HIV This Week

Islam and harm reduction.

Kamarulzaman A, Saifuddeen SM. Int J Drug Policy.2009.Dec [Epub ahead of print].

Although drugs are haram and therefore prohibited in Islam, illicit drug use is widespread in many Islamic countries throughout the world. In the last several years increased prevalence of this problem has been observed in many of these countries which has in turn led to increasing injecting drug use driven HIV epidemics across the Islamic world. Whilst some countries have recently responded to the threat through the implementation of harm reduction programmes, many others have been slow to respond. In Islam, The Quran and the Prophetic traditions or the Sunnah are the central sources of references for the laws and principles that guide the Muslims’ way of life and by which policies and guidelines for responses including that of contemporary social and health problems can be derived. The preservation and protection of the dignity of man, and steering mankind away from harm and destruction are central to the teachings of Islam. When viewed through the Islamic principles of the preservation and protection of the faith, life, intellect, progeny and wealth, harm reduction programmes are permissible and in fact provide a practical solution to a problem that could result in far greater damage to the society at large if left unaddressed.

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Editors’ note: Following an in-depth tour of the epidemiology of illicit drug consumption, injecting drug use, and the HIV epidemic in Islamic countries, this paper presents the basic guidelines provided in the Quran and the Sunnah (Prophetic traditions) that support needle exchange programmes and opioid substitution therapy. The pragmatic evidence-informed public health approach of harm reduction programmes in the Islamic Republic of Iran, Malaysia and Indonesia contrasts starkly with the rejection of harm reduction in Libya, Tunisia, Syria, and Jordan. Despite the tenets of Islam, resistance in the latter countries appears ideological with roots in a criminal justice perspective. As the authors underscore, harm reduction is a public health issue that not only does not violate shariah law, it follows Islamic principles.

Community Involvement in HIV and Tuberculosis Research.

Harrington M. J Acquir. Immune Defic Syndr. 2009; Nov:52(S2)

Since advent of the HIV pandemic in the 1980s, affected communities and individuals living with HIV have played key roles in leading the response to the crisis. Achievements of the HIV treatment activist movement include persuading the US Food and Drug Administration to allow expanded access to experimental treatments for those unable to enter controlled clinical trials; accelerated approval of anti-HIV drugs based on surrogate markers such as CD4 cell and HIV RNA changes; and the involvement ofpeople with HIV and their advocates throughout the research system, including in the design, conduct, and evaluation of clinical trials. HIV treatment activists have adapted these skills to tackle tuberculosis (TB) research and programs. Considering the dearth of adequate diagnostic, treatment, and preventive interventions to control TB among people with HIV, the experiences and efforts of HIV activists are vital to accelerate research and development of new diagnostics, drugs, and vaccines to identify, cure, and prevent TB, especially among people living with HIV. Advocacy to implement World Health Organization collaborative HIV/TB activities and to reduce TB’s toll among people with HIV provides a case study of how scale-up of HIV and TB programs contributes to health system strengthening.

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Editors’ note: This ‘must read’ article presents a succinct history of the HIV treatment activist movement, underscoring the informed and relentless pressure that accelerated the pace of research and development for novel antiretroviral drugs. Community activists used mass media and the internet, political lawsuits and legislation, public demonstrations and civil disobedience, and coalition-building and other strategies to influence both the speed and conduct of treatment research. The article describes the gains made and the challenges ahead, particularly for tuberculosis research. TB urgently requires new diagnostic methods (the ones in common use today date from the 19 th century), improved treatment drugs and programmes, and a new vaccine (Bacille Calmette-Guérin, the TB vaccine, was developed between 1908 and 1921). Among people living with HIV, TB is the commonest cause of death and over 1.4 million people living with HIV develop TB each year. Activists from among all stakeholders (community, scientists, government, funders, and others) need to join in concerted action to ensure rapid development of diagnostics, drugs, vaccines, and delivery systems to prevent people dying from tuberculosis .

Peersman G, Ferguson L, Torres M, Smith S, Gruskin S. J Acquir Immune Defic Syndr. 2009 52(S2)

The 2001 Declaration of Commitment on HIV/AIDS provided impetus for strengthening collaboration between government and civil society partners in the HIV response. The biennial UNGASS reporting process is an opportunity for civil society to engage in a review of the implementation of commitments. The article is reporting on the descriptive analyses of the National Composite Policy Index from 135 countries; a debriefing on UNGASS reporting with civil society in 40 countries; and 3 country case studies on the UNGASS process. In the latest UNGASS reporting round, engagement of civil society occurred in the vast majority of countries. The utility of UNGASS reporting seemed to be better understood by both government and civil society, compared with previous reporting rounds. Civil society participation was strongest when civil society groupings took the initiative and organized themselves. An important barrier was their lack of experience with national level processes. Civil society involvement in national HIV planning and strategic processes was perceived to be good, but better access to funding and technical support is needed. Instances remain where there are fundamental differences between government and civil society perceptions of the HIV policy and program environment. How or whether differences were resolved is not always clear, but both government and civil society seemed to appreciate the opportunity for discussion. Collaborative reporting by government and civil society on UNGASS indicators is a small but potentially valuable step in what should be an ongoing and fully institutionalized process of collaborative planning, implementation, monitoring, assessment and correction of HIV responses. The momentum achieved through the UNGASS process should be maintained with follow-up actions to address data gaps, formalize partnerships and enhance active and meaningful engagement.

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Editors’ note: Civil society is defined in this article as voluntary associations of citizens that undertake actions in support of people living with or affected by HIV; it does not include the private (profit-making) or public (government) sectors. Civil society involvement in national HIV responses has increased since 2005 but there is room for improvement in virtually all countries if civil society participation is to be truly active and meaningful. One indicator is the number of ‘shadow reports’ from civil society groups dissatisfied with the government reporting on progress. This number has declined from 33 countries in 2006 to 15 countries in 2008, and some of the latter reports were simply providing additional information, as opposed to expressing dissenting views. Although UNGASS reporting is an international accountability tool based on the 2001 Declaration of Commitment, the reporting process itself can be a mechanism to increase civil society engagement in the national HIV response and enhance government accountability to its own citizens.

Challenge and co-operation: civil society activism for access to HIV treatment in Thailand.Ford N, Wilson D, Cawthorne P, Kumphitak A, Kasi-Sedapan S, Kaetkaew S, Teemanka S, Donmon B, Preuanbuapan C. Trop Med Int Health. 2009; 14: 258-66 .

Civil society has been a driving force behind efforts to increase access to treatment in Thailand. A focus on HIV medicines brought civil society and non-governmental and government actors together to fight for a single cause, creating a platform for joint action on practical issues to improve care for people with HIV within the public health system. The Thai Network of People with HIV/AIDS, in partnership with other actors, has provided concrete support for patients and for the health system as a whole; its efforts have contributed significantly to the availability of affordable generic medicines, early treatment for opportunistic infections, and an informed and responsible approach towards antiretroviral treatment that is critical to good adherence and treatment success. This change in perception of people living with HIV from ‘passive receiver’ to ‘co-provider’ of health care has led to improved acceptance and support within the healthcare system. Today, most people living with HIV in Thailand can access treatment, and efforts have shifted to supporting care for excluded populations.

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Editors’ note: This ‘participant-observers’ perspective, written by representatives of AIDS ACCESS Foundation, the Thai Network of People living with HIV (TNP+) and Médecins Sans Frontières, describes how civil society activism in Thailand pushed the government to increase availability of affordable antiretroviral drugs and then provided practical support to implementation of treatment programmes. Civil society groups played a pivotal role in Thailand’s decision to establish universal health care coverage for its citizens and used legal and other strategies to fight intellectual property restrictions to medicines, including non-HIV medicines. The groups represented by the co-authors developed a strategy for central involvement of trained people living with HIV in the scale up of treatment programmes through providing systematic peer support in ‘Comprehensive and Continuous Care Centres’ in hospitals. This rich historical analysis of policy change in Thailand is well worth the read.

Vaas JR. The role of HIV/AIDS committees in effective workplace governance of HIV/AIDS in South African small and medium-sized enterprises. SAHARA J. 2008;5(1):2-10.

The primary purpose of this study was to assess the role, status and scope of workplace AIDS committees as a means of effective workplace governance of AIDS impact, and their role in extending social protective HIV-related rights to employees. In-depth qualitative case studies were conducted in five South African small and medium-sized enterprises that were actively implementing HIV policies and programmes. Companies commonly implemented HIV policies and programmes through a workplace committee dedicated to HIV or a generic committee dealing with issues other than HIV. Management, through the human resources department and the occupational health practitioner often drove initial policy formulation, and had virtually sole control of the AIDS budget. Employee members of committees were mostly volunteers, and were often production or blue collar employees, while there was a notable lack of participation by white-collar employees, line management and trade unions. While the powers of workplace committees were largely consultative, employee committee members often managed in an indirect manner to secure and extend social protective rights on HIV to employees, and monitor their effective implementation in practice. In the interim, workplace committees represented one of the best means to facilitate more effective workplace HIV governance. However, the increased demands on collective bargaining as a result of an anticipated rises in HIV-related morbidity and mortality might prove to be beyond the scope of such voluntary committees in the longer term.

Editors’ note: With human resources and occupational health representatives predominating and little trade union involvement, these committees, that have done much to extend employee rights and social protection, are ill equipped to face more serious HIV-related issues. Employee representatives and shop stewards in these companies, some of which have HIV prevalence as high as 20%, need to ensure that collective bargaining agreements include training and policy information for shop stewards. Departments of Labour should be monitoring implementation of the code of good practice on HIV in businesses of all sizes.

Atun RA, McKee M, Coker R, Gurol-Urganci I. Health systems’ responses to 25 years of HIV in Europe: Inequities persist and challenges remain. Health Policy. 2008; 86(2-3):181-94.

Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and Eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as sex workers, prisoners, injecting drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in Eastern Europe, where civil society or Non-Governmental Organization culture is weak as compared to Western Europe. Scaling up of effective responses in many countries in Eastern Europe will be challenging. Increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of civil society in planning and delivery of client-focused services.

Editors’ note: This desk review combined countries with differing socioeconomic, cultural, and health systems characteristics into four broad groupings: Western, Central, Eastern Europe, and Central Asia. The multi-sectored, client-focused interventions of Western Europe are integrated into mainstream health systems offering broad coverage, but inequities persist for marginalized people. In the countries of Eastern Europe facing HIV, IDU, STI, and TB epidemics, new resources directed at programmatic interventions alone will not be effective in addressing either the HIV epidemic or the persistent inequities that exacerbate it, nor will they be sustainable. The design and implementation of multifaceted and multi-sectored programmes must be shaped by the local, political, economic, social, and legal contexts and serve to strengthen health systems, surveillance, monitoring and evaluation, and civil society engagement.

Charalambous S, Innes C, Muirhead D, Kumaranayake L, Fielding K, Pemba L, Hamilton R, Grant A, Churchyard GJ. Evaluation of a workplace HIV treatment programme in South Africa. AIDS 2007;21 Suppl 3:S73-8.

Charalambous and colleagues aimed to review the experience of implementing a workplace HIV care programme in South Africa and describe treatment outcomes in sequential cohorts of individuals starting antiretroviral therapy (ART). The authors reviewed an industrial HIV care and treatment programme. Between October 2002 and December 2005, 2262 patients enrolled in the HIV care programme. CD4 cell counts increased by a median of 90, 113 and 164 cells/microl by 6, 12 and 24 months on treatment, respectively. The viral load was suppressed below 400 copies/ml in 75, 72 and 72% of patients at 6, 12 and 24 months, respectively, at an average cost of US$1654, 3567 and 7883 per patient virally suppressed, respectively. Treatment outcomes in sequential cohorts of patients were consistent over time. A total of 93.6% of patients at 14,752 clinic visits reported missing no tablets over the previous 3 days. Almost half the patients (46.8%) experienced one or more adverse events, although most were mild (78.7%). By the end of December 2005, 30% of patients were no longer on ART, mostly because of defaulted or stopped treatment (12.8%), termination of employment (8.2%), or death (4.9%). The authors conclude that this large workplace programme achieved virological results among individuals retained in the programme comparable to those reported for developed countries and that  more work is needed to improve retention. Monitoring treatment outcomes in sequential cohorts is a useful way of monitoring programme performance. As the programme has matured, the costs of programme implementation have reduced. Counselling is a central component of an ART programme. Challenges in implementing a workplace ART programme are similar to the challenges of public-sector programmes.

Editors’ note: Cohort studies such as this one can provide valuable information on retention rates and treatment outcomes over time which can be used to improve programme performance. Although virological outcomes in this large workplace programme were comparable with those of programmes in resource-poor and resource-rich countries, termination of employment led 8% of patients to stop antiretroviral treatment. Providing bridging treatment until patients are transferred to another HIV treatment programme ensures continuity of care without the unstructured treatment interruptions that can encourage disease progression and drug resistance.

Ramachandran V, Shah MK, Turner GL. Does the private sector care about AIDS? Evidence from firm surveys in East Africa. AIDS 2007;21 Suppl 3:S61-72.

Ramachandran and colleagues aimed to identify determinants of HIV prevention activity and pre-employment health checks by private firms in Kenya, Uganda and Tanzania. The authors used data from the World Bank Enterprise Surveys for Uganda, Kenya and Tanzania, encompassing 860 formally registered firms in the manufacturing sector. Econometric analysis of firm survey data was used to identify the determinants of HIV prevention including condom distribution and voluntary counselling and testing (VCT). Multivariate regression analysis was the main tool used to determine statistical significance. The results showed that approximately a third of enterprises invest in HIV prevention. Prevention activity increases with size, most likely because larger firms and firms with higher skilled workers have greater replacement costs. Even in the category of larger firms, less than 50% provide VCT. The authors found that the propensity of firms to carry out pre-employment health checks of workers also varies by the size of firm and skill level of the workforce. Finally, data from worker surveys showed a high degree of willingness on the part of workers to be tested for HIV in the three East African countries.

Editors’ note: This study found that larger firms, those with trained workers or workers with higher skill levels, or those with unionized workers do more to prevent HIV. Given the high proportion of small companies compared to large ones in African countries, the public sector needs to take the lead on HIV prevention in most workplaces.

Wu Z, Sullivan SG, Wang Y, Rotheram-Borus MJ, Detels R. Evolution of China’s response to HIV/AIDS. Lancet 2007;369:679-90.

Four factors have driven China’s response to the HIV pandemic: (1) existing government structures and networks of relationships; (2) increasing scientific information; (3) external influences that underscored the potential consequences of an HIV pandemic and thus accelerated strategic planning; and (4) increasing political commitment at the highest levels. China’s response culminated in legislation to control HIV -the AIDS Prevention and Control Regulations. Three major initiatives are being scaled up concurrently. First, the government has prioritised interventions to control the epidemic in injection drug users, sex workers, men who have sex with men, and plasma donors. Second, routine HIV testing is being implemented in populations at high risk of infection. Third, the government is providing treatment for infected individuals. These bold programmes have emerged from a process of gradual and prolonged dialogue and collaboration between officials at every level of government, researchers, service providers, policymakers, and politicians, and have led to decisive action.

Editors’ note : In the wake of SARS, China has shown tremendous resolve in responding to HIV decisively and matching programming to the dynamics of its epidemic. When China decides to move forward, it commits to deliver. The speed at which antiretroviral treatment access can be increased; the extent to which key populations can be reached with tailored programmes; and whether the voluntariness of HIV testing, combined with anti-stigma and antidiscrimination measures, can be ensured so that knowledge of serostatus will be sought by people are all key to achieving an effective and sustained result.

Krakauer M, Newbery J. Churches’ responses to HIV/AIDS in two South African communities. J Int Assoc Physicians AIDS Care (Chic Ill) 2007;6:27-35.

Churches have attracted controversy for how they have dealt with AIDS: they have been criticized for moral stigmatism, yet lauded for their charitable works. Krakauer and colleagues examine what churches were doing at the grass-roots level to deal with the impact of AIDS on their communities. This study was conducted in a rural area and an urban area outside of Durban, South Africa, a region with high HIV prevalence rates. The authors examined 2 indigenous churches (Shembe and Zionist) and one international church (Roman Catholic) in each community. The authors found that there was a widespread awareness of AIDS among church leaders and community members, and that churches were used as health resources by their members, yet no AIDS programs were run by any of the churches in the study locations. The authors argue that 4 key characteristics dictated the churches’ responses to AIDS: resources, organizational structure, cultural appeal, and discipline. There are distinct advantages to partnering with churches for AIDS programming, yet significant complexities to navigating a meaningful dialogue with them also exist.

Editors’ note: This study suggests that there is significant untapped potential in faith-based organisations for the response to HIV. Translating high awareness into effective HIV programming for church members and the broader community may require study tours and peer learning about approaches being used effectively in other communities.