HIV This Week

A situation update on HIV epidemics among people who inject drugs and national responses in South-East Asia Region.

Sharma M, Oppenheimer E, Saidel T, Loo V, Garg R. AIDS. 2009;23:1405-13.

The authors explore the magnitude of and current trends in HIV infection among people who inject drugs and estimate the reach of harm reduction interventions among them in seven high-burden countries of the South-East Asia Region. Their data are drawn from the published and unpublished literature, routine national HIV serological and behavioural surveillance surveys and information from key informants. Six countries ( Thailand, Myanmar, Nepal, Indonesia, India, and Bangladesh) had significant epidemics of HIV among people who inject drugs. In Thailand, Indonesia, Bangladesh, Myanmar and India, there is no significant decline in the prevalence of HIV epidemics in this population. In Nepal, north-east India, and some cities in Myanmar, there is some evidence of decline in risk behaviours and a concomitant decline in HIV prevalence. This is countered by the rapid emergence of epidemics in new geographical pockets. Available programme data suggest that less than 12 000 of the estimated 800 000 (1.5%) people who inject drugs have access to opioid substitution therapy, and 20-25% were reached by needle-syringe programmes at least once during the past 12 months. A mapping of harm reduction interventions suggests a lack of congruence between the location of established and emerging epidemics and the availability of scaled-up prevention services. Harm reduction interventions in closed settings are almost nonexistent. To achieve significant impact on the HIV epidemics among this population, governments, specifically national AIDS programmes, urgently need to scale up needle-syringe programmes and opioid substitution therapy and make these widely available both in community and closed settings.

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Editors’ note: This broad mapping, across 7 high drug use burden South East Asian countries with significant, longstanding HIV epidemics among people who inject drugs, draws from a variety of data sources to paint a picture of national prevention responses. In addition to the strikingly inadequate reach of harm reduction programmes, current surveillance systems are not designed to pick up new epidemics. Indonesia is the only country with a national strategy (2005-2009) to guide HIV prevention, treatment, and care in prison settings – the very settings that are known to be high-risk environments worldwide for HIV transmission. Methadone and buprenorphine are unavailable and too expensive in most countries. Tensions between supply/demand reduction and harm reduction approaches call out now for enlightened leadership at all levels to implement effective HIV prevention programmes to cover at least 50-60% of people who inject drugs.  

Rethinking the conceptual terrain of AIDS scholarship: lessons from comparing 27 years of AIDS and climate change research.

Chazan M, Brklacich M, Whiteside A. Global Health. 2009;5:12.

While there has recently been significant medical advance in understanding and treating HIV, limitations in understanding the complex social dimensions of HIV epidemics continue to restrict a host of prevention and development efforts from community through to international levels. These gaps are rooted as much in limited conceptual development as they are in a lack of empirical research. In this conceptual article, the authors compare and contrast the evolution of climate change and AIDS research. They demonstrate how scholarship and response in these two seemingly disparate areas share certain important similarities, such as the “globalization” of discourses and associated masking of uneven vulnerabilities, the tendency toward techno-fixes, and the polarization of debates within these fields. They also examine key divergences, noting in particular that climate change research has tended to be more forward-looking and longer-term in focus than AIDS scholarship. Suggesting that AIDS scholars can learn from these key parallels and divergences, the paper offers four directions for advancing AIDS research: focusing more on the differentiation of risk and responsibility within and among AIDS epidemics; taking (back) on board social justice approaches; moving beyond polarized debates; and shifting focus from reactive to forward-looking and proactive approaches.

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Editors’ note: In the lead up to Copenhagen, this article makes for a very stimulating read. You will learn about the similarities and differences between HIV and climate change research but also about how the response to these two threats was conceptualised at different time periods. Both phenomena are complex, unprecedented, and highly dynamic. For both, scholarship has evolved from a physical or life sciences perspective to one that integrates the social sciences. HIV researchers can learn from the forward-looking and longer-term focus of climate change research, along with its well-considered social vulnerability concepts. A strong message emerges: we need to intervene now proactively to identify and address existing context-specific vulnerabilities to HIV infection and AIDS impacts, before HIV epidemics have fully run their course, in order to mitigate future impacts. It means moving away from a crisis footing to a forward-looking proactive stance to understand was is needed now to reduce or prevent future hardships.

Hecht R, Bollinger L, Stover J, McGreevey W, Muhib F, Madavo CE, de Ferranti D. Health Aff (Millwood). 200 ;28:1591-605.

The HIV pandemic will enter its fiftieth year in 2031. Despite much progress, there are thirty-three million infected people worldwide, and 2.3 million adults were newly infected in 2007. Without a change in approach, a major pandemic will still be with us in 2031. Modelling carried out for the AIDS 2031 project suggests that funding required for developing countries to address the pandemic could reach $35 billion annually by 2031-three times the current level. Even then, more than a million people will still be newly infected each year. However, wise policy choices focusing on high-impact prevention and efficient treatment could cut costs by half. Investments in new prevention tools and major behaviour-change efforts are needed to spur more rapid advances. Existing donors, middle-income countries with contained epidemics, philanthropists, and innovative financing could help bridge the likely funding gap.

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Editors’ note: Looking at what might be done differently to alter significantly the course of the HIV pandemic in order to achieve by 2031 few new infections, nearly all those in need of treatment receiving it, and children orphaned by AIDS assisted to lead normal lives, this costs and financing group lays out some stark choices. Modelling of four scenarios – rapid scale-up, current trends, hard choices for prevention, and structural change – reveals that at best 1 million new adult infections will occur in 2031. The ‘game-changers’, while waiting for a vaccine or cure, are high reach, effective prevention programmes for people who inject drugs, men who have sex with men, people who sell sexual services, and increasing numbers of discordant couples as the epidemic matures. Anticipating that resource requirements are set to increase rapidly over the next 5 to 8 years, six policy actions are described to expand financing for HIV in low- and middle-income countries. This is a sobering but essential read for us all.

HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Abdool Karim S S, Churchyard GJ, Abdool Karim QA, Lawn SD. Lancet 2009; 374: 921-33.

One of the greatest challenges facing post-apartheid South Africa is the control of the concomitant HIV and tuberculosis epidemics. HIV continues to spread relentlessly, and tuberculosis has been declared a national emergency. In 2007, South Africa, with 0.7% of the world’s population, had 17% of the global burden of HIV infection, and one of the world’s worst tuberculosis epidemics, compounded by rising drug resistance and HIV co-infection. Until recently, the South African Government’s response to these diseases has been marked by denial, lack of political will, and poor implementation of policies and programmes. Nonetheless, there have been notable achievements in disease management, including substantial improvements in access to condoms, expansion of tuberculosis control efforts, and scale-up of free antiretroviral therapy. Care for acutely ill AIDS patients and long-term provision of antiretroviral therapy are two issues that dominate medical practice and the health-care system. Decisive action is needed to implement evidence-based priorities for the control of the HIV and tuberculosis epidemics. By use of the framework of the Strategic Plans for South Africa for tuberculosis and HIV, Abdool Karim and colleagues provide prioritised four-step approaches for tuberculosis control, HIV prevention, and HIV treatment. Strong leadership, political will, social mobilisation, adequate human and financial resources, and sustainable development of health-care services are needed for successful implementation of these approaches.

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Editors’ note: This paper is a ‘must read’ for anyone wishing to understand the historical response to the intertwined HIV and tuberculosis (TB) epidemics in South Africa against a political backdrop. From a concentrated subtype B epidemic among men who have sex with men and patients with haemophilia in the early 1980s, the South African HIV epidemic evolved into a predominantly heterosexual clade C epidemic as mini-epidemics coalesced into a country-wide generalised epidemic, the worst in the world. Tuberculosis, which was introduced in the 17 th century from Europe and gained a firm toehold in the 19 th century in South Africa’s mining industry, is the most common notified natural cause of death in South Africa, with multidrug resistant (MDR) TB and extensively drug-resistant (XDR) TB now major causes for concern. This paper includes a scorecard that rates the government’s response in comparison with 5 neighbouring countries, Brazil, and India. It then lays out the challenges clearly, highlighting achievements to build upon, and sets out the priority action steps to achieve HIV and tuberculosis control. Failure is clearly not an option.

Buse K, Lalji N, Mayhew SH, Imran M, Hawkes SJ. Political feasibility of scaling-up five evidence-informed HIV interventions in Pakistan: a policy analysis. Sex Transm Infect. 2009 Apr;85 Suppl 2:ii37-42.

Drawing on policy theories, an assessment was made of the perceived political feasibility of scaling-up five evidence-based interventions to curb Pakistan’s HIV epidemic: needle and syringe exchange programmes; targeted behaviour change communication; sexual health care for male and transgender sex workers; sexual and reproductive health care for female sex workers; and promoting and protecting the rights of those at greatest risk. A questionnaire was emailed to 40 stakeholders and completed by 22. They expressed their level of agreement with 15 statements for each intervention (related to variables associated with policy success). Semi-structured interviews were conducted with 12 respondents. The interventions represent considerable change from the status quo, but are perceived to respond to widely acknowledged problems. These perceptions, held by the HIV policy elite, need to be set in the context of the prevailing view that the AIDS response is not warranted given the small and concentrated nature of the epidemic and that the interventions do not resonate closely with values held by society. The interventions were perceived to be evidence-based, supported by at least one donor and subject to little resistance from frontline staff as they will be implemented by contracted non-government organisations. The results were mixed in terms of other factors determining political feasibility, including the extent to which interventions are easy to explain, exhibit simple technical features, require few additional funds, are supported and not opposed by powerful stakeholders. The interventions stand a good chance of being implemented although they depend on donor support. The prospects for scaling them would be improved by ongoing policy analysis and strengthening of domestic constituencies among the target groups.

Editors’ notes: The complex interactions among institutions, interest groups, and ideas that result in policy and policy change are the subject of policy analysis. It explains why some issues, problems, or solutions grab the attention of policy-makers. This policy analysis based on a key-informant survey suggests that while evidence contributing to the knowledge base is important, often it is superseded by the arguments and stories that resonate with decision-makers and influence their values and beliefs. Supporting the development of constituencies among highly stigmatised key populations most in need of HIV prevention and treatment services could provide a voice for the stories that can change the minds of decision-makers in Pakistan.

Bernays S, Rhodes T. Experiencing uncertain HIV treatment delivery in a transitional setting: qualitative study. AIDS Care. 2009;21(3):315-21.

Advances in HIV treatment availability mean that the promise of highly active anti-retroviral treatment to turn HIV into a manageable chronic illness is becoming a reality for millions. However the mutability of the virus means that treatment adherence demands are high, and the supply of these life-saving treatments needs to be constant. The onus is generally placed on the individual to adhere, and there is little focus in research or policy on the state’s adherence to delivering treatment consistently. Bernays and colleagues undertook in-depth qualitative interviews to explore the narratives of HIV treatment experience among 41 people living with HIV and 18 HIV treatment service providers in Serbia and Montenegro, a transitional setting in which state delivered and funded HIV treatment is inconsistently available. Data were analysed inductively and thematically. Treatment shortages were common so the delivery of appropriate HIV treatment was not continuous. Access to reliable treatment and supply forecast information was weak and uneven. The insecure treatment situation fostered significant anxiety amongst people living with HIV. In the absence of reliable and sustained treatment access, information, and support, people living with HIV absorb the anxieties of system failures. This uncertainty led to an individuation of “treatment”. People living with HIV adopted rationing strategies to mediate their anxiety, energy and hope. This predominately resulted in varying forms of disengagement and neglect for social change. It is likely that this has significant negative implications for the promotion of HIV treatment advocacy and anti-stigma efforts.

Editors’ note: Adherence literature to date has focused primarily on patient adherence to treatment regimens rather than on the social and psychological effects of involuntary treatment interruptions. Fragile treatment delivery undermines the quality of life and capacity of people living with HIV to manage it as a manageable, chronic illness. Although some people in this study reduced their anxiety by fostering networks and resources to gain access to information and treatment, a form of social capital to generate security, others withdrew, trusting no one but their treatment provider and becoming less likely to disclose to others. This research highlights the clear need for a social science of scale-up .

Sopheab H, Morineau G, Neal JJ, Saphonn V, Fylkesnes K. Sustained high prevalence of sexually transmitted infections among female sex workers in Cambodia: high turnover seriously challenges the 100% Condom Use Programme. BMC Infect Dis. 2008;8:167.

Cambodia ’s 100% Condom-Use Programme, implemented nationally in 2001, requires brothel-based female sex workers to use condoms with all clients. In 2005, Sopheab et al conducted a sexually transmitted infection survey among female sex workers. This paper presents sexually transmitted infection prevalence and related risk factors, and discusses prevalence trends in the context of the 100% Condom-Use Programme in Cambodia. From March-May, 1079 female sex workers from eight provinces consented to participate, provided specimens for syphilis, chlamydia, and gonorrhoea testing, and were interviewed. Univariate and multivariate logistic regression analysis was used to determine factors associated with sexually transmitted infections. The prevalence of sexually transmitted infection was compared with data from the 1996 and 2001 sexually transmitted infection surveys. Most female sex workers were young (55% aged 15-24) and new to sex work ( 60% had worked 12 <or= months). Consistent condom use with clients was reported by 80% of female sex workers, but only 38% of female sex workers always used condoms with sweethearts or casual partners. Being new to sex work was the only factor significantly associated with “any sexually transmitted infection” (OR = 2.1). Prevalence of syphilis was 2.3%; chlamydia, 14.4%; gonorrhoea, 13.0%; and any sexually transmitted infection, 24.4%. Prevalence of each sexually transmitted infection in 2005 was significantly lower than in 1996, but essentially the same as prevalence observed in 2001. New female sex workers were found to have substantially higher prevalence than those with longer experience. The percent of female sex workers who used condoms consistently was high with clients but remained low with non-paying sex partners. Because of the high turnover of female sex workers, the prevention needs of new female sex workers should be ascertained and addressed. Despite 100% Condom-Use Programme implementation, the prevalence of sexually transmitted infections among female sex workers was the same in 2005 as it was in 2001. Limited coverage and weak implementation capacity of the programme along with questionable quality of the sexually transmitted infection services are likely to have contributed to the sustained high prevalence. The programme should be carefully reviewed in terms of intensity, quality, and coverage.

Editors’ note: Successful 100% condom use programmes in Thailand in late 1989 and Cambodia in late 1998 were rigorously conducted with high coverage and intensity. Sustaining such results given the high turnover among sex workers requires regular evaluations of programme quality and impact. Using curable bacterial sexually transmitted infection prevalence makes sense as they are good biological markers reflecting recent risk behaviour but different data collection methods, specimen-sampling techniques, and laboratory methods can make comparison of survey results hazardous. One thing is clear – Cambodia’s 100% condom-use programme, implemented nationally in 2001, should focus attention on ascertaining and addressing the prevention needs of new sex workers.

Monteiro S. STD/AIDS prevention in Portuguese-speaking Africa: a review of the recent literature in the social sciences and health. Cad Saude Publica. 2009;25(3):680-6.

The article reviews academic literature in the social sciences and health on the problems and challenges of sexually transmitted diseases and HIV prevention in Portuguese-speaking African countries. Based on a bibliographic survey of the SciELO, PubMed, and Sociological Abstracts databases between 1997 and 2007, the research under review was organized into two groups, according to content. The first group of studies sought to understand sexually transmitted diseases and HIV vulnerability among social groups by examining local cultural and socioeconomic factors as related to gender dynamics, sexuality, colour/race, religion and health care. The second group encompassed critical assessments of shortcomings in the sexually transmitted diseases and HIV educational messages delivered by governments and international agencies. Attention is called to the way in which the presence of traditional medicine systems and the occurrence of civil wars in the post-colonial period affect the sexually transmitted diseases and HIV epidemic in the African countries under study.

Editors’ note: The Portuguese-speaking African countries, known by the acronym PALOP (Países Africanos de Língua Oficial Portuguesa) are Mozambique, Angola, Cape Verde, Guinea-Bissau, Equatorial Guinea, and São Tomé and Principe. Although there are cultural and socio-economic similarities between these countries, appreciation of local contexts is critical to understanding how healthcare practices, gender roles, and the interpretation of prevention messages are mediated locally by cultural dynamics and socio-economic and political contexts. This review suggests that demystifying condom use in a pragmatic CNN approach (condoms, needles, and negotiation) as opposed to the moralizing ABC approach (abstinence, be faithful, and condoms for marginalized populations), along with frank and open discussions of sexuality in public fora and the media, would achieve positive results, particularly if accompanied by advances in citizenship rights and equal opportunities.

Han J, Bennish ML. Condom access in South African schools: law, policy, and practice. PLoSMed. 2009;6(1):e6.

South Africa’s recently adopted Children’s Act provides children the right to access reproductive health services as a way of addressing the HIV pandemic, but there remains confusion about how socially divisive rights provided for by the Act, such as condom access for youth, will be achieved. The Children’s Act, together with South African government policies, allows individual schools to decide whether to distribute condoms, but most school staff are unaware of South African policy and regulations governing condom provision in schools. Because of confusing and contradictory government policies and public pronouncements regarding provision of condoms in public schools, few schools have undertaken to provide condoms, leaving students, especially in rural areas, with few options for obtaining them. US President’s Emergency Plan for AIDS Relief regulations potentially conflict with South African law by prohibiting US President’s Emergency Plan for AIDS Relief-funded organizations from distributing condoms in schools or providing condom information to youth aged 14 and under. The current South African government’s policy of leaving the decision of whether to distribute condoms in schools to the School Governing Body of individual schools, rather than enacting a clear national policy, is unlikely to be an effective public health strategy for improving access to condoms for the population of youths at high risk for HIV.

Editors’ note: South Africa permits 12 year olds to consent on their own to HIV testing but walking the talk on condom access for youth seems a challenge. The Children’s Act grants children age 12 and older access to condoms but adults, both domestic and foreign, are blocking implementation of this legally sanctioned right. Schools are good venues for youth, teachers, parents, community leaders, and health workers to come together to discuss constructive steps forward in the context of a relentless epidemic and a seeming policy vacuum.

L.P. Babichi, W.J. Bicknell, L. Culpepper B.W. Jack, M.W. Phooko, B. Smith & T.T. Thahane. Institutional commitment and HIV/AIDS: Lessons from the first 3 years of the Lesotho. Global Public Health, 2008; 3(4): 417-432.

In mid-2003, Boston University made a decade long institutional commitment to collaborate with the Government of Lesotho as it grappled with the human resource implications of the HIV epidemic. The collaboration is a work in progress. Babichi and colleagues explore the rationale for the University’s commitment, detail the development of the relationship between the Government and the University, review the principles that guide the collaboration, report on the activities, results, and challenges to date, and conclude with a look toward the future. They stress the importance of six principles: trust, mutual respect, shared interests, a long time horizon, sustainability, and a country-driven agenda. Although technical or programme content is important, long-term results of value are difficult to achieve if these principles are not honoured.

Editors’ note: This collaboration followed the ‘country first, donor follows’ principle with a collaborative, interactive, open-ended, non-predetermined 10-day assessment of Lesotho’s needs and Boston University’s areas of relevant strength. The latter’s commitment is long-term and university-wide, engaging university resources as well as external donor funds. The collaboration is characterised by a long time-horizon and a focus on sustainability, excellence, relevance, trust, respect, and openness. These are all essential to maintaining a long-term mutual commitment to effectively addressing the root problems affecting delivery of quality HIV prevention, treatment, and care and support services in Lesotho.

Prata N, Sreenivas A, Bellows B. Potential of dual-use policies to meet family planning and HIV prevention needs: a case study of Zimbabwe and Mozambique. J Fam Plann Reprod Health Care 2008; 34(4):219-26.

The fight against the HIV epidemic in many high-prevalence countries is a struggle to motivate culturally relevant risk reduction in general populations that have been educated to associate HIV risk with commercial sex, injection drug use, and other stigmatised behaviours. Common concurrent partnerships, which facilitate transmission of HIV in many high-prevalence countries, are only beginning to receive the attention they deserve. This has made the promotion of dual-use methods, such as condoms, for individuals who require both HIV protection and contraception very difficult. Recent research on concurrent partnerships and the implications for high HIV risk in sexually networked but sexually modest general populations is forcing another assessment of the response to HIV. In the light of the epidemic, it is important to better understand which policies will better meet HIV prevention and family planning needs. This article explores the potential of dual-use policies by examining Zimbabwe and Mozambique. Zimbabwe, with a vertically driven, stronger family planning programme predating the HIV epidemic, has not yet seen an increase in condom use to the level desired by their moderately strong HIV prevention programme – one that has adopted a primarily single-use condom policy. Mozambique, however, continues to have a much weaker family planning programme, but is witnessing a significant increase in condom use driven by their strong HIV programme – one that is further integrated with family planning content. Integration of HIV and family planning programmes has the potential to meet the need for HIV and pregnancy prevention more efficiently. By themselves, these programmes are unable to meet the need for condoms. The poorest of the poor are feeling the brunt of this inadequacy. Countries such as Zimbabwe and Mozambique have the potential to tremendously improve their efforts in increasing condom use. Prata and colleagues suggest that thoughtful and detailed integration of HIV and family planning programmes will work synergistically to reach common goals. Until a more promising method besides condoms is commercially available for protection against unintended pregnancy and sexually transmitted infections such as HIV, effective strategies must include dual-use policies as well as counselling on all available contraceptive methods so that women can maximise the benefits of mixing methods.

Editors’ note: This case study of Zimbabwe and Mozambique underscores the need for high HIV prevalence countries to move rapidly to promote dual protection to provide the most protection possible for all women from unwanted pregnancy and to address the unmet need for family planning among HIV-positive women. Positioning condoms as primarily contraceptive tools rather than disease protection devices may make condom negotiations in couples easier. Integration of family planning and HIV programmes requires national action supported by alignment of the donors that currently fund family planning and HIV programmes in parallel streams. Essential synergies will not be realised without integration.

R Wilcher, T Petruney, H W Reynolds, W Cates. From effectiveness to impact: contraception as an HIV prevention intervention. Sex. Transm. Inf. 2008;84;ii54-ii60

Most efforts to date to prevent mother-to-child transmission of HIV have focused on provision of antiretroviral prophylaxis to HIV-infected pregnant women. Increasing voluntary contraceptive use has been an underused approach, despite clear evidence that preventing pregnancies in HIV-infected women who do not wish to become pregnant is an effective strategy for reducing HIV-positive births. This paper reviews international, country, and service delivery level opportunities for and obstacles to translating contraceptive efficacy into interventions that will have an impact on the effectiveness of HIV prevention. The integration of family planning services and HIV programmes as a potential intervention were specifically reviewed. Despite substantial policy support for the integration of family planning and HIV programmes, burgeoning resources for HIV ignore the potential impact of contraception on HIV prevention. Moreover, separate funding for these two programmes and the resulting vertical organisation of health ministries and service facilities undermine coordination between departments and limit providers’ ability to address the contraceptive needs of HIV-positive clients. Projects integrating family planning and HIV services are being implemented, allowing for documentation of factors that facilitate or impede integrated service delivery. However, few have been evaluated to demonstrate impact on contraceptive uptake and HIV-positive births averted.

Editors’ note: At country level, policy support for family planning/HIV integration is generally not as strong as at the international level where six major international entities have issued strong statements in the past three years. This paper presents four different integration models for consideration and calls for operational research to inform guidance on how best to integrate services and messages to decrease unintended pregnancies among women living with HIV who want to limit or space their pregnancies.

Chigwedere P, Seage GR 3rd, Gruskin S, Lee TH, Essex M. Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa. J Acquir Immune Defic Syndr. 2008 Oct 16. [Epub ahead of print]

South Africa is one of the countries most severely affected by HIV. At the peak of the epidemic, the government, going against consensus scientific opinion, argued that HIV was not the cause of AIDS and that antiretroviral drugs were not useful for patients and declined to accept freely donated nevirapine and grants from the Global Fund to fight AIDS, Tuberculosis and Malaria. Using modelling, Chigwedere and colleagues compared the number of persons who received antiretroviral drugs for treatment and prevention of mother-to-child HIV transmission between 2000 and 2005 with an alternative of what was reasonably feasible in the country during that period. More than 330,000 lives or approximately 2.2 million person-years were lost because a feasible and timely antiretroviral drug treatment programme was not implemented in South Africa. Thirty-five thousand babies were born with HIV, resulting in 1.6 million person-years lost by not implementing a mother-to-child transmission prophylaxis program using nevirapine. The total lost benefits of antiretroviral drugs are at least 3.8 million person-years for the period 2000-2005.

Editors’ notes: This modelling did not consider the potential lost benefits from the possible impact that treatment could have had on HIV prevention via secondary transmission. Nonetheless, it stands as telling testimony of the burden that must be borne by many for the inaction of a few. The ‘counterfactual’ (what would have happened had a different course of action been taken) is something for us all to consider, for South Africans, for us as committed individuals, and for us as a global health community challenged to facilitate worldwide the best way forward in responding to HIV.

That was HIV this week, signing off.

Gruskin S, Tarantola D. Universal Access to HIV prevention, treatment and care: assessing the inclusion of human rights in international and national strategic plans. AIDS. 2008 Aug;22 Suppl 2:S123-32.

Rhetorical acknowledgment of the value of human rights for the AIDS response continues, yet practical application of human rights principles to national efforts appears to be increasingly deficient. We assess the ways in which international and national strategic plans and other core documents take into account the commitments made by countries to uphold human rights in their efforts towards achieving Universal Access. Key documents from the Joint United Nations Programme on HIV and AIDS (UNAIDS), the World Health Organization (WHO), the World Bank, the Global Fund to Fight AIDS, TB and Malaria (GFATM) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) were reviewed along with 14 national HIV strategic plans chosen for their illustration of the diversity of HIV epidemic patterns, levels of income and geographical location. Whereas human rights concepts overwhelmingly appeared in both international and national strategic documents, their translation into actionable terms or monitoring frameworks was weak, unspecific or absent. Future work should analyse strategic plans, plans of operation, budgets and actual implementation so that full advantage can be taken, not only of the moral and legal value of human rights, but also their instrumental value for achieving Universal Access.

Editors’ note: This review is a mini-primer on human rights, presenting definitions of key human rights terms relevant to universal access, including ‘duty bearers’, rights holders’, and the 3AQ (availability, accessibility, acceptability and quality). It finds that in most countries assessed, universal access remains primarily equated with treatment, underscoring the need to emphasise prevention as the mainstay of universal access. As well, law reform, ensuring confidentiality protection, preventing violence against women, and other strategies beyond traditional health sector approaches essential to an effective response receive little attention. Important strides have been made in the recognition of marginalised communities but much more is needed to operationalise human rights in national HIV strategic plans.

Ojikutu B, Makadzange AT, Gaolathe T. Scaling Up ART Treatment Capacity: Lessons Learned from South Africa, Zimbabwe, and Botswana. Curr HIV/AIDS Rep. 2008;5(2):94-8.

Over the past 3 years, significant strides have been made in the effort to provide antiretroviral therapy to the millions of people worldwide who require treatment for HIV. In 2006, 1.3 million people had initiated antiretroviral therapy in sub-Saharan Africa, which is a 10-fold increase over the number who had access to treatment 3 years prior. Although this progress should be acknowledged, achieving universal access will require much more work. As countries initiate large-scale treatment programmes, many political, social, economic, and operational challenges have become evident. South Africa, Zimbabwe, and Botswana are three neighbouring countries engaged in antiretroviral therapy roll-out. This article describes the HIV epidemic in these three countries, details the most critical challenges inhibiting the progression of antiretroviral therapy roll-out, and highlights successes within each setting.

Editors’ note: This interesting comparative analysis of these three neighbours reveals that although political will and economic stability are predictors of success, weak health care infrastructure and lack of integration of HIV care with primary health care pose challenges to sustained antiretroviral treatment programmes.

Ojikutu B, Makadzange AT, Gaolathe T. Scaling Up ART Treatment Capacity: Lessons Learned from South Africa, Zimbabwe, and Botswana. Curr HIV/AIDS Rep. 2008;5(2):94-8.

Over the past 3 years, significant strides have been made in the effort to provide antiretroviral therapy to the millions of people worldwide who require treatment for HIV. In 2006, 1.3 million people had initiated antiretroviral therapy in sub-Saharan Africa, which is a 10-fold increase over the number who had access to treatment 3 years prior. Although this progress should be acknowledged, achieving universal access will require much more work. As countries initiate large-scale treatment programmes, many political, social, economic, and operational challenges have become evident. South Africa, Zimbabwe, and Botswana are three neighbouring countries engaged in antiretroviral therapy roll-out. This article describes the HIV epidemic in these three countries, details the most critical challenges inhibiting the progression of antiretroviral therapy roll-out, and highlights successes within each setting.

Editors’ note: This interesting comparative analysis of these three neighbours reveals that although political will and economic stability are predictors of success, weak health care infrastructure and lack of integration of HIV care with primary health care pose challenges to sustained antiretroviral treatment programmes.

Walensky RP, Wood R, Weinstein MC, Martinson NA, Losina E, Fofana MO, Goldie SJ, Divi N, Yazdanpanah Y, Wang B, Paltiel AD, Freedberg KA; CEPAC International Investigators. Scaling Up Antiretroviral Therapy in South Africa: The Impact of Speed on Survival. J Infect Dis. 2008 May 1;197(9):1324-1332.

Only 33% of eligible human immunodeficiency virus (HIV)-infected patients in South Africa receive antiretroviral therapy. Walensky and co-authors sought to estimate the impact of alternative antiretroviral therapy scale-up scenarios on patient outcomes from 2007-2012. Using a simulation model of HIV infection with South African data, they projected HIV-associated mortality with and without effective antiretroviral therapy for an adult cohort in need of therapy (2007) and for adults who became eligible for treatment (2008-2012). The authors compared 5 scale-up scenarios: (1) zero growth, with a total of 100,000 new treatment slots; (2) constant growth, with 600,000; (3) moderate growth, with 2.1 million; (4) rapid growth, with 2.4 million); and (5) full capacity, with 3.2 million. The projections showed that by 2011, the rapid growth scenario fully met the South African need for antiretroviral therapy; by 2012, the moderate scenario met 97% of the need, but the zero and constant growth scenarios met only 28% and 52% of the need, respectively. The latter scenarios resulted in 364,000 and 831,000 people alive and on antiretroviral therapy in 2012. From 2007 to 2012, cumulative deaths in South Africa ranged from 2.5 million under the zero growth scenario to 1.2 million under the rapid growth scenario. Alternative antiretroviral therapy scale-up scenarios in South Africa will lead to differences in the death rate that amount to more than 1.2 million deaths by 2012. More rapid scale-up remains critically important.

Editors’ note: Decision-makers can be influenced by modelling which demonstrates the differential impact of choosing various scale-up strategies for programmes. In this case, the speed of treatment scale-up has a large effect on the number of citizens alive in 2012. Although South Africa now has the highest number of people on antiretroviral treatment, two-thirds of eligible people are awaiting the expedient scale-up of services that will make a striking difference to their lives.

Keiser O, Orrell C, Egger M, Wood R, Brinkhof MW, Furrer H, van Cutsem G, Ledergerber B, Boulle A; for the Swiss HIV Cohort Study (SHCS) and the International Epidemiologic Databases to Evaluate AIDS in Southern Africa (IeDEA-SA). Public-Health and Individual Approaches to Antiretroviral Therapy: Township South Africa and Switzerland Compared. PLoS Med. 2008;5(7):e148.

The provision of highly active antiretroviral therapy in resource-limited settings follows a public health approach, which is characterised by a limited number of regimens and the standardisation of clinical and laboratory monitoring. In industrialized countries doctors prescribe from the full range of available antiretroviral drugs, supported by resistance testing and frequent laboratory monitoring. Keiser and colleagues compared virologic response, changes to first-line regimens, and mortality in HIV-infected patients starting highly active antiretroviral therapy in South Africa and Switzerland. The authors analysed data from the Swiss HIV Cohort Study and two highly active antiretroviral therapy programmes in townships of Cape Town, South Africa. They included treatment-naïve patients aged 16 y or older who had started treatment with at least three drugs since 2001, and excluded injecting drug users. Data from a total of 2,348 patients from South Africa and 1,016 patients from the Swiss HIV Cohort Study were analysed. Median baseline CD4(+) T cell counts were 80 cells/mul in South Africa and 204 cells/mul in Switzerland. In South Africa, patients started with one of four first-line regimens, which was subsequently changed in 514 patients (22%). In Switzerland, 36 first-line regimens were used initially, and these were changed in 539 patients (53%). In most patients HIV-1 RNA was suppressed to 500 copies/ml or less within one year: 96% (95% confidence interval [CI] 95%-97%) in South Africa and 96% (94%-97%) in Switzerland, and 26% (22%-29%) and 27% (24%-31%), respectively, developed viral rebound within two years. Mortality was higher in South Africa than in Switzerland during the first months of highly active antiretroviral therapy: adjusted hazard ratios were 5.90 (95% CI 1.81-19.2) during months 1-3 and 1.77 (0.90-3.50) during months 4-24. Compared to the highly individualised approach in Switzerland, programmatic highly active antiretroviral therapy in South Africa resulted in similar virologic outcomes, with relatively few changes to initial regimens. Further innovation and resources are required in South Africa to both achieve more timely access to highly active antiretroviral therapy and improve the prognosis of patients who start highly active antiretroviral therapy with advanced disease.

Editors´note: It is reassuring that the public health treatment approach in South Africa is as effective virologically as is the individualized approach of Switzerland: 96% of patients in both South Africa and Switzerland suppressed viral load to less than 500 copies/ml within a year. Although similar percentages developed viral rebound within two years, there were differences in mortality primarily due to the much lower CD4 count in South Africans (median 80) compared to Swiss (median of 204) at baseline. Know your status campaigns that provide social support for HIV testing and counselling would permit earlier initiation of treatment and reduce early mortality in South Africans on treatment. On the Swiss side, Switzerland could well consider simplifying its 36 first-line regimens.

Youngpairoj AS, Masciotra S, Garrido C, Zahonero N, de Mendoza C, García-Lerma JG. HIV-1 drug resistance genotyping from dried blood spots stored for 1 year at 4 degrees Celsius. J Antimicrob Chemother. 2008 Mar 15 [Epub ahead of print]

Dried blood spots are an attractive alternative to plasma for HIV-1 drug resistance testing in resource-limited settings. Youngpairoj and colleagues recently showed that HIV-1 can be efficiently genotyped from dried blood spots stored at -20 degrees C for prolonged periods (0.5-4 years). Here, the authors evaluated the efficiency of genotyping from dried blood spots stored at 4 degrees C for 1 year. A total of 40 dried blood spots were prepared from residual diagnostic specimens collected from HIV subtype B-infected persons and were stored with desiccant at 4 degrees C. Total nucleic acids were extracted after 1 year using a modification of the Nuclisens assay. Resistance testing was performed using the ViroSeq HIV-1 assay and an in-house nested Reverse Transciptase PCR method validated for HIV-1 subtype B that amplifies a smaller (1 kb) pol fragment. Using the ViroSeq assay, only 23 of the 40 (57.5%) dried blood spot specimens were successfully genotyped; 22 of these specimens had plasma viraemia >10 000 RNA copies/mL. When the specimens were tested using the in-house assay, 38 of the 40 dried blood spots (95%) were successfully genotyped. Overall, resistance genotypes generated from the dried blood spots and plasma were highly concordant. The authors show that drug resistance genotyping from dried blood spots stored at 4 degrees C with desiccant is highly efficient but requires the amplification of small pol fragments and the use of an in-house nested PCR protocol with quality-controlled reagents. These findings suggest that 4 degrees Celsius may represent a suitable temperature for long-term storage of dried blood spots.

Editors´note: Dried blood spots are easy to transport, can be stored for long periods, and can be used now for a variety of micro-level diagnostic tests. The HIV drug resistance genotyping test described here would require product development to move it from an “in-house” modified test to a standardized procedure that could be used in national resistance surveillance.