Elizabeth Marum

Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century.

Approaches to the prevention and control of the HIV/AIDS epidemic in Africa have been heavily based on early experiences and policies from industrialised countries, where the disease affects specific risk groups. HIV/AIDS has been dealt with differently from other sexually transmitted or lethal infectious diseases, despite being Africas leading cause of death. In this review, we discuss the evolution of the global response to the epidemic, and the importance of redefining HIV/AIDS in Africa as a public health and infectious disease emergency. We discuss reconsideration of policies and practice around HIV testing and partner notification, and emphasise the need for an increased focus on treatment. Human-rights based approaches to HIV/AIDS prevention might have reduced the role of public health and social justice, which offer a more applied and practical framework for HIV/AIDS prevention and care in Africas devastating epidemic.

A serostatus-based approach to HIV/AIDS prevention and care in Africa

Africa’s HIV/AIDS epidemic has stimulated calls for increased resources1–3 science-based public-health interventions4–6 and access to treatment.27 The declaration of commitment8 from the United Nations General Assembly Special Session on HIV/AIDS in 2001 called for a 20% reduction in the proportion of infants infected with HIV by 2005 and 50% by 2010 (in this article HIV is used to mean HIV-1 and HIV-2). Describing lack of access to antiretroviral therapy as a global emergency WHO and UNAIDS launched an initiative to treat 3 million people by 2005.7 To address prevention and care WHO estimated that up to 180 million individuals per year will need HIV testing by 2005.9 Current practice around HIV testing counselling and consent is an obstacle to scale-up of services and attainment of targets. How to use testing is perhaps the most challenging question in HIV/AIDS policy today. We argue that universal voluntary knowledge of HIV serostatus should be a prevention goal and that facilitation of HIV testing is central to responding effectively to the epidemic in Africa. (authors)

Rapid HIV testing with same-day results : a field trial in Uganda

Rapid, on-site HIV testing with same-day results may improve services and increase the number of clients who learn their serostatus in developing countries. To validate test performance under field conditions and assess the change in the proportion of clients who learn their serostatus, we conducted a field trial using the Capillus HIV-1/HIV-2 assay (Cambridge Diagnostics) at the AIDS Information Centre counselling and testing sites in Uganda. Compared to the standard 2-EIA testing algorithm, the sensitivity of Capillus was 99.6% (95% CI; 98.5%, 99.9%), the specificity was 98.8% (95% CI; 98.1%, 99.3%), the positive predictive value was 96.5% (95% CI; 94.5%, 97.8%), and the negative predictive value was 99.9% (95% CI; 99.5%, 100%). It took less than 5 min to perform a single test, and results were returned to clients in less than an hour, during which time clients were counselled. This resulted in a 27% increase in the proportion of clients who learned their serostatus and received counselling. We conclude that simple, rapid HIV tests can be performed accurately on-site within the time frame of a clinic visit, increasing the number of clients who learn their serostatus and receive post-test counselling.

Lack of knowledge of HIV status a major barrier to HIV prevention, care and treatment efforts in Kenya: results from a nationally representative study.

Background We analyzed HIV testing rates, prevalence of undiagnosed HIV, and predictors of testing in the Kenya AIDS Indicator Survey (KAIS) 2007. Methods KAIS was a nationally representative sero-survey that included demographic and behavioral indicators and testing for HIV, HSV-2, syphilis, and CD4 cell counts in the population aged 15–64 years. We used gender-specific multivariable regression models to identify factors independently associated with HIV testing in sexually active persons. Results Of 19,840 eligible persons, 80% consented to interviews and blood specimen collection. National HIV prevalence was 7.1% (95% CI 6.5–7.7). Among ever sexually active persons, 27.4% (95% CI 25.6–29.2) of men and 44.2% (95% CI 42.5–46.0) of women reported previous HIV testing. Among HIV-infected persons, 83.6% (95% CI 76.2–91.0) were unaware of their HIV infection. Among sexually active women aged 15–49 years, 48.7% (95% CI 46.8–50.6) had their last HIV test during antenatal care (ANC). In multivariable analyses, the adjusted odds ratio (AOR) for ever HIV testing in women ≥35 versus 15–19 years was 0.2 (95% CI: 0.1–0.3; p<0.0001). Other independent associations with ever HIV testing included urban residence (AOR 1.6, 95% CI: 1.2–2.0; p = 0.0005, women only), highest wealth index versus the four lower quintiles combined (AOR 1.8, 95% CI: 1.3–2.5; p = 0.0006, men only), and an increasing testing trend with higher levels of education. Missed opportunities for testing were identified during general or pregnancy-specific contacts with health facilities; 89% of adults said they would participate in home-based HIV testing. Conclusions The vast majority of HIV-infected persons in Kenya are unaware of their HIV status, posing a major barrier to HIV prevention, care and treatment efforts. New approaches to HIV testing provision and education, including home-based testing, may increase coverage. Targeted interventions should involve sexually active men, sexually active women without access to ANC, and rural and disadvantaged populations.

Using mass media campaigns to promote voluntary counseling and HIV-testing services in Kenya

Background:Kenya, a country with high HIV prevalence, has seen a rapid scale-up of voluntary counseling and HIV-testing (VCT) services from three sites in 2000 to 585 by June 2005. From 2002 onwards, services were promoted by a four-phase professionally designed mass media campaign. Objective:To assess the impact of a mass media campaign on VCT services. Design:Observational data from client records. Methods:VCT client data from 131 voluntary counseling and testing sites were included. Descriptive statistics and Poisson regression were used to assess the impact of campaign phases. Results:Client records (381 160) from 131 sites were analyzed. A linear increase in new sites and an exponential increase in client utilization were observed. Regression analysis revealed that the first phase of the campaign increased attendance by 28.5% (95% confidence interval = 15.9, 42.5%) and the fourth by 42.5% (95% confidence interval = 28.4, 64.1%). These two phases, which directly mentioned HIV, had more impact on utilization than the second and third phases, which did not have a significant effect. Conclusion:The Kenyan experience suggests that a professional, intensive mass media campaign is likely to contribute to increases in utilization of testing. Expansion of programs for counseling and HIV testing in developing countries is likely to be facilitated by mass media promotion of these services.

Voluntary Counseling and Testing

allows individuals to learn their HIV status through preand post-test counseling and an HIV test. VCT is client-initiated, as opposed to provider-initiated testing and counseling (PITC) when health care providers initiate discussion of HIV testing with clients who are seeking health care for other reasons. VCT can be provided through stand-alone clinics or offered through community-based approaches, such as mobile or home-based HIV testing. In addition, counseling for VCT may take place at the individual, couple, or group level. VCT was originally implemented as an individual-level, clinic-based procedure. Different modalities evolved, including communitybased and couple-based approaches, to increase access and uptake. Across all of these different strategies, by combining personalized counseling with knowledge of one’s HIV status, VCT is designed to motivate people to change their behaviors to prevent the acquisition and transmission of HIV, reduce anxiety over possible infection, facilitate safe disclosure of infection status and future planning, and improve access to HIV prevention and treatment services. From 2007-2008, the number of facilities offering VCT increased 35% globally; however, the majority of people globally remain unaware of their HIV status.1 Despite decades of VCT implementation, additional research is needed to understand the best approaches for increasing uptake of VCT and reduction of HIV-related risks in the context of VCT.

What took you so long? The impact of PEPFAR on the expansion of HIV testing and counseling services in Africa.

Abstract: HIV testing and counseling services in Africa began in the early 1990s, with limited availability and coverage. Fears of stigma and discrimination, complex laboratory systems, and lack of available care and treatment services hampered expansion. Use of rapid point-of-care tests, introduction of services to prevent mother-to-child transmission, and increasing provision of antiretroviral drugs were key events in the late 1990s and early 2000s that facilitated the expansion of HIV testing and counseling services. Innovations in service delivery included providing HIV testing in both clinical and community sites, including mobile and home testing. Promotional campaigns were conducted in many countries, and evolutions in policies and guidance facilitated expansion and uptake. Support from Presidents Emergency Plan for AIDS Relief and national governments, other donors, and the Global Fund for AIDS, Tuberculosis, and Malaria contributed to significant increases in the numbers of persons tested in many countries. Quality of both testing and counseling, limited number of health care workers, uptake by couples, and effectiveness of linkages and referral systems remain challenges. Expansion of antiretroviral treatment, especially in light of the evidence that treatment contributes to prevention of transmission, will require greater yet strategic coverage of testing services, especially in clinical settings and in combination with other high-impact HIV prevention strategies. Continued support from Presidents Emergency Plan for AIDS Relief, governments, and other donors is required for the expansion of testing needed to achieve international targets for the scale-up of treatment and universal access to knowledge of HIV status.

HIV, syphilis, herpes simplex virus 2, and behavioral surveillance among conflict-affected populations in Yei and Rumbek, southern Sudan

Little is known about the HIV epidemic in conflict-affected southern Sudan. During 2002–2003, we conducted behavioral and biological surveillance surveys and sequential sampling in antenatal clinics in Yei, Western Equatoria, and Rumbek, Bar-el-Ghazal. HIV prevalence among individuals aged 15–49 years ranged between 0.4% in Rumbek town and 4.4% in Yei town, and among pregnant women between 0.8 and 3.0%, respectively. After the recent peace agreement, targeted prevention programmes are urgently needed to prevent further spread.

Expanding HIV Testing: Back to the Future

Abstract:The value of HIV testing has grown in parallel with the development of increasingly effective HIV treatment. Evidence for the substantial reductions in transmission when persons receive antiretroviral therapy creates a new impetus to increase testing and early diagnosis. Models of treatment as prevention—dubbed “test and treat”—give reason for optimism that control and elimination of HIV may now be within reach. This will be possible only with widespread testing, prompt and accurate diagnosis, and universal access to immediate antiviral therapy. Many successful approaches for scaling up testing were pioneered in resource-limited countries before they were adopted by countries in the developed world. The future of HIV testing is changing. Lessons learned from other case-finding initiatives can help chart the course for comparable HIV testing endeavors.

Knowledge is power; information is liberation

, Dermot Maher discusses the ethics of conduct-ing population-based surveys involving clinical tests for research and surveil-lance purposes without routinely giving participants their test results, if these are positive, so that they can seek access to lifesaving treatment. Maher argues specifically that because antiretroviral treatment is now widely available, even in low- and middle-income countries, it is no longer ethical to fail to inform research participants when the result of a test for the detection of human im-munodeficiency virus (HIV) infection turns out to be positive.