Archived, online coverage of the XVII International AIDS Conference (AIDS 2008) is now available from kaisernetwork.org, the official webcaster of AIDS 2008.
In partnership with the International AIDS Society, kaisernetwork.org has prepared the following online coverage:
- Webcasts, transcripts and slide presentations of the opening and closing sessions, all plenary sessions, and over 75 other sessions and press conferences;
- English- and Spanish-language audio podcasts of more than 80 sessions;
- Narrated video highlights of conference developments;
- News summaries of conference developments and newly-released studies in the Kaiser Daily HIV/AIDS Report; and
- Interviews with newsmakers and journalists summarizing conference developments.
- Some Good News from Zimbabwe!
4 August 2008
Today at the IAC08 researchers from the Imperial College London and Harvard University confirmed the recently documented decline of HIV Prevalence in Zimbabwe.Using robust epidemiology data it was shown that HIV Prevalence in adults aged 15- 49 peaked around 1997/8 at 29.3% then levelled off and declined most significantly in the period 2001 to a current level of 15.6%. This represents a 50% reduction in 6 years and the aversion of an estimated 660,000 new infections.
Zimbabwe is the first country in the region to experience such a significant decline. Not only is this good news for Zimbabwe but also significant for the surrounding countries in the region that are experiencing similar generalised epidemics but as yet have not experienced such trends.
The question is how has this been achieved in Zimbabwe? Is it a demonstration of the natural course of the disease or as a result of major prevention successes in behaviour change in the country?
The mathematical modelling does indeed suggest that this trend of sharp incline, plateau and decline is thought to be the expected norm for the course of the disease and goes some way to explaining the decline; but cannot explain the extent of the decline and therefore must also look to possible behaviour change to explain further the trends.
With use of population based and cohort studies this was the question understudy. Key findings show that whilst mortality certainly has contributed to some decline, migration even in the levels recently seen in Zimbabwe has not significantly contributed.
What is more important is to consider which factors have contributed to a decline in HIV incidence. The studies clearly show that whilst condom use is relevantly high this has remained relatively consistent over the time period 1999-2005 and would have little impact on the decline. Significantly however, is the reported decline in the number of sexual partners of men in this period of 6 years, which also seems to mirror the maturation of the disease when high levels of mortality are experienced in the communities and families. As people see the reality of the disease this appears to impact their behaviour.
This of course can only result in change of behaviour such as reduced number of sexual patterns if there is understanding of HIV transmission routes, which suggests that the general HIV and Aids information available in Zimbabwe has been to some level been understood and used. This was mapped against the National HIV prevention programme interventions in Zimbabwe, which in fact show to be the general HIV response approach seen across the region.
Of course the special context of Zimbabwe in the last decade has been the rapid economic decline and the affect on both rural and urban communities. Certainly this has seemed to play some part in the reduction of sexual partners simply as men report they are unable to afford to socialise as they did, take additional girlfriends or pay for sex. Ironically of course in times of hardship more women are turning to transactional sex for source of additional incomes, but report that ‘business is slow’. HIV is of course a dynamic disease and some men reported certainly they would have more ‘girlfriends’ again once they have overcome the current economic problems!
The clear conclusion of the research suggests the decline can be attributed to a combination of factors; - certainly a reflection of the natural course of the disease plus some change in sexual norms including significant reduction of sexual partners, and additionally influenced by the economic downturn and possibly significantly influenced by the community response as the disease reaches a critical point in the community.
But why Zimbabwe and not the surrounding neighbouring Southern African countries? Is it good news for the region? Well possibly - it is possible that Zimbabwe is simply the earliest in the epidemic and that other countries may follow similar decline in years to come. The research is not there to make these country comparisons as yet. (No examination made of any studies made of the effect of role out of ARV on the prevalence decline).
- HIV, Nutrition, Food Security and Livelihoods (including microfinance)
8 August 2008
1) Supporting quality and delivery of integrated home based care
A satellite session held on HIV food security and livelihoods presented by RENEWAL/FAO/WFP discussed what progress has been made in furthering our understanding on the interactions between HIV, food security and livelihoods and how to respond to this at scale.
The session highlighted how we may be underestimating the impact of the increase in food prices on people’s behaviour and on nutrition and the need to respond to the 3 concurrent epidemics:
· HIV
· TB
· Malnutrition
Studies from Swaziland and Malawi July 2008 demonstrated an increase in risky sexual behaviour as food prices increase.
Also transport costs to collect vital antiretroviral treatment (ART) were placing greater demands on families who at times had to choose between continuing their ART and buying food.
Labour challenges in food security and livelihoods programmes were discussed and the need to ensure more collective actions at community level.
Nutrition counselling within care and support programmes for people living with HIV was highlighted as an area that requires further implementation.
In a further session on the HIV, Nutrition and Food Security, researchers of the University of KZN , AMPATH/USAID , and UNAIDS re-emphasised the importance of nutrition as part of management of HIV. Outlined the increased nutritional requirements of the PLWHIV; and understanding of HIV in weakening household food security.
Conclusions were reached that there is a need for balance of nutrition interventions as therapeutic care for PLWHIV with a strategy for maintaining long term food security of household in long term HIV programming as part of care and support package which is relevant and responsive to PLWHIV, households and communities; and which also contributes to psychosocial well-being as well as nutrition needs. There is Need to develop further partnerships of FS in public health and HIV response with a balance of interventions including micro finance, cash transfers, skills building, community projects leading to increase in income/savings or access to loans and strengthened FS.
If we grasp the issue FS can be part of the combination prevention strategy in increasing access to food, income, health services, treatment, care and well being; and reduce vulnerability that may contribution to increase risk behaviours (such as transactional sex) or weakened immunity.
Responses should be therefore:
· Target those who are food insecure and those nutritionally at risk, which includes people living with HIV
· Integrated to include care and support, water and sanitation, livelihoods
· Gender sensitive- evidence from Ethiopia food for work programmes highlights significant increase in school enrolment for boys but not girls – need to consider in design of programmes
· Long term and built on community response
· Include range of activities including access to nutritional food, nutritional knowledge, agricultural and livelihood skills
Challenges may be:
· Including appropriate exit strategies
· Cash transfers appropriate in stable economies
2) Micro-finance
Presentations at a Poster Session discussed that a large body of research, experience and understanding of micro-finance exits in the development field and in most countries. It is generally accepted that micro-finance programmes can mitigate against the affects of destitution though it is less evident that micro-finance schemes can mitigate GBV or have preventive effects against HIV.
Important not to expect too much – micro credit is about credit!
Key points are:
§ General accept that Microfinance can uplift households and reduce financial pressure. May be particular important to PLWH households to support increase access to services
§ Microfinance not necessarily prove to reduce transmission of HIV but contribute to welfare of households and individuals well being and health, and links to community gains and involvement
§ Work in partnership with those that know Microfinance – knoweldge and experience exits in almost all countries.
§ Consider involvement of volunteers and community based health workers in the microfinance scheme as part of community engagement and also their well being and support.
- Comprehensive Combinations: Key findings from the Mexico IAC 2008
4 August 2008
To more effectively prevent and respond to HIV “Combination HIV prevention at scale with combination care, support and treatment for life within universal primary health care, education and support for all is the minimal action required”.
Currently each year an estimated 1 million people are started on antiretroviral treatment (ART) but 2.7 million people are newly infected, we are not keeping pace with the HIV pandemic.
There is a window of opportunity and vulnerability to HIV – increasing evidence highlights need for rapid point of care, diagnosis and treatment of HIV and Tuberculosis, (TB) including multiple drug resistance (MDR) TB, plus ongoing care and support.
ART has been a major success but only as a disease suppressant- like insulin for diabetes and anti inflammatory for rheumatoid arthritis- a cure still required.
Further details below highlight what combination HIV prevention and care, support and treatment include such as prevention of mother to child transmission (PMTCT), male circumcision, palliative care, care for OVC, TB, HIV in emergencies and in conflict and post conflict, responding to HIV and violence and service delivery. These are all areas for BRC to further consider in future support to HIV programming, which require discussion and action. Immediate points to follow are included within.
Further details are provided on separate papers on HIV and food security and livelihoods, male circumcision and the success of the HIV response in Zimbabwe.
Combination HIV prevention improves life
Proven prevention methods which need to be used include primary prevention through behaviour change communication, life skills linked to education and support, positive prevention, prevention of mother to child transmission (PMTCT), male circumcision, condom use, harm reduction. Not ABC approach !
· Need a combination of biomedical, behavioural and structural interventions using non-judgemental harm reduction approaches
· Countries need to develop evidence driven context-specific national HIV prevention strategies which are better coordinated
· Need to embrace the political, economic and social determinants of risk and not focus on individual behaviours
· Need further research on effectiveness of antiretroviral therapy (ART) in prevention- pre exposure prophylaxis (PreExpP), microbicides, treatment of common infections and vaccines (Ref SCIENCE 28.07.08)
· Need to know where infections will happen
· Need to diversify HIV testing approaches- include opt out, remove barriers, stigma and increase access across communities
· Need to become more effective against stigma as stigma and discrimination increase risky behaviour, decreases uptake of HIV testing and willingness to disclose.
(For further info see special issue www.thelancet.com HIV prevention August 2008)
Prevention of mother to child transmission (PMTCT)
· Some increase in prevention of mother to child transmission to 23 % globally (only 1:10 infants receiving ART within PMTCT) and access to ART for children but coverage and quality remains unacceptably low – Nigeria and Ethiopia below 10% (UNAIDS 2007).
· In 2007 estimated 2.1 million children younger than 15 years were living with HIV. More than 90% of these children had been infected through mother to child transmission.
· Although an increasing number of countries have PMTCT programmes only 18% of pregnant women in low and middle income countries received a HIV test in 2007 and coverage remains low, 11% in West and Central Africa and inadequate in many countries with only 33% of women accessing the most effective regimen of a combination of two or three antiretroviral drugs.
· Globally 80% women have at least 1 antenatal contact but only 50% have skilled care at delivery – need to offer support for PMTCT at first contact and during delivery at minimum.
· Barriers to uptake include negative attitudes from HCWs, poor access to services and poor services, stigma and discrimination and fear of HIV testing and disclosure. Limited male involvement – study S Mamman Uni KZN, SA.
Care, treatment and support
· ART - Challenges to retention 1 in 3 people who start ART are not in care – receiving ART – after 3 years – Nathan Ford MSF SA advised only 60% of clients are continuing to be part of ART programme after 24 months. Reasons include client’s fear of disclosure, costs, negative attitudes by care provider and access to programme – need to consider model of delivery of programme and support such as RCRC community based volunteers.
· Still reaching only 30 % of those in need of treatment – Q do we have the capacity to reach and treat for life everyone who requires ART
· Management of ART related side effects is part of the model of comprehensive care
· According to WHO research gaps March 2008 decision when to start ART still based on personal opinion, general view from conference need improved diagnostic facilities and treatment for HIV globally, start treatment earlier with improved treatment regimes for most people in developing countries.
· What is the optimal non ART care and support package and need for guidelines regarding this (i.e. CHBC minimum standards).
· Palliative care regarded as a key component of care – discussed principles and relevance of palliative care in HIV response. Clear pain and symptoms experienced by people living with HIV and also suffering from TB and other related conditions. Palliative care includes supporting adherence to treatment and also psycho social and spiritual support- improves overall patient care
· Task shifting – resource poor countries don’t or will not simply have the human resources of healthcare workers to implementation to scale. Need to consider alternative health systems management
· More than 50 countries in the world still do not have access to opioids.
· Opioids are not available in rural areas and in home care in most countries.
· Support for palliative care should be in national health plans- guidelines for CHWs available (includes RCRC module).
· Recommended adapting WHO definition to define palliative care services nationally
· Joint declaration and statement of commitment on palliative care and pain treatment in human rights- see www.hospicecare.com/resources/pain_pallcare_hr/
· Also further info from pain and policy studies group Uni Wisconsin in USA
Orphans and vulnerable children (OVC)
· SAfAIDS has produced children’s ART and TB treatment literacy pack targeted at 6-12 years olds in recognition that children are being marginalised from their own treatment literacy. The pack includes booklets for children and activities plus manual for carers and parents/ caregivers- AL requested pack suggested adaptation and use within support groups for OVC
· CRS produced paediatric counselling course –AL follow up
· Recommended policies programmes and funding must be redirected to provide support for children to and though their families. IN generalise epidemics HIV clusters in families, strengthening the capacity of families through systematic public sector initiatives has been identified globally as one of the most important strategies of building an effective response for preventing and mitigating the impact of the epidemic on children.
· Need to reconsider policies to develop comprehensive and integrated family-centred services. Need to address not just children but also family’s health basic material needs, psychosocial support and development.
· More attention is required for social protection for poor families, Households afforested by HIV and AIDS experience a worsening of their socio economic status, suggested loss of at least 25% average household income.
· Critical additional resources including income transfers should go direct to those most affected by HIV and AIDS- includes advocacy and support for universal social security support grants plus programmatic interventions targeted to vulnerable households. The interventions should be regarded as an entry point to large scale integrated national responses characterised by access to essential services, such as health and education, social welfare an social justice, enabled by basic income security.
Tuberculosis TB
· 2 million cases of TB have been missed due to the missed opportunity to offer testing to people who undertake HIV testing
· The number of TB cases has tripled in the high HIV prevalence countries in the last two decades
· TB is the leading cause of death among people living with HIV in Africa and a major cause of death elsewhere.
· WHO recommendation - the three I’s for TB/HIV –Isoniazid preventive therapy, intensified case finding for TB and infection control must be urgently implemented to reduce the burden of TB among people living with HIV.
Caring for Carers
· Highlighted globally we are not caring for health care workers, who are not accessing HIV and TB testing and diagnosis
· Health care workers (and RCRC volunteers) involved in care should know the symptoms of TB and be given counselling and health screening annually for TB and HIV. All should be encouraged to know their status.
HIV in conflict and post conflict
· Research paper UNHCR March 2007 highlighted concerns regarding protection and increasing HIV among internally displaced persons (IDPs) in DRC with particular risks to women. Access to HIV prevention services including behaviour change communication, information education and communication, condoms and HIV testing were limited resulting in low levels of knowledge and high risk behaviours. Recommendations from the study included:
o Supporting community based structures and gender sensitive approach
o Prevention activities should address points above
o Increased support to improve basic health facilities and services, including HIV testing and support
o Implementation of the IASC guidelines
· Kenya – following the civil conflict a study undertaken from Jan – June 2008 found 7.500% increase in sexual violence in Nairobi. Highlighted need for increased support and counselling in gender based violence, rape, trauma and HIV. Lessons from the conflict highlighted need for HIV emergency preparedness plan to be developed by all stakeholders and include people living with HIV and community organisations, consider community support and ongoing access to essential antiretroviral treatment.
HIV violence and women
· WHO multi country study 2005 domestic violence and women’s health- Ethiopia 16% of young women forced to have first sex/60% women interviewed suffering from intimate partner violence
· IMAGE – CBO supporting microfinance for women – recently invited to SA regional HIV meeting SARAWO/Sister ACT and Girl Child network Zimbabwe all promoted as effective supporting organisations in this area.
· Although limited biological evidence re violence and HIV Charlotte Watts – LSHTM - study microfinance and women in SA found in SA women with violent partners 50% more likely to have HIV and UNAIDS in Tanzania x 10 more likely
Harm reduction
· Despite UNGASS recommendation in 2005 for access to prevention to include harm reduction programmes only 78 countries known to have programmes.
· Continued moral and religious beliefs negating services offered and increasing stigma and discrimination
HIV and criminalisation
o Recent Acts in Sierra Leone and Zimbabwe increase risks to women living with HIV. Similar laws are being passed in other African countries – handout available.
Service delivery
· Need for improved leadership and management
· Serious implementation bottlenecks – even if we had effective vaccines and microbicides how would we be able to deliver?
Countries and even districts are working in isolation – unable to effectively respond through this “ cottage industry” approach.
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