HIV This Week

Conflict-affected displaced persons need to benefit more from HIV and malaria national strategic plans and Global Fund grants.

Spiegel PB, Hering H, Paik E, Schilperoord M. Confl Health. 2010;4:2

Access to HIV and malaria control programmes for refugees and internally displaced persons is not only a human rights issue but a public health priority for affected populations and host populations. The primary source of funding for malaria and HIV programmes for many countries is the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). This article analyses the current HIV and malaria National Strategic Plans and Global Fund approved proposals from rounds 1-8 for countries in Africa hosting populations with refugees and/or internally displaced persons to document their inclusion. The review was limited to countries in Africa as they constitute the highest caseload of refugees and internally displaced persons affected by HIV and malaria. Only countries with a refugee and/or internally displaced persons population of >/= 10,000 persons were included. National Strategic Plans were retrieved from primary and secondary sources while approved Global Fund proposals were obtained from the organisation's website. Refugee figures were obtained from the United Nations High Commissioner for Refugees' database and internally displaced persons figures from the Internal Displacement Monitoring Centre. The inclusion of refugees and internally displaced persons was classified into three categories: 1) no reference; 2) referenced; and 3)   referenced with specific activities. A majority of countries did not mention internally displaced persons (57%) compared with 48% for refugees in their HIV National Strategic Plans. For malaria, refugees were not included in 47% of National Strategic Plans compared with 44% for internally displaced persons. A minority (21-29%) of HIV and malaria National Strategic Plans referenced and included activities for refugees and internally displaced persons. There were more approved Global Fund proposals for HIV than malaria for countries with both refugees and internally displaced persons, respectively. The majority of countries with >/=10,000 refugees and internally displaced persons did not include these groups in their approved   proposals (61%-83%) with malaria having a higher rate of exclusion than HIV. Countries that have signed the 1951 refugee convention have an obligation to care for refugees and this includes provision of health care. Internally displaced persons are citizens of their own country but like refugees may also not be a priority for Governments' National Strategic Plans and funding proposals. Besides legal obligations, Governments have a public health imperative to include these groups in National Strategic Plans and funding proposals. Governments may wish to add a component for refugees that is additional to the needs for their own citizens. The inclusion of forcibly displaced persons in funding proposals may have positive direct effects for host populations as international and United Nations agencies often have strong logistical capabilities that could benefit both populations. For National Strategic Plans, strong and concerted advocacy at global, regional and country levels needs to occur to   successfully ensure that affected populations are included in their plans. It is essential for their inclusion to occur if we are to reach the stated goal of universal access and the Millennium Development Goals.

For full text access click here:

Editor’s Note: Despite public commitments by 189 countries to incorporate refugees and internally displaced persons in national HIV strategies, only Egypt and Sierra Leone have included activities for refugees in both their HIV national strategic plans (NSP) and approved Global Fund proposals. Out of 33 African countries with more than 10,000 refugees, 6 countries included them in NSP and 8 in approved Global Fund proposals. Out of 22 countries with more than 10,000 internally displaced persons, 3 countries included them in NSP and 5 in approved Global Fund proposals. This is surprising because refugees and internally displaced persons are often located in isolated and inaccessible areas where government services for the local population are usually poor and where funding proposals for integrated services could have positive direct effects for host populations. Thus, in addition to human rights principles and a public health rationale, there is a straightforward pragmatic health services strengthening justification for addressing the needs of conflict-affected displaced persons.

The Likoma Network Study: Context, data collection, and initial results.

Helleringer S, Kohler HP, Chimbiri A, Chatonda P, Mkandawire J. Demogr Res. 2009;21:427-468

The extent and structure of sexual networks have important consequences for the spread of sexually transmitted diseases such as HIV. However, very few datasets currently exist that allow a detailed investigation of sexual networks in sub-Saharan African settings where HIV epidemics have become generalized. In this paper, the authors describe the context and methods of the Likoma Network Study, one of the few studies that have collected extensive information on sexual networks in sub-Saharan Africa. They start by reviewing theoretical arguments and empirical studies emphasizing the importance of network structures in the epidemiology of HIV and other sexually transmitted infections. The island setting of this study is described, and the authors argue that the choice of an island as a research site limited potential biases that may make the collection of sexual network data difficult. Helleringer and colleagues then document their empirical strategy for the collection of sexual network data and the subsequent identification of sexual network partners. A description of the protocol for the collection of biomarker data (HIV infection) is provided. Finally, they present initial results relating to the socioeconomic context of the island, the size and composition of sexual networks, the quality of the sexual network data, the determinants of successful contact tracing during the Likoma Network Study, and the prevalence of HIV in the study population.

For full text access click here: 

Editor’s note: Although Likoma Island in Lake Malawi is 18 square kilometres and has a population of only 7000 people living in a dozen villages, it has contributed substantially to our understanding of the role of sexual networks in generalized epidemics. Only 7 of 1235 households refused to be interviewed about socioeconomic information and in the seven villages chosen for the sexual network survey (representing 50.9% of 18-35 year olds on Likoma), the participation rate was 88%. Whereas Demographic and Heath Surveys are ‘egocentric’, meaning that they rely on self-reports that have to be taken at face value, the Likoma Study is ‘socio-centric’. It provides detailed data on the extent and structure of sexual networks and evaluates data quality by determining rates of inter-partner agreement about sexual relationships. Understanding patterns of connectivity and overlap between relationships informs modelling of the sexual spread of HIV and can assist in the design of context-appropriate HIV prevention programmes. A big challenge is to explain how individuals are part of sexual networks, even if they themselves have only one partner.

Public financing of health in developing countries: a cross-national systematic analysis.

Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. Lancet. 2010;375:1375-87

Government spending on health from domestic sources is an important indicator of a government's commitment to the health of its people, and is essential for the sustainability of health programmes. The study aimed to systematically analyse all data sources available for government spending on health in developing countries; describe trends in public financing of health; and test the extent to which they were related to changes in gross domestic product (GDP), government size, HIV prevalence, debt relief, and development assistance for health to governmental and non-governmental sectors. The authors did a systematic analysis of all data sources available for government expenditures on health as agent (GHE-A) in developing countries, including government reports and databases from WHO and the International Monetary Fund (IMF). GHE-A consists of domestically and externally financed public health expenditures. They assessed the quality of these sources and used multiple imputation to generate a complete sequence of GHE-A. With these data and those for development assistance for health to governments, the authors estimated government spending on health from domestic sources. They used panel-regression methods to estimate the association between government domestic spending on health and GDP, government size, HIV prevalence, debt relief, and development assistance for health disbursed to governmental and non-governmental sectors. The authors tested the robustness of our conclusions using various models and subsets of countries. In all developing countries, public financing of health in constant US$ from domestic sources increased by nearly 100% (IMF 120%; WHO 88%) from 1995 to 2006. Overall, this increase was the product of rising GDP, slight decreases in the share of GDP spent by government, and increases in the share of government spending on health. At the country level, while shares of government expenditures to health increased in many regions, they decreased in many sub-Saharan African countries. The statistical analysis showed that development assistance for health to government had a negative and significant effect on domestic government spending on health such that for every US$1 of development assistance for health to government, government health expenditures from domestic resources were reduced by $0.43 (p=0) to $1.14 (p=0). However, development assistance for health to the non-governmental sector had a positive and significant effect on domestic government health spending. Both results were robust to multiple specifications and subset analyses. Other factors, such as debt relief, had no detectable effect on domestic government health spending. To address the negative effect of development assistance for health on domestic government health spending, Lu and colleagues recommend strong standardised monitoring of government health expenditures and government spending in other health-related sectors; establishment of collaborative targets to maintain or increase the share of government expenditures going to health; investment in the capacity of developing countries to effectively receive and use development assistance for health; careful assessment of the risks and benefits of expanded development assistance for health to non-governmental sectors; and investigation of the use of global price subsidies  or product transfers as mechanisms for development assistance for health.

For full text access click here:

Editor’s note: ‘Fungibility’ of foreign aid occurs when aid substitutes for government spending, resulting in ‘sub-additionality’ rather ‘additionality’, the goal of most development assistance. Among the factors that are complicating discussions of its extent, and what to do about it, are incomplete estimates of development assistance for health (DAH) in the first place (‘untraceable DAH’), variations in accounting practices at country level for total health expenditures, and lack of information about what the resources taken from ministries of health actually are spent on. Although African leaders pledged in 2001 in Abuja to devote 15% or more of their yearly budgets to the health sector and absolute amounts of domestic funding being spent on health have increased 132-242% between 1995 and 2006 in low-income countries in sub-Saharan Africa, the largest reductions in the proportion that domestic funding contributes to health spending occurred in countries with the largest HIV epidemics and the largest DAH contributions. It is not surprising that increasing domestic contributions are overshadowed by external support as countries try to turn around HIV epidemics that are sapping development. Although investment in effective public expenditure management systems is clearly needed to improve accountability from the global level right through to local level, it is important to remember that country ownership starts with nationally set priorities and reallocation of funding to match these.

Mosaic vaccines elicit CD8(+) T lymphocyte responses that confer enhanced immune coverage of diverse HIV strains in monkeys.

Santra S, Liao HX, Zhang R, Muldoon M, Watson S, Fischer W, Theiler J, Szinger J, Balachandran H, Buzby A, Quinn D, Parks RJ, Tsao CY, Carville A, Mansfield KG,Pavlakis GN, Felber BK, Haynes BF, Korber BT, Letvin NL. Nat Med. 2010;16:324-8

An effective HIV vaccine must elicit immune responses that recognize genetically diverse viruses. It must generate CD8(+) T lymphocytes that control HIV replication and CD4(+) T lymphocytes that provide help for the generation and maintenance of both cellular and humoral immune responses against the virus. Creating immunogens that can elicit cellular immune responses against the genetically varied circulating isolates of HIV presents a key challenge for creating an HIV vaccine. Polyvalent mosaic immunogens derived by in silico recombination of natural strains of HIV are designed to induce cellular immune responses that recognize genetically diverse circulating virus isolates. Here Santra and colleagues immunized rhesus monkeys by plasmid DNA prime and recombinant vaccinia virus boost with vaccine constructs expressing either consensus or polyvalent mosaic proteins. As compared to consensus immunogens, the mosaic immunogens elicited CD8(+) T lymphocyte responses to more epitopes of each viral protein than did the consensus immunogens and to more variant sequences of CD8(+) T lymphocyte epitopes. This increased breadth and depth of epitope recognition may contribute both to protection against infection by genetically diverse viruses and to the control of variant viruses that emerge as they mutate away from recognition by cytotoxic T lymphocytes.

For abstract access click here: 

Editor’s note: In this macaque study, a mosaic immunogen was created by combining the gag and nef genes from geographically and sub-type diverse natural strains of HIV. A much broader immune response was elicited in macaques with this recombinant mix than with a consensus protein. Cellular immune responses to mosaic immunogens recognized a greater diversity of viral epitope variants, with CD+8 T lymphocytes showing significantly greater cross-reactivity, not only to more epitopes but also to more variant sequences of specific epitopes. Keeping up with viral evolution means expanding the breadth and depth of our CD8+ cytotoxic T lymphocyte responses – it looks like mosaic vaccines may be able to give us the leg up that we will need.