The biennial AIDS Conference is so large that everyone who goes has a different conference. There were thousands of presentations and posters at the meeting. Many repeated what we already know – that unsafe sex and IV drug use transmit HIV; that many people deny they are at risk; that many still don’t use condoms even knowing they are at risk; stigma and discrimination are still rife; life-saving antiretroviral drugs are still being denied to the vast majority of those who need them; women have not yet empowered themselves enough to demand safe sex or reject violence and overcome gender inequity. We were therefore once again confronted with the terrible numbers showing how much the epidemic is still growing and how many are dying. A lot of people in a lot of countries, including many attending this conference for the first time, are still having to learn what has been learned by so many of their neighbours who are living with more “mature” epidemics.
As in every conference before it, in addition to the incredible networking that takes place, this conference had much that is new and valuable to offer. Although the world’s newspapers published a lot of the bad news, and the extent of the AIDS epidemic is very bad news indeed in many places, everything is not negative. First, downward trends in HIV prevalence if not also incidence have been recorded in studies in Thailand, Uganda, Brazil and Kenya. Hundreds of presentations showed that AIDS prevention, treatment and care activities actually work when they are applied systematically on a national and local scale. What works is a matter of record. It is only where it is not being done that the epidemic gets a foothold and spreads.
I had the impression that there were more government representatives in this conference compared to previous ones, including from Ministries of Health. They had come to listen as well as to speak, certainly in the sessions I attended, and their interest is very good news indeed.
The price of antiretroviral drugs has not yet dropped to nil, but substantial price cuts have been offered to some middle-and low-income countries. At least two countries – Thailand and Brazil – are now manufacturing their own generic versions of many antiretrovirals for national delivery, and both have offered south-to-south technical assistance to help other countries to do so. Reports were given of the successful delivery of antiretrovirals in extremely poor rural communities, e.g. the work of Paul Farmer in rural Haiti, with clear improvements in health and survival times in a very short time.
New preventive treatment ideas had been tried or were suggested. One, on the drawing board, was proposed by David Cooper, a clinician from Australia. In line with the success of post-exposure prophylaxis in preventing HIV infection following needlestick injuries, rape and other unprotected high-risk sex, he believes that a regular low dose of a non-toxic antiretroviral might be taken by those at regular risk, e.g. in serodiscordant couples or during breastfeeding, to reduce viral load on one hand and protect against infection on the other. Another new idea, which has been shown to work, is to give regular presumptive treatment for STDs of a single dose of azithromycin to women sex workers, based on syndromic management, which has been shown to reduce chlamydia and gonorrhoea substantially in four visits in one study and remove one co-factor for risk of sexual transmission of HIV.
Men still don’t like condoms, and women still don’t insist on them nearly often enough, but James Curran from the US reminded us that there is a two billion condom availability gap in Africa alone. Yet, condoms, he said, are not patented, not expensive to produce and could be free. Why, some of us have been asking for several conferences in a row now, were condoms not on the main agenda more, but only the subject of a UNAIDS satellite meeting? In fact, condoms are mentioned in 777 abstracts but condom promotion was mentioned in only 111 of these. Below are some of the more imaginative condom promotion projects I read about, though there are many others that serve as models. Pregnancy, breastfeeding and prevention of mother-to-child transmission were a focus again this year. However, the importance of saving the lives of women in developing countries by giving them antiretroviral treatment as well their infants, not least to save the lives of their infants in the longer term and reduce mass orphanhood, was finally on the conference agenda – for the very first time.
The summaries below are a selection of information on sexual and reproductive health from the Conference which took place in Barcelona, 7–11 July 2002. Some are based on presentations; the rest are culled from the conference CD using the keywords of pregnancy, fertility, sexually transmitted, and condom promotion. A number of items from the current published literature are also included.
I start with a paper from the Lancet that was published just as the conference was starting, which calls for HIV/AIDS in Africa to be defined and treated as an infectious disease emergency.
Applying public health and social justice principles to AIDS in Africa
This review [1] argues that some approaches to HIV/AIDS are poorly adapted to the crisis in Africa, which should be defined and treated as an infectious disease emergency, and argues for a reconsideration of policy and practices in HIV testing and partner notification. It stresses that among the range of possible philosophical and technical approaches, HIV/AIDS prevention must interrupt HIV transmission, mitigate the epidemic’s clinical and social effect, reduce stigma and vulnerability, and promote the rights and welfare of HIV-infected and uninfected people. For Africa, it calls for a public health model that includes voluntary counselling, testing and partner notification; routine HIV testing in prevention services such as prevention of mother-to-child transmission and treatment for sexually transmitted diseases; routine diagnostic HIV testing for patients seeking medical treatment, both for general medical care and tuberculosis; and enhanced access to HIV/AIDS care, including highly active antiretroviral therapy and treatment for opportunistic infections. However, for treatment to reach the people who need it, routine HIV diagnostic testing is required. It points out that in many African settings, more than half of hospital beds are occupied by patients with HIV-related disease, and more than half of new patients with tuberculosis are HIV-infected, making it urgent that HIV become a routine component of all health care interactions in the long term. It concludes:
“The normalisation of HIV/AIDS in a philosophical context of public health, medical ethics, and social justice is not a threat to individual human rights; rather, failure to prevent HIV transmission constitutes an infringement of human rights that hampers Africa’s human and social development. The concept of social justice is most relevant to the policy issue of how to increase access to effective HIV/AIDS treatment in Africa.”
1. De Cock KM et al. Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century. Lancet 2002;360(6 July):67-72.
HIV drug treatment cost-effective in resource-poor settings
There was a time in the 1980s when no one wanted to recognise the importance of AIDS; it was only advocacy on the part of the populations who first acknowledged they had it that put this disease on the map. Everyone said HIV treatment drugs couldn’t successfully be delivered in resource-poor settings in developing countries either. In Haiti, working with a dedicated team of community health care workers, many of whom are HIV-positive, Paul Farmer, a US medical anthropologist, has proved them wrong. They have set up a system of directly observed antiretroviral treatment, initially for 200 of over 2,000 HIV-positive patients in rural Haiti. Of the 200, mortality has declined dramatically; only one person has died to date. One of the biggest difficulties the Haitian project has encountered in scaling up this project to cover all patients was that many donors declined to provide funding on the basis that the project would not be cost-effective or sustainable. He counters that most cost-effectiveness analyses failed to take into consideration the rapidly changing costs of antiretrovirals, the widening income gulf between rich and poor, and the costs of treating opportunistic infections over and over. Most importantly, he said, these studies do not take into account ethical considerations and issues of social injustice. He highlighted the positive impacts of linking prevention to care, noting a much larger uptake of voluntary testing and counselling services when antiretrovirals became accessible. Farmer highlighted the capacity of antiretroviral treatment to reduce stigma against people living with HIV/AIDS, which is crucial to prevention efforts and people coming forward for help [1].
1. Farmer P. Introducing ARVs in resource-poor settings: expected and unexpected challenges and consequences. Plenary presentation ThOr240. AIDS 2002. Barcelona. July.
Treatment Action Campaign wins against government appeal, South Africa
A high court in South Africa ordered the government to provide access to treatment to reduce the risk of mother-to-child transmission of HIV at birth, following a case filed by the Treatment Action Campaign and others in 2001. The national government and the executive councils responsible for health in all provinces save the Western Cape in South Africa lost an appeal in the Constitutional Court against the order. The finding was that government had acted unreasonably in (a) refusing to make the antiretroviral drug nevirapine available in the public health sector where the attending doctor considered it medically indicated and (b) not setting out a timeframe for a national programme to prevent mother-to-child transmission of HIV. The appeal court ordered government to devise and implement within its available resources a comprehensive and co-ordinated programme to realise progressively the rights of pregnant women and their newborn children to have access to health services to combat mother-to-child transmission of HIV. The programme must include counselling and testing pregnant women for HIV, counselling HIV-positive pregnant women on the options open to them to reduce the risk of mother-to-child transmission of HIV, and making appropriate treatment available, specified as the use of nevirapine unless better treatment becomes available. It was considered insufficient that doctors at public hospitals and clinics other than research and training sites were not enabled to prescribe nevirapine to reduce the risk of mother-to-child transmission of HIV even where it was medically indicated, and that adequate facilities for the testing and counselling of pregnant women concerned did not exist outside those sites. Lastly, government was ordered to pay the applicants’ costs and refused application to adduce further evidence [1].
1. TAC wins Mother-to-Child-Transmission Court Case in the Constitutional Court. Accessed at: www.tac.org.za, 5 August 2002.
Brazil to share generic drugs and technical know-how with other countries
Brazil has implemented a comprehensive HIV prevention and treatment programme that has been a major success. The prevention arm focuses on condom use and has achieved a significant reduction in the rate of HIV incidence, particularly in more vulnerable populations, including men who have sex with men, sex workers and injection drug users. As the main architect of the programme Paolo Teixeira said: “No time can be spent with ambiguous prevention messages. HIV transmission happens [primarily] through sexual contact and prevention is made through condom use. Other alternatives, such as postponement and abstinence are indubitably incompatible with our global reality… Controlling the AIDS epidemic also [requires] mobilising the entire national capacity to offer antiretroviral treatment, even when the optimal infrastructure is not available.” The number of AIDS deaths has fallen dramatically in Brazil since the adoption of antiretroviral therapy in 1996. The average survival time has increased and is now close to five years, a 12-fold increase, reported Dr Ricardo Marins in a poster at the conference.
The number of patients receiving antiretroviral drugs in Brazil is increasing linearly by 1,400 patients a month, but the cost per patient per day has been reduced by 37%. Had it not gone down, $220 million extra would have been required between 1997 and 2000 [1]. The cost per patient decreased as a result of two factors. First, investments were made by the Ministry of Health to establish domestic national pharmaceutical laboratories. Brazil distributes 15 antiretroviral drugs, of which eight are locally produced. Secondly, Brazil has negotiated with Abbott, Merck and Roche to cut the price of four drugs by more than 50%. Teixeira indicated that “national production under compulsory licensing has been a strong argument to push these companies to the negotiation table” [2].
At the conference, Teixeira announced the launch of a Brazilian international cooperation programme in May 2002 to provide donations in kind of locally produced drugs and technical assistance in ten pilot projects in poorer countries, with a value of US$1 million annually. The technical assistance will involve training and capacity-building in clinical management and drug adherence, and transfer of technology for local drug production. [3].
1. HDN Key Correspondent. Scaling up: lessons from Brazil. AIDS 2002 Conference News by Health & Development Networks, E-mail: [email protected]. On: [email protected], 12 July 2002.
2. Szwarcwald CL. The impact of national production of ARV drugs on the cost of ARV therapy in Brazil, 1997-2000. Symposium presentation ThOrE1424. AIDS 2002. Barcelona. July.
3. Tixeira, PR. Program implementation and scaling up: barriers and successes. Plenary presentation ThOr241. AIDS 2002. Barcelona. July.
Thailand offers transfer of technical know-how in drug production
The Thai Health Ministry has launched a programme called the Thai/Africa Collaboration to provide government-to-government transfer of technology of pharmaceutical know-how to interested African countries, based on their existing capacities and investment possibilities. Programmes would aim for as low a profit as possible, working with private manufacturers and established price control agreements. The goal would be sustainability of treatment, a constant supply of drugs and bulk drug purchase through the public health system, as in Thailand. Steps towards setting up such a programme include the identification of drugs to be locally produced and their patent status in the country under TRIPS, contacting the Thai Ministry of Health and Government Pharmaceutical Organisation for their agreement, the establishment of supplies of raw materials, capacity building and training in Thailand on quality assurance [1].
1. Kraisintu K. Technology transfer for local production of HIV/AIDS-related drugs in African countries: collaboration between Thailand and Africa. Symposium presentation ThOrE1422. AIDS 2002. Barcelona. July.
New Indian health minister to include treatment and care in AIDS programme
In a significant shift, the new Health Minister for India, Shatrughan Sinha, acknowledged at the AIDS Conference in Barcelona that care and treatment were a necessary part of an appropriate response to HIV in India. India had previously maintained silence on this issue and made prevention its only agenda to date. India is on the verge of scaling up a prevention of mother-to-child transmission of HIV (PMTCT) project that has shown high rates of effectiveness in its pilot phase. At a special session organized by the UNAIDS country office in Barcelona, the willingness to consider a limited care response was obvious in more than one quarter. The project director of the government-run AIDS Control Society in Tamil Nadu said they could afford to consider antiretrovirals for women who enrolled in the programme. Positive women and men in the room greeted his suggestion with applause and demanded access to treatment for all people in the country. Speaking passionately on behalf of positive women, a woman from the Indian Network of Positive People shouted, “We want drugs. Here in Barcelona we see that so many people in these countries get free drugs. We also deserve to live. Having HIV is not a sin.” There is increasing demand from activists on the ground that access to treatment should be part of the prevention agenda, both on pragmatic as well as ethical grounds. With proof that low viral loads in pregnant women are an effective barrier to transmission, millions of babies born to positive mothers could be HIV-free [1].
1. HDN Key Correspondent. UNAIDS special session on India. AIDS 2002 Conference News by Health & Development Networks. On: [email protected], 24 July 2002.
WHO approves 40 AIDS drugs
The fray over patented and generic anti-AIDS treatment drugs was made more complicated when the World Health Organization approved a list of 40 quality drugs, which includes anti-retrovirals, anti-bacterials, anti-fungals and anticancer drugs. Inclusion of generics lends these drugs legitimacy by offering WHO’s seal of approval, regardless of intellectual property rights. If the drug was legal and registered in the country producing it, that was the entry ticket. Patents were considered a national issue. The list will be expanded and updated every two months [1].
1. WHO unveils list of ‘quality’ drugs for treating AIDS. On: www.aegis.org/news/wsj/2002/WJ020306.htm 2002.
Presumptive STD treatment greatly reduces STD rates, South Africa
At two mobile clinics for sex workers servicing miners in South Africa, peer educators encouraged all women at high risk to attend monthly for examination, STD treatment and counseling. One group of women with STD symptoms was given monthly syndromic management and another was given monthly presumptive treatment with a single dose of azythromycin, then tapered to quarterly after the woman’s sixth visit. In a cohort of women (n=180) attending the clinic at least nine times, the prevalence of gonorrhoea was 15.1% at initial visit, 13.3% at the sixth visit and 8.9% at ninth visit (p=0.18). The prevalence of chlamydia was 16.8%, 2.8% and 3.9% at first, sixth and ninth visits (p<0.001) and of either infection, 25.8%, 15.0% and 11.1% respectively (p<0.001). Women reported no change in numbers of partners, but condom use with last client increased from 63% to 71%. A 46.7% decrease in male STDs was documented from passive surveillance. This represents a successful replication of a targeted intervention resulting in rapid and large decreases in the prevalence of curable STDs. Tapering of presumptive treatment from monthly to quarterly did not result in rebound STD increases. Curative and preventive services, including periodic presumptive treatment for women at high risk, can rapidly reduce prevalence of curable STDs in important core populations, and contribute to reduction of STD prevalence in the wider community [1].
1. Steen R. STD declines in a South African mining community following addition of periodic presumptive treatment to a community HIV prevention project. Abstract TuOrD1150. AIDS 2002. Barcelona. July.
Presumptive STD treatment reduces sexual risk behaviour, Nairobi
This clinical trial assessed whether antibiotic prophylaxis would reduce HIV acquisition in women sex workers. In May 1998 a cohort of HIV seronegative sex workers was established in Nairobi, half of whom were randomly assigned to receive 1 gm of azithromycin monthly and the other half a placebo, in a double-blind fashion. All women are counselled to reduce the risk of STDs, and risk behaviour was assessed at baseline and three-monthly follow-up visits. Urine is collected monthly for STD testing, and full physical examinations, including STD work-ups, are performed at baseline and six-monthly intervals. By November 2001, 457 women had been enrolled. At enrollment, they reported a mean of 15.2 sex partners per week, 22% reported never using condoms in the previous month and 17% always using condoms. At their most recent follow-up visit, they reported a mean of 4.1 sex partners per week and 61% reported always using condoms. Reductions in partners and increases in condom use were statistically significant and associated with reduced STD incidence (p<0.001). 28 women sero-converted to HIV in approximately 718 person-years of follow-up, for an annualised HIV incidence of 3.9 per 100 person-years. Incidence of gonorrhoea was 4.7% by cervical culture/PCR and 10.2% on urine PCR; chlamydial infection 3.8% by cervical PCR and 14.9% on urine PCR; and syphilis incidence 1.7%. Genital ulcers were observed on only six follow-up visits. HIV incidence in this cohort of high-risk women was much lower than anticipated, likely due to a combination of behavioural change after enrollment and low STD incidence, particularly genital ulcers. Other HIV prevention studies such as vaccine trials will face similar challenges, as successful promotion of condom use and other safer sex practices in high-risk individuals can greatly reduce risk for HIV acquisition [1].
1. Kimani J et al. A randomized, placebo-controlled trial of monthly azithromycin to prevent sexually transmitted infections (STI) and HIV in Kenyan female sex workers. Abstract TuOrD1151. AIDS 2002, Barcelona. July.
Contracting private sector GPs to provide STD services, South Africa
Syndromic management of STDs is one of the strategic components outlined by the Department of Health (DoH) in South Africa for fighting HIV. The Western Cape Province has 25 health districts, within which all public health facilities use this approach when treating STDs. About 125,000 patients are treated annually. Health care is also provided by the private sector and it is estimated that private general practitioners (GPs) see ±60% of patients with STDs, where infections are often ineffectively treated, being restricted by drug costs and the lack of training in the syndromic approach. A public–private partnership was set up whereby GPs were trained and contracted to the DoH to provide free STD treatment using the syndromic approach. Drugs were supplied by the DoH to the GPs in a pre-packaged form as part of a complete package. A pilot programme involving eight GPs began province-wide in January 2002. Results will enable planning in terms of how many GPs to contract and what the cost implications will be. In the absence of good surveillance data, this programme is also a good tool to monitor the epidemic. If successful, the eventual aim is to integrate STD management into other programmes through public–private partnership, such as voluntary counselling and testing, prevention of mother-to-child transmission and general HIV and tuberculosis care [1].
1. Patel B et al. Extending the management of sexually transmitted infections to the private health sector by developing a public private partnership. Abstract MoPeF4051. AIDS 2002, Barcelona. July.
Violence, not STDs, main concern of young West African sex workers
Focus group discussions were held with 16 peer educators of young sex workers from seven West African nations over a three-month period by a UNAIDS researcher in Côte d’Ivoire. An unexpected finding was that STDs were not the primary concern of the sex workers. Instead, they were preoccupied with and visibly traumatised by social stigma and physical and emotional violence, which are a daily feature in their lives. They perceive the risk of violence to be greater from their regular sexual partners or “boyfriends” than from paying clients. Even the threat of violence or abandonment by these “boyfriends” seriously disempowers them from negotiating HIV preventive behaviours with them. The violence includes forced sex, physical and emotional abuse and the threat of being abandonned. The non-use of condoms with their regular sexual partners, in the absence of other contraception, results in frequent abortions. The fact that violence prevents sex workers and other vulnerable women from adopting safe sexual behaviours, even if they are highly motivated to do so, is often overlooked. Action is needed to break the silence surrounding gender and sexual-based violence and its role in limiting the effectiveness of condom promotion and HIV prevention efforts [1].
1. Sullivan J. Domestic violence as perceived by sex workers in West Africa. Abstract WePeG6941. AIDS 2002, Barcelona. July.
Improving services for women sex workers in Cambodia
In Cambodia, clinics for the management of STDs in women sex workers were established by the National Center for HIV/AIDS, Dermatology and STD in conjunction with the Institute of Tropical Medicine, Belgium, but without addressing other reproductive health needs. The aim of this study was to assess knowledge about sexual and reproductive health among women sex workers in Cambodia and their needs for more comprehensive sexual and reproductive health services. In January 2000, a review of literature and documents related to sex work, STI and reproductive health in Cambodia was carried out. Group interviews with 38 women sex workers and key informants were carried out. Medical records from women sex workers attending one mobile clinic from 1998–2000 and one government STI clinic for women sex workers from August 2000 to July 2001 were also reviewed. Interviews indicated that 7 out of 38 (20%) women sex workers had ever used a modern contraceptive method besides condoms, and only 2 out of 38 (5%) were currently using one. Data from the government clinic showed that only 1.5% of women sex workers were currently using any modern contraceptive method, excluding condoms (10/648 or 1.5%). Data from the government clinic and the mobile clinic respectively showed that 129 out of 592 (21.8%) and 445 out of 1744 (25.5%) women sex workers reported at least one previous abortion. These findings show the need for contraception and safe, accessible abortion services among sex workers in Cambodia, and raise the issue of reproductive rights and needs of women sex workers in general. However, concerns on the part of the National HIV/AIDS Control Programme about the negative impact of other contraceptive methods on consistent condom use by women sex workers will have to be addressed [1].
Adult HIV prevalence in Cambodia is now the highest among the Asia-Pacific countries. The predominant mode of transmission is sexual contact, often during commercial sex. Médecins sans Frontières (MSF) has been operating four STD clinics in locations with a thriving sex industry in Cambodia. In the beginning, the clinics provided STD consultations and HIV/AIDS education to sex workers and to the general population. One of the four clinics focused exclusively on sex workers from the start. The clinics also do active condom promotion, including day and night condom selling in entertainment establishments in the red-light districts to sex workers and their clients. Since 1999, counselling and basic AIDS care have also been made available in the clinics. In 2000, MSF started focusing more exclusively on sex workers, and the clinics broadened the services to sex workers to include monthly STD screening, literacy classes, safe sex negotiation skills training and empowerment. After analysing the reasons for non-attendance by some sex workers, it was decided to extend the working hours, improve communication through outreach to sex workers and brothel owners, and provide transport from sex establishments to clinics to improve attendance. In 2000, the four clinics sold over 2 million condoms. Of 13,016 STD consultations, 57% were for sex workers. The average monthly attendance rate of sex workers in three of the four clinics for STD screening increased from 43%, 42% and 59% in 1999 to 86%, 80% and 73% respectively in 2000. The clinic that had always focused on sex workers had on average 97% monthly attendance rate. Self-reported condom use was well over 90%. Staff of the clinics also report growing self-esteem among sex workers with more attention to their personal health. It is therefore possible to establish STD care clinics with high attendance of sex workers by providing them more comprehensive services of good quality on a voluntary basis without interventions from the local authorities to force them to come. But, such clinics have to focus on sex workers and create a sex-worker friendly environment [2].
The effectiveness of these and other services for sex workers were reflected in sentinel surveillance studies by Family Health International among representative, population-based samples of brothel-based sex workers (n=141), police (n=165) and women attending antenatal or family planning clinics (n=451) from seven provinces. Low rates of both ulcerative and non-ulcerative STDs support recent behavioural trends showing increased levels of condom use in commercial sex and decreases in commercial sex use among men. These findings are also consistent with recent declining HIV seroprevalence trends showing 21–48% reductions in HIV-1 prevalence for these same groups between 1997 and 2000. Triangulation of data from STD behavioral and HIV surveys provides evidence that Cambodia’s targeted policies of STD control and HIV prevention are having a significant effect.
1. Delvaux T et al. Integrating reproductive health services into STI clinics for female sex workers: the case of Cambodia. Abstract D11354. AIDS 2002, Barcelona. July.
2. Ir P. Reaching sex workers for HIV prevention: lessons learnt from four STI clinics in Cambodia. Abstracts F12473 and WePpF2117. AIDS 2002, Barcelona. July.
3. Hor LB et al. Success of Cambodian HIV prevention efforts confirmed by low prevalence of sexually transmitted infections and declining HIV and risk behaviors. Abstract WeOrC1271. AIDS 2002, Barcelona. July.
Couple counselling on sexual communication and reproductive health during antenatal care, Zimbabwe
Traditionally, couples in Zimbabwe communicate about sex and sexuality through third parties like uncles and aunts. With the advent of the HIV/AIDS epidemic this has been seen as one of the barriers to negotiation for safer sex and adoption of protective behaviours by couples. A study in Zimbabwe involved husbands of 100 pregnant women in antenatal care. In addition to health talks, couples underwent counselling with a trained counsellor covering issues such as general family welfare and support, pregnancy, relationships, couple communication and STIs/HIV. Couples attended up to three counselling sessions, and at the end reported more confidence in talking about their relationships, STIs/HIV, condom use and dealing with situations where one partner is unfaithful. An understanding of couples’ benchmarks in sexual communication is crucial to enable them to do their own risk assessment and therefore adopt appropriate risk reduction measures. Sexual communication must be tackled within the broader context of family health and must be made relevant to all key issues like pregnancy, family planning and STDs/HIV. The next steps in this study include collecting information on sexual behaviour, condom use and partner communication at six months post-partum and comparing this with couples who did not go through couple counselling [1].
1. Tongoona L et al. Couple counseling in the context of antenatal care: a strategy for reducing STD/HIV risk? Abstract TuPeD4913. AIDS 2002, Barcelona. July.
Integrated care for HIV-positive pregnant Ethiopian women, Jerusalem
Of the 87 women currently given care at this AIDS clinic, 88.5% are immigrants from Africa, mostly Ethiopia. This population is characterized by intercultural differences, language barriers, poverty, social withdrawal and stigmatization, complicating care and leading to low compliance with antiretroviral regimens. They have specific reproductive health problems that require attention: cervical and uterine neoplasia, and STDs. They are also in need of effective contraception, counselling for safer sex and antiretroviral treatment during pregnancy and delivery to prevent perinatal HIV transmission. A model of integrated treatment delivered by a multidisciplinary team was developed, which includes the AIDS clinic personnel, a gynaecologist interested in HIV-related conditions and an Ethiopian woman who is familiar with Ethiopian community life to coordinate medical, social and gynaecological aspects of care. The integration of these specialities into one cohesive team has greatly improved the screening efficacy for cervical cancer, the treatment of pregnant women and compliance with complex antiretroviral regimens. It has resulted in a number of cures of cervical neoplasia and had an important effect on mother-to-child transmission of HIV [1].
1. Hauzi M et al. Integrated AIDS care, a multidisciplinary approach to HIV related ob/gyn disorders in an immigrant HIV+ Ethiopian population, Jerusalem. Abstract MoPeB3214. AIDS 2002, Barcelona. July.
First efforts at integration of HIV information into family planning clinic services in Uganda
In 1999 family planning (FP) and HIV programme managers in Uganda developed a package of interventions to strengthen the integration of HIV into FP care. The package included a two-day training on HIV counselling skills, supervisory visits every two months, a new clinical form to assess the client’s need for other services, referral slips and informational materials. Prior to the interventions, baseline observation of client provider interactions during 24 FP care sessions was carried out. After six months of interventions, follow-up observations were conducted at 22 sessions. The observers were clinician counsellors who scored the performance using a checklist which had been extensively piloted. The proportion of sessions in which the provider explained that the risk factors for pregnancy were the same as those for HIV rose from 17.4% at baseline to 25% (p=0.39) at follow-up. Discussion of the need for HIV services rose from 4.3% to 18.2% (p=0.02). Discussion of the need for condoms in addition to any other FP method chosen by the client rose from 13% to 31.8% (p=0.09). Although training of these providers in HIV counselling skills increased the level of HIV discussion with their clients, the level remained unacceptably low. It is recommended that FP and HIV programme managers review the current guidelines, assess the gaps in the communication skills of FP providers and address these gaps [1].
1. Neema S et al. Impact of HIV counseling training on the providers’ ability to discuss HIV with Family Planning clients in 3 rural health centers in Uganda. Abstract D11393. AIDS 2002, Barcelona. July.
Sterilization among HIV-positive pregnant women in two Brazilian cities
In Brazil HIV infection among women of reproductive age continues to rise. Though little is known about contraceptive use among HIV-positive women, female sterilization is the most popular method of contraception for Brazilian women in general. This study assessed demand for sterilization and sterilization rates among pregnant HIV-positive women in two cities, Porto Alegre and São Paulo. All HIV-positive women (154 in São Paulo and 258 in Porto Alegre) who received antenatal care between July 1999 and June 2000 in six selected HIV-specialist centres were included and clinic records abstracted retrospectively. A sample of the women (30 in each city) was interviewed, once during pregnancy and again postpartum. The interviews showed that the desire to end childbearing was nearly universal: 29/30 in Porto Alegre and 28/30 in São Paulo. Although a significant proportion of the women in both cities wanted to be sterilized after delivery, a much higher proportion in São Paulo were sterilized postpartum (50.6% or 78/154) than in Porto Alegre (4.3% or 11/258 in Porto Alegre. While these results cannot be generalized to the entire population of HIV-positive pregnant women in Brazil, HIV-positive women in this sample had higher rates of sterilization than their uninfected counterparts. In addition, the views and practices of local medical professionals regarding sterilization appeared to be more important than the women’s own preferences [1].
1. Barbosa RM et al. Reproductive choices and the impact of the medical culture on female sterilization rates among HIV-positive pregnant women in Brazil. Abstract MoOrE1068. AIDS 2002. Barcelona. July.
Unmet need among women for HIV/AIDS, reproductive and sexual health services in Chiangrai, Thailand
HIV-positive women in Chiangrai province, Thailand, have many reproductive health problems and unmet needs. 101 HIV-positive women of reproductive age were surveyed and 20 were interviewed in-depth by HIV-positive women interviewers who were trained in reproductive health issues and research methodologies and were closed supervised by an experienced researcher. 43% of the women reported that they were in bad health. 76% had at least one symptom of illness during the past three months, 37% had ever had at least one STD and 18% currently had STD symptoms. 83% said they needed STD or AIDS-related sevices, 46% maternal-child health (MCH) services, 45% marital/family counselling, 35% sex education/safe sex counselling, 18% family planning and 6% abortion services. Moreover, many of the women needed antiretroviral drugs, drugs for opportunistic infections, accurate and comprehensible information on AIDS treatment and drugs, health care and herbal drugs, and powdered milk for their babies. However, much lower proportions of women ever sought STD/AIDS, MCH or and marital/family counselling services than said they needed them (51%, 28% and 21%, respectively). The barriers which prevented them from accessing the care were low income, prohibitive costs, long waits, bad services, unkind interactions, discrimination, lack of confidentiality and privacy, and violation of their rights, e.g. involuntary blood testing or enrollment in the prevention of mother-to-child transmission programme. This study highlights the urgent need to develop sustained, community-driven advocacy and policy efforts in order to provide effective and timely responses to improve the reproductive health of HIV-positive women [1].
1. Kanungsukkasem U. Access to reproductive health care services for HIV-positive women. Abstract E11710. AIDS 2002, Barcelona. July.
Low clinical progression after pregnancy in HIV-positive women on HAART, London
Data on the long-term outcome of HIV infection in women who receive ARV therapy during pregnancy are scarce. To determine clinical and immunological outcome in HIV-positive women who commence therapy before or during pregnancy, a prospective cohort study of 49 women delivering at an inner city maternity unit between 1996 and 2000 was carried out with follow-up of at least 12 months. Outcome measures were changes in CD4 counts, HIV viral load, morbidity and mortality. Mean follow-up was 154 weeks. Morbidity following pregnancy in the HAART era is low. Pregnant HIV-positive women who first received monotherapy during pregnancy subsequently responded well to triple therapy following pregnancy. In this cohort, with 350 patient-years, clinical progression was minimal and mortality nil [1].
1. Martin FAZ et al. Long-term clinical outcome of anti-retroviral therapy (ART) naive and experienced HIV-1 positive pregnant women. Abstract MoPeC3526. AIDS 2002, Barcelona. July.
Antiretroviral treatment for women during pregnancy safe for babies, USA
Medical practice in the USA has been to give HIV-positive pregnant women antiretroviral treatment as if they were not pregnant, on the theory that taking care of the disease is best for both mother and child. Until recently, there has been no evidence that this was safe for the children. A study involving 3266 HIV-positive pregnant women showed that those who took antiretroviral drugs were no more likely to give birth to premature or low birthweight babies than those who did not. The study did suggest an association between protease inhibitors and very low birth-weight babies, but only the women who were most ill were treated with protease inhibitors, and the severity of the illness was thought to be responsible for the lower birthweight, as opposed to the drug itself [1].
1. Tuomala RE et al. New England Journal of Medicine 2002;346(24):1863-70.
Mothers say: “Focus on mothers as well as infants”
Therapeutic prevention of mother-to-child transmission of HIV is increasingly available in Kenya. With voluntary HIV counselling and testing (VCT). In-depth interviews and focus group discussions were conducted with 411 antenatal care (ANC) attendees (113 HIV-positive and 117 HIV-negative), and 32 ANC staff members were interviewed. VCT acceptance was more than 70%, although 75% of the HIV-positive women complained that counselling in the ANC setting was not meeting their special needs for confidential and sensitive care. 80% of the ANC attendees and 70% of ANC staff felt that pre-and post-test HIV counselling stigmatised women and discouraged participation in VCT within ANC settings. Most staff (78%) called for policy change to make HIV testing a mandatory ANC procedure. To ease spouse and community anxiety, 70% of women and 7% of staff recommended a rapid HIV test algorithm. Most women (85%) felt that VCT information provided in ANC settings is more focused on interventions to protect infants and on pregnancy outcome than potential or actual infection of the pregnant mother. The authors conclude that changes in ANC VCT services are needed to address these concerns [1].
1. Makokha E et al. Voluntary HIV Counselling and Testing (VCT): A Kenyan experience in support of modifications of the present VCT practises in the ANC setting. Abstract MoPeF3867. AIDS 2002, Barcelona. July.
Anaemia due to pregnancy and HIV=risk of early post-natal death, Harare
In developed countries, anaemia is common during HIV and significantly associated with earlier death. This form of anaemia results from changes in cytokine production, blunted erythropoietin (EPO) response, and antiretroviral use, especially zidovudine. Treatment with recombinant EPO improves this anaemia and survival; iron supplementation does not improve the anaemia and has been hypothesised to hasten progression of disease. In developing countries, anaemia is especially common among pregnant women, usually due to iron deficiency resulting from poor diet and blood loss, malaria, and parasitic infection. This study investigated whether anaemia (likely to be due both to pregnancy and HIV) among HIV-positive women participating in the ZVITAMBO trial in Zimbabwe was a risk factor for early mortality. Between October 1998 and January 2000, 8206 women were enrolled in the trial within 96 hours of delivery, randomised to receive vitamin A or placebo, and tested for HIV and haemoglobin (Hb); CD4 count was also measured in HIV-positive women. Women with Hb<8 g/dl were referred to the study physician and followed up at six weeks, and then three-monthly for a median of 12.0 (9.4–15.6) months. At delivery, 2669 (32.6%) women were HIV-positive. Anaemia (Hb<11 g/dl) was more common among HIV-positive than HIV-negative women (42.4% vs. 24.8%). Vitamin A did not affect mortality at 12 months post-partum; analysis is underway to determine impact on survival time. After adjusting for parity and CD4, women with Hb<7 g/dl and 7<11 g/dl were 4.1 and 1.7 times respectively more likely to die. This study demonstrates that anaemia is a risk factor for earlier death among HIV-positive women of reproductive age in a developing country setting. Analysis is underway to determine the impact of prescribed iron treatment on Hb and mortality, and will have implications for treatment options [1].
1. Zvandasara P et al. Anaemia and associated mortality among HIV-positive post-natal women in Zimbabwe. Abstract TuPeC4782. AIDS 2002, Barcelona. July.
Female condom use reduced unprotected sex among HIV-positive women, Brazil
A prospective descriptive study evaluated the acceptance, adherence and use of the female condom among 76 HIV-positive women attending specialist clinics in Campinas, Brazil. The women were asked to record sexual acts and male condom use on a calendar for 30 days, and were then given a demonstration of female condom use, with an acrylic pelvic model. A structured questionnaire was applied at 30, 60 and 90-day return visits, and throughout they were asked to fill in a calendar with sexual acts and use of female or male condoms. The group consisted predominantly of young women with low education level, two-thirds living with their partners. High rates of use (87%), acceptability (68%) and continuation (78%) of female condom use were observed during the 90-day study interval. There was a noted reduction in the proportion of unprotected sexual acts, from 14% to 6%. The main advantages of the female condom cited included giving the decision-making power to women, dual protection against pregnancy and HIV/STDs and not having to be dependent on the man. Disadvantages included ugly appearance, high price and noise while using it, though the latter was no longer mentioned by the end of the 90 days. Protected sex acts were more prevalent in serodiscordant couples and in previously consistent male condoms users. However, adding the female condom to dual protection options with appropriate counselling reduced unprotected sex among HIV-infected women. This particular population was especially motivated and receptive to female condom use, extracting important benefits from having access to it [1].
1. Magalhaes J et al. Female condom use among HIV infected women: a prospective study. Abstract TuOrD1234. AIDS 2002. Barcelona. July.
Women’s concerns about antiretroviral therapy during pregnancy, Australia
A qualitative research project in Australia collected data in 2001 on the use of and attitudes to antiretroviral therapy during pregnancy among 33 HIV-positive women. Of the 33 participants, 27 women had 47 children; 23 of these children were born after the women became aware of their HIV status. One child was HIV-positive. Although most women agreed to commence treatment either before pregnancy or by the second trimester, many women expressed concern about potential toxicity and/or harm to their unborn child. Some of the women also expressed grave concerns about giving antiretroviral therapy to their newborn baby, which resulted in a detrimental influence on the women’s effective use of antiretroviral therapy. All but one woman refrained from breastfeeding, although this was associated with a considerable sense of loss for a number of the women. Understanding women’s concerns about antiretroviral therapy both antepartum and postpartum is a crucial component of effective and appropriate health care for women living with HIV/AIDS and their babies, so that information given to them addresses their concerns and assists them to make optimal choices for themselves and their children [1].
1. McDonald KM et al. HIV-positive women’s use of and attitudes to antiretroviral treatments during pregnancy in Australia. Abstract MoOrE1069. AIDS 2002, Barcelona. July.
Mothers-to-mothers-to-be: peer support for HIV-positive pregnant women, Cape Town
Many women, when diagnosed with HIV during pregnancy, are unable or unwilling to tell partner, family or friends, resulting in emotional isolation. In Cape Town, South Africa’s publicly funded mother-to-child transmission prevention programmes, education and counselling are limited to before and after HIV testing. Mothers-to-Mothers-to-Be is a mentorship program for HIV infected pregnant women. Recently delivered HIV-positive mothers return to antenatal clinic as mentors to educate, counsel and support HIV-positive pregnant women. At every antenatal clinic visit, pregnant women are engaged by mentor-mothers, who share personal experiences, encourage adherence to treatment plans and assist with negotiating the hospital. Mentor-mothers also receive continuing education and support, and are given a small stipend for their services. The first programme was started at a tertiary care hospital and new programmes are scheduled to open at several primary care maternity centres. Pregnant HIV-positive women now have a better understanding and greater acceptance of interventions to reduce vertical HIV transmission, are better able to participate in decision-making with respect to mode of delivery, use of antiretrovirals to reduce transmission and take decisions about infant feeding method. Empowerment contributes to de-stigmatization of HIV infection and community health [1].
1. Besser MJ. Mothers-to-mothers-to-be: peer counseling, education and support for women in pregnancy in Cape Town, South Africa. Abstract MoOrF1031. AIDS 2002, Barcelona. July.
Infant feeding and HIV status, Kampala
In January 2000, a Ministry of Health-supported programme of prevention of mother-to-child transmission of HIV was started in Nsambya Hospital in Kampala, Uganda. Short-course antiretrovirals, zidovudine or nevirapine, are offered in late pregnancy to women who enrol. The women are counselled and supported to use either infant formula or exclusive breastfeeding. Infants were tested for HIV at week 6 and month 6, home visits were done to trace those who did not attend for follow-up and evaluate compliance with the feeding option adopted. Out of 684 HIV-positive women, 372 have enrolled in the programme to date and 317 have delivered. 236 women received zidovudine and 107 nevirapine. At delivery, 54% of mothers chose exclusive breastfeeding and 46% infant formula. 76% of enrolled woman-baby pairs came for follow-up at week 6. The woman-baby pairs on infant formula were more likely to come to follow-up than the others. During the first three months 20 of the 131 women using infant formula admitted having breastfed, and 17 of the 154 using exclusive breastfeeding admitted having mixed fed. 65% of women using exclusive breastfeeding had done a rapid weaning by three months. At week 6, 14 out of 152 tested children were HIV-positive (9.2%). Transmission rates were similar for the zidovudine and the nevirapine group. In the exclusive breastfeeding group there were 11 positive children out of 78 (14.1%) and in the infant formula group 3 out of 74 (4.1%). Three additional children in the exclusive breastfeeding group tested positive at month 6, bringing the percentage of children positive in the exclusive breastfeeding group to 17.7%. Mortality, morbidity and weight gain were similar in the two groups of babies; clinical and social conditions of the mothers in the two groups were comparable [1].
1. Magoni M. Effectiveness of the prevention of mother-to-child transmission program and the influence of feeding options in an urban hospital in Kampala, Uganda. Abstract TuOrB1178. AIDS 2002, Barcelona. July.
War and peacekeeping forces spread HIV
Graça Machel’s report to the UN, Impact of Armed Conflict on Children says: “Adolescents are at extreme risk during armed conflict. They are targets for recruitment into armed forces and armed groups; they are targets for sexual exploitation and abuse; and they are at great risk of STDs, including HIV/AIDS.” Throughout the world, military personnel are among the most susceptible populations to HIV and AIDS, both during peacetime and during conflicts. Military and peacekeeping service often includes lengthy periods spent away from home, with the result that personnel are often looking for ways to relieve loneliness, stress and their sexual needs. The military’s professional ethos tends to excuse or even encourage risk-taking. A study of Nigerian troops returning from peacekeeping operations in West Africa, for example, conducted by the non-governmental Civil-Military Alliance to Combat HIV/AIDS, found infection rates more than double that of the country overall. The study also found that a soldier’s risk of infection doubled for each year spent on deployment in conflict regions, suggesting a direct link between duty in the war zone and HIV transmission. With 18 violent conflicts, tens of thousands of troops in the field and some 8 million refugees and internally displaced people in Africa, UN Department of Peacekeeping Operations Medical Unit head Dr Christen Halle noted, it would be surprising if war were not a major factor in the spread of HIV.
Most military personnel are in the age group at greatest risk for HIV infection – the sexually active 15–24-year-old age group. Deployment to unsettled areas increases their chances of acquiring HIV, as they are exposed not only to socially disrupted settings where STIs may abound, but also to the possibility of infection through wounding and contaminated blood. A study of Dutch soldiers on a five-month peacekeeping mission in Cambodia found that 45% had sexual contact with prostitutes or other members of the local population during their deployment. In Cameroon, HIV seroprevalence rates in 1994 were at a relatively low 3.2% for the general population, but 6.3% for the military. Mpoudi Ngolle Eitel, Service de Lutte contre le SIDA in Cameroon, utilises compulsory courses in STD prevention, weekly radio programmes on STD/AIDS, and use of peer educators to further HIV/AIDS education. Major Rubaramira Ruranga of the Joint Clinical Research Center in Uganda said the military has a high sense of self-preservation, which can be used to promote prevention efforts and is a largely untapped resource that can be actively used to prevent HIV infection, readily accessible for training and networking. The Vietnamese military has an aggressive HIV education programme. Good examples of addressing risk behaviour with soldiers were described in Botswana, Chile, Philippines, Thailand and Zambia. They provide prevention education, condom distribution, STD treatment and voluntary testing along with counselling services [1].
1. HDN Key Correspondent. WAR and the spread of HIV/AIDS. Health & Development Networks, E-mail: [email protected]. AIDS 2002 Conference, Barcelona. July. On: [email protected], 15 July 2002.
Use of condoms and STD services among young people in western Kenya
Prior to implementing a controlled intervention trial of condom promotion, we conducted formative research among adolescents and young adults in western Kenya, to identify obstacles to condom use, attitudes and beliefs that should be addressed in the intervention, and gain better understanding of youth counselling programmes. In six locations of three districts, we conducted rapid surveys among 183 young people aged 15–24, and in-depth interviews with service providers and youth clients. About half the young people had primary and half had secondary education; 23% were still in school, 82% were never married, and 81% had had intercourse. Awareness of condoms was nearly universal, 46% had ever used male condoms and 36% reported current condom use. The great majority of respondents believed that condoms were effective in preventing both pregnancy and STDs. One third of respondents had received services from a youth agent, mostly HIV/STI counselling, and one in six had sought STD services in the past year. Data from the first 13 interviews with youth counsellors, their adult supervisors and clients suggest that these services are generally well received by the communities, and the counsellors are considered a credible source of information on reproductive health and achieve prestige in their role. They distribute large numbers of condoms, but negative perceptions of condoms persist, as does shame about STDs and reluctance to seek treatment. The programme does not insure uniform access to condoms for all sexually active young people. More training and information, and better meeting places, would be welcome [1].
1. Feldblum PJ et al. Formative research on condom attitudes, use and distribution among young people in Western Kenya. Abstract MoPeD3660. AIDS 2002, Barcelona. July.
HIV and pregnancy prevention programme in secondary schools, Barcelona
Parlem Clar (Straight Talk) is an HIV and pregnancy prevention programme for secondary school youth aged 17. It promotes condom use, enables access to condoms in the school setting and is partially delivered by peer educators. It consists of two classroom sessions, a visit to the neighbourhood family planning centre and condom distribution. Its effectiveness on determinants and behaviour was assessed through a cluster randomised trial among 442 school students. Self-administered questionnaires were filled in by teachers, peer educators and family planning centres. Condom distribution was carried out at schools through a “mobile point” (peer educator) or by teachers. Of 93% of teachers who filled in the questionnaire, 73% implemented all the activities. Of 79% of peer educators who filled in the questionnaire, 72% carried out all the activities. A family planning visit was planned for 20 classrooms, but only seven took place. Condom distribution through mobile peer educators is recommended, but distribution by teachers may be a good alternative option [1].
1. Fernández S et al. HIV intervention program Parlem Clar: Process evaluation. Abstract TuPeD5025. AIDS 2002, Barcelona. July.
In-school HIV/AIDS programmes
Schools that provide HIV/AIDS prevention programmes to their students need to be aware that some students have sex at early ages, that students’ knowledge about sex, HIV and prevention is uneven, and that both male and female students are vulnerable to coercive sex, particularly from older men. In discussions on situations in which youth have sex, the intermittent nature of adolescent sex needs to be taken into account, while peer pressure based on misperception about sex or norms of gender and sexuality should be clarified through specific activities. Teachers and counsellors need to teach students to assess their personal risk of HIV infection. Teachers need special preparation to help them discuss condom use. Discrimination against people living with HIV/AIDS should also be addressed. This information emerged from baseline data collected during an operations research project in Mexico, South Africa and Thailand [1].
1. Reducing HIV infection among youth: what can schools do? Baseline data from Mexico, South Africa and Thailand reveal complex picture of attitudes and behaviour among students. Horizons Report. Fall 2001.
Cone biopsy can be used to treat carcinoma in situ of the cervix in HIV-positive women
Despite lack of evidence, some physicians feel that hysterectomy may be a better option for preventing the recurrence of cervical intra-epithelial neoplasia. A retrospective case-control study in North America of 45 HIV-positive women diagnosed with carcinoma in situ of the cervix (CIS) from 1989–1995 revealed that cone biopsy and hysterectomy appear to be equally safe and effective in the treatment of CIS. Furthermore, there is no evidence to recommend one over the other for HIV-positive women, who are at high risk of recurrence and short times to recurrence with either treatment. LEEP cone biopsy is less invasive, reduces the risk of complications and relies on a see-and-treat approach, however, and may be the best option for treating HIV-positive women with cervical CIS, unless hysterectomy is otherwise indicated [1].
1. Williams FS, Roure RM, Till M, et al. Treatment of cervical carcinoma in situ in HIV positive women. International Journal of Gynecology and Obstetrics. 2000; 71(2):135–45.
Could topical vaginal oestrogen treatment increase women’s resistance to HIV infection?
The human vaginal epithelium is well-supplied with HIV-receptive Langerhans cells, overlain by a stratified squamous epithelium. This epithelium is oestrogen-dependent, being thickest at around the time of ovulation, and thinnest just before menstruation. Vaginal biopsies were obtained from pre-and post-menopausal women undergoing vaginal reconstructive surgery, with or without prior oestrogen replacement therapy. The thickness of epithelium and the distribution of Langerhans cells was assessed histologically and immunocytochemically.
Pre-operative oestrogen treatment increased the thickness of the vaginal epithelium in post-menopausal women, but had no apparent effect on the number and distribution of Langerhans cells. Vaginal biopsies from pre-menopausal women are currently being investigated. In all mammals, the vaginal epithelium is at its thickest, and is most keratinised or cornified at the time of the ovulatory peak of oestrogen secretion. This may have evolved as a natural defence against sexually transmitted infections. Humans are the only species that frequently has intercourse other than at the time of ovulation, perhaps making us particularly susceptible to STD/HIV infection. Oestrogen treatment of Rhesus monkeys whose ovaries have been removed greatly increases their resistance to vaginal SIV infection. This raises the possibility that topical vaginal oestrogen treatment could increase a woman’s resistance to HIV infection [1].
1. Li M et al. The effect of oestrogen on human vaginal susceptibility to HIV-1 infection. Abstract WePeA5740. AIDS 2002, Barcelona. July.
First round for the Global Fund
The Global Fund to Fight AIDS, Tuberculosis and Malaria awarded a total of US$378 million over two years to 40 programmes in 31 countries. Its Board also agreed a fast-track process to approve an additional US$238 million for 18 proposals in 12 countries, plus three multi-country proposals. This will bring the total funding over two years to US$616 million. The grants will be distributed worldwide as follows: Africa 52%, Americas 13%, Eastern Mediterranean 1%, Eastern Europe and Central Asia 8%, Southeast Asia 12%, and Western Pacific 14%. About 60% of the funds granted will go to projects working in HIV/AIDS while another 15% is for programmes fighting HIV/AIDS and one or both of the other diseases. Of the 28 countries that will receive funds to fight HIV/AIDS, grants to 21 specifically include the purchase of anti-retroviral drugs.
More than 300 proposals were submitted for the first round of funding, requesting a total of US$5 billion from the Global Fund for the first five years. Acknowledging that more funds are urgently needed, the UN Secretary General has called for US$7–10 billion each year just to combat HIV/AIDS. To date the Fund has raised approximately US$2.08 billion from industrialised and developing country governments, businesses, foundations and individuals. While governments have pledged a mere US$1.8 billion, the private sector has been even more disappointing with the Bill and Melinda Gates Foundation pledge of US$100 million a year ago being the most significant. So far the Global Fund has raised money through ad hoc voluntary donations. However, alternative means of working out appropriate contribution levels for each country and the private sector may have to be considered. If needs are to be met, the wealthiest countries such as the USA need to contribute considerably more than they currently do, while other wealthy countries who do not contribute at all, such as Australia, Singapore and United Arab Emirates, should do so as well. A second call for proposals is planned for later this year [1,2]. The Fund is supposed to supplement but not replace existing national, bilateral and multilateral donor programmes; whether that will prove to be the case remains to be seen.
1. Global Fund to Fight AIDS, Tuberculosis and Malaria announces first grants. Press release, 25 April 2002. On: <[email protected], 29 April 2002.
2. France T et al. The Global Fund: which countries owe how much? [email protected], 21 April 2002.
Review of financial resources for HIV/AIDS, Vietnam
The HIV/AIDS epidemic is growing rapidly in Vietnam. Government officials and UNAIDS in Vietnam undertook a study on the human and financial resources and goods and services for HIV/AIDS available in the period 1997–2001. Questionnaires were sent to more than 50 organizations and a review of organizational records, financial reports and interviews was carried out. National budget and international donor assistance for HIV/AIDS issues in Vietnam increased sharply (in absolute terms) from a very low base. There was a total commitment of US$ 49 million for surveillance, information/education/communication, capacity building, condom distribution, medical care/counselling, sexually transmitted infections/blood safety, and injecting drug users. However, resource allocations and donor-assisted activities have not always reflected the government’s priorities or national needs in relation to changes in the epidemic in the country. This presentation from a member of the Ministry of Planning and Investment recommended that the Vietnamese government and international donor community needed to re-examine priorities in light of the rapidly growing costs of HIV/AIDS, reallocate existing funds and mobilise other sectors and community support within a flexible policy environment, in order to scale-up interventions [1].
1. DXQ Dao Xuan et al. Analysis of national and international resources available to HIV/AIDS in the Socialist Republic of Vietnam. Abstract MoPeG4210. AIDS 2002, Barcelona. July.
Internet sexual health chatroom
With the advent of advances in computer technology, sexual health promotion can be packaged in more innovative ways so as to sustain sexual health promotion campaigns. Health and development issues are now commonly discussed using e-mail groups, listservers and website hosting. The Youth Zone is a shopping mall-based youth centre set up by the Remedios AIDS Foundation in Manila, Philippines, providing adolescent health information and direct services to youth aged 10–24 years old. The project is providing access to youth practising high risk behaviour for STDs and HIV. Part of the project is an Internet chat counselling service which has been running for two and a half years. For the year 2000, over 3,000 chat counselling sessions were conducted with an average of 15–20 regular active chatters daily. The #youthzone chatroom is operated by someone trained in handling various adolescent health issues as well as basic Internet computer skills The #youthzone chatroom has served as a place to discuss sensitive issues. Topics discussed ranged from relationships (boy-girl, parent-child, same sex relationships, reproductive health issues such as teenage pregnancy, abortion, family planning methods, self-esteem, self-confidence and more. The #youthzone chatroom has at all times rendered confidentiality and anonymity among chatters. Should young adults be in need of specific medical care, appropriate referrals are being made [1].
1. Sescon JNM et al. Youth zone internet chat counseling: Learnings gained in integrating Internet Communication Technology (ICT) with adolescent health concerns. Abstract ThPeF8135. AIDS 2002, Barcelona. July.
Zimbabwe programme for young people: plenty of lessons
The Zimbabwe National Family Planning Council with technical assistance from the Johns Hopkins University Population Communication Services launched a project called Promotion of Youth Responsibility. This was a six-month multimedia campaign to reduce the risk of pregnancy, STDs and HIV infection among 10–24 year-olds, implemented in five pilot sites in Zimbabwe. It encouraged abstinence for young people with no prior sexual experience, and promoted condom use and having fewer sexual partners for those who were sexually active. Based on the Steps to Behaviour Change framework, the media campaign paid attention to the fact that external approval is critical for young people, whose decisions are strongly influenced by friends, family and social norms. Another key focus was on adults, including parents, service providers and political leaders, who control young people’s access to reproductive health information and services. The campaign achieved a high level of exposure to information and message recall, in part due to the appeal of its components, which were developed with the direct participation of young people. Among its most notable accomplishments was the increased support from the community and the health care system for reproductive health interventions directed at young people. It relied on local committees containing representatives of local government, religious, education, health and business groups to reach the adult audience. It also trained providers to confront biases and involved them in campaign activities. The campaign achieved high levels of parent-child discussion about sensitive reproductive health issues, more young people seeking reproductive health services, and increased community support. The main weakness was that it did not address gender inequality or the effects of gender on sexual behaviour and decision-making [1].
1. Kim YM, Kols A, Nyakauru R et al. Promoting sexual responsibility among young people in Zimbabwe. International Family Planning Perspectives 2001;27(1):11-19.
Swedish website on sexuality for young women
In September 2001 LAFA, a project of Stockholm County Council, Sweden, launched a new website on the Internet called <www.p-piller.nu. The site is directed towards young women and contains information about the female body and sexual organs, women’s sexuality and contraceptives, as part of LAFA’s development work on women’s sexuality. The purpose of the website is to give facts and invite reflection, encouraging better conditions for women’s sexual well-being and increasing their opportunities to protect themselves and their partners from unwanted pregnancies and sexually transmitted infections. Visitors to the site can read, among other things, about how women’s sexuality has been viewed throughout history; what happens in a woman’s body when she is sexually aroused and about all kinds of contraceptives. The female sexual organs and the menstrual cycle are shown in illustrations as well. The site also contains a film of a gynaecological examination and telephone numbers of clinics. Since it was launched on the Internet the site has had about 8,000 new visitors every month, and more than 100 women have contributed to an open discussion forum on the site. At present the website is advertised in media directed at young women to further increase the number of visitors. The information on the site is continually updated and LAFA communicates with visitors through e-mail, the discussion forum and various competitions [1].
1. Adin H. <www.p-piller.nu a new website for young women. Abstract TuPeF5238. AIDS 2002, Barcelona. July.
Catch the Sperm: Swiss HIV computer game
At the beginning of 2001, many Swiss NGO Internet sites offered a large quantity of good material on HIV/AIDS, but they suffered from a chronic lack of visitors. The national AIDS prevention campaign (STOP AIDS) set up a portal which would offer basic information and promote other sites by referring visitors to them if they needed more in-depth information or personal advice. Their first aim was to find an eye-catching mechanism that would attract the attention of surfers. ”Catch the Sperm”, a provocative electronic game with attractive graphic animations, was launched with this in mind. “Catch the Sperm” can be downloaded free of charge from the portal. In the game a condom gun is used to neutralise sperm, HIV and other STDs. The game sends out a message that everyone can understand: condoms protect people against STDs. The game has met with tremendous success (about 18 million people throughout the world have visited the site to download the first version). Traffic on <www.stopaids.ch has been very heavy since then. Following the launch of the game, the portal has welcomed an average of 70,000 visitors per month. A significant percentage of surfers have availed themselves of the information provided on the site, and the number of Web visitors to other prevention organisations has doubled. The game has also attracted the attention of the media, providing a platform to promote HIV prevention messages [1].
1. Urfer H. Catch the Sperm: computer game on the internet for AIDS prevention. Abstract TuPeF5284. AIDS 2002, Barcelona. July.
Condom promotion campaigns among youth: Brazil, Tanzania, Mexico
Football and condoms are a winning combination in Brazil. A new line of condoms depicting the logos of the most popular Brazilian teams went on sale in February 2002 and has already become a commercial success. Television advertisements in which supporters wear condom-shaped caps in their team’s colours help to promote the condoms as well [1].
Behavioural change associated with condom promotion is a powerful tool for fighting AIDS among youth. However, social marketing strategies must be demand driven. Current condom social marketing projects are developed based on supply side strategies of price subsidies and retail sales. Lacking the involvement of youth, they result in limited impact for continuous condom use. John Snow/PROMUNDO initiated a condom social marketing plan for promotion of sexual behavioral change and use of condoms among youth in communities of Rio de Janeiro, developed with a national condom manufacturer. Youth provided useful insights during field-testing and these were incorporated into all phases of the project. Sixteen young men were trained as promoters to engage their peers on issues of gender-based violence and sexual health, and to sell condoms at places where young people meet (e.g. funk parties and local bars). The price was set based on willingness to pay at US$0.33 for three condoms. The condoms are sold with a magazine produced with the input of young people and sales are income-generating for the promoters [2].
Misconceptions about condom safety and effectiveness, availability, cost, and fear of censure may limit condom use among adolescents and youth. Community condom provision by youth may address these issues, but presents challenges for logistical support, supervision and sustainability. In March 2000, in rural Mwanza, Tanzania, 210 youths aged 16–25 years, of whom 24 were girls, were selected by other youth in their village to act as condom promoters and distributors. They received a two-day training course, which included a description of correct condom use, addressed misconceptions about condoms, and explained social marketing and record-keeping. Promoters paid 425 Tsh (US$0.50) to purchase their initial stock of condoms and 28 were selected from among the promoters and health workers in the community to act as central distributors of new supplies. Quarterly supervisory visits have been conducted to ensure condom availability, restocking and data collection. In the first 18 months of this initiative, 7,641 people bought 28,550 condoms from the promoters. Of these, 22% were 30 years old or over, 40% were aged 20–29, 23% were under 20 and 15% were school pupils. Overall 15% were female. However 30% of trained promoters were lost because of relocation or other change in circumstances and the level of promotion activity varied markedly between the villages. Promoters cited narrow profit margins, scarcity of capital funds, persistent misconceptions about and stigmatisation of condoms, and cultural resistance to condom use as their major difficulties. While community-based peer condom promotion and distribution are feasible and acceptable for increasing condom uptake, particularly among adolescents and young adults, in order to be sustainable, they must be complemented by additional strategies for increasing demand, decreasing misconceptions in the wider community, and maintaining stocks at local centres [3].
Widespread unprotected sex among young people, low levels of awareness of the risk of contracting HIV and other STDs, and the proactive opposition of churches, conservative media and politicians, facilitate the ongoing and increasing spread of HIV infection. The absence of proactive campaigns promoting sustained and appropriate use of condoms fuels the HIV and STI epidemics. Condomovil is a the only project of its kind in Mexico: it has a small vehicle which travels throughout the country promoting greater visibility of condoms, carrying out outreach activities in public places, universities, market places, bars and discos, addressed to sexually active young men and women. Educational interactive events, social marketing and free distribution of condoms and lubricants, public presentations in relevant fora, media presentations and advocacy among government officials, NGO and community leaders in cities and villages are some of the key components that have made Condomovil a model of condom promotion activities. Young beneficiaries have been able to discuss difficult issues related to HIV and STDs uninhibitedly and to have direct access to condoms. Swift responses to opposition and attacks from conservative groups have given Condomovil an added value and credibility in the cities it visits. As a unique form of outreach, with advantages of mobility and low cost, Condomovil should be replicated at state and local level. The project has already been replicated in Venezuela [4].
1. Brazil’s passion for football condoms. From: JSIUK Monthly HIV Update, May 2002. On: <news.bbc.co.uk/hi/English/world/Americas/newsid_1914000/1914998.html
2. Fontes M et al. Condom social marketing (SM) project in low income communities of Rio de Janeiro, Brazil: a demand driven approach. Abstract MoPeF4026.AIDS 2002, Barcelona. July.
3. Cleophas-Frisch B et al. Community condom promotion and distribution among adolescents in rural Mwanza, Tanzania. Abstract MoPeF4034. AIDS 2002, Barcelona. July.
4. Gómez A. Condomovil: a strategy to overcome barriers for promoting public access to, acceptance and use of condoms through direct action among youth in Mexico. Abstract WePeD6275.
South African study traces condom usage
Early analysis of a pilot study in South Africa to trace the fate of condoms distributed at four clinics reveals that condoms are used quite rapidly, and that the overall rate of actual condom use is high and wastage lower than anticipated in a sample of 46 man. Service providers’ attitudes influenced condom uptake. Providers encouraged individuals whom they knew (and knew that they were likely to use condoms), and discouraged those they thought would waste the condoms, mainly adolescents and young men [1].
1. Myer L, Mathews C, Little F. Tracing condom fates: design and pilot results of a study investigating the use and wastage of public sector condoms. African Journal of Reproductive Health 2001;5(1):66–74.