AIDS: lessons learnt and myths dispelled

[Medical laboratories and quality of care: the most neglected components of rural hospitals in the Democratic Republic of the Congo]

INTRODUCTION

Quality of care is essential to save people living with different diseases. However, inappropriate diagnosis may in no case lead to proper patient management as well as to quality of care. We conducted a cross-sectional descriptive analysis in three laboratories at the General Hospitals in the Democratic Republic of the Congo.

METHODS

A team of national experts in the field of laboratories conducted a survey in the three clinical laboratories of the General Hospitals in the Democratic Republic of the Congo. Observations, visits and structured interviews using a questionnaire were used to assess the performance of these clinical laboratories. We also used a national evaluation guidance for the assessment of laboratories.

RESULTS

The clinical laboratories of the General Hospitals visited showed many deficits, in particular, in infrastructures, in the basic and continuous training of the personnel, in the equipment, in supervision and quality control. Technical performances of these laboratories were not adapted to meet the needs of the population with regard to diseases frequently encountered in these areas. We also noted that these laboratories are little or almost not assisted and that there was no coordination team dedicated to the supervision and the assessment of laboratories in the hospital or even in the health zone. In addition, technicians working in their different laboratories had not been supervised over many years.

CONCLUSION

Clinical laboratory improvement would allow for proper diagnosis of different diseases. This improvement should take into account local diseases. Within the system, it is important to devote more attention to clinical laboratories. Advocacy for this neglected component of the health system is necessary, as this situation could be the same in many developing countries.

'We can act different from what we used to': Findings from experiences of religious leader participants in an HIV-prevention intervention in Zambia

Faith-based organisations (FBOs) have long been part of the fight against HIV and AIDS. International bodies continue to collaborate with FBOs to implement HIV-prevention programmes with mixed success. Zambia has been a target of such programmes in part due to its high HIV prevalence. The Trusted Messenger approach to provide religious leader networks with biomedical, science-focused education about HIV and AIDS was piloted in 2006, but participant experiences of the intervention have not been explored qualitatively. In 2016, in-depth interviews were conducted of 34 randomly chosen individuals who attended Trusted Messenger workshops between 2006 and 2016 in Livingstone, Lusaka, and the Copperbelt region. Findings indicate that the religious leader attendees gained scientific insights about HIV which motivated their action in personal, social, and religious contexts. Participants found the science comprehensible and empowering and identified workshop frequency and language as challenging. Utilising science-focused education within contextual settings of religious leader networks can combat the spread of HIV and the mistreatment of people living with HIV and AIDS.

The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda

Background

Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda.

Methods

Using a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services.

Results

Our final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services.

Conclusions

Our findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.

National laboratory policies and plans in sub-Saharan African countries: gaps and opportunities

Background

The 2008 Maputo Declaration calls for the development of dedicated national laboratory policies and strategic plans supporting the enhancement of laboratory services in response to the long-lasting relegation of medical laboratory systems in sub-Saharan Africa.

Objectives

This study describes the extent to which laboratories are addressed in the national health policies and plans created directly following the 2008 momentum for laboratory strengthening.

Method

National health policies and plans from 39 sub-Saharan African countries, valid throughout and beyond 31 December 2010 were collected in March 2012 and analysed during 2013.

Results

Laboratories were addressed by all countries. Human resources were the most addressed topic (38/39) and finances and budget were the least addressed (< 5/39). Countries lagging behind in national laboratory strategic planning at the end of 2013 (17/39) were more likely to be francophone countries located in West-Central Africa (13/17) and have historically low HIV prevalence. The most common gaps anticipated to compromise the implementation of the policies and plans were the disconnect between policies and plans, under-developed finance sections and monitoring and evaluating frameworks, absence of points of reference to define gaps and shortages, and inappropriate governance structure.

Conclusion

The availability of laboratory policy and plan implementation can be improved by strictly applying a more standardised methodology for policy development, using harmonised norms to set targets for improvement and intensifying the establishment of directorates of laboratory services directly under the authority of Ministries of Health. Horizontal programmes such as the Global Health Security Agenda could provide the necessary impulse to take the least advanced countries on board.

Myths about HIV and AIDS among serodiscordant couples in Malawi

Purpose

The purpose of this paper is to report on research that uncovered myths about HIV and AIDS held by serodiscordant couples in Malawi, and the sources of these myths. The paper reflects on how the myths affect serodiscordant couples’ engagement with HIV and AIDS information.

Design/methodology/approach

Van Manen’s (1997) approach to analysis of phenomenological data was used to analyse data from in-depth interviews conducted in Malawi with 21 serodiscordant couples and three individuals who had separated from their partners because of serodiscordance.

Findings

Serodiscordant couples in Malawi believe and hold on to some inaccurate HIV and AIDS information that can be seen as “myths”. Some of these myths are perpetuated by official HIV and AIDS information when it is translated into the local languages. Other myths derive from social norms of the societies where the couples live.

Practical implications

The findings of this paper have practical implications for how HIV and AIDS information providers should engage with target audiences to understand the origins of the myths they hold. The findings also imply that some myths have technical, religious, moral and cultural bases which need to be addressed before challenging the myth itself.

Originality/value

Using real-life descriptions of experiences of HIV and AIDS information provided by serodiscordant couples, the authors reveal how myths can affect engagement with the information. The authors make recommendations on how to address myths in ways that contribute to a positive experience of HIV and AIDS information by serodiscordant couples.

Gender inequality dynamics in the prevention of a heterosexual HIV epidemic in sub-Saharan Africa

This paper critiques the approach to the elimination of gender inequality as an HIV prevention strategy in the just ended era of the Millennium Development Goals, with the aim of contributing to the formulation of policy guidelines for sub-Saharan Africa in the Sustainable Development Goals. The aim is to underscore the mutual responsibility of women and men in achieving a sustainable HIV response and ending the epidemic. While taking into account the real vulnerability of women, prevention programmes can reflect gender dynamics more accurately so that attention is given to the role of both sexes in propagating - or stemming - a predominantly heterosexual HIV epidemic. More emphasis could be given to the harm caused to both men and women by certain norms related to masculinity and sexuality, and the subsequent need for combined efforts in reducing intimate partner violence and concurrency. The empowerment and engagement of both women and men as agents of change would need to be dealt with more creatively.

Responses to the global HIV and AIDS pandemic: a study of the role of faith-based organisations in Lesotho

This article attempts to establish the key contribution by people of faith to the global HIV pandemic response, using Lesotho as a case study. Particular focus is paid to the work of selected religious organisations in Lesotho in this context, assessing their capacities to coordinate an effective HIV and AIDS action at the grassroots levels through education, health care, development, and social service activities. Empirical evaluations and findings regarding the level and quality of faith-based engagement in this field establish the basic premise of this article, namely, that faith-based organisations are contributing energy, expertise, and experience in order to achieve the commitment of the global commitment to advance universal access to HIV prevention, treatment, and support. Although the article is particularly focused on the Lesotho context, its tremendous implications for simulated studies and approaches across Sub-Saharan Africa are accentuated.

The Effect of Antiretroviral Treatment on Health Care Utilization in Rural South Africa: A Population-Based Cohort Study

Background

The effect of the rapid scale-up of vertical antiretroviral treatment (ART) programs for HIV in sub-Saharan Africa on the overall health system is under intense debate. Some have argued that these programs have reduced access for people suffering from diseases unrelated to HIV because ART programs have drained human and physical resources from other parts of the health system; others have claimed that the investments through ART programs have strengthened the general health system and the population health impacts of ART have freed up health care capacity for the treatment of diseases that are not related to HIV. To establish the population-level impact of ART programs on health care utilization in the public-sector health system, we compared trends in health care utilization among HIV-infected people receiving and not receiving ART with HIV-uninfected people during a period of rapid ART scale-up.

Methods and Findings

We used data from the Wellcome Trust Africa Centre for Population Health, which annually elicited information on health care utilization from all surveillance participants over the period 2009–2012 (N = 32,319). We determined trends in hospitalization, and public-sector and private-sector primary health care (PHC) clinic visits for HIV-infected and -uninfected people over a time period of rapid ART scale-up (2009–2012) in this community. We regressed health care utilization on HIV status and ART status in different calendar years, controlling for sex, age, and area of residence. The proportion of people who reported to have visited a public-sector primary health care (PHC) clinic in the last 6 months increased significantly over the period 2009–2012, for both HIV-infected people (from 59% to 67%; p<0.001), and HIV-uninfected people (from 41% to 47%; p<0.001). In contrast, the proportion of HIV-infected people visiting a private-sector PHC clinic declined from 22% to 12% (p<0.001) and hospitalization rates declined from 128 to 82 per 1000 PY (p<0.001). For HIV-uninfected people, the proportion visiting a private-sector PHC clinic declined from 16% to 9%, and hospitalization rates declined from 78 to 44 per 1000 PY (p<0.001). After controlling for potential confounding factors, all trends remained of similar magnitude and significance.

Conclusions

Our results indicate that the ART scale-up in this high HIV prevalence community has shifted health care utilization from hospitals and private-sector primary care to public-sector primary care. Remarkably, this shift is observed for both HIV-infected and -uninfected populations, supporting and extending hypotheses of ‘therapeutic citizenship’ whereby HIV-infected patients receiving ART facilitate primary care access for family and community members. One explanation of our findings is that ART has improved the capacity or quality of primary care in this community and, as a consequence, increasingly met overall health care needs at the primary care level rather than at the secondary level. Future research needs to confirm this causal interpretation of our findings using qualitative work to understand causal mechanisms or quasi-experimental quantitative studies to increase the strength of causal inference.

Capacity building in national influenza laboratories--use of laboratory assessments to drive progress

BACKGROUND

Laboratory testing is a fundamental component of influenza surveillance for detecting novel strains with pandemic potential and informing biannual vaccine strain selection. The United States (U.S.) Centers for Disease Control and Prevention (CDC), under the auspices of its WHO Collaborating Center for Influenza, is one of the major public health agencies which provides support globally to build national capacity for influenza surveillance. Our main objective was to determine if laboratory assessments supported capacity building efforts for improved global influenza surveillance.

METHODS

In 2010, 35 national influenza laboratories were assessed in 34 countries, using a standardized tool. Post-assessment, each laboratory received a report with a list of recommendations for improvement. Uptake of recommendations were reviewed 3.2 mean years after the initial assessments and categorized as complete, in-progress, no action or no update. This was a retrospective study; follow-up took place through routine project management rather than at a set time-point post-assessment. WHO data on National Influenza Centre (NIC) designation, External Quality Assessment Project (EQAP) participation and FluNet reporting was used to measure laboratory capacity longitudinally and independently of the assessments. All data was further stratified by World Bank country income category.

RESULTS

At follow-up, 81% of 614 recommendations were either complete (350) or in-progress (145) for 32 laboratories (91% response rate). The number of countries reporting to FluNet and the number of specimens they reported annually increased between 2005, when they were first funded by CDC, and 2010, the assessment year (p < 0.01). Improvements were also seen in EQAP participation and NIC designation over time and more so for low and lower-middle income countries.

CONCLUSIONS

Assessments using a standardized tool have been beneficial to improving laboratory-based influenza surveillance. Specific recommendations helped countries identify and prioritize areas for improvement. Data from assessments helped CDC focus its technical assistance by country and region. Low and lower-middle income countries made greater improvements in their laboratories compared with upper-middle income countries. Future research could include an analysis of annual funding and technical assistance by country. Our approach serves as an example for capacity building for other diseases.

Beyond the bedside: A review of translational medicine in global health

Translational research is a broad field of medicine with several key phases moving from scientific discovery to bench research and the hospital bedside, followed by evidence-based practice and population-level policy and programming. Understanding these phases is crucial when it comes to preventing and treating illness, especially in global health. Communities around the world struggle with a variety of health problems that are at some times similar and at others quite different. Three major world health issues help to outline the phases of translational research: vaccines, human immunodeficiency virus and acquired immunodeficiency syndrome, and non-communicable diseases. Laboratory research has excelled in many of these areas and is struggling in a few. Where successful therapies have been discovered there are often problems with appropriate use or dissemination to groups in need. Also, many diseases would be better prevented from a population health approach. This review highlights successes and struggles in the arena of global health, from smallpox eradication to the impending epidemic of cardiovascular disease, in an attempt to illustrate of the various phases of translational research.

Gastrointestinal surgery and the acquired immune deficiency syndrome

Acquired immune-deficiency syndrome (AIDS) is becoming an increasing problem to the surgeon. The impact of HIV/AIDS on surgical practice include the undoubted risk to which the surgeon will expose him or herself, the atypical conditions that may be encountered and the outcome and long term benefit of the surgical treatment in view of disease progression. The two factors most associated with surgical outcome and poor wound healing were AIDS and poor performance status (ASA score). This article questions whether gastrointestinal surgical procedures can be safe and effective therapeutic measures in HIV/AIDS patients and if surgical outcome is worthy of the surgeon's ethical responsibility to treat. As HIV/AIDS patients are not a homogeneous group, with careful patient selection, emergency laparotomy for peritonitis confers worthwhile palliation. However, aggressive surgical intervention must be undertaken with caution and adequate peri-operative care is required. Symptomatic improvement of anorectal pathology may make delayed wound healing an acceptable complication. Alternatives to surgery can be contemplated for diagnosis, prophylaxis or palliation.

Training and nutritional components of PMTCT programmes associated with improved intrapartum quality of care in Mali and Senegal

OBJECTIVE

Scale-up of prevention of mother-to-child transmission (PMTCT) of HIV programmes in sub-Saharan Africa has stimulated interest to assess whether these programmes can indirectly affect other health priorities. This study assesses whether PMTCT programmes, or components of these programmes, are associated with better obstetrical quality of care and how PMTCT may reinforce existing maternal health programmes.

DESIGN

Cross-sectional analysis of data from a cluster-randomized trial called QUARITE.

SETTING

Mali and Senegal, West Africa.

PARTICIPANTS

Thirty-one referral hospitals and 612 obstetrical patients.

INTERVENTION

The exposure of interest was PMTCT measured with a scale containing 10 components describing different prongs of a hospital PMTCT programme. Other variables of interest included: presence of a quality of care improvement programme, hospital resources and patient demographic characteristics.

MAIN OUTCOME MEASURE

Obstetrical quality of care measured through a validated chart abstraction tool.

RESULTS

Of 45 points, the mean hospital PMTCT score was 26.1 (SD: 6.7). Total PMTCT score was not significantly associated with quality of care, but programme component scores were. After adjustment for known predictors of quality of care, staff training in PMTCT (P = 0.03) and complementary nutritional services (P = 0.03) were significantly associated with better quality obstetrical care. A point increase in scores for either of these components was associated with 40% greater odds of good obstetrical care.

CONCLUSIONS

PMTCT training and nutritional components are significantly associated with better quality intrapartum care. Health professionals' training in maternal healthcare and PMTCT could be combined to improve the quality of obstetric care in the region.

The Global Fund to Fight AIDS, Tuberculosis and Malaria: 10 years on

The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund or GFATM) is a private public partnership aimed at leveraging and providing funding for the three focal diseases outlined in its title. Set up in 2002, the fund was part of a new 'breed' of players in the field of global health, combining skills from bilateral and multilateral agencies with private sector and civil society. Highly innovative in its structure and funding model, the Global Fund's secretariat in Geneva provides grants directly to one or more organisations - not just governments - in recipient countries. Despite great successes, including scaling up treatment for AIDS to reach 4.2 million people, the fund has been the subject of intense debate. This includes discussion of its impact on health systems and allegations of financial irregularities among recipients in four countries. The organisation has now emerged with a new strategy, funding model and executive director. This paper charts its history, discusses some of the challenges faced, drawing on fieldwork conducted by the author in 2007-08, and reflects on recent changes and the road ahead.

Health technology assessments as a mechanism for increased value for money: recommendations to the Global Fund

The Global Fund is experiencing increased pressure to optimize results and improve its impact per dollar spent. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. This paper assesses the efficacy of current Global Fund investment and examines how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidized by the Global Fund. In addition, this paper identifies areas where the application of HTAs can exert the greatest impact and proposes ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, it addresses the challenges facing the Global Fund in realizing the full potential of HTAs.

Criminalising consensual sexual behaviour in the context of HIV: consequences, evidence, and leadership

This paper provides an overview of the use of the criminal law to regulate sexual behaviour in three areas of critical importance: (1) HIV exposure in otherwise consensual sex, (2) sex work and (3) sexual activity largely affecting sexual minorities. It analyses criminal law pertaining to these three distinct areas together, allowing for a more comprehensive and cohesive understanding of criminalisation and its effects. The paper highlights current evidence of how criminalisation undermines HIV prevention and treatment. It focuses on three specific negative effects of criminalisation: (1) enhancing stigma and discrimination, (2) undermining public health intervention through legal marginalisation and (3) placing people in state custody. The paper also highlights gaps in evidence and the need for strong institutional leadership from UN agencies in ending the criminalisation of consensual sexual activity. This paper serves two goals: (1) highlighting the current state of research and emphasising where key institutions have or have not provided appropriate leadership on these issues and (2) establishing a forward-looking agenda that includes a concerted response to the inappropriate use of the criminal law with respect to sexuality as part of the global response to HIV.

Experience with synthetic vaccines for cancer and persistent virus infections in nonhuman primates and patients

Synthetic vaccines, in particular long synthetic peptides of approximately 25-50 amino acids in length, are attractive for HIV vaccine development and for induction of therapeutic immune responses in patients with (pre-)malignant disorders. In the case of preventive vaccine development against HIV, no major success has been achieved, but the possibilities are by no means exhausted. A long peptide vaccine consisting of 13 overlapping peptides, which together cover the entire length of the two oncogenic proteins E6 and E7 of high-risk human papilloma virus type 16 (HPV16), caused complete regression of all lesions and eradication of virus in 9 out of 20 women with high-grade vulvar intraepithelial neoplasia, a therapy-resistant preneoplastic disorder. The nature and strength of the vaccine-prompted T cell responses were significantly correlated with the clinical response. Synthetic peptide vaccines are attractive, because they allow rational improvement of vaccine design and detailed pharmacokinetic and pharmacodynamic studies not possible with conventional vaccines. Improvements are possible by addition or conjugation of adjuvants, notably TLR ligands, to the synthetic peptides.

An underestimated lentivirus model: what can HIV-2 research contribute to the development of an effective HIV-1 vaccine?

The development of an HIV-1 vaccine that would be effective against all existing subtypes and circulating recombinant forms remains one of the great scientific and public health challenges of our generation. One of the major barriers to HIV-1 vaccine development is a lack of understanding of the correlates of protective immunity against the virus. In this context, research has focused on the rare phenomenon of spontaneous control of HIV-1 infection, in groups referred to as 'long-term nonprogressors' and 'elite controllers', together with models of nonprogressive sooty mangabey simian immunodeficiency (SIV) infection in African nonhuman primate hosts such as sooty mangabeys and African green monkeys, in which the majority of animals tolerate high levels of viral replication without development of immunodeficiency or disease. Much less attention has been given to humans infected with the nonpandemic strain HIV-2, derived from the SIV in West Africa, most of whom behave as long-term nonprogressors or viral controllers, while a minority develop disease clinically indistinguishable from AIDS caused by HIV-1. This apparent dichotomous outcome is, based on the evidence accumulated to date, more clearly related to the host immune response than the good clinical outcome of HIV-1 controllers. We propose that complementing research into HIV-1 controllers and nonpathogenic SIV models with the prioritization of HIV-2 research could enhance the HIV-1 vaccine research effort. The absence of disease progression or detectable plasma viral replication in the presence of an effective immune response in most patients living with HIV-2 represents an opportunity to unravel the virus' evolutionary adaptation in human hosts and to establish the correlates of such a protective response.

The effects of an HIV project on HIV and non-HIV services at local government clinics in urban Kampala

Background

HIV/AIDS is a major public health concern in Uganda. There is widespread consensus that weak health systems hamper the effective provision of HIV/AIDS services. In recent years, the ways in which HIV/AIDS-focused programs interact with the delivery of other health services is often discussed, but the evidence as to whether HIV/AIDS programs strengthen or distort overall health services is limited. The aim of this study was to examine the effect of a PEPFAR-funded HIV/AIDS program on six government-run general clinics in Kampala.

Methods

Longitudinal information on the delivery of health services was collected at each clinic. Monthly changes in the volume of HIV and non-HIV services were analyzed by using multilevel models to examine the effect of an HIV/AIDS program on health service delivery. We also conducted a cross-sectional survey utilizing patient exit interviews to compare perceptions of the experiences of patients receiving HIV care and those receiving non-HIV care.

Results

All HIV service indicators showed a positive change after the HIV program began. In particular, the number of HIV lab tests (10.58, 95% Confidence Interval (C.I.): 5.92, 15.23) and the number of pregnant women diagnosed with HIV tests (0.52, 95%C.I.: 0.15, 0.90) increased significantly after the introduction of the project. For non-HIV/AIDS health services, TB lab tests (1.19, 95%C.I.: 0.25, 2.14) and diagnoses (0.34, 95%C.I.: 0.05, 0.64) increased significantly. Noticeable increases in trends were identified in pediatric care, including immunization (52.43, 95%C.I.: 32.42, 74.43), malaria lab tests (1.21, 95%C.I.: 0.67, 1.75), malaria diagnoses (7.10, 95%C.I.: 0.73, 13.46), and skin disease diagnoses (4.92, 95%C.I.: 2.19, 7.65). Patients’ overall impressions were positive in both the HIV and non-HIV groups, with more than 90% responding favorably about their experiences.

Conclusions

This study shows that when a collaboration is established to strengthen existing health systems, in addition to providing HIV/AIDS services in a setting in which other primary health care is being delivered, there are positive effects not only on HIV/AIDS services, but also on many other essential services. There was no evidence that the HIV program had any deleterious effects on health services offered at the clinics studied.

Sexual and reproductive health activities in HIV programmes: can we monitor progress?

BACKGROUND

Resource allocation and integration of services have been of interest recently to achieve health-related Millennium Development Goals. This paper analyses the extent to which countries receiving funding in HIV were able to invest in activities in the area of sexual and reproductive health (SRH).

METHODS

The authors screened the Global Fund grants data with an aggregate investment of US$16 billion in 140 countries to identify indicators revealing typical SRH services. The analysis focused on the 'Top Ten' internationally agreed indicators and used international guidelines and frameworks to define services for SRH and opportunities for 'linkage' between HIV and SRH services.

RESULTS

As of December 2008, 238 of all HIV grants (n = 252) from 133 countries included 1620 service delivery indicators related to SRH. The budgets amounted to US$9.1 billion with US$5.9 billion committed and US$4 billion disbursed. Services included (1) prevention of mother to child transmission for 445,000 HIV-positive pregnant women, (2) 5.7 million care and support services, (3) 1.2 billion condoms delivered, (4) 4.4 million episodes of sexually transmitted infections treated, (5) 61 million counselling and testing encounters, and (6) 11.6 million behavioural change communication (BCC) outreach services for people at high risk and 64.5 million BCC activities for the general population, including youth. Information on the linkage and integration of SRH-HIV services was limited.

CONCLUSION

Around 94% of HIV programmes supported SRH-related activities. However, there is a need to systematically capture data on SRH-HIV service integration to understand the benefits of linking these services.

HIV-related risky practices among Brazilian young men, 2007

Behavioral surveillance surveys have been carried among military conscripts, in Brazil, since 1996. This paper presents the results of the 2007 survey and compares actual findings with those obtained in previous studies carried out in the period 1999-2002. The conscripts were selected with a two stage sampling stratified by geographical region. The study included a self-reported questionnaire and blood collection for HIV and syphilis testing. Data from 35,432 conscripts aged 17-20 years old were analyzed. The findings show a reduction in regular condom use, with fixed and casual partners, mainly among those with poor educational level. The proportion of conscripts that have sex with other men was maintained (3.2%), but the index of risky sexual behavioral showed worsening results in this group. Also, the HIV prevalence rate increased from 9 to 11.3 per 10,000 in 2007, though the increase was not statistically significant. In conclusion, the evidences found in this paper indicate the need of reformulate policy among young adults.

The impact of Global Health Initiatives at national and sub-national level - a policy analysis of their role in implementation processes of antiretroviral treatment (ART) roll-out in Zambia and South Africa

Global Health Initiatives (GHIs), such as the President's Emergency Plan For AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB and Malaria (the GFATM), have emerged as new mechanisms for development assistance in health. By 2008, GHIs were providing two-thirds of all external funding for HIV/AIDS globally. In Zambia and South Africa over the past five years, PEPFAR and the GFATM have provided significant funding for the public sector provision of anti-retroviral treatment (ART). GHIs are a feature of a new global health governance. A study of their role in implementation helps to explore some of the challenges of this new system of governance at national and sub-national level. This paper draws on policy analysis research that involved 150 interviews with policy-makers at national, provincial and district level in both countries, conducted as part of Ph.D. fieldwork between August 2007 and June 2008. Research findings show that GHIs impacted on policy-implementation processes at national and sub-national level, on aspects of the ART programme and the wider health system. Study results highlight GHIs impact both through funding and the mechanisms, and processes by which their support is provided. Evidence suggests that while GHIs have contributed significantly to enabling the rapid scale-up of ART in both the countries, they may also have had a negative impact on coordination, the long-term sustainability of treatment programmes and equity of treatment access. In addition, their programmes may have contributed to disconnect between HIV prevention and treatment initiatives. The comparative findings from Zambia and South Africa highlight some of the challenges in implementation of GHI programmes at country and sub-country level that need to be addressed urgently, to mediate against negative consequences for the health systems and policy processes in both countries.

Expansion of cancer care and control in countries of low and middle income: a call to action

Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda.

United States global health policy: HIV/AIDS, maternal and child health, and The President's Emergency Plan for AIDS Relief (PEPFAR)

The Obama administration has unveiled a new 6-year, $63 billion Global Health Initiative. In addition to the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR) to fund HIV/AIDS, tuberculosis, and malaria, the plan also supports maternal and child health (MCH) initiatives that are rooted in a proposal known as the Mother and Child Campaign. The architects of the Obama administration's Global Health Initiative recommend funding the Mother and Child Campaign at the expense of future funding increases for PEPFAR. The idea that differing global health initiatives must compete with each other lacks not only ethical legitimacy but also scientific merit. We believe that MCH need not to be framed in opposition to PEPFAR. Confronting illness in isolation - whether by funding PEPFAR at the expense of programs that target MCH or vice versa - cannot be our way forward. Given the intimate connection between HIV/AIDS and MCH, we affirm supporting PEPFAR and MCH programs together. We argue that policies that de-emphasize PEPFAR threaten to undermine, rather than support, MCH in countries with high HIV/AIDS prevalence. PEPFAR has directly and indirectly supported the care and treatment of other milieu specific diseases, including those afflicting mothers and children, bringing about broad benefits to the primary healthcare systems of recipient countries. We advocate the vertical integration of MCH initiatives into PEPFAR in order to create a comprehensive approach to addressing MCH against the global backdrop of HIV/AIDS.

How HIV/AIDS scale-up has impacted on non- HIV priority services in Zambia

Background

Much of the debate as to whether or not the scaling up of HIV service delivery in Africa benefits non-HIV priority services has focused on the use of nationally aggregated data. This paper analyses and presents routine health facility record data to show trend correlations across priority services.

Methods

Review of district office and health facility client records for 39 health facilities in three districts of Zambia, covering four consecutive years (2004-07). Intra-facility analyses were conducted, service and coverage trends assessed and rank correlations between services measured to compare service trends within facilities.

Results

VCT, ART and PMTCT client numbers and coverage levels increased rapidly. There were some strong positive correlations in trends within facilities between reproductive health services (family planning and antenatal care) and ART and PMTCT, with Spearman rank correlations ranging from 0.33 to 0.83. Childhood immunisation coverage also increased. Stock-outs of important drugs for non-HIV priority services were significantly more frequent than were stock-outs of antiretroviral drugs.

Conclusions

The analysis shows scale-up in reproductive health service numbers in the same facilities where HIV services were scaling up. While district childhood immunisations increased overall, this did not necessarily occur in facility catchment areas where HIV service scale-up occurred. The paper demonstrates an approach for comparing correlation trends across different services, using routine health facility information. Larger samples and explanatory studies are needed to understand the client, facility and health systems factors that contribute to positive and negative synergies between priority services.

Laboratory systems and services are critical in global health: time to end the neglect?

The $63 billion comprehensive global health initiative (GHI) emphasizes health systems strengthening (HSS) to tackle challenges, including child and maternal health, HIV/AIDS, family planning, and neglected tropical diseases. GHI and other initiatives are critical to fighting emerging and reemerging diseases in resource-poor countries. HSS is also an increasing focus of the $49 billion program of the US President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Laboratory systems and services are often neglected in resource-poor settings, but the funding offers an opportunity to end the neglect. To sustainably strengthen national laboratory systems in resource-poor countries, the following approaches are needed: (1) developing integrative national laboratory strategic plans and policies and building systems to address multiple diseases; (2) establishing public-private partnerships; (3) ensuring effective leadership, commitment, and coordination by host governments of efforts of donors and partners; (4) establishing and/or strengthening centers of excellence and field epidemiology and laboratory training programs to meet short- and medium-term training and retention goals; and (5) establishing affordable, scalable, and effective laboratory accreditation schemes to ensure quality of laboratory tests and bridge the gap between clinicians and laboratory experts on the use of test results.

Struggling with growing bodies within silence and denial: Perspectives of HIV and AIDS among youth in Rural Zimbabwe

Concerns regarding HIV and AIDS were elicited from 546 school youth (51% female, age range 9-25 years) in a Zimbabwean rural district, through a self-generated question writing process. Concerns emerged around how to avoid infection at a time when they were undergoing secondary sexual development, had growing feelings for love and were even engaging in sexual activity, but had limited access to preventive methods due to denial by the adult world. Fears were expressed regarding how to tell one's HIV status, even just after sex. HIV and AIDS were visualised in terms of suffering, loneliness, quarantine and death. The youth stressed they would have difficulties communicating with other people should they suspect or find they are infected with HIV, as this would imply they had been sexually active. They seemed to have knowledge around HIV and AIDS that either was incomplete, or they could not apply given a context of silence and denial around their sexuality. Some of the knowledge was coloured with misconceptions, suggesting contradictory information from multiple sources. After more than two decades, the scenario portrayed raises questions about interventions targeting young people. The question is why is their situation in this state when several stakeholders are actively participating in debates and interventions around their well-being? Campaigns and interventions may need to consider young people's complex social contexts, the factors generating and sustaining their situation, and what role diverse actors and social change processes play in this.

Measuring the HIV/AIDS epidemic: approaches and challenges

In this article, the author reviews current approaches and methods for measuring the scope of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic and their strengths and weaknesses. In recent years, various public health agencies have revised statistical estimates of the scope of the HIV/AIDS pandemic. The author considers the reasons underlying these revisions. New sources of data for estimating HIV prevalence have become available, such as nationally representative probability-based surveys. New technologies such as biomarkers that indicate when persons became infected are now used to determine HIV incidence rates. The author summarizes the main sources of errors and problems with these and other approaches and discusses opportunities for improving their reliability. Changing methods and data sources present new challenges, because incidence and prevalence estimates produced at different points in time are not directly comparable with each other, which complicates assessment of time trends. The methodological changes help explain the changes in global statistics. As methods and data sources continue to improve, the development of statistical tools for better assessing the extent to which changes in HIV/AIDS statistics can be attributed to changes in methodology versus real changes in the underlying epidemic is an important challenge.

The development of antiretroviral therapy and its impact on the HIV-1/AIDS pandemic

In the last 25 years, HIV-1, the retrovirus responsible for the acquired immunodeficiency syndrome (AIDS), has gone from being an "inherently untreatable" infectious agent to one eminently susceptible to a range of approved therapies. During a five-year period, starting in the mid-1980s, my group at the National Cancer Institute played a role in the discovery and development of the first generation of antiretroviral agents, starting in 1985 with Retrovir (zidovudine, AZT) in a collaboration with scientists at the Burroughs-Wellcome Company (now GlaxoSmithKline). We focused on AZT and related congeners in the dideoxynucleoside family of nucleoside reverse transcriptase inhibitors (NRTIs), taking them from the laboratory to the clinic in response to the pandemic of AIDS, then a terrifying and lethal disease. These drugs proved, above all else, that HIV-1 infection is treatable, and such proof provided momentum for new therapies from many sources, directed at a range of viral targets, at a pace that has rarely if ever been matched in modern drug development. Antiretroviral therapy has brought about a substantial decrease in the death rate due to HIV-1 infection, changing it from a rapidly lethal disease into a chronic manageable condition, compatible with very long survival. This has special implications within the classic boundaries of public health around the world, but at the same time in certain regions may also affect a cycle of economic and civil instability in which HIV-1/AIDS is both cause and consequence. Many challenges remain, including (1) the life-long duration of therapy; (2) the ultimate role of pre-exposure prophylaxis (PrEP); (3) the cardiometabolic side-effects or other toxicities of long-term therapy; (4) the emergence of drug-resistance and viral genetic diversity (non-B subtypes); (5) the specter of new cross-species transmissions from established retroviral reservoirs in apes and Old World monkeys; and (6) the continued pace of new HIV-1 infections in many parts of the world. All of these factors make refining current therapies and developing new therapeutic paradigms essential priorities, topics covered in articles within this special issue of Antiviral Research. Fortunately, there are exciting new insights into the biology of HIV-1, its interaction with cellular resistance factors, and novel points of attack for future therapies. Moreover, it is a short journey from basic research to public health benefit around the world. The current science will lead to new therapeutic strategies with far-reaching implications in the HIV-1/AIDS pandemic. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of antiretroviral drug discovery and development, Vol. 85, issue 1, 2010.

The impact of HIV scale-up on health systems: A priority research agenda

Although much has been learned about the implementation of HIV prevention, care, and treatment services in resource-limited settings, the broader impact of the rapid scale-up of HIV programs on fragile health systems has only recently been explored. A high-level working group identified priority research questions regarding the impact of HIV scale-up on key elements of health systems: service delivery; management; information, evidence, and strategic planning; medical products, vaccines, and technologies; health financing and payments; leadership and governance; and the behaviors of providers, consumers, and communities. Rigorous multisectoral studies are needed if HIV program expansion to the millions still needing care and treatment is to continue, and if the synergies between vertically funded HIV programs and the health systems of which they are a part are to be maximized to strengthen nations' ability to meet all their health challenges.

Funding for reproductive health in conflict and post-conflict countries: a familiar story of inequity and insufficient data

Paul Spiegel and colleagues discuss a new study that examines funding for sexual and reproductive health programs in conflict-affected low-income countries.