles/s41586-021-03207-w">viral RNA was found</a> four months after infection within intestinal tissues obtained through colonoscopy, when a thin tube is used to take tissue from the large intestine. These patients had asymptomatic COVID and were PCR-negative from swabs of the nose and throat at four months.</p>
<p>A 2022 study found SARS-CoV-2 in the stool of about half of the participants in the first week after infection. At four months, there was no virus present in the respiratory tract but <a href="https://doi.org/10.1016/j.medj.2022.04.001">12.7% of stool samples were RNA positive</a>. A further 3.8% of faecal samples remained positive for RNA at seven months. </p>
<p><a href="https://doi.org/10.1016/S2213-2600(21)00240-X">Initial studies</a> did not always suggest a strong relationship between the long-term detection of SARS-CoV-2 and long COVID symptoms.</p>
<p>But more recently, the presence of SARS-CoV-2 RNA (or protein translated from RNA) in the <a href="https://academic.oup.com/cid/article/76/3/e487/6686531">blood</a> and gut tissue was found to <a href="https://doi.org/10.1053/j.gastro.2022.04.037">increase the likelihood</a> of developing long COVID symptoms.</p>
<figure class="align-center ">
<img alt="Person gets a blood test" src="https://images.theconversation.com/files/530289/original/file-20230606-27-p7vgd8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/530289/original/file-20230606-27-p7vgd8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=335&fit=crop&dpr=1 600w, https://images.theconversation.com/files/530289/original/file-20230606-27-p7vgd8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=335&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/530289/original/file-20230606-27-p7vgd8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=335&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/530289/original/file-20230606-27-p7vgd8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=421&fit=crop&dpr=1 754w, https://images.theconversation.com/files/530289/original/file-20230606-27-p7vgd8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=421&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/530289/original/file-20230606-27-p7vgd8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=421&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The presence of SARS-CoV-2 in the blood increases the likelihood of developing long COVID symptoms.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/ufwC2cmbaaI">Nguyễn Hiệp/Unsplash</a></span>
</figcaption>
</figure>
<h2>How might the delay in clearing the virus impact people with long COVID?</h2>
<p>Delayed clearance of SARS-CoV-2 particles in different parts of the body could drive illness through several potential processes:</p>
<p><strong>1) Inflammation</strong>. The continued immune stimulation by viral proteins causes inflammation, makes our immune system tired, and alters how our immune cells work as time goes on. </p>
<p><a href="https://www.nature.com/articles/s41590-021-01113-x">We have previously shown</a> immune dysfunction and inflammation persist up to eight months in people with long COVID that initially had mild to moderate disease. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-does-covid-become-long-covid-and-whats-happening-in-the-body-when-symptoms-persist-heres-what-weve-learnt-so-far-188976">When does COVID become long COVID? And what's happening in the body when symptoms persist? Here's what we've learnt so far</a>
</strong>
</em>
</p>
<hr>
<p><strong>2) Activation of other dormant viruses</strong>. The continued immune response to persistent SARS-CoV-2 can cause reactivation of latent viruses. </p>
<p>Antibodies reactive to Epstein-Barr virus are elevated in people with long COVID suggesting Epstein-Barr virus <a href="https://doi.org/10.1101/2022.08.09.22278592">reactivation</a>, likely through activating the immune system.</p>
<p>Other latent viruses, such as human endogenous retroviruses (HERVs; ancient viruses that have become a part of our DNA, like a genetic fossil) have recently been shown to become reactivated after infection. HERV proteins <a href="https://www.sciencedirect.com/science/article/pii/S2589004223006818">were detected</a> in blood cells and tissues of COVID patients. </p>
<p>These proteins could potentially drive inflammatory processes in long COVID.</p>
<figure class="align-center ">
<img alt="3D illustration of the Epstein-Barr virus in green and red" src="https://images.theconversation.com/files/530290/original/file-20230606-27-6s4g00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/530290/original/file-20230606-27-6s4g00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/530290/original/file-20230606-27-6s4g00.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/530290/original/file-20230606-27-6s4g00.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/530290/original/file-20230606-27-6s4g00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/530290/original/file-20230606-27-6s4g00.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/530290/original/file-20230606-27-6s4g00.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Reactivation of the Epstein-Barr virus could drive inflammation in long COVID.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/epsteinbarr-virus-ebv-herpes-which-causes-556379407">Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>3) Antibodies made by combating SARS-CoV-2 could become “self” reactive.</strong> These autoantibodies (antibodies produced by our immune system that mistakenly target and attack our own body’s tissues or organs) might cross-react with host receptors or proteins and <a href="https://www.nature.com/articles/s41577-020-00458-y">drive autoimmune</a> disease. </p>
<p>Importantly, recent studies have shown new onset of autoimmune diseases (such as type 1 diabetes, inflammatory bowel disease and psoriasis) are significantly associated with SARS-CoV-2 infection and <a href="https://www.nature.com/articles/s41584-023-00964-y">a link between autoimmunity and long COVID</a> is plausible. </p>
<p>This suggests COVID not only has immediate health impacts but could also potentially trigger long-term changes in the immune system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/viral-infections-including-covid-are-among-the-important-causes-of-dementia-one-more-reason-to-consider-vaccination-190962">Viral infections including COVID are among the important causes of dementia – one more reason to consider vaccination</a>
</strong>
</em>
</p>
<hr>
<p>While the studies mentioned above provide initial evidence of persistence of SARS-CoV-2 long after initial infection, more studies are needed to show a convincing link between lingering virus and long COVID. This should include examination of viral RNA and protein in both blood and tissues in people with long COVID independent of disease severity. And it must involve well-developed cohort studies that track large groups of people internationally.</p>
<p><a href="https://clinicaltrials.gov/ct2/show/NCT05668091">Several</a> <a href="https://clinicaltrials.gov/ct2/show/NCT05576662">trials are underway</a> to assess whether treating long COVID with antivirals such as Paxlovid may reduce viral antigens and improve symptoms, although this remains experimental.</p><img src="https://counter.theconversation.com/content/205025/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Kent receives funding from the NHMRC, the MRFF, the ARC and the NIH. </span></em></p><p class="fine-print"><em><span>Chan Phetsouphanh receives funding from NHMRC and MRFF. </span></em></p>We know from other viruses that viral fragments can remain in different tissues for months or even years. This could be the case for long COVID.Stephen Kent, Professor and Laboratory Head, The University of MelbourneChansavath Phetsouphanh, Senior Research Associate, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2057002023-05-29T13:10:10Z2023-05-29T13:10:10ZDrink up, it’s closing time: South African study calculates that limiting opening hours will save lives<figure><img src="https://images.theconversation.com/files/527034/original/file-20230518-17-8xdcj5.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">Cristi Lucaci/Shutterstock</span></span></figcaption></figure><p>South Africans are among the heaviest drinkers in the world. The country has the highest per capita rate of <a href="https://www.who.int/publications/i/item/9789241565639">alcohol consumption</a> in Africa. Excessive drinking is especially widespread in the Western Cape. Research <a href="https://dgmt.co.za/wp-content/uploads/2023/02/Minumum-Unit-Pricing-Phase-1.1-Modelling-Impact-of-MUP-15112021-FINAL-1.pdf">estimates</a> that per capita alcohol consumption in the province is between 30% and 40% higher than the national consumption. </p>
<p>Alcohol use contributes to <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7771-4">over 200</a> different diseases, injuries and conditions. It is also a risk factor for gender-based violence and <a href="https://www.westerncape.gov.za/assets/departments/health/mortality_profile_2016.pdf">violent crime</a>. </p>
<p>In a bid to reduce alcohol-related harms in the province, the Western Cape government has <a href="https://www.westerncape.gov.za/text/2017/September/white_paper_alcohol-related_harms_reduction.pdf">proposed</a> a policy to restrict trading hours for onsite alcohol consumption. International <a href="https://pubmed.ncbi.nlm.nih.gov/28647704/">research</a> shows that reducing trading hours is an effective way to curb alcohol consumption and its associated harms. This type of policy is also supported by the <a href="https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf">World Health Organization</a>. </p>
<p>My colleagues and I at the University of Cape Town recently conducted a modelling <a href="https://dgmt.co.za/wp-content/uploads/2023/03/Trading-Hours-Phase-2-Modelling-Trading-Times-Final-Report-vf.pdf">study</a>. We wanted to determine the health and economic impacts of restricting the hours of onsite alcohol consumption. </p>
<p>We considered three latest closing-time scenarios: midnight, 1am and 2am. Data for the model baseline was drawn from national surveys on alcohol consumption, the national treasury’s annual budget reviews and publications from Statistics South Africa and the South African Medical Research Council. </p>
<p>We estimated the impact of each of the proposed closing times on the number of cases and deaths associated with certain health conditions. The study also assessed the policy’s impact on alcohol expenditure, excise tax, value added tax and retail revenue. Finally we estimated the impact on the cost of combating alcohol-related crime in the Western Cape.</p>
<p>Our <a href="https://dgmt.co.za/wp-content/uploads/2023/03/Trading-Hours-Phase-2-Modelling-Trading-Times-Final-Report-vf.pdf">results</a> make it clear that limiting the hours for onsite consumption of alcohol will save lives. It will also prevent alcohol-related diseases and injuries, and reduce hospital and crime prevention costs.</p>
<p>On the other hand, national tax revenue and revenue to the alcohol industry will decrease. </p>
<h2>The findings</h2>
<p>We looked at how the policy might affect public health costs of six alcohol-related conditions. We also factored in the hospital costs of treating these conditions. The conditions we looked at were: road injury; intentional injury; liver cirrhosis; HIV; TB; and breast cancer. </p>
<p>Model estimates suggest that all closing-time scenarios correspond to decreases in six areas. These are: </p>
<ul>
<li><p>alcohol consumption</p></li>
<li><p>number of deaths due to the six alcohol-related conditions</p></li>
<li><p>number of cases of these six conditions</p></li>
<li><p>hospital costs of these conditions</p></li>
<li><p>cost of combating alcohol-related crime</p></li>
<li><p>revenue from alcohol sales and alcohol taxation.</p></li>
</ul>
<p>We estimated how much lower the number of cases of the six conditions would be over the next 20 years. The cases averted were:</p>
<ul>
<li><p>163,800 to 453,000 under the midnight closing-time scenario </p></li>
<li><p>88,700 to 220,300 (1am scenario) </p></li>
<li><p>12,600 to 28,300 (2am scenario). </p></li>
</ul>
<p>Correspondingly, the total hospital cost saving over the next 20 years is between: </p>
<ul>
<li><p>R326.8 million and R890.2 million (midnight scenario)</p></li>
<li><p>R130.5 million and R381.2 million (1am)</p></li>
<li><p>and between R18.7 million and R46.0 million (2am). </p></li>
</ul>
<p>(At the time of publication the <a href="https://www.xe.com/currencyconverter/convert/?Amount=1&From=USD&To=ZAR">exchange rate</a> was R19.42 to the US$) </p>
<p>In the year following the policy’s introduction, tax revenue (excise and value added tax) on alcohol sales is expected to decrease by between R100 million and R333 million under a midnight closing-time scenario. Under the 1am scenario it would fall by between R54 million and R179 million. And in the 2am scenario tax revenue would fall by between R9 million and R27 million. </p>
<p>Retail revenue would decrease by between R328 million and R1,093 million (midnight closing time), between R176 million and R587 million (1am) and between R27 million and R89 million (2am).</p>
<h2>What this all means</h2>
<p>The Western Cape government has expressed a clear commitment to protecting health in the Alcohol Harms Reduction <a href="https://www.westerncape.gov.za/text/2017/September/white_paper_alcohol-related_harms_reduction.pdf">White Paper</a>. Introducing uniform trading-time restrictions for onsite retailers of alcohol is a good first step. </p>
<p>A midnight closing time restriction is the most pro-health policy option.
A 2am closing time is the most pro-industry. But the <a href="https://dgmt.co.za/wp-content/uploads/2023/03/Trading-Hours-Phase-2-Modelling-Trading-Times-Final-Report-vf.pdf">research</a> does suggest that, from a public health standpoint, the 2am closing time still represents a modest improvement on the status quo.</p>
<p>Applying <a href="https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf">evidence-based policies</a> to reduce alcohol consumption is necessary to reduce alcohol-related harms and deaths. The possibility of limited economic costs should not be a deterrent to this policy objective.</p>
<p>The alcohol industry may also point to the direct, indirect and induced job losses resulting from this policy. Concerns about employment losses are genuine and valid. But employment losses are only one side of the issue and should be considered with caution. One needs to consider the overall effects of the policy on employment. Jobs will be created in sectors attracting new demand as people spend some of their money on goods and services other than alcohol. It is nearly impossible to predict the number of jobs that will be created directly because of the policy, or because of the lives saved and lengthened.</p>
<h2>What more needs to be done</h2>
<p>Whatever closing time the government chooses, this policy won’t solve every problem. It will need to be enacted alongside other policy interventions geared towards reducing alcohol consumption and its associated harms. </p>
<p>These policies <a href="https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf">include</a> banning alcohol advertising; adopting a minimum alcohol unit price; reducing the legal limits for drinking and driving; and making it easier for people to get counselling and medically assisted treatment if they struggle with alcohol dependence.</p>
<p>A comprehensive policy framework that targets alcohol consumption at an individual and societal level will be required to combat alcohol-related illness and death, and the adverse health, economic and social consequences.</p><img src="https://counter.theconversation.com/content/205700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This modelling study on which this article is based was commissioned and funded by the DG Murray Trust, an organisation which Sam has collaborated with as a consultant. Sam Filby works for the Research Unit on the Economics of Excisable Products based at the University of Cape Town. Her research conducted at the University of Cape Town is funded by the African Capacity Building Foundation through the Bill & Melinda Gates Foundation, Tax Justice Network Africa (also through the Bill & Melinda Gates Foundation), the CDC Foundation, and Cancer Research UK. Sam is also CIO of byegwaai, an app-based smoking cessation program. </span></em></p>Alcohol use contributes to over 200 different diseases, injuries, and conditions. It is also a risk factor for gender-based violence and violent crime.Sam Filby, Research Officer, Research Unit on the Economics of Excisable Products, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045752023-05-02T09:28:01Z2023-05-02T09:28:01ZQueerphobia in Kenya: a supreme court ruling on gay rights triggers a new wave of anger against the LGBTIQ+ community<figure><img src="https://images.theconversation.com/files/523226/original/file-20230427-16-icyfbv.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A demonstrator at Queer Republic protests in Nairobi, Kenya. </span> <span class="attribution"><span class="source">John Ochieng/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p><em>The Kenyan supreme court recently struck down a government decision to ban the registration of an LGBTIQ+ community rights organisation, <a href="https://www.aljazeera.com/opinions/2023/3/15/how-an-lgbtq-court-ruling-sent-kenya-into-a-moral-panic">sparking new homophobic rhetoric</a> in the country. Kenya is one of <a href="https://database.ilga.org/criminalisation-consensual-same-sex-sexual-acts">32 African countries</a> that criminalises homosexuality. Those who identify as part of the LGBTIQ+ community are often discriminated against, harassed and assaulted. Lise Woensdregt and Naomi van Stapele, who have researched queer experiences in Kenya for nine years, explain the impact of this ruling.</em></p>
<hr>
<h2>What is the significance of the recent Kenyan supreme court ruling on a gay rights organisation?</h2>
<p>The Kenyan supreme court ruled on 24 February 2023 that <a href="https://drive.google.com/file/d/10OYaKTuvDvkpBUB5GFLXcf8fmrGFr645/view">the government was wrong</a> to ban the LGBTIQ+ community from registering the <a href="https://nglhrc.com/">National Gay & Lesbian Human Rights Commission</a>. The commission provides legal aid, and works to change the law and policy around LGBTIQ+ persons in Kenya. The commission <a href="https://www.bbc.com/news/world-africa-64491276">celebrated this court ruling</a> as a small but significant affirmation of its place in Kenyan society.</p>
<p>The ruling, however, didn’t alter the <a href="https://www.hrw.org/news/2019/05/24/kenya-court-upholds-archaic-anti-homosexuality-laws">Kenyan penal code</a>, which criminalises sexual acts “<a href="https://www.ilo.org/dyn/natlex/docs/ELECTRONIC/28595/115477/F-857725769/KEN28595.pdf#page=62">against the order of nature</a>”. This, in effect, criminalises same-sex sexual acts. Those found guilty <a href="https://icj-kenya.org/?smd_process_download=1&download_id=5018">face</a> up to 14 years in prison.</p>
<p>The law has <a href="https://www.aljazeera.com/opinions/2023/3/15/how-an-lgbtq-court-ruling-sent-kenya-into-a-moral-panic">fuelled stigma and discrimination</a> against queer individuals, making them more vulnerable to violence. </p>
<p>We have been <a href="https://www.tandfonline.com/doi/full/10.1080/13691058.2020.1842499">studying</a> queer experiences <a href="https://link.springer.com/article/10.1007/s13178-018-0337-x">in Nairobi</a>, working closely with LGBTIQ+ self-led organisations. Those involved in <a href="https://northumbriajournals.co.uk/index.php/IJGSL/article/view/1264">our research</a> have been experiencing mounting violence in recent years. The ruling <a href="https://www.the-star.co.ke/news/2023-03-16-gay-people-fear-for-their-lives-escape-mombasa-over-planned-demos/">triggered fears</a> among members of the LGBTIQ+ community across Kenya of increased violence.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1636702221743079425"}"></div></p>
<h2>What have the political responses been?</h2>
<p>A backlash against progress in gender and sexual rights is not uncommon. Pushing for progress in these areas can <a href="https://www.dailymaverick.co.za/article/2020-07-27-the-pink-line-the-worlds-queer-frontiers-the-new-book-from-mark-gevisser/#gsc.tab=0">evoke hate and counter-offensives</a>. </p>
<p>The Kenyan government has joined churches and mosques in their vitriol condemning not only the supreme court judges, but also LGBTIQ+ activists, organisations and citizens. For example, a member of parliament declared that being LGBTIQ+ is <a href="https://www.the-star.co.ke/news/2023-03-01-lgbtq-is-worse-than-murder-for-us-farah-maalim/">worse than murder</a>. He described homosexuality as </p>
<blockquote>
<p>a foreign practice from the West that’s not aligned with African cultures and as such, severe punishment should be meted out on offenders. </p>
</blockquote>
<p>Kenya’s deputy president Rigathi Gachagua added that the government wouldn’t “<a href="https://twitter.com/rigathi/status/1631244014744739841?s=20">condone</a>” same-sex relations, a sentiment shared by president William Ruto. The president <a href="https://www.africanews.com/2023/03/02/we-shall-not-condone-any-attempts-to-legitimise-lgbtq-kenya-deputy-president-warns//">has previously said</a> that unemployment and hunger are the “real” issues, not LGBTIQ+ concerns, and that tradition must be respected. </p>
<p>Kenya’s first lady, <a href="https://www.the-star.co.ke/news/2023-03-06-first-lady-to-lead-prayers-against-lgbtq-onslaught-on-family/">Rachel Ruto</a>, has also claimed that LGBTIQ+ people are a threat to the institution of the family. Another member of parliament, Peter Kaluma, recently submitted a <a href="https://www.the-star.co.ke/news/2023-04-08-details-of-kalumas-bill-on-criminalising-lgbtq/">family protection bill</a> that includes provisions to criminalise LGBTIQ+ organising, funding and, what is ominously termed, “behaviours”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/kenya-should-decriminalise-homosexuality-4-compelling-reasons-why-203767">Kenya should decriminalise homosexuality: 4 compelling reasons why</a>
</strong>
</em>
</p>
<hr>
<p>Amid all this, LGBTIQ+ self-led organisations <a href="https://www.galck.org/">have struggled</a> to offer a safe space for individuals to <a href="https://www.tandfonline.com/doi/full/10.1080/17450101.2022.2146526?src=">find belonging, acceptance and recognition</a>, and to work towards social, political and economic justice collectively. Some, including those that <a href="https://theconversation.com/kenya-should-decriminalise-homosexuality-4-compelling-reasons-why-203767">provide HIV services</a>, have <a href="https://www.youtube.com/watch?v=O89qRCvXDVU&t=4s">had to close</a> for fear of attacks. </p>
<h2>Based on your research, what have you learnt about what it’s like for LGBTIQ+ people in Kenya?</h2>
<p>Over our nine years of research into queer experiences, we’ve worked closely with grassroots LGBTIQ+ organisations and activists. We are continuously in touch with queer activists, who we speak with as part of our ongoing engagement with and support for queer self-led organisations in Kenya. They have told us that the recent supreme court decision was a step towards decriminalising same-sex sexual acts and was cause for celebration. </p>
<p>Unfortunately, the ruling <a href="https://www.aljazeera.com/opinions/2023/3/15/how-an-lgbtq-court-ruling-sent-kenya-into-a-moral-panic">unleashed vicious anti-LGBTIQ+ attacks</a> targeting organisations, activists and citizens. One young queer activist* told us: </p>
<blockquote>
<p>It is more dangerous now. Our friends are evicted (from their houses). Some have been beaten in the streets. In WhatsApp groups with family or work, people write anti-queer things, and you need to stay silent not to out yourself. You can lose everything if you are found out. </p>
</blockquote>
<p>Another queer activist* told us: </p>
<blockquote>
<p>In the WhatsApp group with parents from school, parents write how to warn our children (against) recruitment by LGBTIQ+ people, and I am in that app. I can’t say anything because it will harm my son. </p>
</blockquote>
<p><em>*Those we interviewed are anonymous for safety reasons</em></p>
<h2>What can be done to empower queer individuals and groups in Kenya?</h2>
<p>Many Kenyan LGBTIQ+ self-led organisations collaborate with government agencies – such as the <a href="https://nsdcc.go.ke/about-us/">National Syndemic Diseases Control Council</a> and the <a href="https://www.nascop.or.ke/about-us/">National AIDS and STIs Control Programme</a>. They also <a href="https://link.springer.com/article/10.1007/s13178-018-0337-x">work with</a> several national and international civil society organisations on health, women rights, sexual and reproductive rights, and social justice. The silence of LGBTIQ+ partners is deafening. As one queer activist told us: </p>
<blockquote>
<p>They eat with us, but when things get tough, we stand alone.</p>
</blockquote>
<p>Eating together here refers to the funds many such organisations receive from donors to work with LGBTIQ+ self-led organisations. </p>
<p>The silence of civil society, including those who collaborate with LGBTIQ+ groups in Kenya and receive funding for this, and the international media is concerning. This silence sends a dangerous message to the government and religious organisations: they can freely target queer individuals and groups without facing resistance or solidarity from the broader community.</p>
<p>The fight for equality and safety for the LGBTIQ+ community requires sustained effort from national and international organisations and governments. On an individual level, financial support is needed as it can empower individuals who identify as LGBTIQ+, providing them with resources, such as the ability to relocate to safer locations. </p>
<p>In our <a href="https://www.tandfonline.com/doi/full/10.1080/13691058.2020.1842499">research</a>, several members told us of the risks they face in Nairobi’s low-income settlements where they live. In these settings, traditional patriarchal masculinity practices – breadwinner-ship, heterosexuality and dominance over women – are celebrated. Not being able to pass as heterosexual is perceived as risky.</p>
<p>Promoting safe spaces and access to stable incomes on a collective level can create a foundation that empowers queer individuals and groups to fight for dignity and respect. </p>
<p>The voices of those affected by anti-LGBTIQ+ violence must be heard and amplified by those who seek a more just and equal world. Only through collective action and solidarity can the LGBTIQ+ community be protected, valued and celebrated.</p><img src="https://counter.theconversation.com/content/204575/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Naomi van Stapele is affiliated with Minority Womxn in Action — MWA, a queer activist organisation in Kenya. </span></em></p><p class="fine-print"><em><span>Lise Woensdregt 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>A backlash against progress in gender and sexual rights is common.Lise Woensdregt, PhD Candidate in Sociology, Vrije Universiteit AmsterdamNaomi van Stapele, Professor in Inclusive Education, Hague University of Applied SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2037672023-04-18T12:19:39Z2023-04-18T12:19:39ZKenya should decriminalise homosexuality: 4 compelling reasons why<figure><img src="https://images.theconversation.com/files/520830/original/file-20230413-14-r1pv5c.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Activists agitate for equal rights for all in Nairobi, Kenya, in January 2020. </span> <span class="attribution"><span class="source">Tony Karumba/AFP via Getty Images</span></span></figcaption></figure><p>Kenya has recently seen the <a href="https://kohljournal.press/health-and-freedom">increasing visibility</a> of sexual and gender minorities. However, this has been met with <a href="https://www.aljazeera.com/opinions/2023/3/15/how-an-lgbtq-court-ruling-sent-kenya-into-a-moral-panic">a growing backlash</a>.</p>
<p><a href="https://www.youtube.com/watch?v=t4uGzjZIzM8">Religious</a> and <a href="https://ntvkenya.co.ke/news/gachagua-on-lgbtq-those-are-satanic-beliefs/">political leaders</a> have been spreading homophobic and transphobic rhetoric. This has happened with the <a href="https://www.hrw.org/report/2015/09/28/issue-violence/attacks-lgbt-people-kenyas-coast">tacit approval</a> of a law enforcement apparatus that’s supposed to guarantee the right to equal protection. </p>
<p>The continued criminalisation of same-sex sexual relations among consenting adults in Kenya worsens social disparities and inequalities. It fuels socioeconomic and health vulnerabilities. </p>
<p>It <a href="https://www.researchgate.net/publication/308163037_Freedom_Corner_Redefining_HIV_and_AIDS_care_and_support_among_men_who_have_sex_with_men_in_Nairobi_Kenya">deprives members of these minority groups</a> access to education, a livelihood, and basic services like housing and healthcare. Criminalisation pushes <a href="https://pure.uva.nl/ws/files/18012125/Thesis.pdf">sexual and gender minorities to the margins of society</a>. Research has shown that sexual and gender minorities are <a href="https://www.researchgate.net/publication/308163037_Freedom_Corner_Redefining_HIV_and_AIDS_care_and_support_among_men_who_have_sex_with_men_in_Nairobi_Kenya">consistently targeted</a> for unfair dismissal from jobs or business opportunities. </p>
<p>The decriminalisation of same-sex relations among adults would lead to four positive outcomes: inclusive development for economic growth, improved health outcomes, the safety and security of sexual minorities, and an acceptance of diversity and equality. This view is based on our <a href="https://www.researchgate.net/profile/Emmy-Kageha">research on social exclusion</a>, with a focus on <a href="https://kohljournal.press/health-and-freedom">sexual and gender minorities</a>.</p>
<h2>Inclusive development for economic growth</h2>
<p><a href="https://www.worldbank.org/en/region/afr/brief/social-inclusion-in-africa">Social inclusion</a> is the process of improving the conditions for individuals and groups to participate in society. Social exclusion based on sexual orientation leads to lower societal standing. </p>
<p>This often leads to poorer outcomes in terms of income, human capital endowments and access to employment. People who are discriminated against tend to lack a voice in national and local decision making. </p>
<p>Decriminalisation of same-sex sexual relations would help address institutionalised stigma and discrimination. It would enhance access to equal opportunities by eliminating barriers to employment and other livelihood opportunities.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/lgbti-refugees-seeking-protection-in-kenya-struggle-to-survive-in-a-hostile-environment-182810">LGBTI refugees seeking protection in Kenya struggle to survive in a hostile environment</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://pure.uva.nl/ws/files/18012125/Thesis.pdf">Research</a> shows that sexual and gender minorities with access to income opportunities support their families financially. This is true even in cases where families aren’t accepting. People who are educated can also compete effectively in the job market. The exclusion of minorities, therefore, means <a href="https://open-for-business.org/kenya-economic-case">the loss of a workforce and their contribution to economic development</a>. </p>
<h2>Better health outcomes</h2>
<p>Social exclusion contributes to poor health among sexual and gender minorities. In 2020, <a href="https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf#page=6">1.5 million people</a> were newly infected with HIV. Those <a href="https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf#page=23">most vulnerable</a> to infection include people who inject drugs, transgender women, sex workers, men who have sex with men, and their sexual partners. </p>
<p>These key populations accounted for <a href="https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf#page=23">65% of HIV infections</a> globally. In sub-Saharan Africa, they accounted for <a href="https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf#page=24">39% of new infections</a>. </p>
<p><a href="https://open-for-business.org/about">Open for Business</a> is a global research coalition that seeks to address the backlash against the LGBTIQ+ community. In a <a href="https://open-for-business.org/kenya-economic-case">2020 report</a>, the group estimated that discrimination against sexual minorities costs Kenya up to Sh105 billion (US$782 million) annually in poor health outcomes. </p>
<p>Decriminalisation enhances access to healthcare. <a href="https://www.tandfonline.com/doi/full/10.1080/17441692.2018.1462841">Our</a> <a href="https://kohljournal.press/health-and-freedom">research</a> shows, for example, better health such as decreased new HIV infections in societies that adopt laws that advance non-discrimination and decriminalise same-sex relationships. </p>
<h2>Enhancing safety and security</h2>
<p>In 2014, the African Commission on Human and Peoples’ Rights adopted <a href="https://achpr.au.int/en/adopted-resolutions/275-resolution-protection-against-violence-and-other-human-rights-violations">Resolution 275</a>. The resolution expresses grave concerns about increasing violence and other human rights violations – including murder, rape and assault – of individuals based on sexual orientation or gender identity. </p>
<p>Safety and security are some of the <a href="https://www.article19.org/resources/kenya-murder-lgbtq-activist-urgent-reform/">biggest challenges</a> facing sexual and gender minorities in Kenya. The country has seen an escalation of <a href="https://www.aljazeera.com/opinions/2023/3/15/how-an-lgbtq-court-ruling-sent-kenya-into-a-moral-panic">negative rhetoric and violence</a> targeting sexual and gender minorities, and <a href="https://www.bbc.com/news/world-africa-64491276">related organisations</a>. Hate speech, verbal and physical abuse, sexual violence and police harassment <a href="https://www.reuters.com/article/uganda-lgbt-hatecrime-idUSL4N3584J1">have increased</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/justiceforsheila-highlights-the-precarious-lives-of-queer-people-in-kenya-183102">#JusticeForSheila highlights the precarious lives of queer people in Kenya</a>
</strong>
</em>
</p>
<hr>
<p>In Kenya’s coastal city of Mombasa, for instance, sexual minorities <a href="https://www.the-star.co.ke/news/2023-03-16-gay-people-fear-for-their-lives-escape-mombasa-over-planned-demos/">fled</a> recent <a href="https://twitter.com/citizentvkenya/status/1636702221743079425?s=20">homophobic street protests</a>. A <a href="https://www.researchgate.net/publication/334681176_Are_we_doing_alright_Realities_of_violence_mental_health_and_access_to_healthcare_related_to_sexual_orientation_and_gender_identity_and_expression_in_East_and_Southern_Africa_Research_report_based_on_">2019 report</a> on the experiences of the <a href="https://ccprcentre.org/files/documents/INT_CCPR_CSS_KEN_44420_E.pdf#page=6">LGBTIQ+ community in Kenya</a> found that 53% have been physically assaulted and 44% sexually assaulted. </p>
<p>The criminalisation of same-sex sexual relations among adults contributes to a climate of violence and discrimination. Moreover, criminalisation supports the perpetrators of violence who take the law into their own hands. </p>
<h2>Acceptance of diversity</h2>
<p>Sexual and gender minorities are socially excluded because of the <a href="https://theconversation.com/homosexuality-remains-illegal-in-kenya-as-court-rejects-lgbt-petition-112149">criminal label</a> the law imposes on them. This affects their self-acceptance and mental health. </p>
<p>Homophobic acts are widespread even in countries where <a href="https://theconversation.com/sam-smith-how-queerphobia-and-fatphobia-intersect-in-the-backlash-to-the-im-not-here-to-make-friends-video-199437">same-sex relations are legal</a>. However, decriminalisation helps facilitate some level of acceptance among minority groups and within wider society. </p>
<p><a href="https://ualr.edu/socialchange/2013/01/13/impact-of-the-decriminalization-of-homosexuality-in-delhi-an-empirical-study">Studies</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9293432/">have found</a> that decriminalisation reduces societal violence. </p>
<h2>The way forward</h2>
<p>Same-sex relations, or sexual and gender minorities, <a href="https://www.jstor.org/stable/43904926">aren’t new</a> <a href="https://www.arcados.ch/wp-content/uploads/2012/06/MURRAY-ROSCOE-BOY-WIVES-FEMALE-HUSBANDS-98.pdf">in Africa</a>. They aren’t a <a href="https://www.researchgate.net/publication/332192031_An_Exploratory_Journey_of_Cultural_Visual_Literacy_of_Non-Conforming_Gender_Representations_from_Pre-Colonial_Sub-_Saharan_Africa">foreign ideology</a>. </p>
<p>Social exclusion constitutes perhaps the most serious challenge towards attaining sustainable and inclusive development. The criminalisation of same-sex relations among consenting adults in Kenya’s penal code exposes the weaknesses of the constitution in ensuring inclusivity. The law must, therefore, be changed. </p>
<p>Repealing criminalisation clauses is an important step toward reducing stigma, violence and discrimination. It would certainly open a new chapter in the lives of sexual and gender minorities.</p>
<p>There’s also an urgent need to make sexual and gender minorities visible. Awareness campaigns can help debunk perceptions that they are “anti-religious” or “un-African”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-does-the-bible-say-about-homosexuality-for-starters-jesus-wasnt-a-homophobe-199424">What does the Bible say about homosexuality? For starters, Jesus wasn't a homophobe</a>
</strong>
</em>
</p>
<hr>
<p>There’s an equally urgent need to identify all forms of discrimination against sexual and gender minorities under domestic and international laws. This will help address the root causes of inequalities.</p>
<p>Decriminalisation of same-sex relations is imperative. It will help address widening disparities, inequalities in society and the gaps in social integration.</p>
<p><em>Nicholas Etyang, a senior policy advocacy officer at the African Population and Health Research Center, is a co-author of this article.</em></p><img src="https://counter.theconversation.com/content/203767/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucy Wanjiku Mung’ala is affiliated with Hivos, where she works as the strategy and impact lead - gender equality, diversity and inclusion. </span></em></p><p class="fine-print"><em><span>Emmy Kageha Igonya 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 criminalisation of same-sex sexual relations among consenting adults in Kenya worsens social disparities and inequalities.Emmy Kageha Igonya, Associate research scientist, African Population and Health Research CenterLucy Wanjiku Mung’ala, PhD Researcher, University of AmsterdamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2020012023-04-10T07:32:28Z2023-04-10T07:32:28ZCervical cancer can be beaten - the key is vaccinating young girls<figure><img src="https://images.theconversation.com/files/518205/original/file-20230329-24-h4txem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The numbers showed a wide variation in coverage in different geographic regions.
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>In 2020 the World Health Organization introduced a plan to eliminate cervical cancer as a public health threat by <a href="https://www.who.int/initiatives/cervical-cancer-elimination-initiative#cms">2030</a>. The first step towards this goal is to have 90% of girls fully vaccinated against human papillomavirus (HPV) by the age of 15 years. Gynaecological oncologist Lynette Denny spells out how much progress still needs to be made, and what hurdles need to be overcome.</em></p>
<hr>
<h2>How big a threat is cervical cancer in sub-Saharan Africa?</h2>
<p>Cervical cancer is one of the most common cancers in women. Sub-Saharan Africa has the highest <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X%2822%2900501-0">cervical cancer diagnoses</a> worldwide. Cervical cancer mortality rates in the region are <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X%2822%2900501-0">three times higher</a> than the global average. The burden of HIV in sub-Saharan Africa contributes to the disparity. In 2021, in southern Africa, <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X%2820%2930459-9">63.8%</a> of women with cervical cancer were living with HIV, as were 27.4% of women in eastern Africa. </p>
<p>Most cases of cervical cancer are caused by the human papillomavirus (HPV), which is transmitted through skin to skin contact, including sexual activity.</p>
<h2>How do countries compare in meeting the WHO target?</h2>
<p>By <a href="https://www.sciencedirect.com/science/article/pii/S0091743520304308?via%3Dihub">June 2020</a>, more than half of the WHO member states – that’s 107 out of 194 – had introduced HPV vaccination nationwide or partially.</p>
<p>The numbers showed a wide variation in coverage in different geographic regions. High-income countries such as Australia and New Zealand had the highest complete coverage with HPV vaccination at 77%. Low- and middle-income countries lagged far behind – only 41% had introduced HPV vaccination by the end of 2019. Only 20% of the eligible population in sub-Saharan Africa has been vaccinated. </p>
<p>Levels of vaccination matter because, with wide coverage of the appropriate age group, over time it is theoretically possible to eliminate HPV as a human pathogen. This was the case with <a href="https://www.who.int/health-topics/smallpox#tab=tab_1">smallpox</a>.</p>
<p>Most (90%) of low- and middle-income countries deliver vaccination through schools and facility-based vaccination. The two-dose schedule is the most common. When the HPV vaccine was initially approved for use, it was given to girls aged 9-13 in three doses. Dose one intially; dose two at one or two months after the first dose; and a third dose six months later. </p>
<p>It later became evident that two doses gave the same level of immunity as three doses. </p>
<p>It is now recognised that one dose is as good as three doses in preventing HPV infection in the general population. In <a href="https://www.nitag-resource.org/sites/default/files/2022-12/grade-evidence-profile-single-dose-hpv-vaccine-vs-no-vaccination.pdf">April 2022</a> the WHO Strategic Advisory Group of Experts on Immunisation concluded that a single-dose HPV vaccine delivers “solid protection against HPV, that is comparable to two-dose schedules”. However, they recommended that people living with HIV continue to receive three doses where feasible, and if not, at least two doses, due to the limited evidence. </p>
<p>The lower number of doses has important cost and logistical implications. Administering one dose may be a game changer in widening the coverage of eligible girls. In South Africa, the <a href="https://immunizationdata.who.int/pages/coverage/hpv.html?CODE=ZAF&ANTIGEN=&YEAR=">dropout rate</a> from the vaccination programme after the first vaccination in 2014 was 18% and it increased to 26% in 2018 and 2019. The equivalent dropout rate in high-income countries averages 11%. </p>
<p>In <a href="https://www.sciencedirect.com/science/article/pii/S0091743520304308?via%3Dihub">2019</a>, 33 of the 107 HPV vaccination programmes were gender neutral – both girls and boys were being vaccinated. Vaccinating both boys and girls will increase what is known as herd immunity, which means that the prevalence of HPV in the population will decrease. In addition, boys will be protected from HPV associated anal, penile and oro-pharyngeal cancers. However, including boys in vaccination programmes when most girls aren’t vaccinated is not cost-effective. </p>
<p>Globally, it was estimated in 2019 that 15% of girls and 4% of boys were vaccinated. </p>
<h2>What’s the surest way of achieving the WHO goal?</h2>
<p>There are many important steps. </p>
<p>A critical starting point is to gain political support for HPV vaccination. There needs to be high level collaboration between the ministries of health, education, social development and existing immunisation programmes. </p>
<p>The most successful programmes have used school-based facilities for vaccination. But this excludes adolescents who are not in the school system, hence the need to create facility-based programmes. </p>
<p>Widespread information and population education is critical - education campaigns should include parents, the general population, teachers and healthcare workers.</p>
<p>An adequate supply of vaccine is crucial and the vaccine administration infrastructure must be robust. All the logistics of vaccine implementation, such as distribution, cold chain management, waste control and clinical care must be attended to. Good statistics and information should be maintained and monitored regularly. </p>
<p>Anti-vaccination programmes need to be monitored and their allegations responded to promptly and with cultural sensitivity. </p>
<h2>What are the hold-ups?</h2>
<p>COVID has had a major impact on many HPV vaccination programmes. Low- and middle-income countries were particularly hard hit. As an example, the South African programme <a href="https://immunizationdata.who.int/pages/coverage/hpv.html?CODE=ZAF&ANTIGEN=&YEAR=">coverage reduced</a> from 85% when introduced in 2014 to 3% in 2020. The programme is still trying to recover.</p>
<p>Along with the impact of COVID on immunisation practices, the recommendation to include boys and older women in vaccination programmes resulted in a worldwide shortage of HPV vaccines. The shortage was recognised in 2020 and was <a href="https://ipvsoc.org/wp-content/uploads/2021/05/IPVS-Statement_HPV-vaccine-shortage.pdf">predicted</a> to last three to five years. A statement released by the International Papillomavirus Society recommended that gender neutral vaccination as well as that of older women be temporarily suspended. And that, during the supply constraint, HPV vaccination should be reserved for girls aged 9 to 14. </p>
<h2>What should countries be focused on?</h2>
<p>Current commercially available HPV vaccines are prophylactic. They will protect individuals who have never been exposed to HPV infection from being infected, and prevent <a href="https://www.who.int/publications/i/item/9789240014107">70%-90%</a> of all cervical cancers. (No vaccine is 100% effective.) </p>
<p>I have spent the past <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00120-4/fulltext">30 years</a> researching safe, feasible and effective alternatives to the <a href="https://www.cdc.gov/cancer/cervical/basic_info/screening.htm">Pap smear</a> for the prevention of cervical cancer. When I began this work in 1995, the HPV vaccine had not yet been produced. Its arrival made the possibility of ending cancer associated with HPV infection a reality.</p>
<p>Who gets vaccinated should depend on age, gender and resources. Girls aged 9-14 years should be prioritised. As resources increase, girls aged 15-18 years should be included. Thereafter, women aged 19-26 years should be included. Vaccinating boys should go ahead only once at least 90% coverage has been achieved in girls aged 9-14 years.</p>
<p>Vaccinating older women, most of whom would already have been exposed to HPV infection (even if subsequently cleared) should be reserved for high resource settings that have reached widespread vaccination coverage. </p>
<p>There are many advantages to vaccinating boys, particularly in preventing HPV-associated cancers in men and in men who have sex with men, as well as increasing herd immunity. However, expanding the programme to include men has implications for resource distribution and possible exclusion of other vulnerable groups.</p><img src="https://counter.theconversation.com/content/202001/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lynette Denny receives funding from National Institutes of Health, USA</span></em></p>Cervical cancer is one of the most common cancers in women. Mortality rates in sub-Saharan Africa are three times higher than the global average.Lynette Denny, Professor, Special Projects, Obstetrics & Gynaecology, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2030372023-04-07T13:48:03Z2023-04-07T13:48:03ZMillions of Americans at risk of losing free preventive care after Texas ruling on ACA<figure><img src="https://images.theconversation.com/files/519403/original/file-20230404-473-pq24if.jpg?ixlib=rb-1.1.0&rect=19%2C0%2C2121%2C1406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Raising the cost barriers for health care will harm the most vulnerable patients.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mother-talking-with-daughter-while-male-doctor-royalty-free-image/1321467310">Maskot via Getty Images</a></span></figcaption></figure><p>Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act in place following the law’s <a href="https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf">third major legal challenge</a> in June 2021. This decision left <a href="https://source.wustl.edu/2017/02/americans-divided-on-obamacare-repeal-poll-finds/">widely supported policies</a> in place, like ensuring coverage <a href="https://www.healthcare.gov/coverage/pre-existing-conditions/">regardless of preexisting conditions</a>, granting coverage for <a href="https://www.healthcare.gov/young-adults/children-under-26/">dependents up to age 26</a> on their parents’ plan and removing <a href="https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/">annual and lifetime benefit limits</a>.</p>
<p>But now, millions of people in the U.S. are holding their breath again <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.114.0_1.pdf">following a March 30, 2023 ruling</a> in Braidwood v. Becerra that would <a href="https://www.healthaffairs.org/content/forefront/texas-judge-just-invalidated-preventive-services-mandate-happens-next">eliminate free coverage</a> for many basic preventive care services and medications.</p>
<h2>Litigating preventive care</h2>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the ACA requires insurers to offer <a href="https://www.healthcare.gov/coverage/preventive-care-benefits/">full coverage of preventive services</a> endorsed by one of three federal groups: the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices or the Health Resources and Services Administration. If one of those groups recommends a preventive care service as essential to good health outcomes, then you shouldn’t have to pay anything out of pocket. For example, <a href="https://www.congress.gov/bill/116th-congress/house-bill/748/">the CARES Act</a>, which allocated emergency funding in response to the COVID-19 pandemic, used this provision to ensure COVID-19 vaccines would be free for many Americans.</p>
<p>Immunizations, including COVID-19 vaccines, require a recommendation from the <a href="https://www.cdc.gov/vaccines/acip/index.html">Advisory Committee on Immunization Practices</a> of the Centers for Disease Control and Prevention, while women’s health services require approval from the <a href="https://www.hrsa.gov/womens-guidelines/index.html">Health Resources and Services Administration</a>. Most other preventive services require an A or B rating from the <a href="https://uspreventiveservicestaskforce.org/uspstf/home">U.S. Preventive Services Task Force</a>, an independent body of experts trained in research methods, statistics and medicine, and supported by the <a href="https://www.ahrq.gov/cpi/about/otherwebsites/uspstf/index.html">Agency for Healthcare Research and Quality</a>.</p>
<p>The lead plaintiff in the ACA case, <a href="https://khn.org/news/article/braidwood-becerra-aca-preventive-services-court-decision-reed-oconnor/">Braidwood Management</a>, is a Christian for-profit corporation owned by Steven Hotze, a physician and conservative activist who has <a href="https://www.texastribune.org/2013/05/15/republican-donor-releases-songs-opposing-obamacare/">previously filed</a> multiple lawsuits against the Affordable Care Act. Braidwood and its co-plaintiffs, a group of conservative Christian employers, objected to being forced to provide their 70 employees free access to pre-exposure prophylaxis, or PrEP, a medicine that is <a href="https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html">nearly 100% effective</a> in preventing HIV infection. Hotze claimed that PrEP “facilitates and encourages homosexual behavior, intravenous drug use and sexual activity outside of marriage between one man and one woman,” despite a lack of evidence to support this. He also claimed that his religious beliefs prevent him from providing insurance that covers PrEP.</p>
<p>PrEP received an <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">A rating</a> from the U.S. Preventive Services Task Force in June 2019, paving the way for it to be covered at no cost for millions of people. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Red ribbon hanging from the North Portico of the White House" src="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">PrEP is a key tool to helping the U.S. reach its goal of substantially reducing new HIV infections by 2030.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ObamaWorldAidsDay/c146dee7e944420482f3e5786d4d2e50">AP Photo/Pablo Martinez Monsivais</a></span>
</figcaption>
</figure>
<p>Though Section 2713 of the ACA <a href="https://doi.org/10.1016/j.ypmed.2021.106690">doesn’t work perfectly</a>, sometimes leaving patients frustrated by <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">unexpected bills</a>, it has made a huge difference in reducing costs for services like <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a>, just to name a few.</p>
<p><a href="https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf">Over 150 million Americans</a> are enrolled in private health insurance, allowing them to benefit from free preventive care, with <a href="https://www.healthsystemtracker.org/brief/preventive-services-use-among-people-with-private-insurance-coverage/">about 60%</a> using at least one free preventive service each year. Raising the cost barrier again for PrEP, for example, would <a href="https://doi.org/10.1001/jamanetworkopen.2021.22692">disproportionately harm</a> younger patients, people of color and those with lower incomes.</p>
<p>As public health researchers at <a href="https://www.bu.edu/sph/profile/paul-shafer/">Boston University</a> and <a href="https://sph.tulane.edu/sbps/kristefer-stojanovski-phd-mph">Tulane University</a> who study <a href="https://scholar.google.com/citations?user=bDT820kAAAAJ&hl=en">health insurance</a> and <a href="https://www.researchgate.net/profile/Kristefer-Stojanovski-2">sexual health</a>, we believe that prevention and health equity in the U.S. stand to take a big step backward with this policy in jeopardy.</p>
<h2>What preventive services are affected?</h2>
<p>The ruling in Braidwood rests in large part on the <a href="https://www.law.cornell.edu/constitution/articleii">appointments clause</a> of the U.S. Constitution, which specifies that certain governmental positions require presidential appointment and Senate confirmation, while other positions have a lower bar. </p>
<p>Texas federal <a href="https://www.healthaffairs.org/content/forefront/texas-judge-just-invalidated-preventive-services-mandate-happens-next">District Judge Reed O'Connor ruled</a> that because the U.S. Preventive Services Task Force is an independent volunteer panel and not made up of officers of the U.S. government, they do not have the appropriate authority to make decisions about which preventive care should be free, unlike the Advisory Committee on Immunization Practices or Health Resources and Services Administration. O'Connor also ruled that being forced to cover PrEP violated the religious freedom of the plaintiffs.</p>
<p>Following his initial ruling in September, both sides submitted briefs that tried to inform the “remedy,” or solution, the judge would ultimately recommend. He could have chosen, as the <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.112.0_3.pdf">federal government advocated</a>, to grant only the plaintiffs an exemption from covering PrEP under the Religious Freedom Restoration Act. But O'Connor instead chose to make his “remedy” apply nationally and cover more services.</p>
<p>He invalidated all of the task force’s recommendations since the Affordable Care Act was passed in March 2010, returning the power to insurers and employers to decide which, if any, preventive care would remain free to patients in their plans. A few of the <a href="https://www.bloomberg.com/opinion/articles/2023-04-01/braidwood-ruling-further-weakens-aca-on-prep-drugs-preventive-care">recommendations covered by his ruling</a> include PrEP; blood pressure, diabetes, lung and skin cancer screenings; and medications to lower cholesterol and reduce breast cancer risk. As of 2022, <a href="https://www.commonwealthfund.org/blog/2022/aca-preventive-services-benefit-jeopardy-what-can-states-do">15 states</a> have laws with ACA-like requirements for plans in the insurance marketplace, but not for large employer plans generally <a href="https://blog.petrieflom.law.harvard.edu/2023/04/03/three-reactions-to-braidwood-v-becerra/">exempt from state oversight</a>.</p>
<p>Insurance contracts are typically defined by calendar year, so most people will <a href="https://www.kff.org/policy-watch/qa-implications-of-the-ruling-on-the-acas-preventive-services-requirement/">see these changes</a> starting only in 2024. Importantly, these services will likely still need to be covered by health insurance plans as <a href="https://www.law.cornell.edu/uscode/text/42/18022">essential health benefits</a> through a separate provision of the ACA – they just won’t be free anymore. </p>
<p>Other U.S. Preventive Services Task Force recommendations and those made by the Advisory Committee on Immunization Practices or Health Resources and Services Administration – namely, immunizations and contraception, respectively – will remain free to patients <a href="https://www.kff.org/womens-health-policy/issue-brief/explaining-litigation-challenging-the-acas-preventive-services-requirements-braidwood-management-inc-v-becerra/">for now</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Demonstrator holds a sign saying 'Save the ACA' in front of the U.S. Supreme Court." src="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.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 Affordable Care Act has faced many legal challenges over the years.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtHealthCare/af7a18ea1fc84b39af301fa84aec0672">AP Photo/Alex Brandon</a></span>
</figcaption>
</figure>
<h2>What’s next?</h2>
<p>The <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.115.0.pdf">federal government appealed</a> the ruling to the 5th U.S. Circuit Court of Appeals on March 31, 2023, buoyed by a <a href="https://newsroom.heart.org/news/23-national-health-organizations-respond-to-braidwood-v-becerra-ruling-that-threatens-no-cost-preventive-care">coordinated response</a> from 23 patient advocacy groups. They have asked for a stay while the case continues, which pauses the effects of the ruling. If either O'Connor or a higher court grants their request, it will leave the status quo of free preventive care in place. </p>
<p>But there are also concerns that either the 5th Circuit orthe Supreme Court could take the ruling even further, endangering the free coverage of contraception and other preventive care that remains in place. </p>
<p>The ending to this case may still be several years off, with <a href="https://news.yahoo.com/americans-surprise-medical-bills-health-care-loopholes-131630868.html">even more frustration</a> ahead as the courts undermine national goals in <a href="https://www.whitehouse.gov/cancermoonshot/">fighting cancer</a>, <a href="https://www.whitehouse.gov/briefing-room/presidential-actions/2022/10/31/a-proclamation-on-national-diabetes-month-2022/">diabetes</a> and <a href="https://www.cdc.gov/endhiv/index.html">ending the HIV epidemic</a>.</p>
<p><em>Portions of this article originally appeared in previous articles published on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">Sept. 7, 2021</a>, <a href="https://theconversation.com/hiv-prevention-pill-prep-is-now-free-under-most-insurance-plans-but-the-latest-challenge-to-the-affordable-care-act-puts-this-benefit-at-risk-171086">Dec. 1, 2021</a>, and <a href="https://theconversation.com/free-preventive-care-under-the-aca-is-under-threat-again-a-ruling-exempting-prep-from-insurance-coverage-may-extend-nationwide-and-to-other-health-services-190317">Sept. 13, 2022</a>.</em></p><img src="https://counter.theconversation.com/content/203037/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Arnold Ventures, Robert Wood Johnson Foundation, Kate B. Reynolds Charitable Trust, Starbucks Coffee Company, and Renova Health.</span></em></p><p class="fine-print"><em><span>Kristefer Stojanovski 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>On the basis of government appointment technicalities and religious freedom, Americans may lose free coverage for cancer and blood pressure screenings, HIV prevention medication and other essential services.Paul Shafer, Assistant Professor of Health Law, Policy and Management, Boston UniversityKristefer Stojanovski, Research Assistant Professor of Social, Behavioral and Population Sciences, Tulane UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2023542023-03-28T00:31:23Z2023-03-28T00:31:23ZThe ABC’s In Our Blood shines a light on lesbian activism during the AIDS crisis – but there’s more to their story<figure><img src="https://images.theconversation.com/files/517581/original/file-20230327-14-y6a0wp.jpg?ixlib=rb-1.1.0&rect=11%2C5%2C3982%2C2652&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">ABC</span></span></figcaption></figure><p>The recent ABC mini-series, In Our Blood, offers a fictionalised account of Australia’s response to AIDS, focusing on the development of a <a href="https://unsw.press/books/learning-to-trust/">partnership</a> between impacted communities, health professionals and government. </p>
<p>Lesbians are placed at the centre of this narrative, but more needs to be done to ensure these representations capture the complex histories of AIDS <a href="https://www.dukeupress.edu/information-activism">information activism</a> in Australia.</p>
<p>The series features two lesbian characters: activist Deb (Jada Alberts) and high-school teacher Mish (Anna McGahan). Deb and Mish are shown attending activist rallies, speaking up in meetings with government representatives, transforming their home into an office for AIDS activists, and caring for people living with HIV.</p>
<p>Their inclusion serves to historicise lesbians’ immense contribution to Australian AIDS activist movements – but it perpetuates a well-established trope of the “altruistic” <a href="https://researchers.mq.edu.au/en/publications/the-fabric-of-resistance-care-domestic-objects-and-hiv-self-narra">lesbian carer and advocate</a>. </p>
<p>In this re-telling, we risk forgetting that lesbians also protested their own exclusion from epidemiological, medical and public health information about AIDS.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/6F70kankd6Q?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Are lesbians at risk of HIV?</h2>
<p>The answer is complicated. </p>
<p>While sex between cisgender women is thought to be low risk, several studies suggest that <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(87)93071-6/fulltext">transmission is possible</a>. </p>
<p>It is, however, important to understand how HIV risk transmission hierarchies can render lesbian and queer women invisible in our surveillance data. </p>
<p>When a person is diagnosed with HIV, risk transmission hierarchies are used to record their most probable source of exposure to the virus. <a href="https://www.tandfonline.com/doi/full/10.1080/14680777.2020.1837907">In Australia</a>, these risk hierarchies have never recognised female-to-female sex as a potential route for HIV transmission.</p>
<p>This means, for example, that if a woman reports having sex with both men and women, her exposure to the virus is recorded as “heterosexual contact”. If she has never had sex with a man but uses injecting drugs, her exposure is recorded as “injecting drug use”. And if she has never had sex with a man or used injecting drugs, her exposure is recorded as “undetermined”.</p>
<p>Yet, even if we understand sex between cisgender women as low risk, lesbians are not a homogenous group. Some lesbians use injecting drugs, have sex with men or could become infected with HIV through another source of transmission. </p>
<p>But for these lesbians to be included in HIV surveillance data, their sexual identities <a href="https://www.tandfonline.com/doi/full/10.1080/13691058.2012.738430">must be obscured</a>.</p>
<p>Because of this, we have no way of knowing how many lesbian and queer women are living with HIV or have died from AIDS-related illness in Australia. Although, anecdotally, we do know that <a href="https://www.positivelife.org.au/wp-content/uploads/2021/01/plnsw-talkabout-46.pdf">four of the first seven</a> women diagnosed with HIV were lesbians.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=837&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=837&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=837&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1052&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1052&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1052&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Part of the safe-sex campaign during the 1980s.</span>
<span class="attribution"><span class="source">Act Up Melbourne</span></span>
</figcaption>
</figure>
<h2>Untold histories of lesbian AIDS activism</h2>
<p>Since the 1980s, when In Our Blood takes place, lesbians have advocated for their inclusion in Australia’s public health, medical and epidemiological response to AIDS. </p>
<p>Much lesbian AIDS activism occurred from within Australian AIDS organisations, such as the AIDS Council of New South Wales (now known as ACON). In 1988, ACON’s Women and AIDS Working Group produced the organisation’s first lesbian information pack, entitled <a href="https://www.positivelife.org.au/wp-content/uploads/2021/01/plnsw-talkabout-46.pdf">Sapph Sex</a> – its title a pun on safe and sapphic sex.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=584&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=584&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=584&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=734&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=734&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=734&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">ACON’s Women and AIDS Working Group produced the organisation’s first lesbian information pack.</span>
<span class="attribution"><span class="source">ACON</span></span>
</figcaption>
</figure>
<p>Outside the context of Australian AIDS organisations, activists used lesbian magazines to produce, debate and circulate lesbian-specific information about HIV. Lesbian magazines published articles <a href="https://nla.gov.au/nla.obj-881421990/view?partId=nla.obj-881436490#page/n5/mode/1up">contesting the dominant assumption</a> that lesbians were “immune” to HIV, and provided a platform for HIV-positive lesbians to write on their experiences. </p>
<p>Readers of Australia’s largest lesbian magazine, Lesbians on the Loose, were also encouraged to write in to the magazine’s resident doctor, Doctor on the Loose, to request guidance on a range of health-related concerns.</p>
<p>During the height of the epidemic, Doctor on the Loose provided readers with advice on the risks associated with specific practices: sex, injecting drug use, sperm donation, and blood sharing rituals. In their responses, Doctor on the Loose worked to dispel <a href="https://nla.gov.au/nla.obj-884067310/view?partId=nla.obj-884070012">common misunderstandings</a> about HIV transmission:</p>
<blockquote>
<p>you can’t catch it from toilet seats, sharing food, sharing joints, shaking hands or kissing (there is no evidence that tongue kissing passes on HIV).</p>
</blockquote>
<p>HIV-positive lesbians were, of course, at the forefront of these activist endeavours. One such lesbian was Jennifer Websdale. As one of the first seven women diagnosed with HIV in Australia, she was committed to ensuring lesbians were visible as a distinct population in the global AIDS epidemic. </p>
<p>In 1991, Websdale received funding to attend the Ninth National AIDS/HIV Forum in New Orleans. When she returned to Australia, she coined the term “<a href="https://nla.gov.au/nla.obj-888349986/view?partId=nla.obj-888383459#page/n11/mode/1up">cuntaphobia</a>” to describe the complex intersections of sexism and homophobia that work to silence HIV-positive lesbians in wider conversations about HIV.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=717&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=717&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=717&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=901&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=901&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=901&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">AIDs campaigning in Australia 1985.</span>
<span class="attribution"><span class="source">ACON</span></span>
</figcaption>
</figure>
<p>Websdale died from AIDS-related illness in 1994 at the age of 33. Three decades on, her activism retains an enduring relevance. </p>
<p>As we move toward <a href="https://www.afao.org.au/our-work/agenda-2025/">ending HIV</a> in Australia, it is imperative for us to interrogate how our ingrained re-tellings of the Australian AIDS epidemic foreground some histories, and marginalise others. </p>
<p>After all, the project of ending HIV will require us to ensure that HIV prevention, testing and treatment information and services are available to all Australians – including lesbian and queer women.</p><img src="https://counter.theconversation.com/content/202354/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Manlik received funding from a Research Training Program (RTP) Scholarship while undertaking this research.</span></em></p>The ABC mini-series, In Our Blood, offers a fictionalised account of Australia’s response to AIDS – but more can be done to remember lesbians’ immense contribution to AIDS activist movements.Kate Manlik, Casual Academic and PhD Candidate, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2021512023-03-23T07:51:28Z2023-03-23T07:51:28ZTB kills 75,000 children in Africa every year: how this can stop<figure><img src="https://images.theconversation.com/files/516948/original/file-20230322-26-dpm8er.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There have been substantial improvements in some areas of TB therapeutics. </span> <span class="attribution"><span class="source">Punit Paranjpe/AFP via Getty Images</span></span></figcaption></figure><p><em>Tuberculosis (TB) is a preventable and curable disease. Half of the world’s 30 highest TB burden countries are in Africa. In many of these countries, TB is the leading cause of death across age groups, but especially among children. Globally, TB is the <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden/2-2-tb-mortality">leading cause of death</a> by any single infectious agent (above COVID-19 and HIV).</em></p>
<p><em>The people most affected by TB are often the most socio-economically marginalised, with the fewest reserves to take them through the treatment journey. This is extremely challenging, with complex, often delayed diagnosis, many months of treatment, and often long-term effects after treatment. The Conversation Africa’s Ina Skosana spoke to Graeme Hoddinott, a socio-behavioural science lead at the Desmond Tutu TB Centre, Stellenbosch University, and an African Academy of Sciences ARISE Fellow.</em></p>
<hr>
<h2>What’s the TB burden among young people?</h2>
<p>In Africa, of the <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden/2-1-tb-incidence">three million people</a> who develop TB disease every year, nearly 160,000 are children 0-4 years old, and another 160,000 are 5-14 years old. Every year, about <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden/2-2-tb-mortality">500,000 people in Africa</a> die because of TB. Children make up 15% (75,000) of these deaths. </p>
<p>Less than half of the children aged 0-14 who have TB are diagnosed – so they never even start treatment.</p>
<h2>What are some of the drivers?</h2>
<p>TB is transmitted between people through the air. When a person with TB coughs or breathes out, some of the TB bugs are expelled to float in the air. If someone else then breathes the bugs in, they cause a new infection. There are several factors that increase the risk of TB transmission. These include actions that increase the number of bugs in the air, such as not wearing a mask and coughing more. And actions that increase exposure, such as spending long periods of time breathing the air in. </p>
<p>A person might breathe the TB bugs in (that is, become infected), but not become ill. This is known as latent TB. Sometimes, though, the TB bugs are able to multiply and escape the body’s immune system. As the number of bugs increases, the person begins to experience symptoms such as coughing, drenching sweats and weight loss. This is then called TB disease. </p>
<p>A variety of factors increase the risk of progressing from TB infection to disease. These are factors that might impede the body’s natural immune functioning, such as undernourishment or smoking. </p>
<p>Children (especially young children) have less developed immune systems. This makes their chance of progressing from infection to disease higher than it is for adults. </p>
<p>Prevention of infection can be done through reducing risks of transmission, for example by opening windows to allow the bugs to blow away. Also, if a person with TB is on treatment, then the number of bugs they expel is dramatically reduced. That’s why it’s important to get an early diagnosis and start treatment.</p>
<p>Where there is an exposure risk, we can also use medicines to reduce the chance of developing disease – this is called TB preventive therapy. The most recent World Health Organization <a href="https://apps.who.int/iris/bitstream/handle/10665/331170/9789240001503-eng.pdf">guidelines</a> suggest that preventive therapy be offered to everyone who has significant exposure risk to an adult or adolescent with TB. For example, think about young children who are sharing a bed with their mother. If she has TB, then the child should be offered preventive therapy, as should other people who share their home. </p>
<p>Unfortunately, in most settings in Africa, implementation of TB preventive therapy is either non-existent or extremely sub-optimal. Historically, the only available TB preventive regimen was a once-daily treatment for six months that is burdensome to administer; new regimens are becoming available. Unfortunately, the limited resources available to TB services have prioritised TB treatment and not prevention. </p>
<h2>Where are the gaps?</h2>
<p>There have been <a href="https://www.nejm.org/doi/10.1056/NEJMoa2104535">substantial</a> <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-017-2377-x">improvements</a> in some areas of <a href="https://www.ingentaconnect.com/content/iuatld/ijtld/2023/00000027/00000003/art00005;jsessionid=2sjtfaionun19.x-ic-live-03">TB therapeutics</a>, with <a href="https://erj.ersjournals.com/content/48/5/1503">shorter</a>, more <a href="https://www.ingentaconnect.com/content/iuatld/ijtld/2023/00000027/00000002/art00006">palatable</a> regimens and more <a href="https://www.ingentaconnect.com/content/iuatld/ijtld/2023/00000027/00000001/art00005">easy-to-use</a> <a href="https://www.ingentaconnect.com/content/iuatld/ijtld/2022/00000026/00000012/art00006">formulations</a>. However, these are not universally available and are still not optimal. Even “shorter” treatment is four months long. Health systems are poorly equipped to support continuity of care when patients (including children and adolescents) move between facilities.</p>
<p>Far too many children who initiate both TB preventive therapy and TB treatment <a href="https://www.jahonline.org/article/S1054-139X(22)00778-9/fulltext">are lost</a> to <a href="https://www.ingentaconnect.com/content/iuatld/pha/2022/00000012/00000004/art00003">follow-up</a>. TB programmes across the world have yet to operationalise the high-minded ideals of “<a href="https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0001357">patient-centred care</a>”. The experiences of adolescents and young people (10-24 years old) accessing TB services are often especially <a href="https://www.jahonline.org/article/S1054-139X(22)00778-9/fulltext">problematic</a>. For example, <a href="https://www.mdpi.com/2076-0817/10/12/1591">adolescents report</a> being assumed to have HIV, being shouted at for being sexually active (even if they are not) and being told to access TB services at times when they are in <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000989">school</a>. </p>
<p>There is also limited integration between health services and other sectors (like basic education) to make care easier to get. There remain <a href="https://www.ingentaconnect.com/content/iuatld/ijtld/2017/00000021/a00111s1/art00013">high rates</a> of TB-associated <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1250-8">stigma</a>, and the <a href="https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-018-0777-3">costs of TB care</a> (economic, social and psychological) can be <a href="https://thorax.bmj.com/content/76/4/387">catastrophic and long-lasting</a>. </p>
<h2>How must TB programmes be tailored?</h2>
<p>A fraction of the funding and collective effort that was mobilised for COVID-19 could realistically push towards TB elimination. Perversely, instead, resources redirected towards COVID-19 have <a href="https://www.theglobalfund.org/en/news/2021/2021-09-08-global-fund-results-report-reveals-covid-19-devastating-impact-on-hiv-tb-and-malaria-programs/">set the global TB programme back</a> by a decade’s worth of progress. </p>
<p>TB programmes must be tailored by listening to the preferences and priorities of people affected by TB, by working to address the real-world limitations experienced by frontline health services, and by continuing to develop better, more acceptable therapeutics; especially medicines that are more acceptable for children and easier for caregivers to prepare and administer. </p>
<p>But really all of that can only make a big difference if we all wake up to this leading cause of death, especially among children, and care more.</p><img src="https://counter.theconversation.com/content/202151/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Graeme Hoddinott is a fellow of the African Research Initiative for Scientific Excellence (ARISE) programme. His ARISE research is focused on optimising care for adolescents with tuberculosis. The ARISE programme is implemented by the African Academy of Sciences (AAS) with support from the European Commission and the African Union Commission.</span></em></p>Less than half of the children aged 0-14 who have TB are diagnosed – so they never even start treatment.Graeme Hoddinott, Socio-behavioural Scientist and Senior Researcher, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1987422023-03-01T13:35:41Z2023-03-01T13:35:41ZSex work in South Africa: why both buying and selling should be legal<figure><img src="https://images.theconversation.com/files/509181/original/file-20230209-24-3kfqso.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Members of the African Christian Democratic Party protesting against the decriminalisation of sex work in South Africa.</span> <span class="attribution"><span class="source">Brenton Geach/Gallo Images via Getty Images</span></span></figcaption></figure><p><em>It is illegal to buy or sell sex in South Africa. But this may soon be a thing of the past if a recently published draft bill to decriminalise sex work is passed. Researchers and activists Marlise Richter and Monique Huysamen set out what’s in the new law, what’s good about it and what still needs work.</em></p>
<hr>
<h2>What’s envisaged under the proposed new law?</h2>
<p>If the <a href="https://www.justice.gov.za/legislation/invitations/20221208-CriminalLawSexualOffences-%20AmendmentBill.pdf">Criminal Law (Sexual Offences and Related Matters) Amendment Bill 2022</a> is passed, South Africa will become only the third country in the world to fully decriminalise sex work. It would no longer be illegal to buy or sell sex. New Zealand and <a href="https://www.lemonde.fr/en/international/article/2022/06/02/belgium-decriminalizes-sex-work_5985486_4.html">Belgium</a> are the other countries where this is the position.</p>
<p>The draft law proposes the removal of the criminalisation of buying and selling of sex. It also proposes to clear the criminal records of those who have been prosecuted for buying or selling sex.</p>
<p>Predictably, various groups have pushed back against the bill, mostly on moral grounds. Opponents of the bill recommend that either: </p>
<ul>
<li><p>the current law that fully criminalises all aspects of sex work remains in place; or</p></li>
<li><p>that sex workers are decriminalised but that clients remain criminalised.</p></li>
</ul>
<p>This last idea is drawn from what’s called the “Nordic model” – an approach followed by <a href="https://www.nswp.org/sex-work-laws-map?colour_value%5B0%5D=2">some Nordic countries</a>, including Sweden. </p>
<h2>Why is full decriminalisation in South Africa so important?</h2>
<p>Women in South Africa face very high levels of gender-based violence. Female sex workers are even more exposed than other women. A recent <a href="https://www.sciencedirect.com/science/article/pii/S2666560321000128">study</a> showed that 70% of female sex workers had experienced violence in the past year. More than half had been raped by intimate partners, police, clients or other men. <a href="https://www.theguardian.com/society/2018/dec/11/criminalisation-of-sex-work-normalises-violence-review-finds">Criminalisation normalises violence</a> in the sex work context.</p>
<p>Another argument for decriminalisation relates to health. HIV prevalence of between <a href="https://www.thelancet.com/pdfs/journals/lanhiv/PIIS2352-3018(22)00201-6.pdf">39% and 89%</a> has been documented among female sex workers across different areas of South Africa in the last decade. This is extremely high when compared to the country’s <a href="https://www.statssa.gov.za/publications/P0302/P03022021.pdf">national HIV prevalence rate of 13.7%</a>.</p>
<p>Sex workers are <a href="http://apps.who.int/iris/bitstream/handle/10665/77745/9789241504744_eng.pdf;jsessionid=3D4FC895B2108AE64D1EED482E817C23?sequence=1">particularly vulnerable to HIV</a> infection because of the many dangers associated with sex work in a criminalised context. Sex workers typically have many sexual partners. Their working conditions are precarious and unsafe. And the unequal power relationship between sex worker and client makes it very hard to consistently negotiate safer sex. </p>
<p>The social stigma attached to sex work also means that some healthcare providers hold <a href="https://ritshidze.org.za/wp-content/uploads/2023/02/Ritshidze-State-of-Healthcare-for-Key-Populations-2023.pdf">prejudiced and vindictive views against sex workers</a>. These views can drive sex workers away from health services, including HIV prevention, treatment and support.</p>
<p>The repeal of <a href="https://www.tandfonline.com/doi/abs/10.1080/19962126.2009.11865199">outdated apartheid-era laws</a> would have a far-reaching, positive impact on <a href="https://link.springer.com/article/10.1007/s13178-022-00779-8">individual sex worker health and well-being</a> and therefore also public health. </p>
<p>If sex work was not a crime, clients <a href="http://www.sweat.org.za/wp-content/uploads/2019/09/Policing-Report.pdf">and police</a> wouldn’t have the power to abuse sex workers. Sex workers would be able to regularly negotiate safe sex. Police would have to take their complaints seriously. Sex workers would also feel more confident to report discrimination and disrespectful healthcare workers. </p>
<p>Under decriminalisation, sex work would be recognised as work. Occupational health and safety and fair labour principles would apply. Decriminalisation is particularly important for the dignity of poor black sex workers from working class backgrounds, who currently <a href="https://www.pins.org.za/pins/pins57/huysamen-boonzaier.pdf">bear the brunt of the stigma</a> associated with the criminalisation of sex work. </p>
<h2>What is the Nordic model?</h2>
<p>The <a href="https://nwac.ca/assets-knowledge-centre/CLES-What-We-Know-About-the-Nordic-Model.pdf">Nordic model</a> is a legal framework adopted by several Nordic countries, including Sweden and Norway.</p>
<p>According to this approach, selling sex should be decriminalised, but buying sex remains a crime. </p>
<p>The model <a href="https://www.versobooks.com/books/3039-revolting-prostitutes">assumes</a> that criminalising the clients of sex workers would dissuade people from buying sexual services, and thus end the demand for sex work. </p>
<p>Research in countries that have adopted this shows that it <a href="https://www.nswp.org/resource/nswp-publications/advocacy-toolkit-the-real-impact-the-swedish-model-sex-workers">has not made sex work safer for sex workers, nor has it eradicated sex work</a>. Evidence also shows that criminalisation of clients is <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002680">bad for sex workers’ health</a>. </p>
<p>If buying sex is illegal, sex workers have less time <a href="https://bhekisisa.org/health-news-south-africa/2023-01-31-decriminalising-sex-work-can-protect-sex-workers-and-everybody-else-from-gbv/">to screen out dangerous clients</a> and clients can put pressure on sex workers to agree to risky transactions in compromising situations. </p>
<p>South Africans have had painful lessons about why the state has <a href="https://www.groundup.org.za/article/where-the-criminal-law-has-no-place-sex-work/">no business in people’s bedrooms</a>. The apartheid-era state prohibited sex across “colour” and “same-sex” configurations which South Africa subsequently strongly rejected under democracy. Yet this same law still survives for adult, consensual sex work.</p>
<h2>Why arguments against criminalising clients should be resisted</h2>
<p>Our research shows that while most of the <a href="https://www.routledge.com/A-Critical-Reflexive-Approach-to-Sex-Research-Interviews-with-Men-Who-Pay/Huysamen/p/book/9780367554477">clients of sex workers in South Africa</a> are men, they are a diverse group from all walks of life. Some are <a href="https://pubmed.ncbi.nlm.nih.gov/22911711/">violent and abusive</a> towards sex workers. But many are not. Some sex workers report having <a href="https://genderjustice.org.za/publication/towards-harm-reduction-programmes-with-sex-worker-clients-in-south-africa/">mutually respectful interactions and contracts with clients</a>. </p>
<p>In our research, very few men self-reported perpetrating violence against sex workers. Most actively distanced themselves from the violence associated with men who pay for sex, making it clear that they <a href="https://www.tandfonline.com/doi/full/10.1080/00224499.2019.1645806">did not engage in or condone violence against sex workers</a>. </p>
<p>Based on our research and that of others, we <a href="https://genderjustice.org.za/publication/towards-harm-reduction-programmes-with-sex-worker-clients-in-south-africa/">believe</a> that the decriminalisation of clients would have positive spin-offs. </p>
<p>First, recruiting clients who have been identified by sex workers as non-violent and respectful as peer educators could instil and reinforce positive norms among clients.</p>
<p>Second, clients are well placed to serve as <a href="https://www.routledge.com/Paying-for-Sex-in-a-Digital-Age-US-and-UK-Perspectives/Sanders-Brents-Wakefield/p/book/9781138318731">whistle-blowers</a> when they notice human rights violations such as human trafficking or child exploitation in the sex industry. </p>
<p>Third, clients can be <a href="https://theconversation.com/why-south-africas-hiv-prevention-programmes-should-include-sex-worker-clients-157264">key to reducing HIV transmission</a>. Scaling up antiretroviral therapy among clients of sex workers would avert almost <a href="https://pubmed.ncbi.nlm.nih.gov/33533115/">one-fifth of new HIV infections</a> in South Africa over the next decade.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-south-africas-hiv-prevention-programmes-should-include-sex-worker-clients-157264">Why South Africa's HIV prevention programmes should include sex worker clients</a>
</strong>
</em>
</p>
<hr>
<p>The Nordic model is flawed and demonises clients. Putting sex work clients in jail punishes them for buying a service. This is ultimately bad for everyone’s health. </p>
<p>The draft bill should be passed as it is and as quickly as possible.<br>
It will make sex work less risky and dangerous, and our society safer.</p>
<p><em>This article has been updated to reflect the fact that Belgium decriminalised sex work in 2022.</em></p><img src="https://counter.theconversation.com/content/198742/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marlise Richter works for the Health Justice Initiative and is an associate with the African Centre for Migration & Society, university of the Witwatersrand. She served on the Sisonke Sex Worker Movement Board from 2017-2022.</span></em></p><p class="fine-print"><em><span>Monique Huysamen is a Senior Research Associate at Manchester Metropolitan University and an Honorary Research Affiliate at University of Cape Town. Her research has been funded by The National Institute for Health Research (NIHR), NRF, and Harry Crossley Research Foundation</span></em></p>The repeal of outdated apartheid-era laws would have a far-reaching, positive impact on individual sex workers’ health and well-being.Marlise Richter, Research fellow, African Centre for Migration & Society, University of the WitwatersrandMonique Huysamen, Senior Research Associate in Sexual and Reproductive health, Manchester Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1949082023-01-24T13:23:01Z2023-01-24T13:23:01ZGrassroots AIDS activists fought for and won affordable HIV treatments around the world – but PEPFAR didn’t change governments and pharma<figure><img src="https://images.theconversation.com/files/505231/original/file-20230118-18-a5un95.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">AIDS activists have used protests to demand access to treatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-from-africa-action-mark-world-aids-day-with-a-rally-news-photo/78178017">Jim Watson/AFP via Getty Images</a></span></figcaption></figure><p>The <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/">President’s Emergency Program for AIDS Relief, or PEPFAR</a>, has revolutionized the fight against global AIDS over the last 20 years. <a href="https://www.state.gov/wp-content/uploads/2021/12/PEPFAR-Latest-Global-Results.pdf">In that time</a>, the U.S. program has brought antiretroviral treatment to nearly 19 million people living with HIV, the virus that causes AIDS; prevented mother-to-child transmission of HIV for 2.8 million babies; and brought HIV testing and prevention services to millions of others. </p>
<p>But this program would not be so successful – and might not even exist – without the work of grassroots AIDS activists around the world.</p>
<p>As a <a href="https://scholar.google.com/citations?user=pTaBXaIAAAAJ&hl=en">historian of social movements</a>, I spent years interviewing AIDS activists, digging through their papers and scanning old websites, group email lists and message boards. These sources showed that, over the course of more than a decade, these activists challenged the status quo to demand – and deliver – HIV treatment to millions of poor people around the world.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/HnM0IGeoF7o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Treatment Action Campaign activists in South Africa put pressure on drugmakers and governments for access to HIV medication.</span></figcaption>
</figure>
<h2>AIDS drugs for Africa</h2>
<p>In his <a href="https://www.washingtonpost.com/wp-srv/onpolitics/transcripts/bushtext_012803.html">2003 State of the Union address</a>, then-U.S. President George W. Bush announced the creation of PEPFAR when he called for an astounding US$15 billion in funding over five years for the fight against AIDS in Africa and the Caribbean.</p>
<p>His announcement did not come out of nowhere. By that point, AIDS activists had spent years fighting to bring treatments for HIV to low- and middle-income countries hardest hit by the epidemic. My book, “<a href="https://uncpress.org/book/9781469661339/to-make-the-wounded-whole">To Make the Wounded Whole</a>,” describes how members of the AIDS Coalition to Unleash Power (ACT UP) Philadelphia linked their own struggles for affordable, quality health care for poor people with AIDS in the U.S. to similar struggles around the world.</p>
<p>This fight began in earnest in the late 1990s when highly effective antiretrovirals to treat HIV became available, giving a new lease on life to those who could access them. But the new drugs were expensive, and activists saw that their high cost would <a href="https://actupny.org/Vancouver/sawyerspeech.html">put them out of reach for most who needed them</a>.</p>
<p>Some low- and middle-income countries took their own steps to make life-saving antiretrovirals available. In 1997, South Africa, in the midst of a rapidly growing HIV epidemic, passed the <a href="https://www.jstor.org/stable/24115724">Medicines and Related Substances Act</a>, allowing the government to produce or acquire less-expensive generic versions of the drugs. Meanwhile, <a href="https://doi.org/10.1016/s0140-6736(02)11775-2">domestically produced generics</a> were a cornerstone of Brazil’s program to provide access to free antiretrovirals for people living with HIV/AIDS in the country.</p>
<p><a href="https://web.archive.org/web/20000524182434/http://www.aegis.com:80/news/ct/1999/ct990404.html">Pharmaceutical companies opposed these efforts</a>, with a representative of the Pharmaceutical Research and Manufacturers Association (PhRMA) claiming that countries that produced generics committed “a form of patent piracy.” So, too, did the Clinton administration, claiming that South Africa and Brazil violated intellectual property agreements under the World Trade Organization. In particular, former Vice President Al Gore, acting as chair of the U.S.-South Africa Binational Commission, and Charlene Barshefsky, the U.S. Trade Representative, <a href="http://www.cptech.org/ip/health/sa/stdept-feb51999.html">pressured their South African counterparts</a> to change the law in 1999.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Activists marching with signs reading 'Europe! Hands off our medicine'" src="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">AIDS activists in Nairobi, Kenya, protested against a free trade agreement between the European Union and India that would have phased out generic AIDS drugs.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/KenyaAIDS/a45c66d0b20044878765422e1f099f09">Khalil Senosi/AP Photo</a></span>
</figcaption>
</figure>
<p>Activists fought back against both the pharmaceutical industry and the policymakers who put intellectual property rules, and the corporate profits they protected, ahead of saving people’s lives. Members of ACT UP Philadelphia, along with others, <a href="https://actupny.org/actions/gorezaps.html">hounded Gore on the presidential campaign trail</a>, chanting, “Gore is killing Africans – AIDS drugs now,” and <a href="https://www.democracynow.org/1999/11/19/act_up_activists_storm_office_of">occupied Barshefsky’s office in Washington</a>. They also participated in a massive demonstration at the 2000 International AIDS Conference in Durban, South Africa, with thousands of marchers from around the world crying “<a href="https://actupny.org/reports/durban-march.html">Phansi, Pfizer, phansi!</a>” (“phansi” is Zulu for “down”) to demand a reduction in the drug company’s AIDS treatment prices.</p>
<p>All of this agitation worked. Clinton <a href="https://www.sfgate.com/health/article/Poor-Nations-Given-Hope-on-AIDS-Drugs-New-2892857.php">curbed his administration’s pressure campaign</a> against South Africa. Thanks in part to the wider availability of generics, the average cost of antiretrovirals <a href="https://www.msf.org/patents-prices-patients-example-hivaids">fell dramatically</a>. And the <a href="https://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm">2001 World Trade Organization Ministerial Conference in Doha, Qatar</a>, affirmed that public health and “access to medicines for all” would be paramount in the fight against HIV/AIDS and other epidemics.</p>
<p>Having succeeded in making antiretrovirals more affordable, activists pressed for an international program to purchase and distribute them. According to journalist Emily Bass, <a href="https://www.publicaffairsbooks.com/titles/emily-bass/to-end-a-plague/9781541762459/">external pressure from grassroots activists</a> gave global health advocates within the Bush administration, including National Institute of Allergy and Infectious Diseases Director and chief medical advisor Anthony Fauci, the opportunity to push forward their proposal for a massive effort by the U.S. to treat AIDS in Africa. That proposal quickly evolved into PEPFAR.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xaCk3-FG9Rw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">John Robert Engole was the first patient to receive HIV treatment under PEPFAR.</span></figcaption>
</figure>
<p>Activists continued to shape PEPFAR as the program came together. They advocated for people with AIDS to be treated with generic antiretrovirals, which allowed more people to be treated than would otherwise be possible with patented drugs. And when it came time to renew PEPFAR in 2008, they <a href="https://healthgap.org/wp-content/uploads/2018/11/Bird-dogging-101.pdf">extracted promises from presidential candidates</a> to <a href="https://fpif.org/how_to_stop_aids_now/">reauthorize the program at $50 billion</a>, over three times Bush’s initial pledge.</p>
<p>Today, PEPFAR <a href="https://www.state.gov/where-we-work-pepfar/">works in over 50 countries</a>, including in Central and South America, Southeast Asia and the former Soviet Union. Since 2003, the program has injected <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/">over $100 billion</a> into the fight against global AIDS, although <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/#endnote_link_559116-23">annual funding levels have been flat for most of that time</a>. Yet despite stagnant funds, PEPFAR has brought treatment to an increasing number of people in need. That it has done so is in no small part thanks to the AIDS activists who fought to make generic antiretrovirals available, allowing the program to treat many more people than would otherwise be possible.</p>
<h2>Lessons unlearned</h2>
<p>To be sure, the Bush administration had its own reasons to address AIDS in Africa. National security experts at the U.S. State Department had <a href="https://uncpress.org/book/9780807872116/infectious-ideas/">long worried that AIDS would destabilize the continent</a>, as historian Jennifer Brier has shown, and PEPFAR burnished the president’s commitment to “<a href="https://newrepublic.com/article/86075/compassionate-conservative-hiv-pepfar-bush-gop-budget">compassionate conservatism” and faith-based social programs</a>. </p>
<p>But by the time of Bush’s announcement, grassroots activists had already spent years arguing in public that treating AIDS in Africa was not only possible but imperative. And their advocacy for low-cost generic antiretrovirals paved the way for global AIDS treatment on a scale that had once been thought impossible.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protestors holding a black coffin, wearing paper skull masks and signs reading 'I died on an ADAP waiting list' and 'Gilead gouges gov' AIDS dollars'" src="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">AIDS protestors called upon pharmaceutical companies to lower drug pricing to affordable levels.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSHealthcareFoundationProtestatGileadSciences/3937be37fe0b45339e1518d5ad3c48b2">Alison Yin/AP Images for AIDS Healthcare Foundation</a></span>
</figcaption>
</figure>
<p>Unfortunately, U.S. responses to recent viral epidemics have not shown evidence that the nation has learned from the PEPFAR example. The <a href="https://doi.org/10.1038/d41586-022-03529-3">hoarding of COVID-19 vaccines</a> by the U.S. and other wealthy nations shows the same persistent disregard for human life that was evident in attempts to block generic medicines from reaching people who needed them. At the same time, millions of doses of a highly effective vaccine against mpox in the U.S. national vaccine stockpile were <a href="https://www.nytimes.com/2022/08/01/nyregion/monkeypox-vaccine-jynneos-us.html">allowed to expire</a> while outbreaks of the virus <a href="https://doi.org/10.1038/d41586-022-01686-z">raged in West and Central Africa</a> in 2022. And early 2023 announcements that Pfizer and Moderna may both price their COVID-19 vaccines at <a href="https://arstechnica.com/science/2023/01/moderna-may-match-pfizers-400-price-hike-on-covid-vaccines-report-says/">well over $100 per dose</a> in the U.S. recalls the exorbitant drug prices that aroused activist fury in the fight against AIDS.</p>
<p>PEPFAR has saved millions of lives, in no small part because activists thought big and fought hard for justice in the U.S. response to global AIDS. Although the program is far from perfect, it serves as a reminder of what is possible when solidarity guides responses to humanity’s biggest challenges, and the power of grassroots organizing in turning principles into policy.</p><img src="https://counter.theconversation.com/content/194908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dan Royles has received funding from the National Endowment for the Humanities and the National Park Service. He is affiliated with the Miami-Dade Democratic Party. </span></em></p>The US PEPFAR initiative has brought HIV medication to millions of people globally. Behind this progress are the activists that pressured politicians and companies to put patients over patents.Dan Royles, Associate Professor of History, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1959972023-01-08T08:47:21Z2023-01-08T08:47:21ZHIV remains a leading killer in Africa despite medical breakthroughs – how to eliminate it<figure><img src="https://images.theconversation.com/files/500741/original/file-20221213-13937-sc773c.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><em>About <a href="https://www.unaids.org/en/resources/fact-sheet">38 million</a> people around the world are living with HIV. About 70% of them live in Africa. This shows that there is no solution to the AIDS pandemic without a solution in Africa. In 2021, there were 1.5 million <a href="https://www.unaids.org/en/resources/fact-sheet">new cases</a> of HIV – just over 4,000 cases per day around the world. At the same time, close to <a href="https://www.unaids.org/en/resources/fact-sheet">700,000 people died</a>. The big challenge is to address the dual realities of people still dying from HIV in large numbers, and the large numbers of new infections. The upside is that there is a clear plan with clear goals on how to address this. In 2016, countries came together at the United Nations to <a href="https://www.unaids.org/en/resources/909090">agree</a> on what the world’s strategy should be. The goal is to end AIDS as a public health threat by 2030. We spoke with leading scientist Professor Salim Abdool Karim about how to close the gaps.</em></p>
<hr>
<h2>What are we getting wrong?</h2>
<p>It’s not like we’re doing something wrong, but you can always do better than what we do now. Most new infections are coming from two different groups.
The first is key populations. The largest number of new infections is occurring in <a href="https://www.unaids.org/sites/default/files/media_asset/2022-global-aids-update-summary_en.pdf">men who have sex with men</a>. Especially young men – often young black men. These infections occur largely in Eastern Europe and in Russia.</p>
<p>The second high priority is the large numbers of new infections in <a href="https://www.sciencedirect.com/science/article/pii/S2772707622001035">young women in Africa</a>. If we don’t address those two groups, we won’t solve the problem.
But to address those two groups is not easy. The challenges in much of Eastern Europe and Russia relate to their marginalisation and discrimination as much as they are about services for key populations.</p>
<p>In Africa, we have simply not been able to stem the number of new infections in young women to the extent we had hoped. The problem is the way in which society has supported or entrenched age disparate sex, where teenage girls are having sex with men about eight to 10 years older than them.</p>
<p>And the means we have to slow the rate of new infections in young women is not well suited to the need. It’s not feasible for a young woman who is not thinking about HIV and aware of her risk regularly to take a tablet every day or even to get an injection. So we have to develop new technologies.</p>
<p>We need a combination of new approaches in our society to reduce age disparate sex. And we need new technologies to protect young women. And thirdly, we need to get more young men and more men in their 20s and 30s into health services so that they test and they go on to treatment before they infect young girls.</p>
<h2>How do we change this?</h2>
<p>There are three things we have to think about.</p>
<p>The first is we must appreciate that each of us is mutually interdependent: each person’s risk affects the risk faced by others. Hence, we need solutions that involve everyone working towards a common purpose. We saw that very clearly in COVID-19. Omicron was first described in South Africa in November 2021 – within a week this variant was detected in 16 countries. Within two weeks omicron was in several countries on all continents. This shows that we are all interconnected and dependent on each other. We have a shared responsibility to deal with the problem. </p>
<p>We can’t take the attitude that it’s somebody else’s problem. In many ways, in HIV, the response has taken our interdependence into consideration. For example, wealthy countries put resources into the <a href="https://www.theglobalfund.org/en/">Global Fund to Fight AIDS, TB and Malaria</a> for poor countries to benefit. It’s a shared responsibility. The countries are not saying, “It’s Africa’s problem, we don’t care.” No, they’re saying, “We understand that if we don’t get HIV under control in Africa, it affects the whole world.”</p>
<p>Second is that we have to mobilise the resources to at least get treatment up to the levels that we have set in our targets. That means we have to get 95% of people knowing their HIV status, 95% of people with HIV on treatment, and 95% of them virally suppressed. This is the global target for 2025. We need to help each other to get to that target.</p>
<p>We’re going to need to do better with prevention. That’s the third point. Treatment is not going to be enough on its own to enable us to reach the 2030 target. We need to improve prevention. That means we’re going to need to continue our efforts in circumcision and condom promotion, and to do better with pre-exposure prophylaxis.</p>
<h2>What are the next steps?</h2>
<p>We need to build on the momentum from the COVID-19 pandemic. The introduction of new technologies such as <a href="https://medlineplus.gov/genetics/understanding/therapy/mrnavaccines/#:%7E:text=Currently%20vaccines%20for%20COVID%2D19,as%20the%20%E2%80%9Cspike%20protein%E2%80%9D.">mRNA</a> is a good example. This is technology we can tap to improve the research on vaccines against tuberculosis and malaria, particularly in HIV.
We don’t have a vaccine for HIV yet, but there are now new candidates being made with mRNA. At least we can do better with existing TB vaccines and existing malaria vaccines with a new platform such as using mRNA technology. It is also an important platform for HIV vaccines in the pipeline.</p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195997/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Salim Abdool Karim 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>We need a combination of new approaches to reduce age disparate sex. And we need new technologies to protect young women.Salim Abdool Karim, Director, Centre for the AIDS Program of Research in South Africa (CAPRISA)Licensed as Creative Commons – attribution, no derivatives.