Contraceptive Use and Uptake of HIV-Testing among Sub-Saharan African Women

Despite improved availability of simple, relatively inexpensive, and highly effective antiretroviral treatment for HIV/AIDS, the disease remains a major public health challenge for women in sub-Saharan Africa (SSA). Given the numerous barriers in access to care for women in this region, every health issue that brings them into contact with the health system should be optimized as an opportunity to integrate HIV/AIDS prevention. Because most non-condom forms of modern contraception require a clinical appointment for use, contraception appointments could provide a confidential opportunity for access to HIV counseling, testing, and referral to care. This study sought to investigate the relationship between contraceptive methods and HIV testing among women in SSA. Data from the Demographic and Health Survey from four African countries—Congo, Mozambique, Nigeria, and Uganda—was used to examine whether modern (e.g., pills, condom) or traditional (e.g., periodic abstinence, withdrawal) forms of contraception were associated with uptake of HIV testing. Data for the current analyses were restricted to 35,748 women with complete information on the variables of interest. Chi-square tests and logistic regression models were used to assess the relationship between uptake of HIV testing and respondents'' baseline characteristics and contraceptive methods. In the total sample and in Mozambique, women who used modern forms of contraception were more likely to be tested for HIV compared to those who did not use contraception. This positive association was not demonstrated in Congo, Nigeria, or Uganda. That many women who access modern contraception are not tested for HIV in high HIV burden areas highlights a missed opportunity to deliver an important intervention to promote maternal and child health. Given the increasing popularity of hormonal contraception methods in low-income countries, there is an urgent need to integrate HIV counseling, testing, and treatment into family planning programs. Women on hormonal contraceptives should be encouraged to continue to use condoms for HIV-prevention.     

Keeping the faith: African American faith leaders' perspectives and recommendations for reducing racial disparities in HIV/AIDS infection

In Philadelphia, 66% of new HIV infections are among African Americans and 2% of African Americans are living with HIV. The city of Philadelphia has among the largest numbers of faith institutions of any city in the country. Although faith-based institutions play an important role in the African American community, their response to the AIDS epidemic has historically been lacking. We convened 38 of Philadelphia's most influential African American faith leaders for in-depth interviews and focus groups examining the role of faith-based institutions in HIV prevention. Participants were asked to comment on barriers to engaging faith-based leaders in HIV prevention and were asked to provide normative recommendations for how African American faith institutions can enhance HIV/AIDS prevention and reduce racial disparities in HIV infection. Many faith leaders cited lack of knowledge about Philadelphia's racial disparities in HIV infection as a common reason for not previously engaging in HIV programs; others noted their congregations' existing HIV prevention and outreach programs and shared lessons learned. Barriers to engaging the faith community in HIV prevention included: concerns about tacitly endorsing extramarital sex by promoting condom use, lack of educational information appropriate for a faith-based audience, and fear of losing congregants and revenue as a result of discussing human sexuality and HIV/AIDS from the pulpit. However, many leaders expressed a moral imperative to respond to the AIDS epidemic, and believed clergy should play a greater role in HIV prevention. Many participants noted that controversy surrounding homosexuality has historically divided the faith community and prohibited an appropriate response to the epidemic; many expressed interest in balancing traditional theology with practical public health approaches to HIV prevention. Leaders suggested the faith community should: promote HIV testing, including during or after worship services and in clinical settings; integrate HIV/AIDS topics into health messaging and sermons; couch HIV/AIDS in social justice, human rights and public health language rather than in sexual risk behavior terms; embrace diverse approaches to HIV prevention in their houses of worship; conduct community outreach and host educational sessions for youth; and collaborate on a citywide, interfaith HIV testing and prevention campaign to combat stigma and raise awareness about the African American epidemic. Many African American faith-based leaders are poised to address racial disparities in HIV infection. HIV prevention campaigns should integrate leaders' recommendations for tailoring HIV prevention for a faith-based audience.     

HIV: evolution of a pandemic.

Although the prevalence of AIDS is still relatively low in many countries in Asia and the Pacific Rim, the rate of HIV transmission in this region continues to rise inexorably and will surpass that of sub-Saharan Africa by 1997. The challenge of mobilizing governments and communities to counter this largely invisible threat was the theme of the Third International Conference on AIDS in Asia and the Pacific, held in Chiang Mai, Thailand, in September 1995. Thailand has led the way with bold and far-reaching HIV prevention programs. Nevertheless, the long-term consequences of existing HIV infection in Thailand and elsewhere in Asia will be severe. Moreover, these repercussions will be felt globally as productivity is undermined, health care costs soar and purchasing power weakens. Supporting programs for HIV prevention and care abroad is thus an urgent matter of economic and political self-interest as well as a humanitarian imperative.     

Mandela restores morale of AIDS conference

During the 13th international AIDS conference in Durban, former president Nelson Mandela pulled the morale of the conference highlighting the need to confront the needs and concerns of those suffering and dying of HIV/AIDS in South Africa, mostly in sub-Saharan. He also stated that to challenge the grave threat posed by HIV and AIDS, efforts should be combined to save the people. This concluding remark was in direct contrast to the opening words of South Africa's current president, Thabo Mbeki, who failed to deal with the impression he has created internationally that he has doubts about the etiology of AIDS. In addition, the need to focus on the accessibility and affordability of treatment for HIV/AIDS or the opportunistic infections associated with it was highlighted. The conference focused on this issue with the help of AIDS activists, who emphasized that pharmaceutical companies needed to address how their drugs could reach those who most need them.     

Potential initiators of HIV-related stigmatization: ethical and programmatic challenges for PMTCT programs

HIV/AIDS continues to constitute a serious threat to the social and physical wellbeing of African mothers and their babies. In the hardest hit countries of sub-Saharan Africa, more than 60% of all new HIV infections are occurring in women, infants and young children.Mother-to-child transmission (MTCT) constitutes 90% of new HIV infections among infants and young children. Most of these infection scan be prevented. However, the social stigma of HIV/AIDS insidiously continues to undermine the success of prevention programs.Ironically, some attributes or characteristics of prevention of mother-to-child transmission (PMTCT) programs may in fact serve as catalysts to the stigmatization process. This paper identifies and discusses six potential initiators: (1) Routine HIV testing, (2) Six months exclusive breastfeeding, (3) Incentives, (4) Home visits, (5) Location of PMTCT program, and (6) PMTCT terminology. In all these areas, there are practical strategies that may be applied to reduce the chances of being stigmatized. These strategies are introduced and discussed.     

Effect of Media Use on HIV/AIDS-Related Knowledge and Condom Use in Sub-Saharan Africa: A Cross-Sectional Study

It is known that the level of HIV/AIDS-related knowledge and the degree of condom use varies by socioeconomic status (SES). However, there is limited research on the effect of mass media use on HIV/AIDS-related cognitive and behavioral outcomes in low-income countries and how it might influence the association between SES and HIV-related outcomes. We investigated the moderating effect of media use on the relationship between SES and HIV/AIDS-related knowledge and condom use in sub-Saharan Africa in terms of communication inequalities. Cross-sectional data from the Demographic Health Surveys from 13 sub-Saharan countries (2004–10) were pooled. Gender-stratified multivariable poisson regression of 151,209 women and 68,890 men were used to calculate adjusted relative ratios and 95% confidence intervals for the associations between SES, media use, HIV-related outcomes, and condom use. We found significant disparities in mass media use among people from different SES groups as well as among countries. Education and wealth are strongly and positively associated with awareness of HIV/AIDS and knowledge about transmission and prevention of HIV/AIDS and are significantly associated with condom use. These associations are attenuated when the use of various types of mass media is added to the models, with newspapers showing the strongest effect. The findings of this study suggest that media use has the potential to blunt the impact of socioeconomic status though not completely eliminate it. Thus, we need to pay attention to reducing communication inequalities among social groups and countries to moderate the effect of wealth and SES on HIV/AIDS.     

Preventing Death from HIV-Associated Cryptococcal Meningitis: The Way Forward

Cryptococcal meningitis (CM), a fungal disease caused by Cryptococcus species, is one of the most common opportunistic infections among persons with HIV/AIDS. The highest burden of disease is in sub-Saharan Africa and Southeast Asia, where limited access to antiretroviral treatment and appropriate antifungal therapy contributes to high mortality rates. Increasing focus has been placed on earlier detection and prevention of disease. Primary prophylaxis and screening may provide a survival benefit and can be cost-effective in settings where CM prevalence is high. The development of a new point-of-care cryptococcal antigen assay has the potential to transform both disease prevention and diagnosis.     

Drug companies cut HIV drug prices in the developing world

The UN has reported that five multinational pharmaceutical companies would cut down HIV drug prices in the developing world. One of these drug companies is GlaxoWellcome, which has promised to reduce the price of zidovudine and lamivudine to US$2 in the poorest nations, a fifth of its price in the US. Although Peter Piot, director of the UN Program on HIV/AIDS, welcomed the companies' promises, he warned that price cuts alone will not curb the epidemic. He stated that this initiative is only one critical factor in what must become a much broader and more urgent effort to help people living with HIV/AIDS. Moreover, health and development agencies expressed concern that AIDS drugs will still be unaffordable for the vast majority of those in need in developing countries. In addition, poor countries lack the infrastructure to deliver these drugs safely and effectively. During the time of the UN announcement, US President Bill Clinton also signed an executive order allowing sub-Saharan Africa to adopt legal measures to obtain cheap HIV drugs. Meanwhile, South Africa's reaction to the offer to cut antiretroviral drug prices has been lukewarm.     

Towards a family-centered approach to HIV treatment and care for HIV-exposed children, their mothers and their families in poorly resourced settings

This article provides a summary of emerging psychosocial evidence relevant to the success of comprehensive family-centered approaches to HIV prevention, treatment, care and support programs in poorly resourced settings. This report synthesizes current evidence on maternal, paternal and family experiences of HIV prevention, diagnosis, treatment, adherence and disclosure, with special focus on HIV-infected mothers and HIV-exposed children. Taking a developmental approach, we explore the current challenges and opportunities towards a family-centered approach within the continuum of HIV treatment and care, beginning in pregnancy and following the course of childhood. The discussion is limited to early and middle childhood and excludes discussion of special issues emergent in adolescence, which would warrant discussion outside the scope of this article. Attention is drawn to the complexity of problems arising within the family context and the need for improvements in the integration of aspects of treatment, care and support. While this article focuses on examples from sub-Saharan Africa, the lessons learnt and future challenges outlined are applicable to most low- and middle-income countries, and to poorly resourced contexts in higher-income countries.     

Epidemiology of Kaposi’s sarcoma in sub-Saharan Africa

Kaposi’s sarcoma (KS) has become a common AIDS-defining cancer in sub-Saharan Africa. Kaposi’s sarcoma-associated human herpesvirus strongly modulated by HIV-related immune suppression are the principal causes of this cancer. No other risk factors have been identified as playing a strong role. HIV prevention programs and good coverage of antiretroviral therapy (ART) in developed countries resulted in a remarkable decline in HIV-KS incidence and better KS prognosis. By contrast, in sub-Saharan Africa, population ART rollout has lagged, but clinical studies have shown positive results in reduction of KS incidence and better KS prognosis. However, the effect of ART rollout in relation to population KS incidence is unclear. We describe the incidence of KS in sub-Saharan Africa, in four time-periods, (1) before 1980 (before HIV/AIDS era); (2) 1981–2000 (early HIV/AIDS era, limited or no ART coverage); (3) 2001–2010 (early ART coverage period); and (4) 2011–2016 (fair to good ART coverage period). We used KS incidence data available from WHO-International Agency for Research on Cancer (IARC) publications and the Africa Cancer Registry Network. National HIV prevalence and ART coverage data were derived from UNAIDS/WHO. A rapid increase in KS incidence was observed throughout sub-Saharan Africa as the HIV epidemic progressed, reaching peak incidences in Period 2 (pre-ART rollout) of 50.8 in males and 20.3 per 100 000 in females (Zimbabwe, Harare). The overall unweighted average decline in KS incidence between 2000 and 2010 and 2011–2016 was 27%, but this decline was not statistically significant across the region. ART rollout coincides with a decline in KS incidence across several regions in sub-Saharan Africa. The importance of other risk factors such as reductions in HIV incidence could not be ascertained.     

UN says up to half the teenagers in Africa will die of AIDS

According to the Joint UN Programme on HIV/AIDS report, AIDS will cause early death in as many as half of the teenagers living in southern Africa. In Botswana, demographers have predicted that two-thirds of the 15-year-olds will die of AIDS before the age of 50. In terms of global estimates, the report indicated that there are 34.3 million people infected with HIV, of whom 1.3 million are children under the age of 15. The impact of the AIDS epidemic is accounted for in the erosion of all key measures of a nation's health, especially in much of sub-Saharan Africa. These key measures include economic development, educational attainment, and child survival. Although there are a few success stories in the countries of Uganda and Thailand, which show that strong prevention campaigns and increased condom use help in curbing the epidemic, the report revealed the need for a massive increase in political will.     

UN warns that AIDS deaths are set to reach record level

The Joint United Nations Programme on HIV/AIDS (UNAIDS) warns that AIDS deaths are set to reach a record level during the year 1999. Estimates from UNAIDS reveal that 2.6 million people will die from diseases related to HIV and AIDS during 1999--a higher global total than any year since the beginning of the epidemic. In addition, 32.4 million adults and 1.2 million children are estimated to be living with HIV infection by the end of 1999. About 95% of those infected live in the developing world, and this proportion was predicted to rise even further as infection rates continued to rise in countries where poverty, poor health systems, and limited resources for prevention and care fueled the spread of the virus. The highest prevalence of the infection is seen in sub-Saharan Africa; close to 70% of the global total of HIV-positive people come from this region. However, the challenge also remains in industrialized countries, where unsafe sexual behavior and drug injection are practiced.     

From PMTCT to a more comprehensive AIDS response for women: a much-needed shift

Half of the 33.2 million people living with HIV today are women. Yet, responses to the epidemic are not adequately meeting the needs of women. This article critically evaluates how prevention of mother-to-child transmission (PMTCT) programs, the principal framework under which women's health is currently addressed in the global response to AIDS, have tended to focus on the prevention of HIV transmission from HIV-positive women to their infants. This paper concludes that more than ten years after their inception, PMTCT programs still do not successfully ensure the adequate treatment, care and support of HIV-infected women. Of particular concern is the continued widespread use of single-dose nevirapine despite World Health Organization recommendations to employ more effective combination therapies that do not potentially jeopardize women's future treatment outcomes. In response, the article calls for a more comprehensive approach that places women's health needs at the centre of AIDS responses. This is critical in settings where the pandemic is generalized and there is a push to greatly expand PMTCT programs, as a more effective and equitable way of meeting the needs of women in the context of HIV. Without such a comprehensive approach, women will continue to be impacted disproportionately by the pandemic, and current strategies for prevention, including PMTCT, and treatment will not be as effective and responsive as they need to be.     

Allocating HIV prevention funds in the United States: recommendations from an optimization model

The Centers for Disease Control and Prevention (CDC) had an annual budget of approximately $327 million to fund health departments and community-based organizations for core HIV testing and prevention programs domestically between 2001 and 2006. Annual HIV incidence has been relatively stable since the year 2000 and was estimated at 48,600 cases in 2006 and 48,100 in 2009. Using estimates on HIV incidence, prevalence, prevention program costs and benefits, and current spending, we created an HIV resource allocation model that can generate a mathematically optimal allocation of the Division of HIV/AIDS Prevention's extramural budget for HIV testing, and counseling and education programs. The model's data inputs and methods were reviewed by subject matter experts internal and external to the CDC via an extensive validation process. The model projects the HIV epidemic for the United States under different allocation strategies under a fixed budget. Our objective is to support national HIV prevention planning efforts and inform the decision-making process for HIV resource allocation. Model results can be summarized into three main recommendations. First, more funds should be allocated to testing and these should further target men who have sex with men and injecting drug users. Second, counseling and education interventions ought to provide a greater focus on HIV positive persons who are aware of their status. And lastly, interventions should target those at high risk for transmitting or acquiring HIV, rather than lower-risk members of the general population. The main conclusions of the HIV resource allocation model have played a role in the introduction of new programs and provide valuable guidance to target resources and improve the impact of HIV prevention efforts in the United States.     

The factors influencing transactional sex among young men and women in 12 sub-Saharan African countries

Transactional sex may put young women and young men in sub-Saharan Africa at increased risk of contracting sexually transmitted infections (STIs), including HIV/AIDS. This behavior may also put young women at higher risk of pregnancy and childbearing. Policymakers and program managers need to know what factors put youth at increased risk. We investigated this issue using logistic regression analyses of data from male and female modules of Demographic and Health Surveys from 12 sub-Saharan African countries. We found that young men and young women are at greater risk of engaging in transactional sex than are older people. Unmarried young women and young men were significantly more likely to engage in transactional sex than married youth. Based on these results, our conclusions were that programs geared toward reducing the incidence of transactional sex or protecting men and women already in transactional sexual relationships should be aimed at both young women and young men. Due to our finding that unmarried young women and young men are more vulnerable to experiencing transactional sex, programs to prevent transactional sex should be specifically directed to this subgroup of young people.     

Integrating HIV prevention and treatment: from slogans to impact

Background

Through major efforts to reduce costs and expand access to antiretroviral therapy worldwide, widespread delivery of effective treatment to people living with HIV/AIDS is now conceivable even in severely resource-constrained settings. However, the potential epidemiologic impact of treatment in the context of a broader strategy for HIV/AIDS control has not yet been examined. In this paper, we quantify the opportunities and potential risks of large-scale treatment roll-out.

Methods and Findings

We used an epidemiologic model of HIV/AIDS, calibrated to sub-Saharan Africa, to investigate a range of possible positive and negative health outcomes under alternative scenarios that reflect varying implementation of prevention and treatment. In baseline projections, reflecting “business as usual,” the numbers of new infections and AIDS deaths are expected to continue rising. In two scenarios representing treatment-centered strategies, with different assumptions about the impact of treatment on transmissibility and behavior, the change in the total number of new infections through 2020 ranges from a 10% increase to a 6% reduction, while the number of AIDS deaths through 2020 declines by 9% to 13%. A prevention-centered strategy provides greater reductions in incidence (36%) and mortality reductions similar to those of the treatment-centered scenarios by 2020, but more modest mortality benefits over the next 5 to 10 years. If treatment enhances prevention in a combined response, the expected benefits are substantial—29 million averted infections (55%) and 10 million averted deaths (27%) through the year 2020. However, if a narrow focus on treatment scale-up leads to reduced effectiveness of prevention efforts, the benefits of a combined response are considerably smaller—9 million averted infections (17%) and 6 million averted deaths (16%). Combining treatment with effective prevention efforts could reduce the resource needs for treatment dramatically in the long term. In the various scenarios the numbers of people being treated in 2020 ranges from 9.2 million in a treatment-only scenario with mixed effects, to 4.2 million in a combined response scenario with positive treatment–prevention synergies.

Conclusions

These analyses demonstrate the importance of integrating expanded care activities with prevention activities if there are to be long-term reductions in the number of new HIV infections and significant declines in AIDS mortality. Treatment can enable more effective prevention, and prevention makes treatment affordable. Sustained progress in the global fight against HIV/AIDS will be attained only through a comprehensive response.     

25 years of HIV/AIDS science: reaching the poor with research advances

Last year marked the 25th anniversary of the recognition of what we now call AIDS. The AIDS pandemic has claimed more than 25 million lives, the majority of them in the developing world, and has exacerbated poverty and slowed human development. Although much has been accomplished in HIV/AIDS research, much remains to be done, especially regarding delivery of HIV/AIDS therapies and care and prevention interventions to the poorest countries that need them most.     

Expanding HIV testing efforts in concentrated epidemic settings: a population-based survey from rural Vietnam

Background

To improve HIV prevention and care programs, it is important to understand the uptake of HIV testing and to identify population segments in need of increased HIV testing. This is particularly crucial in countries with concentrated HIV epidemics, where HIV prevalence continues to rise in the general population. This study analyzes determinants of HIV testing in a rural Vietnamese population in order to identify potential access barriers and areas for promoting HIV testing services.

Methods

A population-based cross-sectional survey of 1874 randomly sampled adults was linked to pregnancy, migration and economic cohort data from a demographic surveillance site (DSS). Multivariate logistic regression analysis was used to determine which factors were associated with having tested for HIV.

Results

The age-adjusted prevalence of ever-testing for HIV was 7.6%; however 79% of those who reported feeling at-risk of contracting HIV had never tested. In multivariate analysis, younger age (aOR 1.85, 95% CI 1.14–3.01), higher economic status (aOR 3.4, 95% CI 2.21–5.22), and semi-urban residence (aOR 2.37, 95% CI 1.53–3.66) were associated with having been tested for HIV. HIV testing rates did not differ between women of reproductive age who had recently been pregnant and those who had not.

Conclusions

We found low testing uptake (6%) among pregnant women despite an existing prevention of mother-to-child HIV testing policy, and lower-than-expected testing among persons who felt that they were at-risk of HIV. Poverty and residence in a more geographically remote location were associated with less HIV testing. In addition to current HIV testing strategies focusing on high-risk groups, we recommend targeting HIV testing in concentrated HIV epidemic settings to focus on a scaled-up provision of antenatal testing. Additional recommendations include removing financial and geographic access barriers to client-initiated testing, and encouraging provider-initiated testing of those who believe that they are at-risk of HIV.     

AIDS and ‘building a wall’ around Christian country in rural Papua New Guinea

This paper explores an ongoing dialogue about Christianity in light of the recent influx of HIV and AIDS into the villages of the Gogodala of Western Province, Papua New Guinea. I argue that a suggestion by a woman in late 2004 to ‘build a wall’ around the Gogodala region in Western Province in order to stop or slow the spread of HIV/AIDS reflects a recent concern with the sustainability of this rural Christian community, referred to in English as ‘Christian country’. Understanding AIDS to be a threat posed largely from outsiders, whether Papua New Guinean or European, sections of these primarily village‐based communities aim to create both a physical and metaphorical boundary between themselves and outsiders. At present, local prevention and intervention strategies concerning HIV and AIDS focus on conservative, evangelical narratives about the preservation of the principles and practices of Christian country, through the repudiation of unrestrained sexuality, for example, which is believed to be increasingly prevalent not only in their own area but throughout urban Papua New Guinea. A growing divide between rural and urban Gogodala, then, has become a major part of the local dialogue about AIDS and represents significant contestation over the practices and ideational basis of Christian country.     

Bone marrow suppression and severe anaemia associated with persistent Plasmodium falciparum infection in African children with microscopically undetectable parasitaemia

In sub-Saharan Africa the highest overlap between malaria and HIV infections occurs in female adolescents. Yet control activities for these infections are directed to different target groups, using disparate channels. This reflects the lack of priority given to adolescents and the absence of an accepted framework for delivering health and health-related interventions to this high-risk group. In this paper it is argued that female adolescents require a continuum of care for malaria and HIV – prior to conception, during and after pregnancy and that this should be provided through adolescent services. The evidence for this conclusion is presented. A number of African countries are commencing to formulate and implement adolescent-friendly policies and services and disease control programs for malaria and HIV will need to locate their interventions within such programs to ensure widespread coverage of this important target group. Failure to prioritize adolescent health in this way will seriously limit the success of disease control programs for malaria and HIV prevention.