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Achieving UNAIDS 90-90-90: More haste less speed?

31 Aug, 17 | by Leslie Goode, Blogmaster

UNAIDS (2014) has set targets for HIV management that seem ambitious, if not unrealistically so  (UNAIDS: 90-90-90): 90% of those living with HIV to know their status; 90% of known HIV+ individuals to undergo ART initiation; 90% of ART+ initiated to achieve viral suppression. A one-year-in report from a large cluster-randomized study of home-based testing and treatment in four Zambian communities, HPTN-071 (Hayes & Fidler (H&F)), recently discussed in this blog (Mountainous challenge of 90-90-90/STI/blogs), suggests that engagement with care may constitute a significant challenge. It gives rates of engagement after six months and one year of care of 42% and 53% respectively. It also confirms what earlier studies (Schwartz & Baral/STIs)  ( say about the difficulty of attaining this second target. Estimates as of 2015 for engagement with care in southern and eastern Africa range from 17% to 78% (Wringe & Skovdal/STIs).

Against this somewhat gloomy backdrop, the 2016-17 results from the Swaziland HIV Incidence Measurement Survey (SHIMS2)( from a house-hold based national survey strike a surprisingly hopeful note. 84% of people living with HIV (PLHIV) aged 15 or over report knowing their HIV status; 87.4% of PLHIV knowing their status self-report current use of ART; 91.9% of PLHIV on ART are virally suppressed. Furthermore, rates of response to the survey, at 84.5% (=6,417 eligible households) are impressive. However, PLHIV who are diagnosed but not engaged in care and PLHIV who have become disengaged from care are notoriously difficult to reach (Wringe & Skovdal (STIs)), and likely to be among the non-respondents.

So maybe there is some hope that the UNAIDS targets can be realized by the deadline of 2020 …..

Yet amidst all the anxiety to achieve these targets, a series of qualitative studies reported in the recent supplementary issue of STIs sound a note of caution (STIs: July 2017: 93-3: Understanding the Bottlenecks). This work emphasizes the importance of clients’ personal experiences of health care as a factor in determining likely success in terms of retention in care over time. Among factors likely to have an impact are the painful or disagreeable side-effects from treatment (Renju & Wringe (STIs), or the coercive nature of testing itself (Wringe & Renju (STIs). They also include the attitudes of health-care workers, who are often ‘expert patients’, as well as inappropriate or pressurizing assumptions that test social and moral expectations regarding women’s relationship with men and invoke their moral duty as mothers (Kielmann & Cataldo (STIs). In short, achievement of the benefits of viral suppression requires cooperation of individuals over the longer-term. This in turn depends on trust and good will that are easily forfeited where the pressure to achieve quick results leads health systems to overlook the dimension of personal experience.

Health interventions can change systemic and cultural determinants of STI/HIV transmission

30 Mar, 17 | by Leslie Goode, Blogmaster

The causal pathway linking intimate partner violence (IPV) and health may be two-way.  We are used to thinking of IPV as a determinant of STI; but sexual health also has an impact on IPV.  This, at any rate, is the conclusion of a recently issued working-paper from the US National Bureau of Economic Research uniting a highly interdisciplinary team of researchers from a range of US universities and medical institutions.  The researchers seek to demonstrate that health is kind of human capital, and that a technological advance in medicine can affect ‘some of the most frustratingly persistent social problems’.  This finding will be particularly interesting to readers of this journal.  Health, in the context of this study, happens to be sexual health, and the technological advance is the introduction of HAART in 1996.

Papageorge & Pollack (P&P) base their work on data from the Women’s Intra-Agency HIV Study (WIHS), and compare a cohort of HIV+ women who were, in 1996, just beginning to experience immune system deterioration, with two control cohorts, using a ‘difference in difference’ approach.  One control consisted in HIV+ women not experiencing such effects, another in HIV- women included in the same WIHS data.  Much of the researchers’ task consists in establishing the relative dependence/independence of causal pathways linking IPV with drug use, perceived mental and physical health, and employment.  Their headline finding is a c.10% reduction in IPV a c.15% reduction in IDU attributable to HAART introduction.

The idea that the causative link could flow from STIs to IPV, as well as from IPV to STIs, may not be new to our readers.  Indeed, an ongoing concern for sexual health interventions has been that STI/HIV disclosure (a potentially important element of risk reduction) could result in domestic violence (Partner delivered STI self-testing (STI/blogs)).  This has not prevented other studies from pointing to a potentially positive role for sexual health clinics in relation to IPV (Lockart & McNulty (STIs); Decker and Silverman I (STIs); Decker & Silverman II (STIs)).  The nature of IPV itself is not always well understood, and probably varies with social and cultural context.  For example, it is not restricted to short-term or casual relationships (Silverman & Raj (STIs)), and may be reciprocal (Norris & Hindin (STIs)) as well as man-on-woman.  The nature of the causal link with HIV/STI might be expected to vary with the nature of the IPV itself.

So there is nothing new about the idea that a change in respect to sexual health could influence IPV.  What P&P contribute to the debate is genuinely encouraging, for all that.  Recent characterizations of the global efforts to curb the HIV epidemic (e.g. UNAIDS: On the Fast Track) make a two-fold classification of interventions into, on the one hand, biomedical interventions such as PrEP or cART, and, on the other, vaguer, and longer-term non-biomedical interventions such as legislative or attitudinal change.  The latter correspond to systemic or cultural determinants of sexual health that can seem to mark the ultimate limits on sexual health interventions rather than realistic targets for those interventions.  However, P&P point in this report to the case of a biomedical intervention that would, for once, seem to have achieved something more than an immediate biomedical impact.  HAART introduction, on P&P’s interpretation, effectively provided an additional ‘source of human value’ – an enhancement of women’s social ‘capital’.  Thereby, it would seem to have impacted the fundamental social and cultural determinants of sexual health – those ‘frustratingly persistent social problems’ that constitute the constraints within which sexual health is normally compelled to operate.

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