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International report

UNAIDS 2016 Report: How a ‘life-cycle’ approach can help the world ‘get on the fast track’ to HIV prevention

7 Dec, 16 | by Leslie Goode, Blogmaster

‘Get on the Fast Track: a Life-cycle Approach to HIV’ is the latest UNAIDS report, following on from the UN Assembly’s 2016 declaration of commitment to ‘Fast Track’ goals for ending the HIV/AIDS epidemic. The major theme of the ‘life-cycle’ appears to owe much to the findings of the South African CAPRISA study – above all, the idea of a transmission cycle between younger (25 year-old) women and older (>25 year-old) men.  Broadly, phylogenetic analysis reveals that the prevailing pattern of transmission is as follows.  Younger women appear to get infected through casual relationships with considerably older men, who have, in turn, been infected by their longer-term partners; in time, the younger women grow up and form longer-term relationships – and the cycle is repeated.  The former group – younger (≤25 year-old) women – appear to be more vulnerable to infection than men of the equivalent age due to complex social factors, and have recently seen only c. 6% declines in annual incidence; older (>25 year-old) men have incidence rates that have remained obstinately high despite all recent efforts to reduce them.  These are best explained by poor rates of testing, integration into treatment, and viral suppression making them a potential risk to non-HIV-infected partners.

Diagnosing a problem is one thing; framing the solution quite another.  In case of the younger women, the dominant factors appear to be structural and societal – e.g. gender inequalities.  These are difficult to address without major social and political change.  The authors suggest a number of prevention tools, including sexual education in schools, the introduction of pre-exposure prophylaxis (PrEP), and social transfers.  However, recent trials of PrEP in sub-Saharan Africa do not bode well for this intervention (STI/blogs/’Failed PrEP trial’; STI/blogs/‘Another failed PrEP trial’); while the evidence for the effectiveness of sexuality education and ‘social transfers’ is far from conclusive (School-based Sexuality Programmes/STI/blogs; STI/Galarraga & Sosa-Rubi; STI/Minnis & Padian; STI/Khan & Khan).  However, in the case of the other group – i.e. older men – the obstacles to HIV prevention (poor rates of testing and viral suppression) may be less intractable, and the report proposes a number of very practical measures that could help, including: distribution of self-test kits through female partners attending ante-natal clinics (STI/blogs/’Partner-delivered STI testing’); simplifying ART regimens so individuals have to take just one tablet a day; shifting from CD4 count testing to viral load testing.

The report also has much to say about other phases of the life-cycle, as well as about ‘key populations’ (estimated 45% of new infections).  Regarding the latter, the authors report the stability, or even rise, in new infections amongst sex-workers, drug-users and MSM. They emphasize the negative impact of criminalization of key populations and same-sex relations (73 countries) (see STI/blog/’HIV criminalization’/; STI/blog/’Health workers violate human rights’), the very low levels of domestic funding (on average, only 12% of total spending on MSM prevention), and the relatively young age of many in the ‘key populations’.  The authors recommend ‘comprehensive’ programmes for these populations incorporating access to a range of health care programmes, such as the Red Umbrella programme for sex workers in South African, and the ‘Targeted Strategy Plan’ for the transgender population in Lima, Peru.


Why Tanzania seems unlikely to meet UNAIDS targets for HIV/AIDS prevention.

12 Jun, 15 | by Leslie Goode, Blogmaster

The UNAIDS 90-90-90 Target has set the goal that, by 2020, 90% of the HIV infected should know their status, 90% of those diagnosed should be in treatment, and 90% of those in treatment should achieve viral suppression.  The  UNAIDS GAP Report (2014) presses the need for countries to achieve a major redeployment of effort and resources towards tackling HIV among at-risk populations with a view to achieving that target (UNAIDS (STI/blog)).

Redeployment, a report by Congressional staff delegates on a visit to Tanzania hosted by the Infectious Diseases Society of America’s (IDSA) Global Education and Research Foundation gives a detailed account of the practical problems facing the attempt to make such ambitions a reality on the ground – even where UNAIDS recommendations are embedded in official government planning policy.  Evidence from visits of the staff delegates to Dar-es-Salaam, Zanzibar and Mbeya in the rural highlands is illustrated with well-chosen photographs.   These problems fall into three general categories.

First, there is a human resource problem.  At present, there is a 65% vacancy rate for health-care positions in the public sector.  According to the government figures, health workforce capacities have steadily declined from 67,000 in 1994/5 to 54,245 in 2002 to 48,000 in 2015.  The PEPFAR (President’s Emergency Plan For AIDS Relief) operational plan attributes this in some measure to gaps in Tanzania’s education capacities with large classes and poorly trained teachers, leading to pupils leaving school without adequate study, problem solving and analytic skills.

As regards redeployment of these limited resources in line with UNAIDS recommendations, this is hindered by the fact that at risk groups may be criminalized (e.g. drug-users, sex workers, MSM) and are certainly stigmatized.  Much of the outreach to them is through civil society organizations.  While the government has policies to support and defend their efforts, there is little in the way of financial investment.  Civil society organizations are hampered by the largely voluntary nature of their workforce, and the absence of adequate data concerning the size and whereabouts of at-risk populations (though it is estimated that between 2010 and 2015 the number of IDU rose from 25,000 to 50,000).  The prison population seems to be altogether inaccessible.

Thirdly, HIV transmitted to children born to infected mothers is often ignored, and the number of adolescents dying of AIDS has risen by a third since 2005.  This is partly because stigma surrounding a disease associated with IDUs, sex-workers MSM prevents parents from seeking diagnoses for their children.  The situation is not helped be the frequently poor state of record-keeping with no digitalization and folders “jammed into, stacked on top of, and spilling out of record cabinets”.

Though no doubt inadequate, data on “at risk” populations is not altogether absent.  Studies published in STI journal relevant to populations in specific places visited by delegates include an evaluation of surveys of MSM in Zanzibar, Haji & Kibona (STIs), and a discussion of the socio-demographic context of the epidemic in Mbeya, Riedner & Groskurth (STIs), focussing on female bar-workers.  As a poor but high-mobility rural population, Mbeya appears to share some socio-demographic characteristics with Mzanza province in the NW (bordering Lake Victoria) which has figured in a number of studies at the beginning of the last decade.  A number of these focus on barmaids as a particularly high-risk population (Hoffmann & Hoelscher(STIs); Boerma & Mwaluko (STIs); Bloom & Boerma (STIs)).


Indiana State ban on Needle Share programmes faces challenge of an IDU-fuelled HIV spike

20 Apr, 15 | by Leslie Goode, Blogmaster

In 2011 18.5% of HIV infections in the US were attributable to intravenous drug-use (IDU) – a significant proportion (Lansky & Wejnert (STIs)).  The issue of IDU fuelled HIV transmission has been brought forcibly to the attention of Americans in the last few weeks by the recent HIV outbreak in Scott County, Indiana, US.  This local epidemic appears to have been the result of the recreational use of the opiate, Opala. The number of infections has continued to rise, reaching a new peak of 130 this last week (Indystar/needle exchange; npr/Indiana’s HIV spike).

The effectiveness of public health interventions amongst IDU, including needle exchange programmes is well-established. Recent studies in Russia and East-European contexts (Vagaitseva & Demyanenko (STIs); Boci & Bani (STIs)), where IDU accounts for greatest proportion of infections,  have also come to very positive conclusions about their cost-effectiveness (Demyanenko & Vagaitseva (STIs).  They have also considered ways of improving uptake among drug-users (Boci & Hallkaj (STIs).  Sadly, in 23 states of the US – as in Russia and some East-European countries – traditional legal restrictions on needle exchange programmes remain in force (LawAtlas/US).  Indiana just happens to be one of these US states.  Its governor, who has had to authorize a short-term moratorium on the legal restriction of needle exchange in response to the outbreak, just happens to be Mike Pence, a republican who is known for his especially hawkish views on social issues (see “US Republicans prepared to put the poor at risk” (STI/blogs)) and favours continuation of the ban.

Needless to say, an order authorizing the temporary suspension of the restrictions on needle exchange was issued last month.  A needle-exchange programme has distributed 5,300 clean needles to drug-users since 8th April when it began its activities.

Unfortunately, however, the temporary suspension is due to expire on 25th April.  It also applies only to Scott County. Health experts are pushing legislators to allow needle exchange in neighbouring counties of Indiana, where high levels of HCV indicate a high risk of similar outbreaks.  On Monday, a joint Senate and House Legislative Committee will consider a measure, authored by Ed Clere, a representative from a neighbouring county, to authorize local public health and law enforcement authorities to work together to start their own need exchange programmes. But Governor Pence has threatened to veto the measure.  He declines to explain his position in public, but is said by Senate President, David Long, to believe that needle exchange programmes lead to greater drug use (News & Tribune/Indiana’s needle exchange bill).

Shared needles for Viagra injection fuel STIs among the Korean elderly

1 May, 14 | by Leslie Goode, Blogmaster

UK BBC radio’s 4’s Korean correspondent, Lucy Williamson refers in last Tuesday’s Crossing Continents to a category of STI transmission through IVDU, which is unlikely to be familiar to our readers.  A recent article in the Korea Times  gives further details.  The individuals at risk are the 16% of South Korean seniors (65+) in Seoul who pay for sex (Korea Herald).  The means of transmission are the syringes used by elderly prostitutes carrying on trade in soft drinks (Korean-style Bacchus) to inject their elderly patients with Viagra, and then “recycled” – according to the interview, “ten or twenty times, or until the needle breaks”.  No surprise, levels of STIs among these elderly partners were found by a recent survey to be as high as 40%.

The proportion of seniors in Seoul who pay for sex (16%) (half of these five times over the last two years) seems high. The percentage of individuals who use sex workers varies enormously between countries, as does the age profile of the typical user (Prostitution: the Johns Chart).  By comparison, rates of use in the US and a number of European countries stand at around 20%, in Spain and Italy nearer 40%, though the typical user is likely to be in his 30s or 40s – not his 60s and 70s.  (For the situation in the UK, see STIs/Ward & Mercer).

Prostitution is illegal in Korea, and most safe-sex counselling is aimed at young people.  “There is a great lack of instructors for sex education for senior citizens”, says a welfare professor at Baekseok University.  “We also need to create quality programs, through which senior citizens can meet friends of the opposite sex and form wholesome relationships” (Korea Herald) .

This problem may currently be local to Seoul.  Commentators  attribute it, however, to rising levels of poverty among seniors – a consequence, they argue, of a fast ageing population in a culture that once placed a high value on Confucian values of filial duty, but has now ceased do so.  If these commentators are right, one can well imagine these conditions being replicated in other Asian countries, as they follow the trajectory of Korea.  In which case, Jong-myo Park may be the shape of things to come (Korea Times).

UNAIDS assesses progress towards #HIV Millennium Development Goal

28 Oct, 13 | by Leslie Goode, Blogmaster

In the run-up to the 2013 General Assembly of the UN in New York, a new report from the Joint United National Program on HIV/AIDS seeks to give an overview of progress to date towards Millenium Goal 6 – the goal of halting and beginning to reverse the HIV/AIDS epidemic by 2015 (UNAIDS Report 2013).  Progress is evaluated in terms of the ten targets and elimination commitments established by the 2011 UN Political Declaration.

The headline figures relate largely to the targets involving specific health outcomes (5 targets out of 10l).  At 33%, the decline between 2001 and 2013 from 3.4 to 2.3 million in annual new HIV infections is perhaps within striking distance of the 50 % target (no.1) set by the Declaration, and at 36%, the reduction in HIV-related TB deaths is similarly within reach of an identical 50% target (no.5).  A sharp reduction – of 35% between 2009 and 2012 – in mother-to-child transmission is also encouraging, though, say the authors, the target (no. 3) of “elimination” will require greater integration of HIV and antenatal care than has so far been achieved.  As regards ART, the world looks set to achieve the regard of 15 million in treatment by 2015 (no.4), with 61% of those eligible under WHO guidelines already receiving treatment.  Efforts fall woefully short, however, in respect to the target (no.2) of halving HIV transmission in injecting drug users.

The remaining five targets include: closing the “resources gap” (no.6); service integration (no.10); various “elimination” targets involving structural change – i.e. gender inequality (no.7); stigma (no.8); entry and residence restrictions (no. 9).  So far as resources are concerned (no.6), the available US$18.9 billion for 2012 is up by an encouraging 10% on 2009, though still short of the target of US$22-24 for 2015.  On integration (no.10), things are also moving in the right direction, with 53% reporting integration of HIV and TB services, and an encouraging two thirds already integrating HIV and sexual and reproductive services. However, on all the elimination targets (no.7-9), progress seems very slow: <50%  of countries allocate funds for women’s organizations, integrate HIV and antenatal services, or engage men in national responses (no.7); 60% of countries report laws which present obstacles to effective HIV prevention (no.8); only eight countries have eliminated restrictions on freedom of movement (no.9).

It is interesting to read this report in the light of the concerns widely voiced prior to, and contemporaneously with, the 2011 UN Political Declaration, that the Millennium Goals risked favouring an “outcomes-based” emphasis on “quick-fix” interventions – and that a more “holistic” approach was needed, along with “smarter metrics”( STI blog: Right Way Forward?; STI blog: MDGs Bad for your Health?) .  These concerns seem to be reflected in the formulation of the 2011 targets, with their emphasis on holistic factors (no.s 7-9), and on service integration (UNAIDS Report 2011).  It is precisely in these latter areas that the progress noted by the recent UNAIDS report seems slowest, and is hardest to evaluate.  Regarding HIV integration (no. 10), however, the authors note that “a clear trend towards integration of HIV with diverse systems and sectors apparent”, though they also call for “greater efforts”.



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