Though ART programmes are doing well in most countries, there are significant disparities between and within different geographical areas and populations, the International AIDS Conference in Mexico City heard.
Dramatic benefits have come from antiretroviral therapy rollout programmes in resource-limited settings and around three million people are now receiving antiretroviral therapy in low- and middle-income countries. However, there are significant disparities between and within different geographical areas and populations,
Alex Coutinho, Executive Director of the Infectious Disease Institute of Kampala, Uganda, presented a summary of the achievements of African programmes at the ongoing XVII International AIDS Conference in Mexico City.
More aggressive testing programmes have allowed many more HIV-positive people to be identified at early stages of the disease, particularly in Africa. In many cases this allows people to access antiretroviral therapy before their disease progresses into serious clinical manifestations, allowing for greatly improved health outcomes and survival rates.
Much of the improvement in testing and treatment stems from prevention of mother-to-child transmission (PMTCT) programmes for pregnant women. Some 33% of HIV-positive pregnant women globally received PMTCT services, including antiretroviral treatment provision, in 2007 – up from 10% in 2004. And the number of children receiving antiretroviral therapy has more than doubled since 2005 – from 75,000 to almost 200,000 in 2007. However, only 12% of pregnant women are assessed for their own treatment needs, beyond the goals of PMTCT.
Researchers presented data on large-scale antiretroviral treatment rollouts in the Caribbean and Latin America, Botswana, and China
The study looked at mortality rates during the first year of antiretroviral treatment for 5,152 patients in seven Caribbean and Latin American countries who initiated antiretroviral treatment between March 1996 and April 2007. The investigators concluded that "the overall one-year mortality rate and risk factors for death observed in this region were similar to that reported for [other] lower income countries with active follow-up."
Tendani Gaolathe of the Botswana Harvard Partnership reported that an overall six-year survival rate of 88.6% has been observed among the over 75,000 people currently receiving antiretroviral treatment through Botswana's public health care system.
Botswana has had one of the highest HIV prevalence anywhere in the world – an estimated 17.1% and some 113,000 HIV-positive Botswanians require treatment.
However, Botswana's national free antiretroviral treatment programme, which began in 2002, has been one of the world’s most successful in terms of outreach, reaching over 80% of those estimated to need treatment. At present, 32 hospitals and 128 satellite clinics offer screening and treatment services. As of December 2007, a total of 92,932 patients were on antiretroviral treatment in Botswana. The majority of these patients receive care through the public sector.
The overall six-year survival rate of the 75,082 public-sector antiretroviral treatment recipients was reported to be 88.6%.
The researchers stated that "unwavering political commitment, translated into resources and collaboration of development partners, has enabled the successful implementation of Botswana's HAART program. The roll-out of treatment facilities to districts, training and authorisation of nurses to dispense treatment to stable patients, and social mobilisation have enabled high enrolment rates despite constraints on resources."
In the past five years, free antiretroviral therapy access has rapidly expanded in China and as of June 2007, a total of 35,557 patients nationwide received antiretroviral treatment, with 82 per cent currently in treatment. An analysis of virologic response found that rates of treatment response increased with the length of time on therapy.
No differences were found within duration groups according to age or gender.
People receiving care at the level of a county hospital or larger site had by far the lowest failure rates. Failure rates were highest in rural village clinics. This has major implications for the Chinese treatment model, which is based on community-level care.
Male circumcision, math and the distant future
Tripling the rate of male circumcision in a country with a current circumcision rate of 25% and a high rate of heterosexually-acquired HIV will eventually halve HIV incidence, according to a mathematical model by Richard White of the London School of Hygiene and Tropical Medicine presented at the International AIDS Conference.
However, this will take 50 years and the majority of sexually-active adult men (aged 15-45) would have to be circumcised rather than, as recommended by the World Health Organisation, males aged 12-30. Still, circumcision would immediately result in savings, as the cost per HIV infection averted would always be lower than the cost of providing care if that infection had not been averted.
White’s mathematical model explained what a national circumcision programme would have to do to be effective. Alongside, Nicolai Lohse of UNAIDS presented a synthesis of the many recent models of the effect of circumcision, showing that there would be fewer HIV infections in men even if condom use shrank to nothing, and women would benefit as long as condom use did not fall by more than two-thirds.
Frederick Sawe of the Kenya Medical Research Institute reported on how HIV prevention messages were being rapidly integrated into traditional circumcision ceremonies.
John N Krieger of the University of Washington, Seattle, USA, reported that men circumcised in a Kenyan randomised controlled study had no higher rates of sexual dysfunction than uncircumcised controls and reported more sexual pleasure post-circumcision.
Bertran Auvert of the French health research agency INSERM reported that two-thirds of men in the township where the first randomised controlled trial (RCT) of circumcision was carried out, Orange Farm near Johannesburg, South AFrica, would be willing to be circumcised.
Unprotected sex among people with HIV
HIV prevention targeted at people with HIV has been the focus of attention at the International Aids Conference in Mexico City. A number of studies have investigated the factors associated with unprotected sex amongst people with HIV.
A study in South Africa (in KwaZulu Natal Province, with one of the highest HIV prevalences anywhere in the world – 44.4% of the adult population) found that unprotected sex in HIV-positive women was associated with being unemployed, being subjected to physical abuse within a relationship, feeling lonely and marginalised, and feeling unable to negotiate the use of condoms. One of the biggest predictors for unprotected sex in HIV-positive men was drinking alcohol before sex.
European research presented to the conference found that HIV-positive people who had an HIV-positive partner were more likely to report unprotected sex. Amongst HIV-positive women, unprotected sex was associated with older age, wanting a child and use of cannabis.
Risk factors for unprotected sex were somewhat different for gay men in the study, and included younger age and use of recreational drugs as well as drugs which are intended for the treatment of erectile dysfunction. Gay men who reported unprotected sex were also more likely to say that they had a better quality sex life.
The European study also found that people taking anti-HIV drugs were less likely to report unprotected sex, and that those who knew their viral load were even less likely to do so.
Source: Aidsmap News http://www.aidsmap.com/en/news/ux/default.asp
InfoChange News & Features, August 2008