The UNAIDS Reference Group on HIV and Human Rights has updated its statement on HIV testing — which continues to emphasise that human rights, including the right to informed consent and confidentiality, not be sacrifced in the pursuit of 90-90-90 treatment targets — in the light of “three key trends that have emerged since the last statement regarding HIV testing was issued by the UNAIDS Reference Group (in 2007).”
One of these is “prolific unjust criminal laws and prosecutions, including the criminalization of HIV non-disclosure, exposure, and transmission.” The other two involve the recognition that HIV treatment is also prevention, and policies that aim to “end the AIDS epidemic as a public health threat by 2030.”
This statement is an important policy document that can be used to argue that public health goals and human rights goals are not mutually exclusive.
This statement is issued at a time when UNAIDS and the Global Fund are renewing their strategies for 2016–2021 and 2017–2021, respectively.
To support these processes, the Reference Groups offer the following three key messages:
1. There is an ongoing, urgent need to increase access to HIV testing and counselling, as testing rates remain low in many settings. The Reference Groups support such efforts unequivocally and encourage the provision of multiple HIV testing settings and modalities, in particular those that integrate HIV testing with other services.
2. Simply increasing the number of people tested, and/or the number of times people test, is not enough, for many reasons. Much greater efforts need to be devoted to removing barriers to testing or marginalized and criminalized populations, and to link those tested with prevention and treatment services and successfully keep them in treatment.
3. Public health objectives and human rights principles are not mutually exclusive. HIV testing that violates human rights is not the solution. A “fast-track” response to HIV depends on the articulation of testing and counselling models that drastically increase use of HIV testing, prevention, treatment, and support services, and does so in ways that foster human rights protection, reduce stigma and discrimination, and encourage the sustained and supported engagement of those directly affected by HIV.
The section on HIV criminalisation is quoted below.
The criminalization of HIV non-disclosure, exposure, and transmission is not a new phenomenon, but the vigour with which governments have pursued criminal responses to alleged HIV exposures — at the same time as our understanding of HIV prevention and treatment has greatly advanced, and despite evidence that criminalization is not an effective public health response — causes considerable concern to HIV and human right advocates. In the last decade, many countries have enacted HIV-specifc laws that allow for overly broad criminalization of HIV non-disclosure, exposure, and transmission. This impetus seems to be “driven by the wish to respond to concerns about the ongoing rapid spread of HIV in many countries, coupled by what is perceived to be a failure of existing HIV prevention efforts.” In some instances, particularly in Africa, these laws have come about as a response to women being infected with HIV through sexual violence, or by partners who had not disclosed their HIV status.
Emerging evidence confrms the multiple implications of the criminalization of HIV non-disclosure, exposure, and transmission for HIV testing and counselling. For example, HIV criminalization can have the effect of deterring some people from getting tested and finding out their HIV status. The possibility of prosecution, alongside the intense stigma fuelled by criminalization, is good reason for some to withhold information from service providers or to avoid prevention services, HIV testing, and/or treatment. Indeed, in jurisdictions with HIV-specific criminal laws, HIV testing counsellors are often obliged to caution people that getting an HIV test will expose them to criminal liability if they find out they are HIV-positive and continue having sex. They may also be forced to provide evidence of a person’s HIV status in a criminal trial. This creates distrust in relationships between people living with HIV and their health care providers, interfering with the delivery of quality health care and frustrating efforts to encourage people to come forward for testing.
The full statement, with references, can be downloaded here and is embedded below.
Short description: This document discusses the new HCT policy, covering diffirent topics such as Policy Vision, Mission and Aims. It gives guidelines on HCT. The objectives of this policy guideline are to:
-Provide core requirements and guidance to ensure the delivery of standardised, high quality, ethical HIV counselling and testing services;
-Outline different types of HIV counselling and testing approaches for different circumstances and target groups;
-Ensure compliance with a legal and human rights approach to HIV counselling and testing;
-Expand access to HCT beyond formal health-care settings into community, private sector and non-health care environments; and
This week the OraQuick In-Home HIV Test, which will be sold over the counter and used without medical supervision, received its final approval from the Food and Drug Administration (FDA), meaning that it can be legally sold in the United States. Similar approvals may follow for other countries. But who is likely to use it and in what circumstances? And will the increased accessibility of HIV testing make any difference to the epidemic?
Whereas French research suggests that men who are secretive about their homosexual behaviour will have a particular interest in home testing, a study from New York indicated that some gay men will use it to test sexual partners, sometimes as a prerequisite for unprotected sex. And a rich discussion between HIV prevention advocates and researchers, which recently took place on the email forum of International Rectal Microbicide Advocates (IRMA), highlighted the key issue of whether people who test positive at home will subsequently connect with health services. While some participants had concerns about the potential for coercion and abuse, others felt that home testing could increase choice and autonomy.
The OraQuick In-Home HIV Test will be sold from October onwards in pharmacies and over the internet, for a price somewhere between $20 and $60. The packaging will include instructions, advice on what to do after getting the result and details of a 24-hour phone helpline. The test's sample is taken by swabbing an absorbent pad around the outer gums, adjacent to the teeth; the results are given in twenty minutes.
At the FDA hearing, there was overwhelmingly supportive public testimony from HIV activists, black community representatives and public health experts. Nonetheless, in the days that followed, some advocates raised a number of concerns.
For many advocates, a key issue is the support that can be offered by professionals during the testing process. “HIV testing is not a matter of poking the person, sitting quietly for 15 minutes and then sending them on their way without any other discussion,” as someone commented. While testing is going on, there is a dialogue about why the test is being done, what the test is for, what the results mean, safer sex practices and referrals to other services. Moreover, there is considerably more talking should the result turn out to be positive.
Many feel that this personal, direct discussion cannot be replicated with a pamphlet, which may or may not be read and understood.
This puts testing into the hands of the individual, not a healthcare professional.
Some people fear that the limitations of the test will not be fully understood. In the trial that led to the test's approval, 7% of people who really did have HIV received false-negative results. Moreover the test has a considerable window period – a negative test result is not considered accurate if a risk has been taken in the previous three months.
But others point out that the window period problem has always been with us. “Many people – perhaps most – assume that all is well after a visit to the local clinic and an antibody negative result,” noted Timothy Frasca of the HIV Center for Clinical and Behavioral Studies in New York. He suggested that people’s behaviour is not necessarily influenced by the cautionary messages they hear from healthcare staff.
A number of advocates felt quite strongly that despite certain limitations of the home test, its key advantage is that it puts testing into the hands of the individual, rather than being controlled by healthcare professionals. “Attempts to overly mediate how I receive information about my body amount to little more than a paternalistic view of what I can handle,” said Jerome Galea of Epicentro in Peru.
Galea went on to say that while many people will continue to want and need in-person counselling and testing, those who do not should not be forced to have it. He said that he’d probably had about 50 tests in the past 25 years and doesn’t need to go through the counselling again.
Who will want to use a home test?
Studies are beginning to highlight particular uses of home testing and particular groups who are likely to use it. Much of the research to date has been with gay and bisexual men.
For example, French research suggests that gay and bisexual men living away from the big cities and those with concerns about privacy are the most likely to use home tests. Tim Greacen and colleagues recruited over 9000 men for an online survey and found that 30% had already heard of home tests, but 70% had not.
Among the HIV-negative men who hadn’t previously heard of home tests, 86% said they would be interested in using one.
The main reasons to be interested in the home test are its convenience, accessibility, rapidity and privacy.
Men who were interested tended to live their male-male sex life in total secrecy, live in a conventional family structure and live in smaller towns. There were also associations with being employed, being less educated, never having tested for HIV, testing for HIV infrequently, and having unprotected anal sex with casual partners.
Respondents said that the main reasons to be interested in the home test were its convenience and accessibility (31.5%), rapidity (28.5%) and privacy (23.2%).
Among men who had previously heard of tests, 3.5% (69 men) had used one. They had mostly been purchased illegally through the internet. Men who lived their male-male sex life in total secrecy were almost four times as likely as men who were open to have used a home test (odds ratio 3.9).
Three men got a reactive result from the home test – in other words, one which could indicate a positive result but which needed to be confirmed by further testing. Two men did seek further tests (one took another home test, the other went to a professional laboratory), but the third man did not, although he did call a telephone helpline. None of the three men had seen a doctor about their test results.
Linkage to care
The question of what happens to people who get a reactive (‘positive’) result is crucial to David Barr of the Fremont Center. “The failure of HIV testing is our poor linkage from testing to care,” he said. “This failure is present in pretty much every approach to testing, with many, many testing programmes not even considering linkage to care a priority – their responsibility ends with testing, counselling and perhaps, a referral.”
He is concerned that this will be a particular weakness of home testing. “Self-testing, by its nature, will only link people to care in passive ways,” he said.
“The failure of HIV testing is our poor linkage from testing to care." David Barr
Others point out that, in many places, post-test support is already inadequate, as demonstrated by the large number of people who hide themselves from health services after receiving a positive diagnosis. In which case, perhaps an alternative approach is warranted.
Ebony Johnson of the Athena Network spoke of services which are over-burdened and under-staffed, and where some workers lack training and cultural competency in relation to HIV and confidentiality. As a result, some people are fearful of testing in some clinical services. “At home testing may provide the autonomy and privacy that some need in order to digest their diagnosis,” she said.
Charles King of Housing Works noted how the arguments against home testing "closely tracked the arguments against over the counter pregnancy tests" in the 1970s. At the time, there was widespread concern that adolescents would misuse pregnancy tests (if they could afford them) or that those finding out they were pregnant without professional support would not take confirmatory tests, would not connect with clinical services, would self-harm and would suffer violence from their parents or boyfriend. These fears turned out to be largely unfounded.
Screening sexual partners
One of the particular scenarios that has been much discussed and cited as a potential misuse of home testing is of people asking sexual partners to take HIV tests, perhaps immediately before intercourse. Apart from the possibility of partners being pressurised to test against their will, the other fear this plays on is of individuals using negative results as a license to have unprotected sex, regardless of any information about the test’s limitations.
“It is interesting to me, and not a little sad, that so many of us conjure up hypothetical worst-case scenarios of sexed up gay men behaving recklessly,” commented Jim Pickett, chair of IRMA. He pointed out that testing is a health-seeking behaviour and something that advocates normally greatly encourage. “Why must our hypothetical scenarios always bend toward gay men behaving ‘badly?’” he asked.
In fact, the French study discussed above found that just 4.5% of men interested in home tests said they wanted to test their partners.
Men could see that taking a test could easily be a mood killer when meeting a sexual partner.
Rather different results have come from a study in New York, but this may be an artefact of different recruitment methods and the way in which the American interviewers actively raised the topic of testing before sex.
Alex Carballo-Diéguez, Timothy Frasca and colleagues recruited ‘high-risk’ HIV-negative gay or bisexual men who regularly had unprotected receptive anal intercourse and who were interested in talking about home testing. Fifty-seven men completed the surveys and in-depth interviews.
In total, 87% of participants said that they would use the test. Moreover, 80% would use it with sexual partners at home.
The interviews explored how men envisaged using the test, in particular with sexual partners. Men expressed a variety of opinions about when to bring the issue up, where and with who.
One man said:
“I guess before we leave the bar, like, so, Are you a top? Are you a bottom? Oh, you’re bottom, great, I’m a top. That’s good. HIV negative? Positive? . . . Negative? Cool. You’re not going to feel funny about me asking you to take the test, right? Because you know, I got—I went to [name of drugstore] last night and I bought a bunch of them so we’ve got to put the bitches to use. I test everybody…”
But men could see that taking a test could easily be a mood killer when meeting a sexual partner. In fact, the same man who was quoted above could also see how badly he might react if someone asked him to take a test before sex.
“I’d probably freak out… Like, what, who are you? Are you trained to do this? Like, who are you? Like, I’m just coming over to fuck you.”
If a casual partner’s result was reactive (‘positive’), most men didn’t anticipate continuing with sex. Some said they would show empathy and try to be helpful.
Men noted that the test itself couldn’t be used in many environments where men meet for sex (such as saunas or sex clubs) and that use would be tricky if men were high on alcohol or drugs.
Some men thought that raising the issue of testing would require the intimacy of being at home.
“I will slowly, slowly talk my way into it, or persuade the person to take an interest in it. I probably would do it first so that somebody could feel comfortable with it.”
Moreover, some men felt that the test could be used as a relationship moved from casual to being more steady. But if either partner’s test was reactive, this was thought to be extremely problematic. It could signify the breaking of an agreement either to be monogamous or to always use condoms with other partners. Reactions could be aggressive or violent.
There are particular concerns about people being coerced into testing in situations in which there are already stark imbalances of power. Women and children may be particularly likely to suffer.
The way in which the test is priced, distributed and promoted may be crucial in determining whether it is used by those who are most at risk.
Paul Semugoma recalled an incident when a woman was brought by her in-laws for testing at his medical practice in Kampala, Uganda. “They were sure she would infect their son, so the family had mandated that she tests, and had sent a sister in law to observe the test,” he said. “That's the kind of situation in which I would imagine a family meeting being called and the lady being forced to take the test, before everyone.”
Andrew Hunter of the Global Network of Sex Work Projects commented: “For the millions of sex workers and others already facing compulsory testing, this could well be another way for brothel owners, mafias and corrupt cops to be able to enforce even more testing.”
But some see home testing as offering particular possibilities to marginalised groups – such as men who have sex with men and injecting drug users – in places where they currently have poor access to health services.
And despite the limitations and possible abuse of home testing, Paul Semugoma felt that it could be of real benefit in resource-limited settings. “The testing that is given by NGOs and government is still falling far behind what is required,” he said. Long waiting times, poor confidentiality and staff stigma put many people off. “A commercially available test at a pharmacy or drug shop, if competitively priced (meaning it is low enough for uptake) would be the best,” he continued.
Cost could also be a barrier in richer countries. “We want to be sure this will be accessible to those most at risk, who tend to be poorer, and not in the health care system,” commented Jim Pickett. “We don’t want this to be just some niche product for the ‘worried well’ in the suburbs.”
The US regulators took the view that a home test would lead to more people testing more often, and so lead to a reduction in the number of undiagnosed infections. But the way in which the test is priced, distributed and promoted may be crucial in determining whether the test is used by those who are most at risk and so whether home testing makes a real difference to the epidemic.
Greacen T et al. Internet-using men who have sex with men would be interested in accessing authorised HIV self-tests available for purchase online. AIDS Care, online ahead of print, 2012. DOI:10.1080/09540121.2012.687823
Greacen T et al. Access to and use of unauthorised online HIV self-tests by internet-using French-speaking men who have sex with men. Sexually Transmitted Infections, online ahead of print, 2012. doi:10.1136/sextrans-2011-050405
Carballo-Diéguez A et al. Will Gay and Bisexually Active Men at High Risk of Infection Use Over-the-Counter Rapid HIV Tests to Screen Sexual Partners? Journal of Sex Research 49: 379-389, 2012.
Laboratory Diagnosis of Sexually Transmitted Infections, Including Human Immunodeficiency Virus. 20/05/2015.
Published at WHO Written by WHO PDF Size: 4.7MB Download here
This new manual, 'Laboratory Diagnosis of Sexually Transmitted Infections, Including Human Immunodeficiency Virus', provides a basic understanding of the principles of laboratory tests in the context of screening and diagnostic approaches, as well as antimicrobial susceptibility testing, as components of sexually transmitted infections (STI) control.
As with the 1999 manual, this manual covers each disease in a separate chapter that provides detailed information on specimen collection, transport, and laboratory testing. Two useful annexes covering equipment, tests, media, reagents, and stains are included at the end of the manual.
National Guidelines for HIV Counseling and Testing in Clinical Settings
Subtitle: Provider initiated counseling and testing.
Published 10 August 2010
Written by Thato Farirai
Abstract: This document discusses PICT. PICT Objectives includes to assist HCP to expand quality HCT services in clinical settings to reduce the impact of HIV among individuals, families and communities by reducing HIV transmission. People intended to use these guidelines include:
-HCP involved in the clinical care and management of patients
-Providers in both public and private facilities
-Need for supportive health system
i. Trained personnel
ii. Logistics supply at community and facility level
National Guidelines for Implementation of Home-based HIV Counselling and Testing (HBHCT) in South Africa
Department of Health of the Republic of South Africa
This guideline provides guidance on the implementation of HBHCT and all implementers are urged to adhere to them in order to facilitate common understanding, effective implementation and support for all implementers.
The purpose of these guidelines is to provide national standards that will guide all institutions, organizations and individuals in the provision of high quality home-based HCT
National Implementation Guidelines on Provider Initiated Counselling and Testing (PICT)
Department of Health of the Republic of South Africa
In order to guide the national response to HIV and AIDS pandemic, the South African Government develops the HIV & AIDS and STI National Strategic Plan (NSP). The two main targets in the latest NSP (2007 – 2011) are:
-To reduce the national HIV incidence rate by 50% by 2011
-To provide an appropriate package of treatment, care and support services to 80% of the people living with HIV and their families by 2011
This guideline provides guidance on the implementation of Provider Initiated Counselling and Testing in all province
2. Goal of the PICT guidelines
3. Intended users of the guideline
4. PICT as an HIV counselling and testing model
5. General guidance for implementing PICT
6. Key principles of PICT
7. PICT linkage to HIV comprehensive management care and support services
Home-based HIV testing and counselling refers to HIV testing and counselling (HTC) services conducted by trained HTC service providers in someone’s home. The main purpose of HBHTC is to bring HTC services to households, overcoming some of the barriers of access to testing services and providing testing to individuals who might not otherwise seek services. It has been used successfully in rural and urban populations of sub-Saharan Africa with a high HIV prevalence and low coverage of HTC services.
Policy Statement on HIV Testing and Counselling in Health Facilities for Refugees
This policy statement examines the role of HIV testing and counselling in health facilities in increasing access to HIV prevention, treatment, care and support services for refugees, internally displaced persons (IDPs) and other persons of concern to UNHCR. It also identifies specific issues regarding HIV testing and counselling amongst these populations as well as makes recommendations for future action.
To download this document, click here (pdf, 805.89 KB, 21 pg)
Quality Assurance Guidelines
Simple HIV tests present unique challenges
Subtitle: Q.A on Rapid HIV Testing
Author: Honwani F.J
Published 10 August 2010
Abstract: These simple HIV tests present unique challenges – testing is often performed by persons without formal laboratory training, there is no residual sample that can be checked or re-tested, conventional quality control methods cannot be used, and there are special problems associated with efforts to provide conventional external quality assessments (e.g. proficiency testing)
Regional Minimum Standards for Harmonised Guidance on HIV Testing and Counselling (HTC) in the SADC Region
The review notes modest achievements in priority areas
Published by SADC August 2009
The SADC region bears the brunt of the HIV and AIDS epidemic, which is diverse with varying levels of adult HIV prevalence fuelled by behavioural, social, cultural, biomedical and economic factors. HIV remains the leading cause of morbidity and mortality in the region.
SADC Heads of State and government made several commitments to fight the HIV and AIDS epidemic and other communicable diseases through the Maseru Declaration and other global commitments such as the Abuja Declaration, Maputo Declaration 2005, Brazzaville Commitment 2006 and Millenium Development Goals. Additionally, in order to implement some of the commitments, the SADC region developed the SADC Regional Prevention Strategy and Action plan to support Member States’ efforts to significantly reduce the incidence of new HIV infections with the ultimate aim of declining prevalence.
The review notes modest achievements in priority areas of prevention of mother-to-child transmission of HIV (PMTCT), condom use, management of sexually transmitted infections (STI), HIV testing and behaviour change which have not been sufficient to reduce the incidence enough to turn back the epidemic.
South African Tools and Guidelines for Counselling and Testing Children for HIV. 04/2013
Dr Heidi van Rooyen
A new set of guidelines and training tools dealing with the legal, ethical and counselling issues related to HIV testing of children is now available for HIV/AIDS practitioners working with children.
Dr Heidi van Rooyen, project team leader and research director at the Human Sciences Research Council (HSRC), explains: “These guidelines explore in simple and practical terms the psychosocial implications as well as the legal and policy obligations relating to HIV counselling and testing of children.
“The tools describe what practitioners can do to ensure that HIV testing of children takes place in a way that protects and promotes their rights and is conducted in their best interests."
Examples of the lively illustrations included in the trainer's manual
HIV Counselling and Testing (HCT) is the most important entry point for HIV-related treatment, care, support and prevention.
A significant number of children in South Africa live with HIV. According to figures provided by the Department of Health, an estimated 32 940 children under 15 years of age were living with HIV and AIDS but were not on treatment. These facts highlight that every effort must be made to facilitate HIV testing in this population within the framework of applicable legislation and policy. Once tested, children can be placed on treatment, and linked to care and support.
The HSRC, through the SA National AIDS Council (SANAC), was commissioned to provide technical support to the Department of Health to ensure implementation of the goals for voluntary counselling and testing (VCT) as set out in the 2006-2011 National Strategic Plan on HIV, STIs and TB (NSP). The Bill and Melinda Gates Foundation provided the funding for this initiative.
Through an extensive consultative process with key staff from the Department of Health, the US Centers for Disease Control and Prevention (CDC), civil society, non-governmental organisations, academics, policy makers and practitioners working with children more generally and in HIV/AIDS specifically, the HSRC led the development of a series of implementation guidelines and training tools, dealing with the legal, ethical and counselling issues related to HIV testing of children.
This package of tools, announced in Pretoria, Sweetwaters outside Pietermaritzburg and Cape Town are also available on this website and include: a trainers' manual, participants' manual, legal guidelines for implementers, as well as counselling and testing implementation guidelines. A CD containing all these resources is also being made available.
In 2010, the South African Government launched a massive campaign to test 15 million people for HIV in 12 months. One element was to offer voluntary testing and counselling in schools, which raised concerns as to whether this delicate aspect would be handled appropriately. These new guidelines finally provide the information that was missing.
HIV & AIDS have ravaged the African continent. Worldwide, approximately 68% of individuals infected with HIV have been identified as originating within sub-Saharan Africa.(2) Above this, current estimates suggest that 72% of the 1.8 million deaths occurring due to HIV & AIDS-related causes in 2009 were Africans.(3)
Among the key interventions identified internationally for curbing the spread of HIV & AIDS is voluntary counselling and testing (VCT). A Policy Statement on HIV Testing released by the Joint United Nations Programme on HIV & AIDS (UNAIDS) and the World Health Organisation (WHO) states: “Without effective HIV prevention, there will be an ever-increasing number of people who will require HIV treatment. Among the interventions which play a pivotal role both in treatment and in prevention, HIV testing and counselling stands out as paramount.”(4) In fact, VCT has been consistently promoted by both organisations as a routine and essential part of HIV testing in developing countries.(5)
Any individual who seeks to know their HIV serostatus will ideally undergo this process, expanded upon in the paper which follows. The experience of learning one’s serostatus is widely accepted to be psychologically taxing, with possible implications for the mental health of the presenting client. Conversely, and of equal importance, is the ability of the counsellor to provide a psychologically supportive environment in which the diagnosis may be received. This paper therefore serves to explore the tenuous nature of the HIV testing process. Despite its touted importance and effectiveness as a means to combat the spread of HIV & AIDS, it remains a psychologically threatening process for many, and this may continue to hamper the potential efficacy of this critical point of intervention.
VCT in sub-Saharan Africa
According to a 2010 progress report released by the United Nations Children’s Fund (UNICEF), UNAIDS and the WHO, the median percentage of people in sub-Saharan African living with HIV who are aware of their serostatus is below 40%.(6) Further, the report suggests that at present, “considerable gaps remain between testing and counselling needs and existing practices.”(7) These ‘gaps’ highlight deficiencies in the capacity for care in this region, and call attention to the need for policy and practice to be revised accordingly.
Examining the availability of testing services of approximately 40 countries in sub-Saharan Africa, the median number of facilities per 100,000 members of the population improved from 5.9 in 2008 to 8.4 in 2009, while the median number of tests per 1,000 members of the adult population improved from 58 to 66.(8) These figures suggest an increasing availability and uptake of testing services throughout the region.
Despite these improvements, however, the number of people who have never been tested for or know their serostatus continues to outweigh those who do. There are a number of possible reasons why these figures are low, ranging from socio-culturally based motivations to individual anxieties and concerns around the testing process. It is also likely that it is a combination of these factors that presents barriers to an individual’s willingness to test. It is therefore important to consider the nature of the counselling and testing experience as experienced by the client.
Voluntary counselling and testing
Voluntary counselling and testing represents, as mentioned, a core intervention against the spread of HIV. Procedurally, it is composed of three key segments: pre-test counselling, the HIV test, and post-test counselling. The review which follows is based on WHO regulations and guidelines, as they appear in the Voluntary HIV counselling and testing: Manual for training of trainers,(9) as well as the manual titled Guidance on provider-initiated HIV testing and counselling in health facilities.(10)
The initial intake session aims to assess the client’s motivation for finding out his or her serostatus. The counsellor will assess the client’s current risk behaviour profile and advise him or her accordingly. This establishes the basis from which the client must now decide whether to seek testing or not. Ethically, one of the central tenets of this process is that the client must elect to undergo the HIV test. After being given appropriate time to consider, should the client decide to undergo the test, the pre-test counselling session will also entail talking with the client about the potential outcomes of the test, and appropriate coping strategies to apply in these instances.
Most testing centres employ a rapid HIV test. Once the results of the test have been obtained, the presenting client will enter into a post-test counselling session –with his or her consent– to receive the results of the test. The content of this session will be determined by the serostatus diagnosis of the client. Should the client obtain a diagnosis of being HIV-negative, the counsellor will discuss with the client his or her feelings, as well as the importance of appropriate lifestyle choices to maintain this state. Additionally clients will be reminded of the window period, during which one may be infected but testing will not yet be able to detect the presence of the virus.
Should the test return an HIV-positive diagnosis, the counselling session will involve a number of aspects. Primarily, the counselling session will focus on the emotional content of the diagnostic experience. It is the responsibility of the counsellor to ensure that the news is received in a safe and sensitive environment. The client’s coping skills and support systems will be assessed as it is crucial to ensure that he or she is equipped with the necessary resources to adjust to the diagnosis. Counsellors will also focus on how to make appropriate and reasonable plans for the client’s now altered future. These discussions will include the necessity to seek and establish an appropriate treatment regime based on the client’s particular profile. Also of crucial importance is encouraging the client to share his or her diagnosis with present as well as past sexual partners. In some instances the opportunity for ongoing counselling will be made available to clients.
Implicit in this discussion is the fact that both pre- and post-test counselling sessions must proceed with sensitivity and caution, and require some therapeutic micro-skills on the part of the counsellor. If one examines training materials and VCT guidelines, these skills are often identified to include verbal and non-verbal behaviour. The former is composed of types of questions, appropriate phrasing, and language sensitivity, as well as active listening to allow for thoughtful and insightful reflection. The latter is characterised by appropriate body language (including body orientation, eye-contact, gestures and facial expressions) and paralinguistic cues (including voice pitch, volume and fluency). These skills are employed by the counsellor to put the client at ease, and to optimise the efficiency of any session. Additionally, counsellors must be contextually sensitive–particularly in a region characterised by its crucible of cultures, each with its own specific dictates surrounding the norms and dynamics of interpersonal and therapeutic interactions.
The counselling and testing experience
Having acknowledged the importance of VCT in encouraging individuals to test for HIV as well as its potential to facilitate the process of discovery, one must acknowledge that in order to initiate this process an individual needs to make the conscious decision to find out his or her diagnosis. In order to do this, a supportive environment must exist which would allow for the individual to feel safe and comfortable in the decision to test.
Research has shown that the diagnostic testing procedure and receiving the test results are associated with moderate to intense levels of anxiety and distress for the client.(11) One prominent issue here is that of stigma. Stigma represents a considerable threat both to people who are concerned about their statuses and to those living with HIV & AIDS.(12) A study conducted at a South African university revealed that while the main benefit of VCT was seen to be ‘knowing your status’ the main barriers were described as a fear of being stigmatised and a fear of being diagnosed HIV positive.(13) Further, the study showed that AIDS-related stigma was attributed to three main factors–a lack of HIV & AIDS related knowledge, the life-threatening character of the disease, and blaming those who have contracted the virus for their infection.(14) Despite the considerable advances which have been achieved in the options available for care for those living with the virus, interpersonal, communal, and societal-based discrimination remains rife. At a psychological level (as well as social and communal levels) this stigma represents a considerable barrier even before the process has begun.(15)
Another important factor to consider in terms of the psychological components of the testing experience is the fact that although HIV has come to be conceptualised as a chronic illness, at a more intimate level, as well as within certain culture-bound settings, a diagnosis as HIV positive is still strongly associated with a death sentence.(16) Of concern is the fact that it has been suggested that even certain health care professionals continue to view the diagnosis in this way.(17) The notion of an HIV diagnosis as a ‘death sentence’ can have adverse implications for healthcare. Firstly, the possibility of receiving such a decree may act as a deterrent from presentation for testing. Fear of psycho-social abandonment as a result of one’s diagnosis presents a significant barrier in such instances. Secondly, should one receive a diagnosis of a positive serostatus, the experience can be regarded as emotionally traumatic. On receiving a positive diagnosis, the client will likely undergo a paradigm shift in terms of their self-concept and experience concern and fear regarding their future and prognosis.
Addressing this shift, Stevens and Doerr, in their exploration of the narratives of women who had been diagnosed with HIV, described how each participant referred to the traumatic nature of the diagnosis.(18) Their report highlighted the sense of ‘imminent demise’ and helplessness with which these individuals reported being faced.
Notably, Olley, Zeier, Seedat and Stein have described how recently-diagnosed patients may present with symptoms indicative of Post-traumatic Stress Disorder as a result of the acutely traumatic event of being diagnosed as HIV& AIDS positive.(19) They note how when infected individuals receive their serostatus diagnosis they may experience intrusive and recurrent thoughts or dreams of illness and death, and in addition may also avoid people, activities and places that serve as reminders of the illness.(20) The capacity of the event to affect the psyche in this way highlights the potential influence on the mental health of any presenting client.
Post-test counselling, as well as long-term counselling or support-group meetings must be sure to take cognisance of this inherent trauma, and the emotional consequences of the diagnostic experience. Counsellors are charged with the responsibility of imparting appropriate information and skills to clients to ensure that they are able to cope, both physically and psychologically, with the consequences of diagnosis.(21) Coping skills, available support networks and services are therefore core components of HIV-specific counselling sessions.
It is clear that at each stage of the VCT process the adoption of a psychological lens adds depth to an understanding of the efficacy of the intervention. Whether it is the micro-skills necessary to facilitate the session on the part of the counsellor, or the fears, concerns and emotional complexities of the decision to test and the diagnosis of the client’s serostatus, sensitivity to these aspects must be shown at all times. To present for testing suggests that one is already intimately associated with the nature of infection with HIV & AIDS. The psychological journey undertaken when choosing to test is by its nature complex and extremely sensitive. This paper therefore contends that it is imperative that an empathetic and psychologically supportive environment be established as core components of the VCT experience.
With the incidence of HIV & AIDS rife in sub-Saharan Africa, it is critical the VCT service be seen to be a psychologically safe and supportive one, in order to ensure an optimal opportunity to effective intervention. Willingness to test is impacted by such factors as a fear of stigmatisation, discrimination and blame for the need to test, let alone a positive diagnosis. Thus by adopting the lens described, and allowing it to inform the process of intervention, as well as advocacy and information dissemination around this important topic, this service will be increasingly able to reach its maximum potential.
HIV testing, or VCT (Voluntary Counselling and Testing), is something we often hear and read about. The reactions you hear from people about VCT differ widely.
Some of the reactions are:
* Some people say it has nothing to do with them. As they are not at risk, they do not need testing.
* Some people say that it is no use anyway. They don't want to know their status, as they cannot do anything about it if they are positive. If they are negative, nothing changes anyway.
* Some say they do not want to know their status. Being HIV+ means you will die, and they do not want to know that.
* Some might feel that they can't make decisions about when and with whom they have sex in any case, so why test if you cannot protect yourself.
* Some people even believe that you can be infected through the testing procedure, that it is just another trick to infect some group deliberately.
How should we look at all these different viewpoints? Not one of these statements are scientifically accurate, or the most healthy way to look at the matter.
HIV and AIDS affect us all. If you are sexually active, your partner may place you at risk. This may also happen if you are faithful. More than 70% of HIV+ women in Africa are in a relationship where they are faithful to one partner. You may even be at risk through contact with blood of a HIV+ person. If you are not at risk, being tested may help others. If testing becomes routine and commonplace, it will help break down the stigma of HIV.
If you are HIV positive, practising safe sex will protect present and future partners from HIV. If you are pregnant and HIV positive, you can take measures that may help protect your unborn baby from being infected. If you are HIV negative, you can protect yourself and stay that way.
Although the HI-virus can not be destroyed, being HIV positive is not the end of your life. By living a healthy lifestyle you can strengthen your immune system. This includes diet, exercise, good sleeping patterns, stress management, getting emotional support and avoiding other infections. If your immune system becomes weaker, antiretroviral medication is available to suppress the virus. You may also qualify for certain government grants to help you financially. If treatment is unsuccessful, knowing this may give you and your family the opportunity to make important arrangements about your children and your belongings.
Some persons (especially women) do not have the power to say no to husbands or partners, or may even be raped. In this situation, knowing your status means that you can do everything possible to keep yourself healthy, and to protect others.
We do not like to think about unpleasant things such as HIV and getting ill, maybe even dying. If you live in an ethical and responsible manner, it is your responsibility to think about, and make a decision about, testing for HIV.
Written for The Communicator, Staff Newsletter of the Trans 50 organisation, by Lyn van Rooyen on 20/04/2005
HIV Testing and Counseling: New Guidance. 30 May 2007.
WHO and UNAIDS issued new guidance on informed, voluntary HIV testing and counselling in health facilities on Wednesday 30 May, with a view to increase access to needed HIV treatment, care, support and HIV prevention services. The new guidance focuses on provider-initiated HIV testing and counselling (PICT). The complete document is large (2.78MB) and can be downloaded here or you can the executive summary.
HIV Counseling and Testing for Youth: A Manual for Providers. 2005
Family Health International. This manual is designed for service providers and counselors working with youth. Approximately one-third of clients who seek HIV testing are youth, and these young people often have different needs than do adults. With this easy-to-use, spiral-bound booklet, service providers and counselors can improve their skills and assist youth with the difficult issue of HIV counseling and testing. The tool emphasizes integrated services with handy references and charts on contraceptives, other STIs, youth-friendly services, and other information. Download full manual or in sections( 88p, 559 KB)
Horizons Report, Examine HIV Testing From Different Angles.
This issue of Horizons Report, the biannual newsletter of the Horizons Program, examines HIV testing from different angles, drawing from relevant studies in several countries. These include the readiness of health workers in Kenya to provide routine HIV testing, and the effectiveness of workplace VCT programs in Kenya and Zambia to reach health workers and teachers. The issue also describes strategies for increasing uptake of testing by truckers in Brazil and the role of families in youths' decision-making to get tested for HIV in Zambia. Download
Let's Talk About HIV Counselling and Testing - Facilitators' Guide.
Tools to build NGO/CBO capacity to mobilise communities for HIV counselling and testing. (International HIV/AIDS Alliance International HIV/AIDS Alliance) This toolkit is designed to help NGOs, CBOs and other civil society organisations responding to HIV/AIDS in developing countries increase their knowledge and improve the quality of their work onHIV counselling and testing. It has eight sections covering different aspects of HIV counselling and testing. Each section begins by providing essential information comprising key definitions, concepts and messages after which participatory activities are presented for carrying out with NGO/CBO staff. Download PDF (428KB).
Let’s Talk About Voluntary HIV Counselling and Testing.
International HIV/AIDS Alliance. Has ten sections covering different aspects of voluntary HIV counselling and testing. Each section begins by providing essential information comprising key definitions, concepts and messages after which participatory activities are presented for carrying out with NGO/CBO staff. Download (337kb).
Models for HIV Testing.
The traditional focus internationally was on VCT - voluntary testing.
* The South African Guidelines on operating a VCT service is available here (Document incomplete) (100KB)
The move in many circles now seems to be towards Routine opt-out testing; a model of HIV testing and counselling that makes the HIV test a routine part of medical care in countries. A number of article on this topic can be found:
* One of the strong South African advocates is Judge Cameron. An article from PlusNews is available here (35KB)
* A more scientific article on "Changing the Paradigm for HIV Testing" can be found here.(76KB)
* The newest recommendations from the CDC can be downloaded (251 KB)
* A comprehensive article with a note of caution about some of the challenges of this model can be found in this article (85.0 KB) reporting on the 2006 PEPFAR Meeting
* An individual living with HIV shares his concern in the PositvelyAware Journal.
* "WHO/UNAIDS endorse opt-out HIV testing" -read this AIDSMAP article published on 30 May 2007. The complete guidelines are available here.
The last option is compulsory testing. Other than in selected cases (eg " to protect victims of crime, emergency service workers and persons who provide emergency first aid") this is mostly frowned on in Human Rights circles, although it is legal in countries like Hungary and suggested by people like Bill Clinton as a solution. Read more about Mr Clinton's view here.
Routine Opt-Out Testing.
A model of HIV testing and counselling that makes the HIV test a routine part of medical care in countries. A number of article on this topic can be found:
A comprehensive article with a note of caution about some of the challenges of this model can be found in this article(85.0 KB) reporting on the 2006 PEPFAR Meeting.
A more scientific article on "Changing the Paradigm for HIV Testing" can be found here.(76KB)
An individual living with HIV shares his concern in the PositvelyAware Journal.
The recommendations from the CDC can be downloaded (251 KB).
One of the strong South African advocates is Judge Cameron. An article from PlusNews is available here (35KB).
The first legally approved HIV self-test kit that allows people to get a result in 15 minutes at home has gone on sale in England, Scotland and Wales. Unlike other kits, these tests do not need to be sent off to a lab to get the results.
It works by detecting antibodies on a small drop of blood, which are often only detectable three months after the infection is caught.
Experts warn that any positive tests must be reconfirmed at clinics. Charities hope it will reduce some of the 26,000 people estimated to have undiagnosed HIV in the UK.
An early diagnosis allows people to get treatment quickly and can prevent serious complications. And individuals successfully treated for HIV are less likely to pass the infection on.
This new "do-it-yourself" test is made by company Bio Sure UK and can be bought online.It works in a similar way to a pregnancy test, measuring levels of antibodies - proteins made in response to the virus - in a person's blood.
The device analyses a small droplet of blood, taken from the finger-tip using a lancet. Two purple lines appear if it is positive.
The company recommends attending sexual health clinics for advice and further blood tests if both lines appear.And even if the test is negative experts say it does not mean people are definitely virus free - especially if exposure occurred within the last three months.
The three-month window period, between the moment someone catches the infection and the time it can take for antibodies to develop, means the kit is not reliable during this time.
Charities have welcomed the test and hope it will encourage more people to get checks - particularly those reluctant to go to clinics in the first instance.
Dr Rosemary Gillespie, chief executive at Terrence Higgins Trust, said: "We campaigned for a long time to secure the legalisation of HIV self-test kits which happened in April 2014, so it is great to see the first self-test kits being approved.
"However, it is important to make sure people can get quick access to support when they get their result."
Shaun Griffin, also at the charity, said: "At the moment there are funding challenges throughout the NHS, including for sexual health services.
"It is absolutely critical that people have access to HIV tests and advice they need."
Free HIV tests are available across the NHS.
In Northern Ireland ministers are considering legal changes to allow the sale of home testing kits.
New HIV testing guidance to help reach the 90-90-90 targets. 22/04/2015
The WHO Department of HIV plans to release new guidance for countries concerning HIV testing services, which will include updated and consolidated recommendations. Countries are working towards the 90-90-90 targets proposed by UNAIDS, which call for a scale-up of HIV testing so that 90% of people with HIV are aware of their infection, 90% of people diagnosed with HIV are linked to antiretroviral treatment (ART) and 90% of those on ART adhere and have undetectable levels of HIV in their blood.
To reach the first 90 — diagnosing 90% of people with HIV who do not know their HIV status — countries need to improve the effectiveness of their HIV testing services and reach people with HIV who are undiagnosed so they can be linked to HIV prevention, care and treatment. Countries have indicated to WHO that the consolidation of guidance for HIV testing services will help them achieve this goal.
The new guidelines focus on HIV testing services (HTS) to capture the full range of services that should be provided together with HIV testing. All HIV testing services should continue to be provided within WHO's essential 5Cs: Consent, Confidentiality, Counselling, Correct test results and Connection (linkage to prevention, care and treatment). This includes pre-test information, post-test counselling, linkage to appropriate HIV prevention, care and treatment services and other clinical and support services, quality HIV testing, accurate test results and diagnosis, and coordination with laboratory services to support quality assurance.
The consolidated HIV testing guidelines are the result of a combination of existing guidance and new recommendations. It is hoped they will provide more comprehensive guidance that will assist countries in selecting approaches to deliver HIV testing services more efficiently and effectively, assure the accuracy of HIV testing and diagnosis, and improve the quality of HIV testing services. The guidance will also include new recommendations to help countries scale-up their capacity to administer quality HIV testing services, particularly in community settings.
WHO plans to release the new guidelines at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment & Prevention taking place in Vancouver, Canada on 19-22 July 2015.
Happy 30th birthday to the first HIV blood test, and the countless lives it has saved. 4/3/2015
Published at Quartz Written by Tim Lahey 2 March 2015
Thirty years ago, on March 2, 1985, the Food and Drug Administration approved a new HIV test. It was the result of nine months of round-the-clock labor by dozens of scientists. Immediately adopted by the American Red Cross and other institutions, the blood test marked the beginning of a new era in HIV medicine.
Scientists scrambled for answers, doctors fought a protean array of oddball diagnoses, and activists tried to protect a largely marginalized population of patients from systematized neglect.
Patients with HIV, caught in the crossfire between high-minded science and low-brow politics, wondered what would come next, and almost universally discovered it wasn’t good. Their partners and friends in turn wondered if they too would be hospitalized with a mysterious pneumonia or develop the stigmatizing purple skin spots of Kaposi sarcoma.
Finally, when the first HIV test came out in 1985, doctors and patients could know who was or was not infected. We could at least name our viral enemy. Famously, the AIDS activists Act Up proclaimed “Silence = Death,” the converse of which was the radical concept that speaking up about the diagnosis of HIV restored some measure of power to the powerless. On the other hand, in those days a positive test result was sometimes seen as an identity-changing death sentence. As Susan Sontag wrote in AIDS and Its Metaphors, “Fear of sexuality is the new, disease-sponsored register of the universe of fear in which everyone now lives.”
Technology has changed, but so have we
We have come so far since then. Over 70 million people have been diagnosed with HIV worldwide, and once-politicized HIV testing is becoming a routine governmental health recommendation. The US Preventive Services Task Force, for instance, recommends HIV testing for all US adolescents and adults. Worldwide HIV testing drives and shapes the allocation of dozens of billions of dollars of funding for HIV treatment and prevention programs.
HIV testing technology too has evolved with time. Despite sensitivity and specificity rates over 99%, early generation HIV tests still could remain falsely negative for months after initial infection. This meant newly infected patients went unconnected to lifesaving prevention and treatment opportunities and often did not know how important it was for them to alter risky behaviors that could transmit HIV.
Fortunately HIV tests have steadily gotten better through the years. The latest fourth generation tests can detect nearly all cases of HIV from the first few weeks of initial infection, and can do so in hours. As a result, in 2014 the CDC updated its testing guidelines and recommended a new testing algorithm that uses fourth generation HIV tests.
The technology of HIV testing isn’t the only thing that has evolved significantly in the last 30 years. The science of HIV treatment and prevention has evolved as well, in turn changing the way a positive HIV test is perceived.
Diagnosis now means treatment
Perhaps the most critical change has been the development of safe and effective HIV treatments. People with HIV who promptly access and take HIV therapy now live as long as people without HIV infection, and are at least a hundred times less likely to transmit HIV than they were off of therapy. These are major accomplishments for an infection unheard of 35 years ago.
It is never good news to learn you have HIV, but at least now people with HIV have options. Beyond HIV treatment, another option is serosorting, in which people with a positive HIV test elect to have sex only with others with the same serostatus, thereby reducing the risk of transmission to people without HIV. This is yet another example of how HIV testing can empower people with HIV to help contain the epidemic.
Decades of public health messaging and activism have also changed the societal context of HIV testing. When the HIV epidemic was first recognized, public mention of homosexuality in particular was stigmatized, and governmental squeamishness with the issue is widely credited for exacerbating the early US AIDS epidemic. We are still a long way from providing optimal care to everyone who needs it, but every time I see patients with HIV in clinic I am reminded of the distance we have traveled. A married gay patient recently told me that, besides the few seconds it takes to swallow his nightly pill, “I completely forget I even have HIV.”
In 2015, there is hope we will beat HIV. From a partially active vaccine to Timothy Ray Brown, the only person ever cured of HIV, many in the HIV field are newly starting to hope for an HIV cure for all. Until that day comes—and it will!—one of our best tools in the fight against AIDS is HIV testing, at 30 years and counting.
No improvements in CD4 count at diagnosis in African patients in last decade. 10/2/2015
Published at AIDSmap Written by Gus Cairns 4 February 2015
A study by Harvard Medical School has found that the average CD4 count in sub-Saharan African people who are diagnosed with HIV has not risen since 2002. Neither has the average CD4 count on initiation of treatment, which remains well below the AIDS-defining limit of 200 cells/mm3. The authors call for far more active HIV testing and facilitated referral programmes, and continued global financial support for HIV testing and treatment.
A second study of a number of different prevalence and incidence surveys conducted by the International AIDS Vaccine Initiative (IAVI) among selected populations in the region shows that annual HIV incidence ranges from zero to 19% according to the population studied, indicating that specific groups should be the subject of testing and referral initiatives. Groups with especially high incidence included the negative partners in sero-different couples, female sex workers (FSWs), men who have sex with men (MSM), young women in certain locations, and specific communities such as fisherfolk on Lake Victoria. Equally, however, surveys of some similar groups in different locations reported low incidence, showing that it may change rapidly and that regular studies should track incidence hotspots.
It was notable that the incidence rate in most populations with high rates fell two- to threefold after the first three months of being included in an incidence survey, showing that clinical referral and monitoring is itself a useful HIV prevention measure.
CD4 count at diagnosis and at start of treatment
The Harvard study looked at CD4 count on diagnosis and at initiation of antiretroviral therapy (ART) in 127 different studies covering over half a million patients between 2002 and 2012. Only six studies looked at CD4 count at both HIV diagnosis and ART initiation in the same patients.
It found that the average CD4 count at HIV diagnosis was 250 cells/mm3 in 2002 and 309 cells/mm3 in 2012. This increase – amounting to a 5.8 cells cells/mm3 increase per year – was not statistically significant.
The average CD4 count at ART initiation actually decreased very slightly, from 152 cells/mm3 in 2002 to 140 cells/mm3 in 2012, well below the AIDS-defining limit of 200 cells/mm3. This decrease was also not significant. There was no change in CD4 count at initiation after the issue of the World Health Organization’s 2009 treatment guidelines, which changed the recommended CD4 count at which to start ART from 200 to 350 cells/mm3.
There were exceptions to these CD4 figures. When ART was given to pregnant women for the prevention of mother-to-child transmission, the CD4 count at diagnosis and at ART initiation were 395 and 313 cells/mm3 respectively.
More significantly in terms of general testing and treatment policy, CD4 counts were a lot higher at both diagnosis and ART initiation in so-called ‘active HIV screening’ programmes. This means initiatives such as community-wide screening, community-based combination prevention programmes that include testing, home-testing and home-based testing by visiting health workers. In active programmes, CD4 counts at diagnosis and initiation were 405 and 268 cells/mm3 respectively. However, only 3.3% of all the people whose CD4 counts were included were involved in studies of such programmes.
South Africa is the one country that had higher CD4 counts on diagnosis in 2012 than 2002: its year-on-year increase in average CD4 count at diagnosis of nearly 40 cells/mm3 a year would appear to be an endorsement of that country’s HIV awareness strategy. However this has not been matched by an increase in CD4 count at ART initiation, which at 123 cells/mm3 averaged over the whole decade is the second-lowest among countries surveyed after Ethiopia.
The researchers comment that there is a relative lack of data post-2010, with only 14% of studies reporting figures from beyond that year: this is because some multi-year studies do not report till the end, so recent improvements in CD4 count at diagnosis and ART initiation could be missed.
HIV prevalence studies
Meanwhile a series of observational studies conducted by IAVI document extremely high HIV prevalence and incidence rates in some populations and surprisingly low ones in others. IAVI runs a project called the African HIV Prevention Partnership that conduct observational studies in different parts of Africa to uncover populations in particular need of prevention intervention. This is work preparatory to creating an African HIV Clinical Research and Prevention Trials Network similar to HPTN in the US.
Their paper looks at three prevalence and ten incidence studies in varied populations in the countries of Uganda, Rwanda, Kenya, Zambia and South Africa.
In the prevalence studies, a variety of populations in Uganda and Kenya were studied including rural communities, clinic attendees, a random whole-area population sample, and in Nairobi female sex workers (FSWs) and their clients.
Groups in which there was particularly high HIV prevalence includes FSWs (20% - in their clients it was 7%), and divorced and widowed people (as opposed to single or married ones), where prevalence was 28% in a Kenyan study, and 22% in a Ugandan one. HIV was also more common in urban versus rural populations: it was 9% urban versus 2% rural people in a Kenyan study, and, in a Ugandan one, 16% versus 10% for people who lived near a highway versus people whose homes were only accessible by foot.
Peak prevalence age was 30-34 in two studies (16.5% in Uganda and 24% in FSWs) and in the non-FSW studies women had higher prevalence than men (in women, 10% and 13% in two studies versus, in men, 5% and 9%).
Condom use, especially irregular use, was actually associated with higher HIV prevalence than not using them at all, but possibly because it was associated with casual sex. In Nairobi FSWs and clients, prevalence was 17.5% in condom users versus 10% in non-users. In Masaka, Uganda prevalence was 10% in people who never used condoms, and also in people who used them more than half the time: but it was 15% in people who used them only occasionally. Prevalence in people with one steady partner was lower (8-11% across studies) than in people who had more than one (14-17%).
Genital ulcer disease (herpes, syphilis and the like - GUD) were associated with 2.5 to four times the prevalence than in people who did not have GUD.
HIV incidence studies – very high rates in some groups
But it was the incidence studies that found continuing high, and in some cases extraordinarily high, rates of ongoing HIV infection in some communities and groups – and low rates in seemingly similar ones.
One of the easiest and most important populations in which to conduct incidence is serodiscordant couples. In most but not all studies of serodiscordant couples annual HIV incidence was higher where the female partner was the initially HIV-negative one. Very high rates were observed in Lusaka, Zambia (9% a year in female partners, 7% in male) and Ndola in the same country (11% in women and 6% in men).
The ‘real-life’ effect of placing the positive partner on ART was documented in one study in Masaka, Uganda where annual HIV incidence in serodiscordant couples was 4% in male partners and 5% in female but only 1% in partners of either gender when the HIV-positive partner was on ART.
In the latter case particularly, much of this continued HIV infection may have come from outside the main relationship: IAVI genotyped all viruses in the HIV positive partners and found that from 20% to 33% of the infections in their studies came from someone other than the main partner, with one exception on Uganda where there were no ‘unlinked’ infections.
Other groups in which very high incidence was found were MSM, with annual incidence rates of 7% and 6% at two places in Kenya and 9.5% at Rustenberg in South Africa; women in ‘peripheral communities', i.e. irregular housing in Rustenburg (9%) and members of fishing communities in Lake Victoria (10% in women in one Ugandan location and 5% in men).
And yet, at the same time, some groups with very high prevalence did not have a high rate of ongoing HIV infection. Even though HIV prevalence in Nairobi FSWs was high (see above), annual incidence was very low: in rural communities in Masaka where HIV prevalence was 10%, ongoing HIV incidence was so low in the general population that the team shifted their incidence survey to serodiscordant couples and fishing communities. And in one study in Kenya there were no infections observed within discordant couples at all (this study is unpublished so there is as yet no explanation for this).
One striking and near-universal finding was that enrolment into an HIV incidence study brought down incidence in itself. There were astoundingly high HIV incidence rates among some people in the first three months of their involvement in incidence studies: 15% and 19% in HIV-negative women in Zambian serodiscordant couples, 16% in Kenyan MSM, 12% among women with casual partners in South Africa. In all cases, although incidence remained high, it fell 1.5 to 4-fold after the first three months of being in the survey. This phenomenon has been seen in HIV prevention studies before and may be due to regular monitoring and the attention and counselling of healthcare workers.
HIV prevalence in sub-Saharan Africa has been in decline throughout the period of these studies and access to ART has expanded hugely. However what these two studies show is that the HIV epidemic is still very much an ongoing one in some groups in Africa.
The IAVI writers comment that their findings "provide valuable data for prevention trial design and conduct, prevention planning, and service delivery," especially in key affected populations where there is high HIV incidence "despite regular HIV testing and counselling."
Siedner MJ et al. Trends in CD4 count at presentation to care and treatment initiation in sub-Saharan Africa, 2002-2013: a meta-analysis. Clinical Infectious Diseases, e-pub ahead of print: pii: ciu1137. 2014.
Kamali A et al. Creating an African clinical research and prevention trials network: HIV prevalence, incidence and transmission. PLoS One, Doi:10.1371/journal.pone.0116100. 2015.
Closing the HIV testing gap in eastern and southern Africa. 3/12/2014
More than 50 000 people in eastern and southern Africa received HIV testing and counselling services as part of national campaigns held between 17 and 30 November. On 1 December, World AIDS Day, countries unveiled the number of people tested during the campaigns, which took place in Botswana, Ethiopia, Lesotho, Namibia, South Africa and United Republic of Tanzania.
While the campaigns sought to reach the general population, some countries focused on reaching populations at higher risk of HIV infection, including young people, women and migrants.
Ethiopia held a one-day campaign in Gambella, which has the highest HIV prevalence in the country, at 6.5%, according to the 2011 Ethiopian Demographic Survey. Botswana provided HTC services at 10 testing sites in Maun District, with a special focus on couples and young people. Lesotho undertook a two-week nationwide campaign focusing on young people, migrants, men and traditional healers. Namibia held the testing in Katutura—a township of the capital Windhoek—to reach underserved communities in informal settlements.
Communities, non-profit organizations and national partners supported the campaigns by mobilizing communities, procuring test kits or distributing HIV information materials and commodities. The campaigns also ensured that people who tested positive for HIV were referred and linked to HIV treatment and care services.
The number of people tested during the campaigns reaffirms the strong commitment of countries to accelerate community action and galvanize the active involvement of young people and networks of people living with HIV to end the AIDS epidemic by 2030.
“Our efforts to ending the AIDS epidemic in this region will not be successful if people do not know their HIV status. Voluntary HIV testing and counselling is the starting point that will get countries to zero new HIV infections, zero discrimination and zero AIDS-related deaths.” Sheila Tlou, Director, UNAIDS Regional Support Team for Eastern and Southern Africa
“Today is our one month anniversary and we both tested negative for HIV. This has been a perfect anniversary present for both of us. Our status will allow us to move forward in our relationship with trust and protecting each other.” Prudence, 25, and Thabiso, 27, a couple at the Union Building HIV testing site in Pretoria, South Africa
“I wanted to know my HIV status for some time now but I have always been too afraid. I have been engaged in unprotected sex with my partner, who told me that I should get tested for the both of us. Now that I know my status, I will tell my partner, my friends and family to come and get tested as well.” Magano, at a testing site in Katutura informal settlement, Windhoek, Namibia
“I just found out that I have HIV. It seems I have a new life and I cannot change my result. But I am determined to lead a healthy life for me, my child and my husband.” Nyanhial Gach, a 22-year-old mother, at Gamebella Stadium testing site, Gambella, Ethiopia
HIV Testing Recommended for All 25/02/2013
HIV testing should be part of routine care for adults and teens says panel of experts (dailyRx News)
Should all people get an HIV test, or just people at high risk? These questions are at the heart of long debate about HIV testing. And the debate may be coming to an end.
A panel of experts whose recommendations guide clinical care and public policy said that all adults and teens over age 15 should have routine HIV tests. Some doctors think this marks the end of the debate about who should be tested and when.
Once the panel’s recommendations are final, HIV testing will be more accessible. The cost of HIV testing will be covered by healthcare plans as part of routine medical care.
The US Preventive Services Task Force (USPSTF) is a panel of independent doctors and experts. They review research about medical conditions and provide recommendations for doctors and policymakers about what the evidence says is best for a particular health condition.
The USPSTF recommendation is still in draft form and awaiting final edits. In its present form it says: “The US Preventive Services Task Force recommends that clinicians screen adolescents and adults ages 15 to 65 years for HIV infection. Younger adolescents and older adults who are at increased risk should also be screened.”
Ronald Bayer, PhD, and Gerald M. Oppenheimer, PhD, MPH, presented their perspective on the new USPSTF recommendations about HIV testing.
They said that the new recommendation ends a long-standing debate about whether or not routine testing is helpful or harmful. They also said that they hope this is the first step toward making HIV testing more accessible for everyone and reducing the number of people who progress to acquired immune deficiency syndrome (AIDS) without ever knowing they were HIV positive.
In 2006, the USPSTF did not feel that the benefits outweighed the risks of routine HIV testing. Research at the time seemed to show that early detection of HIV meant that people were more likely to respond well to treatment – and live long, healthy lives.
But the stigma surrounding HIV infection meant that testing presented a psychological burden to patients and could impact their lives in various ways. So the USPSTF recommended that only people at risk for HIV infection should receive regular testing.
The USPSTF began reviewing all the research again in 2011. Now, after reviewing the research, the USPSTF has decided that the benefits of routine HIV testing outweigh the risks of testing.
The rationale they gave for the new recommendations is that starting antiretroviral drugs before symptoms appear has been shown to lower the risk of developing AIDS, AIDS-related complications and death. Also, using antiretroviral drugs is linked to lower risk of passing HIV to others.
Therefore, routine testing is likely to give more people the opportunity to start antiretroviral treatments early.
The new USPSTF recommendations mean that HIV testing will be available free-of-charge to anyone – regardless of risk. The Affordable Healthcare Act requires that health plans pay the cost of treatment and tests that are recommended by USPSTF without any copay by the patient.
Many people who are HIV positive don’t know it. An estimated 20 to 25 percent of Americans living with HIV are not aware they have the disease.
Many people do not get tested for HIV. As such, the infection is caught in later stages of the disease when people are sicker.
The Centers for Disease Control and Prevention (CDC) estimated that as many as 41 percent of people who tested positive for HIV had never had an HIV test before. And about a third of these people developed AIDS within the first year.
Overall, the USPSTF recommends that all adults should have regular screening for HIV. Catching it early can lead to early treatment. Early treatment can help people with HIV live longer, be healthier and protect their loved ones.
The opinions of Drs. Bayer and Oppenheimer were published February 20 in the New England Journal of Medicine.
Newer HIV Tests Better Identify Acute Infections - 29 Jan 2014
The more recently developed “fourth-generation” HIV tests are far superior to older antibody assays at detecting the virus during the first few weeks of infection, aidsmap reports. (This article first published on poz.com) Publishing their findings in PLOS ONE, researchers analyzed the success rates of various types of HIV tests conducted between 2003 and 2008 in high-risk populations in San Francisco. Out of 21,234 HIV tests, there were 761 HIV diagnoses, of which 58 were determined to be acute, or very recent, infections.
One purpose of the research was to assess less expensive methods of detecting acute infections. During the time period the study covered, acute infections were found by pooling blood samples and then running a viral load screen—considered the most accurate means of detection. So the investigators tested stored samples from the 58 acute diagnoses with a variety of HIV tests looking for an alternative.
Fourth-generation laboratory tests produced the best results. These tests screen both for HIV antibodies and for the p24 antigen, which appears in the body shortly after infection and sooner than antibodies, thus cutting down the “window period” during which false-negative results are likely following a recent exposure to the virus. With one such test, 87.3 percent of those with acute infection and an estimated 99.1 percent of all people with HIV would receive an accurate test result. One hundred percent of HIV-negative people would accurately test negative, meaning there would be no false positives.
A fourth-generation rapid (as opposed to laboratory) test, providing results in minutes, did not fare as well. Just 54.4 percent of acute infections were accurately identified.
The first- through third-generation tests were perfect at correctly identifying HIV-negative cases, except for the OraQuick Advance rapid saliva test, which was 99.9 percent accurate. Their success rate at identifying all HIV-positive cases ranged between 86.6 percent for the OraQuick saliva test and 96.2 percent for the Genetic Systems laboratory test. Three tests were shown to detect acute infections: Genetic Systems had a 34.5 percent success rate; Uni-gold Recombigen rapid test had a 25.9 percent success rate; and the OraQuick Advance rapid blood test had an only 5.2 percent success rate.
Science Speaks is in Atlanta, Georgia this week and will be live-blogging from the 20th CROI — Conference on Retroviruses and Opportunistic Infections from Sunday to Wednesday, covering breaking developments from investigators on cure research, new antiretroviral agents, hepatitis, tuberculosis and treatment as prevention.
The following is a guest post by HIVMA executive director Andrea Weddle.
Scaling up of mobile community-based voluntary HIV counseling and testing and post-test support services can reduce HIV incidence at the community level, research results presented Tuesday at the 20th Conference on Retroviruses and Opportunistic infections. presenting findings from Project ACCEPT (HPTN 043), Dr. Tom Coates highlighted a 14% decrease in HIV incidence in communities where community-based testing was scaled up, in a National Institutes of Mental Health-supported .study evaluating whether a community-level intervention could change the trajectory of the epidemic at the community level in developing countries.
The first randomized control trial of its kind included 48 communities in South Africa, Tanzania, Zimbabwe and Thailand with HIV prevalence ranging from 1 percent in a participating Thai community to 31 percent in a South African community. Mobile community-based voluntary counseling and testing, as well as community engagement, along with post-test support was provided over a 36-month in the intervention communities. HIV incidence was in those communities was then compared to communities receiving standard facility-based testing.
During the first year, HIV testing increased by25 percent in the mobilized community . Among men a 45 percent increase was noted, while women showed a a 15 percent increase (lwomen already showed higher testing rates, likely due to routine HIV testing of pregnant women. A four-fold increase in the detection of previously undiagnosed HIV infection was reported.
Dr. Coates noted that over the course of the study which began in 2003, significant advances in HIV prevention and treatment occurred, offering hope for an even greater impact when community-wide voluntary counseling and testing mobilization is paired with scale up of antiretroviral therapy, male circumcision and pre-exposure prevention from antiretroviral treatment.
A team of researchers, led by Samuel K. Sia, associate professor of biomedical engineering at Columbia Engineering, has developed a low-cost smartphone accessory that can perform a point-of-care test that simultaneously detects three infectious disease markers from a finger prick of blood in just 15 minutes. The device replicates, for the first time, all mechanical, optical, and electronic functions of a lab-based blood test. Specifically, it performs an enzyme-linked immunosorbent assay (ELISA) without requiring any stored energy: all necessary power is drawn from the smartphone. It performs a triplexed immunoassay not currently available in a single test format: HIV antibody, treponemal-specific antibody for syphilis, and non-treponemal antibody for active syphilis infection.
Sia’s innovative accessory or dongle, a small device that easily connects to a smartphone or computer, was recently piloted by health care workers in Rwanda who tested whole blood obtained via a finger prick from 96 patients who were enrolling into prevention-of-mother-to-child-transmission clinics or voluntary counseling and testing centers. The work is published February 4 in Science Translational Medicine. Sia collaborated with researchers from Columbia’s Mailman School of Public Health; the Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center; Department of Pathology and Cell Biology, Columbia University Medical Center; Centers for Disease Control and Prevention—Laboratory Reference and Research Branch, Atlanta; and OPKO Diagnostics.
“Our work shows that a full laboratory-quality immunoassay can be run on a smartphone accessory,” says Sia. “Coupling microfluidics with recent advances in consumer electronics can make certain lab-based diagnostics accessible to almost any population with access to smartphones. This kind of capability can transform how health care services are delivered around the world.”
Sia’s team wanted to build upon their previous work in miniaturizing diagnostics hardware for rapid point-of-care diagnosis of HIV, syphilis, and other sexually transmitted diseases. “We know that early diagnosis and treatment in pregnant mothers can greatly reduce adverse consequences to both mothers and their babies,” Sia notes. The team developed the dongle to be small and light enough to fit into one hand, and to run assays on disposable plastic cassettes with pre-loaded reagents, where disease-specific zones provided an objective read-out, much like an ELISA assay. Sia estimates the dongle will have a manufacturing cost of $34, much lower than the $18,450 that typical ELISA equipment runs.
A step-by-step demonstration of a smartphone dongle to diagnose sexually transmitted infections through a fully automated immunoassay
—Video courtesy of Tassaneewan Laksanasopin and Tiffany Guo for Columbia Engineering
The team made two main innovations to the dongle to achieve low power consumption, a must in places that do not always have electricity 24/7. They eliminated the power-consuming electrical pump by using a “one-push vacuum,” where a user mechanically activates a negative-pressure chamber to move a sequence of reagents pre-stored on a cassette. The process is durable, requires little user training, and needs no maintenance or additional manufacturing. Sia’s team was able to implement a second innovation to remove the need for a battery by using the audio jack for transmitting power and for data transmission. And, because audio jacks are standardized among smartphones, the dongle can be attached to any compatible smart device (including iPhones and Android phones) in a plug-and-play manner.
During the field testing in Rwanda, health care workers were given 30 minutes of training, which included a user-friendly interface to aid the user through each test, step-by-step pictorial directions, built-in timers to alert the user to next steps, and records of test results for later review. The vast majority of patients (97%) said they would recommend the dongle because of its fast turn-around time, ability to offer results for multiple diseases, and simplicity of procedure.
“Our dongle presents new capabilities for a broad range of users, from health care providers to consumers,” Sia adds. “By increasing detection of syphilis infections, we might be able to reduce deaths by 10-fold. And for large-scale screening where the dongle’s high sensitivity with few false negatives is critical, we might be able to scale up HIV testing at the community level with immediate antiretroviral therapy that could nearly stop HIV transmissions and approach elimination of this devastating disease.”
“We are really excited about the next steps in bringing this product to the market in developing countries,” he continues. “And we are equally excited about exploring how this technology can benefit patients and consumers back home.”
The study was funded by Saving Lives at Birth transition grant (USAID, Gates Foundation, Government of Norway, Grand Challenges Canada, and the World Bank) and Wallace H. Coulter Foundation.
A massive population-based study launched in the Western Cape and Zambia yesterday is aiming to answer the critical question whether testing large populations for HIV and immediately starting those infected on effective antiretroviral treatment programmes, could close the tap on new infections.
The study, HPTN071 (PopART) will aim to find out whether offering a combination of several HIV prevention methods to a community will better prevent the spread of HIV that the standard individual methods currently on offer.
A five-year study, PopART will help researchers see if house-to-house voluntary HIV counseling and testing, combined with the offer of earlier antiretroviral therapy (ART) for those who test HIV-positive, can reduce the number of new HIV infections in a community.
Research has shown that the viral load of an HIV positive person is reduced significantly while on ART, reducing the likelihood of transmission when unprotected sex takes place.
“The pool of people with HIV in South Africa and sub-Saharan Africa is not getting smaller and the idea with this trial is see if we can turn off the tap (of new infections),” said Dr Peter Bock of the University of Stellenbosch’s Desmond Tutu TB Centre and one of the principal investigators.
He added that another study (HPTN052) had already confirmed modeling research, which found that the test-and-treat strategy could be the answer to stemming the epidemic, but that it had not yet been proven at population level.
Bock said the study, of which the results are expected in five years time, would look at among others the acceptance of taking treatment when people are not yet ill, the issue of adherence, the capacity of a health system to cope with such a scale-up and the cost of this intervention.
“PopART will evaluate all of these components including the qualitative factors such as stigma and treatment attitudes,” Bock explained.
The 21 communities, nine in the Western Cape and 12 in Zambia, were yesterday (SUBS: WED) randomly divided into three study arms.
Arm A communities will receive all of the HIV prevention methods via an army of community workers going door-to-door and offering HIV testing in the home. Other HIV prevention methods such as condom use and medical male circumcision will also be promoted. Those who test positive will be referred to government health facilities for ART.
Arm B communities will receive the same intervention as Arm A, but only those who meet the health department guidelines in terms of ART initiation will start their treatment.
Arm C communities will have no community workers and will receive the standard package of health care. Those prevention programmes that are identified as poor, will be strengthened.
The primary measurable outcome of the study will be the number of new HIV infections.
Professor Nulda Beyers, another principal investigator and Director of the Desmond Tutu TB Centre, said it was critical to acknowledge the willingness of the communities to participate in an effort to provide potentially lifesaving answers.
Conducted by the HIV Prevention Trials Network (HPTN), the study is led by investigators at the London School of Hygiene and Tropical Medicine, in collaboration with Imperial College London, the Zambia AIDS Related Tuberculosis (ZAMBART) project and the Desmond Tutu TB Centre at the University of Stellenbosch.
The initial phase of the study will cost in excess of U$60-million and is funded by United States government National Institutes of Health (NIH) and the Bill and Melinda Gates Foundation. – Health-e News Service
· 265 000-275 000 adults living with HIV
· 13 000 new HIV infections between 2012 and 2013
· 132 000 people were on ART by December 2012
· Ante-natal survey: 18.4% of pregnant women HIV-positive with curve going up
· 196 ART sites
Taking HIV Testing to Homes. 20/9/2012
Home-based HIV testing is one of the newest efforts to get people to know their HIV status
Home-based HIV testing, which enables you and your family to have an HIV test in the privacy of your own home without having to go to a health facility, is one of the newest efforts to be introduced to get people to know their HIV status.
The Mncwarhane family in Hlalanikahle Extension 1 township in eMalahleni, in Mpumalanga, is one of the first house-holds to test for HIV together in a home-based HIV testing programme.
“Almost all of us tested. Only one child wasn’t around when we got tested. But all of us got tested, except for the under-age child”, says sixty-something year-old David Mcnwarhane, the patriarch of the family of seven.
Home-based HIV testing gave David’s oldest off-spring, 39-year-old Esther, her first ever opportunity to test for HIV.
“I probably wouldn’t have tested if there was no home-based HIV testing. Even though I always wanted to go the clinic to test, I was fearful”, Esther admits.
Five members of the Mncwarhane family all tested together in a new home-based testing programme initiated by New Start, a non-profit organisation that promotes HIV prevention. The programme involves visiting house-holds to educate people about HIV prevention and treatment and the need for people to know their status. It also offers HIV testing in people’s homes. But how did the programme come about?
“Basically, we’ve been doing HIV counselling and testing at shopping malls, at taxi ranks and prisons. We’ve been going to people where they work or where they play. But we have been missing people who are stay at home people – that are sort of at home most of the time. So, the idea is to capture people everywhere they are. To get them we have to go where they are – in their homes. Definitely, it was an observation that we are missing out on a lot of people who are stay at home and, also, there are programmes like this in other countries where they’ve been doing this programme and it’s been running successfully. So, it’s a combination of observation and learning from others”, explains Nkanyiso Ndlovu, the manager of the HIV Counselling and Testing programme at the Society for Family Health, which manages New Start.
Home-based HIV testing is already practiced in countries such as Uganda and Zimbabwe. Since the start of the programme in Hlalanikahle township in Mpumalanga, about 110 families have tested. Ndlovu explains that the programme has advantages.
“It saves time for the people that we test because we actually come to them. They don’t have to go anywhere. It saves them money. They don’t have to pay to get on a taxi. They are all in their home… everybody is there, so they encourage each other. Those that need support, find support within their immediate family. So, it’s much easier and much more beneficial to test in your house because you’ve got all your family members with you.
And if you need to disclose, you don’t have to stress a lot about who you’re going to disclose to because everybody in the home is already informed about what’s happening. So, it’s easier to disclose and get support. We do encourage it, but it’s not something that we force people to do”, he says.
The matriarch of the Mncwarhane family, Martha, says if families test together it’s important to disclose their results to one another.
“We deemed it important to share our results so that we can support one another. If you’re HIV-positive and you don’t disclose your status, it might affect you emotionally and that secret might result in illness. So, it was important to know who has HIV and who doesn’t so that we know what to do”, says Martha.
Four out of the five family members tested HIV-negative. One of the children was found to be positive.
“We don’t discriminate against him. We tell him to be open and to look after himself the right way and to go on with life”, says the father, David.
New Start’s home-based testing programme goes beyond offering just the HIV test.
“In addition, we do tests for their CD4 count right in their homes. We also do TB screening and collect sputum for TB. We then refer to clinics that are close by or the clinics that people prefer to be sent to. We already have established relationships with those clinics. So, by the time the client goes there they are being expected by the clinic and it saves them on waiting time as well because if you go on your own straight from nowhere, it might take you a whole day to get served. But if you have been at New Start already, they already know… So, they’ll take you through the service quickly”, says David Ndlovu.
The manager of the programme in Hlalanikahle, Edith Nqakuvane, said home-based HIV testing is able to take testing services to members of the population who wouldn’t otherwise have the opportunity to go for HIV testing, such as the elderly.
“The elders have a privilege of being tested. Because they’ve got arthritis, they can’t walk for distances. So, when we come into their homes they are so happy. They say: ‘I wanted to test, my child. But I can’t walk to the clinic’,” Nqakuvane says.
The programme offers testing to people from the age of two, with the consent of their parents or guardians. New Start currently offers home-based HIV testing in the Nkangala district of Mpumalanga and the Motheo and Lejweleputswa districts of the Free State.
New HIV Testing Guidelines. 20/4/12
New international HIV testing guidelines encouraging couples to test together
New international HIV testing guidelines are encouraging couples to test together and for immediate initiation on antiretrovirals for the one testing positive.
The World Health Organisation this week issued the guidelines recommending that a person living with HIV who has an HIV-negative partner (a 'sero-discordant' partnership) be offered HIV treatment regardless of their CD4 cell count level (measure of their immunity).
This would be potentially earlier than they would otherwise be 'eligible' for treatment under current treatment guidelines.
The move by WHO is a reflection of last year's landmark new data that showed that early HIV treatment can prevent the spread of the virus from one person to another by 96% (Human Prevention Trials Network study HPTN 052).
Médecins sans Frontières’ Access Campaign Medical Director, Nathan Ford welcomed the guidelines “as a major advance in the fight against HIV and puts us on the road toward reversing the epidemic.
It's time for policy makers to ensure these recommendations are translated into more people put on treatment to both save lives and prevent infections. Now governments need to stop the drastic decline in support for global HIV that is already having a negative impact in countries where we work."
The Joint United Nations Programme on HIV/AIDS (UNAIDS) has called on on all countries to implement them to reach the targets set in the United Nations 2011 Political Declaration on AIDS.
“Couples can now reap the benefits of antiretroviral therapy, to improve their own health, and to protect their loved ones,” said UNAIDS Executive Director Michel Sidibé. “By encouraging couples to test together, we can provide comprehensive options for HIV prevention and treatment—that they can discuss and manage jointly.”
WHO recommends that antiretroviral therapy be offered to HIV-positive individuals in discordant relationships even when they do not require it for their own health. The guidance also states that it is possible for couples to stay HIV serodiscordant indefinitely if they consistently practice safer sex using condoms.
“I am excited that with the roll out of these new guidelines, millions of men and women have one additional option to stop new HIV infections,” said Mr Sidibé. “This development begins a new era of HIV prevention dialogue and hope among couples.”
According the new guidelines, “couples who test together and mutually disclose their HIV status are more likely than those testing alone to adopt behaviour to protect their partner. Another potential benefit of couples testing together and sharing their results is that they can support each other, if one or both partners are HIV-positive, to access and adhere to treatment and prevent transmission of HIV to children”.
UNAIDS recommends that HIV testing and counselling should always be confidential and initiation of treatment must always be voluntary and never mandatory or coercive. Couples should have access to the full range of HIV prevention options available including the use of male and female condoms and medical male circumcision. They should also be provided with access to health services such as tuberculosis screening and reproductive health services including family planning with access to effective contraceptives and conception counselling for sero-discordant couples.
According to UNAIDS estimates, around 14 million people are eligible for antiretroviral treatment. At the end of 2011, only 6.6 million people were receiving the life-saving medicines. The guidelines recommend that in situations of limited or inadequate resources, people who require antiretroviral therapy for their own health should always be given priority.
Push For Routine Offers of HIV Tests. 11/11/09
Health Minister is proposing that doctors and nurses routinely offer screening to all their patients.
CAPE TOWN — Health Minister Aaron Motsoaledi is pushing for a radical change in SA’s approach to HIV testing, proposing that doctors and nurses routinely offer screening to all their patients instead of waiting for them to volunteer or get AIDS- related illnesses.
People would still be able to decline the offer of an HIV test.
At the same time, Motsoaledi is leading a government charge to get more people to take voluntary tests. Both measures are meant to increase acceptance of testing and raise the proportion of HIV-positive people who know their status, in the hope that they will take precautions to protect others from infection and seek help if they fall ill.
SA has an estimated 5,3-million people infected with HIV, according to the Department of Health. Yet few of them know their status; last year only a quarter of South Africans had taken a test in the previous 12 months, according to the Human Sciences Research Council.
Motsoaledi said he expected the Cabinet and other leaders to be at the forefront of a huge public HIV testing campaign, possibly on World AIDS Day on December 1 — yet another mark of the current administration’s clear break with the Mbeki era’s lacklustre efforts .
“I will ask him (Zuma) to be in front of the queue, and indications are that he will agree,” Motsoaledi told reporters yesterday. “And I told the bishops to lead their flocks,” he said, referring to a recent meeting with religious leaders.
While prominent South Africans have on occasion taken public HIV tests there has not yet been a co- ordinated campaign involving high- profile figures. Public HIV tests for senior politicians became a contentious issue under the previous administration as neither former president Thabo Mbeki nor his health minister Manto Tshabalala- Msimang would take a such a step, defending their position as a personal matter. Tshabalala-Msimang was so irritated by Business Day’s questions at a press conference two years ago that she broke into Russian, which she had learnt during her time in exile. Tshabalala-Msimang did take a blood pressure test at a public event in a Cape Town township several years ago, in order to encourage people to follow suit.
By contrast, Zuma took a public HIV test in rural KwaZulu-Natal in March 2007, and the then deputy health minister Nozizwe Madlala- Routledge, in no less deliberate fashion, did so too.
The progression of the pan demic could be reversed with appropriate leadership, Motsoaledi said, citing the example of the Western Cape which broke ranks with national government. The province provided HIV-positive mothers with two drugs instead of one to reduce the risk of mother-to-child transmission of HIV. Dual therapy enabled the Western Cape to significantly cut its AIDS- related infant mortality rate.
Motsoaledi said he had asked the South African National AIDS Council to review SA’s capacity to conduct a huge voluntary HIV testing campaign and to determine whether the facilities existed to provide care to the people identified as infected.
Francois Venter, President of the Southern African HIV Clinicians Society, welcomed Motsoaledi’s suggestion of introducing provider- initiated HIV testing, saying such tests should be routinely offered.
Linkage to facility-based HIV care from a mobile testing unit is feasible, South African researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.
In a stratified random sample of 192 newly diagnosed individuals who had received CD4 test results, linkage to care was best among those who were ART eligible, Darshini Govindasamy and colleagues found.
The lower the CD4 cell count the greater the linkage to care: all of those with CD4 counts at or under 200 cells/mm3, two-thirds of those with CD4 counts of 201-350 cells/mm3 and a third of those with CD4 counts over 350 cells/mm3 linked to care.
An estimated two million people died as a result of HIV/AIDS in sub-Saharan Africa in 2008. South Africa now has the largest ART programme in the world, yet half of those in need of treatment do not get it. And a large number of those who do present for care, present late with low CD4 cell counts increasing their risk of early death.
In South Africa traditional HIV counselling and testing (HCT) sites at stationary facilities have increased and consequently so have the numbers tested. Yet this has not resulted in increased numbers on treatment and in care.
Transport costs, being male and having a low CD4 cell count have been well documented as the primary barriers of non-linkage to care.
Successful early diagnosis of HIV has to be accompanied by strategies that assure timely linkage to care and treatment so improving health outcomes.
Mobile testing units offer several advantages: people are often tested at an earlier stage of HIV; it is easier for hard-to-reach and high-risk populations to test; and they are cost-effective. However, maintaining on-going HIV care may prove difficult, requiring referral to stationery facilities.
The authors note no studies have looked at the performance of mobile testing units in linking people diagnosed with HIV to care at public health facilities.
The authors chose to look at whether disease progression as defined by CD4 cell count had an effect on access to care and the associated barriers in a nurse-run, counsellor-supported mobile testing unit.
From August 2008 until December 2009 those diagnosed for the first time with HIV were identified retrospectively from the mobile unit records. Those who got a CD4 cell count were prospectively followed from April to June 2010 to determine linkage to HIV care.
The unit, in the Cape Metropolitan region, Western Cape, South Africa, provides free HCT services to underserved communities.
Along with free client-initiated HCT free screening for other chronic conditions including high blood pressure, diabetes and obesity as well as TB is offered. The population is predominantly black Xhosa-speaking Africans.
Following rapid testing and a positive result and CD4 testing individuals are given detailed referral letters to help their access to care. Individuals are called when results of CD4 counts are available (within 72 hours). Those with no contact number are followed up by home visit or letter. Counselling is provided and patients are encouraged to go to clinics for either pre-ART care or to start ART as appropriate.
Of the 6738 records, overall prevalence of new diagnosis was 6.9% (463), of which 376 met the study’s inclusion criteria.
Because of a higher proportion of patients with CD4 counts at or above 350 cells/mm3 the authors took one-third of patients from this cohort (76), together with all 36 individuals with CD4 cell counts at or below 200 cells/mm3, and the 80 patients with CD4 counts between 201 and 350 cells/mm3.
Of the sample 27% (43) did not get their CD4 test result. Being female, having a CD4 cell count at or under 350 cells/mm3 and having a cellphone improved the likelihood of getting a CD4 count result. These results echo recent studies in South Africa showing a high loss to follow-up prior to receiving a CD4 test result; highlighting the critical need for point of care CD4 testing in both mobile and stationary facilities.
Of the 145 (73%) remaining individuals 10 refused to participate and 56 could not be traced in spite of previously having been contacted and receiving their CD4 counts.
52.5% (49) linked to care, including 100% of those ART-eligible. While the sample size is small, note the authors, the results are considerably higher than in studies of stationary facilities, where rates of post-diagnosis linkage to care varied from 30% to 80% among the ART-eligible.
Over 70% said that the mobile unit’s referral letter helped them access care at a public health facility.
Nonetheless over 30% of those eligible to start ART still had not started two months after their diagnosis but were still in the ART screening process. These results support other studies in sub-Saharan Africa also showing a delay in starting ART after diagnosis.
Having a higher CD4 count, no TB symptoms, not having disclosed and being employed increased the risks of not accessing care.
Not being able to access public health facilities was the most common barrier reported (41%) to linking to care. Other barriers included: 13% worried about ART toxicity and side effects and 9% fearing stigma and disclosure.
Extending hours and opening on the weekends at public facilities and setting up workplace programmes with mobile units could improve linkage to care for the employed, note the authors.
Limitations include the small sample size; the inability to track over 40% of eligible study participants in spite of persistent follow-up so potentially biasing the findings; and incorrect contact information. The study was undertaken 6-18 months after HIV diagnosis makingfollow-up especially challenging.
Strengths include validation of self-reported linkage to HIV care; trained bilingual counsellors assured minimal respondent bias; no incentives were given for participation.
The authors note HIV services at the mobile unit and public health facilities were free so their findings can be generalised to similar settings.
The authors conclude that while linkage to care was best among those ART-eligible, there is an urgent need to design interventions to improve linkage to care for the employed.
Lessons from HCT Campaign. Living with AIDS # 481. 21/7/11
Never has any country in the world targeted such a huge population – 15 million citizens to test for HIV – and had 10.2 million people accepting the HIV test
About 15 million South Africans were targeted for HIV testing in the government’s HIV Counselling and Testing (HCT) campaign, but the effort got slightly over 10 million people to test. The campaign has challenged South Africans and the health system in significant ways.
The campaign has been described as ambitious. Never has any country in the world targeted such a huge population – 15 million citizens to test for HIV – and had 10.2 million people accepting the HIV test. But the campaign was not without any flaws. There are reports that some of the tests were obtained in a manner that violated the human rights of people.
“We are hearing stories of people being tested without their consent. We are hearing stories of people being told: ‘If you don’t have an HIV test, we’re not going to give you the treatment that you need’. We are hearing stories of people saying: ‘Look, I already know that I’ve got HIV. Why do I need to test again’?”, says Mark Heywood is the deputy chairperson of the South African National AIDS Council (SANAC), which is responsible for co-ordinating the HIV Counselling and Testing (HCT) campaign.
Heywood says that in carrying the campaign forward there needs to be systems to identify human rights violations as they occur and there also needs to be better education of health workers and the public around issues relating to human rights.
“If we are having a big campaign amongst rural people, what do we do to make sure that those people who test positive have support, that they are not isolated and victimised within their community? If we’re targeting men who have sex with men we can’t just test men who have sex with men for HIV. We also have to be educating health care workers to make sure that clinics and hospitals are friendly – not discriminating against, not stigmatizing men who have sex with men. I don’t want to discover my HIV status and, then, find that if I go into a clinic that I’m going to be humiliated and made fun of because I’m gay”, he says.
From April last year, the Health Department aimed to test 15 million South Africans for HIV by this June. So far, the campaign has tested 10.2 million people. This is out of 12 million citizens who were counseled for HIV testing since the start of the campaign. The enormity of the effort, which came into an already over-burdened health sector, has “tested the totality of the health system”, says Dr Thobile Mbengashe, the Chief Director of the HIV and AIDS and STIs unit in the national Health Department.
“It has always been unknown to what extent can you stretch the system to actually achieve high output, high qualities and reach many people within a short time. That’s the first thing. I think the second one is that you can learn more by doing and fix the things that need to be fixed as you do. And you actually become very effective. Let me give you an example. When we started the campaign, there were only about 490 facilities that were providing ART services out of the 4 300. Between the time when the HCT campaign was launched and now, over 2 000 facilities are able to provide ART.
We learned that it is possible to provide ART services and provide quality using nurse practitioners who are actually trained to provide this. We had about 290 nurses who were actually qualified to provide ART. We trained and we have now 1 700. Those are actually providing services in those health facilities which were not there. And all that was done during this time”, Mbengashe says.
“This is learning as we go, it’s about doing things differently”, says SANAC’s Mark Heywood.
“Some people might argue that you should not undertake a campaign like this at all until you are absolutely sure that the system can support that sort of campaign. But I think in a country like ours to do that would be irresponsible because part of this campaign is about: How can we get ahead of the HIV epidemic? One way to get ahead of the epidemic is to normalise HIV testing, is to use HIV testing as a way to try to begin to break down the stigma around HIV, and it’s to use HIV testing to try to get much larger numbers of people onto treatment. There are certain risks in that. But I think it is more irresponsible to sit back and wait until we have the perfect system before we embark on something like this”, he adds.
Of the 10.2 million people who tested for HIV in the campaign, about 1.7 million were found to be HIV-positive. About 1.4 million people have been put onto the government’s AIDS treatment programme since April last year. But it’s not clear as to how many are receiving treatment as a result of testing in this campaign.
“One of the lessons we have learned”, says Dr Thobile Mbengashe of the Health Department, “is that the biggest need is that once people have been identified positive, they must not be lost from the system. If you lost from the system… you might have done something extraordinary in terms of coming up early, but you might not get the good benefit of starting treatment early. So, this is one of the components that we are really strengthening in our system”.
The formal run of the HCT campaign officially ended in June. The Health Department is yet to communicate the final achievements of the campaign, which it says will continue being offered to encourage as many South Africans as possible to know their HIV status.
Tragic Mix Up over HIV Test at Royal Berks. 21/4/11
Positive HIV tests were routinely rechecked but negatives were not; Double-checking of negative HIV tests as well as positive ones introduced to prevent false negatives
A 56-year-old Calcot woman would have had a 70 per cent chance of survival if an HIV test 11 months before her death had been correct.
But coroner Peter Bedford heard at an inquest yesterday the test made at Royal Berkshire Hospital in June 2009 produced a false negative and Karen Goodridge, of Corsham Road, was not re-tested for HIV until three days before her death on May 17 last year.
The final result of the second test came on the day she died.
He also heard that another HIV test made on a different patient on the same fateful day had also produced a false negative because the machine used to make the tests had been incorrectly loaded.
The other HIV patient, according to the hospital chief medical officer Dr Jonathan Fielden, is now receiving “the appropriate treatment”.
The inquest heard how Mrs Goodridge’s doctor at the hospital Dr Ann McGown was concerned at her patient’s failure to respond to treatment but was consistently told by the hospital’s haematologists her condition called myelodysplasia – or failure to make red and white blood cells – had been caused by the chemotherapy treatment she received for breast cancer in 2005.
During the months before her death she was in and out of hospital, treated for TB and other microbiological infections with antibiotics and at times her condition rallied.
Dr McGown told the inquest she had questioned the diagnosis but had not questioned whether the HIV test was incorrect.
She told the inquest she could have ordered another test at any time but in 20 years as a doctor she had never heard of a negative HIV test being wrong.
The inquest heard that positive HIV tests were routinely rechecked but negatives were not.
She also told the coroner at a meeting with Mrs Goodridge’s family after her death she was “close to tears” when describing how she had asked the haematologists to check their diagnosis and they had come up with the same conclusion.
She also described how it had been “difficult to talk to” a haematologist called Dr Hassan and get a “face-to-face” meeting with him to review Mrs Goodridge’s case.
The coroner had been unable to trace Dr Hassan to call him as a witness. Dr Bedford put it to Dr McGown one of the family’s concerns that the hospital believed her condition was psychological, that she was “attention–seeking” and that she was treated “with a lack of respect and negativity”.
“Hopefully not by me,” Dr McGown replied.
She told the inquest “she could well have survived” had the first HIV test been correct.
Dr Fielden said an independent review after Mrs Goodridge’s death found she would have had a 70 per cent chance of survival if the test had been right.
He also acknowledged that pressure of work in the pathology lab and a possible design problem with the machine used to make the test contributed to the “system failure”.
He said the hospital has made a number of changes since Mrs Goodridge’s death. He said there had been additional training, the introduction of double-checking of negative HIV tests as well as positive ones and additional supervision of tests by a consultant.
He said the hospital had not yet replaced the equipment used.
The coroner gave a lengthy narrative verdict saying Mrs Goodridge had died of pnuemocystiscarinii pneu-monia or PCP due to hospital-acq-uired pneu-monia and from the human imm-unodeficiency virus HIV.
He said if she had received a diagnosis of HIV in June 2009 she would have had a “good chance of survival”, in excess of 70 per cent.
He said the design of the blood testing machine and reduced staffing increased the risk of the false negative test. However he did not make any further order to the hospital under coroner rule 43.
Mr Bedford said the false negative was a very rare occurrence and he commended the efforts the hospital had made and for the “candid nature of its evidence”.
After the hearing Mrs Goodridge’s family declined to comment. They were represented by counsel at the inquest.
Frequent Testing for HIV Results in Better Prognosis for Those who do get HIV. 23/2/11
People who tested regularly for HIV but subsequently contracted the infection had half the risk of death when compared to people diagnosed at their first HIV test, the researchers found.
Frequent testing for HIV is associated with improved outcomes after diagnosis, Dutch investigators report in the online edition of AIDS. People who tested regularly for HIV but subsequently contracted the infection had half the risk of death when compared to people diagnosed at their first HIV test, the researchers found.
Patients who tested for HIV at least annually had higher CD4 cell counts at the time HIV therapy was started and lower mortality rates compared to individuals who tested for HIV less frequently. The worst outcomes were seen in patients who were diagnosed at their first HIV test, and a high proportion of these individuals already had a CD4 cell count below 200 cells/mm3 at the time of diagnosis.
“Patients repeatedly tested for HIV antibodies…had higher CD4 cell counts at cART [combination antiretroviral therapy] initiation and a lower rate compared to those initially tested positive,” comment the authors.
Thanks to antiretroviral therapy, many HIV-positive individuals can look forward to a long and healthy life.
However, even with HIV therapy mortality rates are still higher among HIV-positive individuals than the general population, and this is largely because many people have their HIV diagnosed late.
Guidelines in the Netherlands and many other countries recommend that individuals at high risk of HIV, such as gay men, should test for HIV at least annually.
“Although seemingly obvious, it has never before been demonstrated that patients who were repeatedly tested for HIV before testing positive have a better clinical prognosis than patients who initially tested positive,” write the investigators.
They therefore designed a study involving 5494 patients who were newly diagnosed with HIV in the Netherlands between 2004 and 2008.
On the basis of their HIV testing history prior to diagnosis, these patients were divided into three groups:
-Never previously tested – HIV-positive at first test.
-Infrequently tested – last negative test between twelve and 24 months before positive result.
-Frequently tested – tested HIV-negative less than a year before repeat tests and positive diagnosis.
The investigators then conducted analyses to see if frequency of testing was associated with two outcomes:
-CD4 cell count at the time HIV treatment was started.
The vast majority of patients were diagnosed with HIV at their first HIV test (4067 individuals vs 561 infrequent testers vs 866 frequent testers)
There were important demographic differences between these three groups, most notably, 23% of individuals diagnosed at their first test were sub-Saharan Africans, but just 4% of those diagnosed with HIV after frequent screening came from this group.
The median CD4 cell count at the time of diagnosis was associated with testing history, and was lowest for those whose HIV was diagnosed at a first test (350 cells/mm3 vs 470 cells/mm3 for infrequent testers, and 550 cells/mm3 for patients who tested frequently).
Frequency of testing was also associated with the presence of an AIDS diagnosis at the time of diagnosis (16% first test vs 2% infrequent testing vs 3% frequent testing).
Overall, 186 patients died. The mortality rate was highest for patients diagnosed at a first HIV test (1.33 per 100 person years), and was significantly lower for individuals who had tested previously (infrequent test = 0.58 per 100 person years, p = 0.02; frequent testing = 0.54 per 100 person years, p = 0.003).
After taking into consideration differences in baseline characteristics, the investigators calculated that individuals with a history of HIV testing had a 50% reduction in their risk of death compared to patients whose HIV was detected the first time they had an HIV test.
Median CD4 cell count at the time HIV therapy was started was 190 cells/mm3 among patients diagnosed the first time they had an HIV test, compared to 250 cells/mm3 (difference, p < 0.0007) for patients with a history of infrequent testing, and 260 cells/mm3 (difference, p < 0.0007) for patients who tested for HIV at least once a year.
Patients diagnosed the first time they had an HIV test were also the group most likely to have an AIDS diagnosis and CD4 cell count below 200 cells/mm3 at the time antiretroviral therapy was initiated.
“Our findings illustrate the benefit of repeated testing for HIV,” write the investigators, “it shortens the time between infection and diagnosis and improves the likelihood of timely treatment, with the prevention of clinical progression to AIDS and death.”
The researchers also believe that “increasing testing to annually may greatly impact on transmission rates at a population level.” They quote a modelling study that suggested that transmission rates in the Netherlands could be reduced by 40% over a decade “if the average time between infection and diagnosis was reduced to 1 year.”
Text Message Reminders Double HIV Re-testing Rates in Gay Men. 22/2/11
Text reminder allowes large numbers of messages to be sent simultaneously and automatically, reminders are direct, immediate and cheap to send and demanded minimal labour
Text message reminders significantly increase re-testing rates in gay men for HIV and other sexually transmitted infections (STIs), Australian investigators report in the online edition of Sexually Transmitted Infections.
Testing rates were twice as high among men who received the reminders than in men who did not.
“To our knowledge, this is the first published study to demonstrate improved HIV/STI re-testing in MSM [men who have sex with men] through SMS [short message service] reminders,” comment the investigators.
Gay and other men who have sex with men in Australia are recommended to have an annual HIV test. More frequent tests, at intervals of every three to six months, are recommended for individuals with riskier sex lives. Mathematical modelling has suggested that increasing the proportion of individuals who are aware of their HIV status could help reduce HIV incidence.
However, only a quarter of high-risk gay men have two or more HIV tests and sexual health screens each year.
Investigators from the Sydney Sexual Health Centre wished to see if sending text or SMS reminders to gay men increased testing rates.
To test this, they designed a study involving 714 HIV-negative gay men who had an HIV test and sexual health screen between January and August 2009. Every four months, reminders to re-test were sent to these individuals.
Testing frequency in these individuals was compared to those of two other groups. The first included 1084 men who had an initial HIV test or sexual health screen in the same period, but did not receive text reminders. The second comparison group included 1753 men who were tested at the clinic in 2008, and therefore before the introduction of the text reminder service.
Results of the study showed that re-testing rates were significantly higher in the group who received text reminders (64%) than the comparison group (30%, p < 0.001), and the pre-text population (31%, p < 0.001).
After taking into account some differences in the study groups, the investigators found that receiving a text reminder was associated with a four-fold increase in the chances of re-testing (odds ratio [OR] = 4.4; 95% CI, 3.5 – 5.5, p < 0.001).
“The HIV/STI re-testing rate was more than double among MSM who received SMS reminders compared to those who did not,” write the investigators, adding “after adjusting for differences in baseline characteristics, HIV/STI re-testing was three to four times more likely in the SMS group than the comparison group.”
The investigators believe that the text reminder service has a number of attractive features: “it allowed large numbers of messages to be sent simultaneously and automatically, reminders were direct, immediate and cheap to send and demanded minimal labour.”
They believe that if adopted more widely, text reminder to attend for repeat HIV tests and sexual health screens, “have great potential to reduce HIV/STI infection rates in the MSM community. More randomised trials at other sexual health clinics and primary care settings are needed.”
HIV Testing 'Not a Once-off Thing'. 14/2/11
South African health minister, Motsoaledi, hopes the programme would be an annual feature of the orientation week at various universities.
Johannesburg - Testing for HIV/Aids has to be done regularly and is not just a "once-off thing", Health Minister Aaron Motsoaledi said on Monday.
"... It would be a grave mistake for South Africans to think it's a once-off thing... It's a lifelong thing... You have to just keep on testing," Motsoaledi said in Johannesburg at the launch of a testing campaign targeting first-year university students.
Motsoaledi said the widespread testing and counselling programme launched last year was "progressing well".
"We have now reached close to six million people," he said.
The campaign was launched with President Jacob Zuma getting tested last year, and runs through to June 2011.
Motsoaledi said in the duration of the campaign, there was heightened awareness of the necessity for all South Africans to get tested.
But, it was important for South Africans to continue getting tested throughout their lifetime - long after the campaign concluded.
South Africa is the worst affected in the world, with about 5.7m people living with the virus that causes Aids.
The campaign - a public, private partnership - will target first year students at 18 universities across the country.
Motsoaledi said he hoped the programme would be an annual feature of the orientation week at various universities.
Getting tested is only one of nine HIV preventative measures, but is arguably one of the most important, he said.
How to Build a Lab in a Shipping Container. 1/2/11
Tiny laboratory capable of handle 100 sputum samples a day (using four technicians) to test for TB in Zambia
Lusaka - A tiny laboratory capable of doing big things is what Barry Kosloff, working with the London School of Hygiene and Tropical medicine, has created - a new type of high-tech, low-cost, tuberculosis (TB) lab in a shipping container. He walked IRIN/PlusNews through what it takes to build one.
“I don’t know if this is normal but it’s almost like I had a photograph of it in my head,” said Kosloff, who designed such a lab for the national reference laboratory in the capital, Lusaka. It is part of efforts by the Zambia AIDS-Related TB Project, a local NGO, to expand the country’s diagnostic capacity.
The facility is the first in Zambia to be equipped with infection controls that make it safe for staff to grow the TB cultures needed to diagnose HIV-positive patients, and to determine whether TB patients have successfully completed treatment.
Communicate with your suppliers
Based on his experience in designing container labs, Kosloff said it was important to get suppliers talking and listening.
“[Suppliers] didn’t really understand what we were trying to do, and we didn’t understand what the capabilities were,” he told IRIN/PlusNews. “It came with very small sinks, and it used US-style air conditioners - the ones where you have to make a big hole in the wall [to mount it], and that brought in a lot of dust.”
This time Kosloff made sure that suppliers installed bigger sinks and mounted air conditioners internally to avoid letting in dust that could damage equipment and contaminate TB cultures.
“We wanted bigger sinks because in TB labs you make smears or stain slides, so we needed sinks you could actually work in,” he said.
The space race
The lab can handle 100 sputum samples a day, using four technicians.
Kosloff said many people were surprised that a lab this small could be so efficient. He said a container lab’s size could improve efficiency if you utilized the space to best advantage.
“In most container labs I’ve seen they tend to just have counters and equipment along one wall - they don’t make use of both sides …[like] I did,” he told IRIN/PlusNews.
“It’s like a [ship’s] galley kitchen, where you have equipment on both sides and all you have to do is turn around and there’s more equipment,” he said. “The layout is very efficient - when you sit down everything is close by. You’re not having to get up every five minutes and get something from down the hall.”
The efficient use of space also allows more room for storing supplies, which is important because the lab could be stationed in a remote location for a period of time.
Go with the flow
The possibility of spilled specimens that could send a spray of infectious TB bacteria into the air and into a technician’s respiratory tract makes working in a TB lab dangerous. Well-designed ventilation and exhaust systems are critical.
In Kosloff’s lab, air is drawn into the container and filtered, then moves in a one-directional flow from the least dangerous part of the lab to the room where cultures and sputum are handled, which has negative pressure. If an accident occurred, the direction of the air flow would prevent dangerous bacteria from being carried out of the negative pressure zone and reaching technicians in other rooms.
“This also works better when you have a long, narrow room. If you have a big room, the air is getting stirred around in all different directions, and that doesn’t protect you very well,” Kosloff commented.
The doors are self-closing but the air flow also helps make sure they stay shut - a standard infection-control measure. In more expensive labs the doors are also fitted with electromagnetic locks to ensure that they do not stay open, and that no two doors are open at the same time. In the space-constrained container, Kosloff placed doors between rooms close together, which makes opening any two at the same time very awkward.
The ventilation and air filtration systems also help keep the lab clean. In Zambia’s dusty climate, the filters in lab equipment typically have to be replaced every year but Kosloff estimated that those in the container lab could last up to four years, making maintenance cheaper and easier.
Kosloff looked for regional expertise to fit out the lab and used Air Filtration Maintenance Services (AFMS), a South African company, to design and install the ventilation and exhaust systems. Although AFMS had not worked on a container before, their knowledge of resource-poor settings like Zambia meant the company used as many locally obtainable parts as possible, making it easier to find replacements and do small repairs in Lusaka.
“In the US, when you have a problem you call someone and they’re there in an hour. Here, if something breaks we have to fly people in from South Africa because there’s no one in the country that can do the work,” Kosloff told IRIN/PlusNews. “The fancier the system, the more you need highly skilled people to fix it.”
HIV Testing should be Promoted in School Sex Education Classes and on Facebook. 26/1/11
In order to reach those Australian gay and bisexual men who have never tested for HIV, innovative methods needed
In order to reach those Australian gay and bisexual men who have never tested for HIV, innovative methods will have to be developed, Martin Holt and colleagues write in the online edition of AIDS and Behavior. Health messages delivered through gay community outreach and by clinicians will tend to reach men who have already tested.
The researchers’ analysis of the demographic and behavioural characteristics of men who have never tested suggests school and college sex education classes could play an important role. Moreover internet interventions, especially on social networking sites, can reach men with fewer ties to metropolitan gay communities.
In order to have an up to date understanding of men who have never tested or not done so recently, the researchers included relevant questions in a national, online survey of gay and bisexual men in Australia in 2008. The e-male survey was promoted through a wide variety of methods (adverts and links on relevant websites; promotion by gay and HIV organisations; flyers in gay venues; adverts in the gay media; adverts in the personal, adult or classified sections of local newspapers).
A total of 3457 men took part in e-male. However the analysis that is reported here excludes men who have ever tested HIV-positive. Moreover as only half the participants were asked the full set of questions on testing (the other half were given questions on other topics), the data here is of 1770 participants.
How many men have tested?
HIV testing is generally considered to be far more common among Australian gay and bisexual men than among men in other countries, including the UK. However this understanding comes from surveys conducted at gay community events and gay venues. For example, in the 2009 Gay Community Periodic Surveys, 87% had ever been tested and 60% had done so in the past year.
Such surveys are likely to under-represent younger men, non-gay identified men and men living in rural or remote areas, whereas online surveys tend to recruit more of these men. Indeed, one in five e-male respondents identified as bisexual or heterosexual.
In this sample, 72% of the participants had ever been tested for HIV and 28% had never been tested. Around half the men (48%) had tested in the last twelve months.
To put this in context, back in 2001-2002, a representative survey of Australian adults had found that 77% of gay men and 71% of bisexual men had ever tested. Furthermore, the Gay Community Periodic Surveys have found testing rates to be stable over the past decade.
The rest of the analysis considered the profiles of the men who had never tested and recently tested in the e-male study.
Men who had never tested, compared to men who had tested more than twelve months ago, tended to be younger and have lower levels of education.
Moreover, they had fewer gay male friends and were less likely to seek sexual health advice from a gay community or HIV organisation. This confirms previous findings which suggest that men who are more attached to the gay community are more likely to test.
Untested men were also much less likely to seek sexual health advice from a doctor or nurse.
The researchers believe that these findings suggest that the promotion of HIV testing through gay venues, gay social networks and clinicians will fail to reach men who have never tested. They argue for school and college based sex education as an alternative.
Untested men tended to spend more time using Facebook and other social networking websites. The researchers note that “The internet is particularly good at reaching those men who have not been tested for HIV and who may be geographically or socially distant from metropolitan centres of gay community activity.” They recommend that health promotion messages about testing should be placed on social networking sites, especially those which allow advertisers to target male and same-sex-attracted users.
Men who had had unprotected anal intercourse with a regular male partner in the past six months were more likely to have tested. The researchers consider that this is probably due to HIV testing being used to inform decisions about condom use in relationships.
Men who had never tested were more likely to agree with the idea that HIV-negative men should disclose their HIV status before sex. While more men expected HIV-positive men to disclose their status, this belief did not distinguish non-testers from testers.
Moreover other factors such as unprotected anal sex with casual partners or use of particular venues were not significantly associated with having been tested or not.
Men who had tested in the past year, compared to men who had tested more than a year ago, were more likely to have a larger numbers of gay male friends and to have attended a pool, beach or gym used by gay men in the past year, reinforcing the association of HIV testing and gay community attachment. On average, they also had more sexual partners.
Men testing in the past year were younger (mean age 35) than men who had tested more than a year ago (mean age 39). On the other hand, men who had never tested were younger still (mean age 30).
Recent testers were more likely to have ever sought advice or information on sexual health from a doctor or nurse.
Moreover these men were more likely to expect that HIV-negative men should disclose their status before sex. They were also more likely to report HIV disclosure to or from some of their casual male partners in the last six months. The researchers comment: “This appears to indicate that as HIV disclosure becomes more common between casual male partners in Australia, MSM who engage in HIV disclosure (or rely upon it as a way to assess HIV transmission risk) may be increasing the frequency with which they get tested for HIV”.
Other factors did not distinguish recent testers from other men in the multivariate analysis.
Comparison with the UK
In the 2008 United Kingdom Gay Men’s Sex Survey, 68% of respondents had ever tested, and 44% had tested in the past year. (These figures exclude men with diagnosed HIV).
Although there are important differences between the two samples, it remains possible that the numbers who have ever tested in the UK and Australia are not as dissimilar as is often thought.
In the UK survey, a number of the same factors are also associated with ever testing for HIV or having done so recently - older age, more education and more sexual partners.
In addition, the UK study found that men who had sex with both men and women were less likely to test. While a similar finding was initially found in the Australian study (and large numbers of bisexual men took part), this did not remain a significant factor in the multivariate analysis - which provides the most reliable results.
Moreover in the 2006 UK survey, men who had never tested were more likely to expect HIV-positive men to disclose their status before sex. Again, this was found in the Australian raw data, but not in the multivariate analysis.
Firm Develops Early HIV Diagnosis System for Infants. 16/12/10
Infants infected with HIV/Aids will now be able to access diagnosis within two days after testing
Kenyan infants infected with HIV/Aids will now be able to access diagnosis within two days after testing, drastically reducing the high infant death rate linked to late data delivery.
This follows the ongoing installation of a technology that can link remote medical institutions across the country.
With the help of Strathmore University students, Hewlett Packard has developed a custom database application that uses cloud computing to capture, manage and return infant HIV test results in one to two days, a significant improvement from the previous paper-based system that took over one month.
"Parents of the infant were required to travel to take blood samples to the nearest health facility from where it was brought to Nairobi via courier service. Results of the test were then taken back via courier service, taking a lot of time and resources," said Mr Matilu Mwau, the director and principal investigator of early infant diagnosis at the Kenya Medical Research Institute (Kemri) in Busia.
The technology will now make test results available online, as well as via SMS and GSM in real time, thereby drastically reducing the time taken to inform parents of the test results.
The turn-around time for test results is especially critical, as infants diagnosed with HIV must begin anti-retroviral treatment (ART) as quickly as possible to ensure survival.
Without immediate treatment, half of HIV-positive infants are unlikely to survive past age two.
Cloud computing refers to accessing computing resources that are typically owned and operated by a third-party provider.
"Currently, we are working with HP and they are in the process of setting up the system from which we expect to speed up delivery of the test results," said Mr Mwau.
The initial phase of the project that cost Sh88 million comprises the installation of two data centres at the Kenya Medical Research Institute (Kemri) and the National Aids/STI Control Programme (Nascop) headquarters in Nairobi.
The initiative will provide structural and systemic improvements in testing and treatment of more than 120,000 infants exposed to HIV in Kenya each year.
Out of every 10,000 infants, 300 are HIV positive while 45 per cent die due to delayed medication arising from late diagnosis.
Without treatment, an infant infected with HIV in Kenya has a 35 per cent chance of dying by his first birthday and a 53 per cent chance of dying before the age of two, according to a study by Pathfinder International Kenya.
But if the baby receives prophylactic antibiotics soon after birth and anti-retroviral therapy (ART) early enough, he has a good chance of surviving childhood and living a long and healthy life.
Three additional sites are expected to be online next year at Kemri centres in Busia, Kisumu and the ministry of Health headquarters at Afya House.
The investment also includes servers, storage, PCs, networking equipment, SMS-enabled printers, and personnel training and support.
The system will also scale up to support the Ministry of Public Health and Sanitation as it expands prevention of mother-to-child transmission services to more than 3,000 facilities during the next two years.
"We believe these efforts will facilitate our ability to provide long-term health interventions that truly make a difference in keeping our population healthy and productive," said Public Health Services minister Beth Mugo.
Additionally, the results will be made available via an online database to communicate with rural health centres and through SMS.
The HP technology provisioning also includes five data centres connected with four existing laboratories.
Within the first year in operation, about 70,000 infants will be reached.
In Kenya, about one in every 10 pregnant women is HIV-positive.
That means that of the 1.3 million children born in Kenya each year, more than 120,000 have HIV-positive mothers.
Without intervention, there is up to a 45 per cent chance that an infant born to a mother with HIV will become infected.
Due to the high rate of HIV in Kenya, infants are required to be tested for the disease before they are six weeks old.
However, the current testing procedure is paper-based and results can take up to three months to arrive in rural areas.
This delay reduces the efficacy of life-saving anti-retroviral treatment, which needs to be started immediately following a diagnosis.
For example, an HIV-positive infant who does not receive ART has less than a 50 per cent chance of living to see his or her second birthday.
The Clinton Health Access Initiative (CHAI), which is supporting HP financially, is a global health organisation committed to strengthening integrated health systems in the developing world and expanding access to care and treatment for HIV/Aids, malaria, and tuberculosis.
CHAI's solution-oriented approach focuses on improving market dynamics for medicines and diagnostics, lowering prices for treatment, accelerating access to life-saving technologies, and helping governments build the capacity required for high-quality care and treatment programmes.
EU Drugs Agency Launches New Guidelines for HIV Testing in Injecting Drug Users. 30/11/10
The new guidelines recommend a strategy to increase testing uptake
More injecting drug users should undergo tests for HIV, viral hepatitis and other infections such as tuberculosis, says the EU drugs agency (EMCDDA). In new guidelines published today on the eve of World AIDS Day, the agency describes how, in this group, the uptake of testing is still low in many European countries (1).
Infectious diseases are among the most serious health consequences of injecting drug use and can lead to significant healthcare costs. The new guidelines recommend a strategy to increase testing uptake, both in Europe and beyond, that would ensure earlier treatment for injecting drug users (IDUs) and would lower the risk of infection spreading to the wider population.
IDUs are vulnerable to a range of infectious diseases due to a variety of risk behaviours and underlying conditions, such as poor hygiene, homelessness and poverty. The EMCDDA estimates that 30–50% of HIV positive IDUs in Europe are unaware of being infected. It also estimates that around 50% of IDUs (varying between countries from 10% to 90%) are infected with viral hepatitis (notably hepatitis C), which can lead to severe liver disease and premature death.
Commenting today, EMCDDA Director Wolfgang Götz said: ‘It is crucial that those infected are aware of their condition so that they can protect their partners and access the appropriate care and treatment. We encourage service providers and healthcare professionals to take a more proactive approach and ensure that clients at the highest risk of contracting drug-related infections are offered testing on a regular basis. Until now, timely diagnosis and treatment of infectious diseases has often been too low a priority among professionals in contact with drug users’.
Today’s manual provides guidance at a practical level, proposing a series of standard tests to be undertaken regularly on a voluntary and informed basis. Among these are serology tests for HIV, hepatitis (A, B, C, D) and other sexually transmitted infections; general blood tests; and tests for tuberculosis. For high-risk IDUs, these tests should be considered annually, or even bi-annually. The guidelines also offer a package of prevention, primary care and referral routines in relation to IDUs and infections.
The guidelines recommend that health providers initiate examination, testing and counselling in IDUs in a variety of healthcare settings (e.g. primary healthcare; special health services for IDUs; low-threshold service centres visited by IDUs; rehabilitation centres; dedicated sexually transmitted infections clinics and prison healthcare facilities). Developed in collaboration with European experts on drug-related infectious diseases, the guidelines are now being distributed across the European Union and globally. They are intended to be of use to thousands of service providers, and may potentially benefit hundreds of thousands of IDUs.
HIV Home Testing - Should we or Shouldn’t we? 30/11/10
Should HIV testing be left to individuals - under little or no supervision?
As the government seeks to make HIV testing the norm, some in the health field are suggesting that HIV home testing kits should be promoted as part of the strategy. But should HIV testing be left to individuals - under little or no supervision? Ayanda Yeni, of Health-e News Service, takes up the story.
In a recent open letter to the public, three HIV/AIDS specialists suggest that HIV home testing should be made readily available to the public. The letter argues that South Africans should be able to take an HIV test in the comfort of their homes. One of the authors of the letter is Deputy Executive Director of the Wits Institute for Sexual Health and Related Diseases at Wits University, Professor Francois Venter. He says the country is in crisis and innovations like the HIV home testing kit will help us understand and deal with the extent of HIV infection.
“I think this country is in denial about HIV. I think the problem is that our government, the churches, unions and so on... everybody is able to say they are doing their bit for World Aids Day, then they pack up for the rest of the year. This country is in absolute crisis at the moment. Almost half of all deaths are related to HIV. We have a massive orphan population, we see huge impacts on our working population, and it has implications on our grants systems. The healthcare system is under a huge amount of pressure from people falling ill, yet we can mobilise the whole country behind the World Cup, the Gautrain but we cannot mobilise ourselves around HIV”.
Professor Venter argues that home testing is also about convenience. He says it needs to be taken into account that some people may not want to be put through the whole process of waiting in queues or being counselled when taking an HIV test.
“Personally, I sometimes would like to know my HIV status and I don’t want to go to the clinic. I don’t want to go through the rigmarole of counselling. I don’t want to repeatedly go through the same process again. I want to do it when it suits me, to be honest. And at the moment I don’t think our HIV services suit most of us”, says Professor Venter.
However, not everyone is in agreement. The South African Medical Association, SAMA, has spoken out against HIV home testing, saying it has the potential of damaging many peoples’ lives. It says key to HIV testing is the pre and post- counselling and that that component should not be taken for granted. SAMA Chairperson Poppie Ramathuvha explains why.
“When you do your pre-test counselling, you counsel an individual in such a way that he or she is sure that she is positive before you even do the test. So, when you do the test and find that they are negative, it’s a bonus. When you counsel a person you have to be sure that even if they are positive they’ll still go home knowing it’s okay. Without such a process it’s going to be a problem”.
Dr Ramathuvha added that there could be severe repercussions to testing yourself without a professional at hand.
“When you are alone you say to yourself: ‘Am I going to die? I know there are ARV’s, but how do I access them?’ You don’t know which regimen you are supposed to be on. Many tests need to be done on you, but you then go and find means to get ARV’s, and then you access wrong ones that further complicate things. Or, immediately when you test and it comes back positive you commit suicide. Many of us when we go for an HIV test it’s very stressful, including myself, knowing everything I do about HIV. But when I go for that test I need somebody with me, otherwise I become scared”.
The Treatment Action Campaign, TAC, has also added its voice to the debate. It has reinforced the importance of pre and post-counselling when taking an HIV test. TAC’s Ekurhuleni Branch Representative, Luckyboy Mkhondwane, says an HIV test is more complicated than a pregnancy test.
“In order for one to do an HIV test you have to be in your right mind, that’s why we prefer someone to go for counselling. But if you go and buy your own home test and do it, it will have many implications that are bad because you won’t have the coping mechanism that someone who has been to a clinic has. You need to be prepared; you can act brave and think you are ready to know your HIV status, but when you do it’s different”, he says.
With the focus being on World Aids Day this week, many South Africans still don’t know their HIV status and government has embarked on a massive effort to encourage the public to get tested with the launch of the HIV Counselling and Testing (HCT) campaign in April. But Professor Francois Venter argues that the country’s current HIV testing system is not yet up to scratch, hence the need for the home kit.
“The process of testing by counsellors, in particular and the pricking of patients by nurses... there have been lots of quality over-sight problems. People haven’t been waiting long enough to get the test read, the counselling has been very poor quality and the post-counselling hasn’t referred people into the system. What we’re seeing now at the clinics is that instead of people waiting for 15 minutes they take 8 minutes to read the test, and that’s not good. So, I do worry about the HIV testing system in our country and if we don’t focus on the quality of that test, particularly of reading the test result, we run the risk of undermining what is a very important programme. South Africans need to know their status and to trust the systems that give them that”, says Professor Venter.
Call for Home Testing for HIV. 1/11/10
Home HIV testing kits should be made widely available in South Africa
Home HIV testing kits should be made widely available in South Africa, three Aids experts have urged in the latest issue of the SA Medical Journal.
Laws and policies should be changed to pave the way for the kits' distribution, said Wits University academics Marlise Richter and Dr Francois Venter, and Andy Gray, a senior lecturer at the University of KwaZulu-Natal's medical school.
"South Africa has reached a point in its Aids epidemic where individuals should be able to decide when and where they would like to test for HIV, and do so without having to involve anyone else," they said.
They said the SA Medical Association (Sama) earlier this year warned the public against HIV self-testing kits.
Sama had said it was risky for patients to test themselves "unmonitored", and warned this could lead to patients committing suicide. The warning had been echoed by the national department of health and the Treatment Action Campaign.
The three experts said however the same objections would apply to any medical self test, including the existing test for type 1 diabetes, which had been a certain death sentence before there was widespread access to insulin.
"The arguments against self-testing are largely based on vague fears with little or no evidence to support them," they said.
"It would seem sensible to provide increased access to HIV testing in a facilitatory way, encouraging people to access care in a way that suits them, rather than based on a model that encourages unnecessary 'Aids exceptionalism' and fear-mongering."
They said it seemed that at present there was no legal impediment to supermarkets selling HIV testing kits, but that pharmacists were prevented by their code of practice from stocking them. There was no mechanism to regulate the quality and reliability of any self-tests, a matter which should be addressed urgently.
People who Stigmatise HIV are Less Likely to Take an HIV Test. 30/10/10
People who tested were significantly less likely to hold negative attitudes and beliefs about people living with HIV
Individuals with stigmatising beliefs about HIV are less likely to test for the virus, an international team of investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The research involved 5249 individuals in the South African townships of Soweto and Vulindlela. Only 41% had ever tested for HIV.
“Compared to those who had never tested, people who tested were significantly less likely to hold negative attitudes and beliefs about people living with HIV, more likely to believe people with HIV face discrimination, more likely to hold beliefs that people living with HIV should be treated equally, and more likely to believe that most people have previously tested for HIV”, write the investigators.
Stigma must be addressed in future studies looking at improving HIV testing rates in South Africa, the authors stress.
Many patients with HIV die needlessly because their HIV is diagnosed late. There is also good evidence that many new HIV transmissions originate in undiagnosed individuals. Therefore increasing rates of HIV testing is a public health priority, especially in South Africa, where there is a high prevalence of undiagnosed infections.
Investigators from Project Accept wanted to examine the associations between HIV testing and perceptions of stigma and social norms in South Africa.
A total of 5259 individuals aged between 18 and 32 were therefore asked to complete a questionnaire. This enquired about the individuals’ HIV testing history.
Questions were also included on HIV-related stigma. These were designed to see if the participants had negative attitudes towards people with HIV. For example, they were asked to agree or disagree with statements such as “people who have HIV/AIDS are cursed”, and “people with AIDS are disgusting.”
Participants were also asked if they thought people with HIV were discriminated against, and if they believed people with HIV should be treated equally.
Finally, a question was included to see if testing for HIV was perceived to be the social norm, and participants were also asked to indicate if they believed “most people have been tested for HIV.”
Overall, 41% of individuals reported that they had had an HIV test. These individuals were older (25 vs. 22) and better educated than those who had never tested (13+ years of education: 11% vs. 7%).
The investigators’ first set of analyses showed that the following factors were associated with an increased likelihood of testing:
· More years of education (p = 0.04).
· Less stigmatising beliefs about people with HIV (p = 0.0028).
· A greater belief that people with HIV faced discrimination (p = 0.0086).
· A belief that people with HIV should be treated equally (p = 0.0086).
· A belief that most people have had an HIV test (p = 0.0115).
Further analysis showed that women (p = 0.0078), older individuals (p = 0.0141), and those with 13 or more years of education (p = 0.0016) were significantly more likely to have tested.
However, the relationship between two of these measures (sex and education) and an increased likelihood of testing, weakened with age.
In contrast, the relationship between testing and a belief that people with HIV experienced discrimination increased with age (p = 0.001). Women who believed that people with HIV should be treated equally were more likely to have tested than men who had this belief (p = 0.009).
‘The present study suggests a link between HIV testing, stigma, and social norms such that decreasing HIV-related stigma may help to increase testing”, comment the investigators.
They continue, “interventions that culturally and demographically tailored toward populations of interest might prove to be more effective in decreasing stigma and increasing testing.”
Use of self-reported testing history, and gathering information on stigma via a questionnaire was, the investigators acknowledge, a potential limitation of their study. They comment, “it is possible that participants were motivated to underreport negative attitudes related to HIV because of social desirability.
However, the researchers are confident that their study “builds on results of previous research on stigma and testing and suggests that stigma is associated with people’s HIV testing behaviour.”
They conclude that it is “imperative” that future studies looking at ways of increasing HIV testing in South Africa address stigma.
Deadly Consequences of Inadequate HIV Counselling. 28/10/10
I apologized to her but all she says is I betrayed her; I didn't know it would end like this
Gulu - Carol Apiyo* is struggling to cope with bitterness and anger towards her husband, whom she blames for infecting her with HIV; a few months ago, she tried to kill him by poisoning his food.
Fortunately her husband recovered after treatment at Gulu Hospital in northern Uganda. "I can't forgive him for what he has done to me – he is the only man I have known in my life," she told IRIN/PlusNews. "I [still] feel like killing him."
Her husband, Richard Okello*, told IRIN/PlusNews he had no idea he was HIV positive. "I [only] knew the result when my wife told me that I was required to undergo HIV testing with her at the antenatal clinic," he said. "The result was shocking because I have been using condoms with my other partners.
"I apologized to her but all she says is I betrayed her; I didn't know it would end like this," he added.
According to health workers in Gulu district, the counselling given to people such as Otto and Adiyo is insufficient to deal with the complicated feelings and issues they face following a positive diagnosis.
"Counselling lasts less than 15 minutes when patients are given their results; they are later left on their own without follow-up counselling," said William Odur, senior psychiatrist at Gulu Hospital. "After they are given their HIV status, a number develop mental disorders, are depressed, commit suicide or kill their partners."
The country has had several cases of murder following HIV-positive diagnoses, including a man in the southwestern district of Rukungiri murdering his wife in 2008, the lynching of a woman in Gulu suspected of infecting a man and, in September, a 20-year-old woman in the eastern district of Soroti being sentenced to death for killing her soldier husband after she tested positive and he was negative.
"One session is rarely sufficient, especially with discordant couples," said Goretti Nakabugo from Strengthening HIV/AIDS Counsellor Training in Uganda (SCOT), part of the national NGO, The AIDS Support Organization (TASO). "Counsellors need to put couples in touch with peer support networks or arrange for follow-up home visits."
She noted that over and above dealing with the fear, suspicion and anxiety when one partner is found to be HIV-positive, counselling was needed to support both the negative partner - now at high risk of contracting HIV - and the positive partner, who needed to know how to live a healthy life.
Under Ministry of Health guidelines on HIV counselling and testing, only trained counsellors should provide HIV pre- and post-test information or counselling; training for counsellors is at least one-month long and must be conducted by a government-approved institution.
Need for more counsellors
However, Zainab Akol, head of the HIV programme in the Ministry of Health, told IRIN/PlusNews the government had no register of all the HIV counsellors operating in the country; she added that many professionally trained counsellors worked in fields other than HIV.
A counsellor at Gulu Hospital told IRIN/PlusNews that counsellors often conducted their work hurriedly due to the high volume of people turning up for VCT after public campaigns encouraging widespread testing.
Paul Olobo said he was counselled for just 10 minutes at Gulu Hospital.
"Your test result shows that you are HIV positive, it's not the end of the world and you should accept it - that is what I was told at the hospital and the health worker sat quietly waiting to see the next patient in the line as I walked out of the counselling room," he said. "It's up to the patient to decide what next; it's not easy."
Uganda is also in the process of rolling out provider-initiated counselling and testing - where health workers routinely offer HIV counselling and testing to all patients visiting health facilities - and couples counselling and testing, which will require even more health workers.
Quality over quantity
"Counsellors need to look beyond targets and numbers and try to provide a quality service to their clients," SCOT's Nakabugo said. "The 45 minutes or one hour allocated for each client is often not enough to ease their anxiety; shock is a natural reaction so both pre-test and post-test counselling must be provided.
"Counsellors should also make use of the wealth of the communities they work in - use their referral networks to put people in touch with people who can support them," she added. "Guidance on disclosure is also important - for example, if telling your family that your partner is HIV-positive and you are not will cause trouble, perhaps it's better not to do so."
Physician: HIV Test Guidelines not being Followed. 5/10/10
"Physicians still haven't given up the old 'I can tell by looking,' risk-based" testing
Wichita physician Donna Sweet says neither patients nor physicians are following HIV screening guidelines unveiled four years ago by the federal Centers for Disease Control and Prevention.
In 2006, she said, the CDC recommended "with very good reasoning" that every sexually active American, age 13 and older, be tested for HIV.
"That was four years ago. It is one of the most widely undone (tests) and disregarded guidelines in medicine," she said. "Physicians still haven't given up the old 'I can tell by looking,' risk-based" testing.
The case of an Air Force sergeant accused of having unprotected sex without disclosing his HIV-positive status "points out that people have forgotten about this disease," she said.
Sweet, an internal medicine practitioner and professor at the University of Kansas School of Medicine-Wichita, has a large patient base of people who are infected with HIV or have AIDS.
An estimated 1.1 million people in the United States are HIV-positive and about 250,000 of them don't know they are infected, she said.
"They're not going to be able to say to you, 'Hey, let's use a condom because I could give you something.' It's back to the day of buyer beware."
Sweet said it's easy for a physician to offer an HIV test along with any other age- or risk-appropriate screening tests. An HIV test used to require a signed consent form, similar to the ones used for surgery, but no longer does.
If a patient declines the offer to be tested, that can be noted in his or her file.
But if a patient sees two or three doctors and never gets the offer for a test, then turns out to be infected, "It's just like a failed diagnosis for cancer, and you've got a lawsuit there," she said.
"It's really about the fact that this disease carries so much stigma and always has," she said.
Her practice normally gets about 100 to 110 new patients a year. "We're going to beat that record this year."
Early detection and treatment work, she said, and someone diagnosed at age 20 can expect to live to about 70 "if they take care of themselves and do things right."
Sandra Springer, HIV and AIDS director for the Kansas Department of Health and Environment, said people who are high risk for HIV and other STDs should get tested every three to six months.
Because people are living with HIV and AIDS and not seeing the devastating effects that were common early in the disease, "there are a fair amount of folks that have kind of a prevention burnout. It's not as on the forefront of people's minds as it was."
But knowing your status and being treated is important to the health of a community, Springer said, because "if someone is in care, they are less likely to transmit the disease to their partner because of their decreased viral load. It's still possible but not as likely if on treatment."
In addition, after people find out they're infected, "they do tend to change behavior," Sweet said. Medications can lower the presence of the virus to an undetectable level in the blood, at which point "they're much less likely to infect anyone," Sweet said.
Home HIV Testing Helps Early Diagnosis of High-risk Children. 21/9/10
It took some convincing to get parents to allow their children to be tested
Nairobi - Home-based voluntary counselling and testing (HCT) can help to diagnose HIV early among high-risk children, new research in western Kenya has found.
"Through home-based counselling and testing, you are able to get children and parents who might not go to health facilities for these services," said Samson Ndege, one of the authors of the study and HCT project coordinator with the USAID-supported Academic Model Providing Access to Healthcare (AMPATH), which cares for more than 100,000 HIV-positive adults and children in the region. "HCT provides an opportunity to... link children and parents to treatment."
The study, published in the Journal of Acquired Immune Deficiency Syndromes, looked at the uptake of HIV testing and HIV prevalence among children given HCT and aged between 18 months and 13 years, whose mothers were either dead, HIV-infected or of unknown HIV status.
Ndege noted that it took some convincing to get parents to allow their children to be tested. "One reason many parents did not want their children tested was fear of disclosing their HIV status, but through counselling, many parents now know the children can access treatment and therefore there is an increase of those willing to have children tested," he said.
Diagnosis and treatment of HIV-positive children remains very low in much of sub-Saharan Africa; the UN Children's Fund (UNICEF) estimates that without treatment, about half of HIV-infected children will die before their second birthday.
Kenya's 2008 national HIV testing guidelines single out diagnosis of children as a benefit of HCT.
Of the 2,289 children offered HCT in the Kenyan study, 57 percent participated and of these nearly 5 percent were found to be HIV-positive.
"In every place where we carried out the research... there are AMPATH clinics where the HIV-positive children and their parents are referred to for treatment," Ndege said. "Community health workers are employed to make follow up visits and ensure that those enrolled in treatment do not default."
Some limitations of the study included the fact that it was restricted to "high-risk" children, it did not test children younger than 18 months - who would have required more complex tests than the rapid one administered in the home - and the limited geographical and cultural scope of the study, which means the results cannot be generalized.
The authors concluded that while HCT did provide an opportunity to diagnose HIV among high-risk children, further investigation was needed to identify and overcome barriers to testing uptake.
Centre for HIV/AIDS Networking Monthly HCT Campaign Media Round-up/ 9/2010
HIVAN’s monthly update series tracks media coverage of South Africa’s HIV Counselling and Testing (HCT) campaign.
Our fifth edition reflects two important concerns about the campaign’s reach and efficacy: the urgent need for a mass-media communications drive to boost uptake, and the ethical issues involved in conducting HCT at schools. Related topics include the effects of the recent health sector strike on drug resistance, the ongoing debate about virginity testing, the momentum of national medical male circumcision, commentary on task-shifting, and news on provincial and sectoral efforts to strengthen AIDS responses.
What can you tell us about the HCT roll-out within and beyond your community?
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The Health Department has acknowledged in mainstream media reports that the HCT campaign is behind schedule in terms of reaching its targets. An August progress report showed that 1,5 million people – half the desired number – had been tested since the launch.
The 2010 FIFA World Cup and the public health strike were cited as two factors that had hampered HCT over the past three months, and SANAC Deputy Chairperson Mark Heywood highlighted other shortcomings under the components of funding, monitoring and implementation.
There is evidence of inadequate links between testing and care, poor referral to health services (especially ARV treatment), low quality control of national counselling and testing protocols, coercive testing in some provinces, and no clear mandates for co-ordination.
Heywood has frequently lamented the lack of budget for a mass communications strategy to promote the campaign, but has also explained that “adverse events” create negative perceptions on the ground. Certainly, if health workers do not administer the tests properly, or insist that clients undergo testing in order to receive health services, no amount of PR around the campaign will persuade the public to join it.
Nonetheless, the campaign has generated the adoption of task-shifting to strengthen implementation, with lay counsellors being empowered to conduct testing. There are reservations about this policy: some contest that less trained community health workers are usurping professional health workers’ jobs, and that the policy might lower the quality of healthcare. However, studies show that in a country burdened with a severe AIDS epidemic and a drastic shortage of health staff, task-shifting can contribute to more efficient use of resources, better working conditions and higher retention of scarce skills in the health sector. An article published in The Lancet on 25 September cites research findings that in South Africa, Malawi and Ethiopia, task-shifting has achieved higher levels of ART coverage, and services by nurses are not inferior to those offered by doctors. In fact, the authors recommend that to address unmet needs in ART access, further task-shifting to lay providers, the community and trained AIDS patients should be considered.
The HCT campaign has normalised HIV testing, as is shown in the unprecedented numbers of people coming forward for HCT – despite the absence of concerted mass-media promotion. For example, the North West reported that just over 365 000 people had been tested since the April launch: if these levels can be sustained or increased, the province can achieve its target of testing one million people by June 2011.
Moreover, the degree of openness displayed by health leadership in relaying and confronting the campaign’s impediments continues to inspire. We as citizens are not off the hook in terms of owning and demonstrating our own responsibility for health-seeking behaviour. This is the key message of the HCT campaign, and one that each one of us has a duty to espouse.
Take HCT out of schools
To advance progress towards 15-million people being tested by mid-2011, the Health Ministry plans to re-launch the HCT campaign and extend its reach to workplaces and schools. However, the risk of “adverse events” for youth in HCT is exemplified in warnings issued by child rights advocates, who advise that learners in the 12 to 18-year age group are unable to exercise choice in the midst of a mass campaign, that educators and health workers are not properly supported to implement schools-based testing, and that confidentiality can be easily breached in this setting.
Clearly, such challenges require special contextualised responses, so that children can be afforded safe and easy access to HCT and health services. Heywood agrees that this motive is sound, but the means to achieve it need careful attention. Whilst logic directs the roll-out to target people where they are, child-focused organisations recommend that HCT should not take place in schools, but rather in child- and youth-friendly clinics. Cati Vawda of the Children’s Rights Centre urges the Health Department to gear its health facilities towards attracting children and youth with the assurance of proper monitoring and support as well as dealing with related discrimination. This tack would also enable the distribution of condoms to young people, which is not possible at schools in terms of the Education Department’s policy.
Efforts on the ground
-In the Eastern Cape, the Health Department and the Men’s Christian Guild of the Presbyterian Church in Southern Africa partnered to run HCT and a TB survey during the MCG’s four-day annual conference, held early in September in Port Elizabeth. The event gathered men from 15 regions in Southern Africa, and the MCG is piloting health promotion and HIV prevention initiatives at Empilweni Hospital in New Brighton, PE, with the vision of rolling out nationally.
-At the Tehillah Community Centre in Soweto, Gauteng, Collin Williams is a gay HIV-positive health activist who runs an outreach campaign for HIV prevention, treatment and support. His experiences with youth in the community offer a portrayal that differs from recent data showing that condom usage is highest among the 15-24 age group; he says condoms are often used by youngsters to polish shoes and should not be cited in statistics as being used for safe sex. In his view, government has a detached stance towards prevention, while his Centre practices an interactive approach, with five on-duty nurses available for counseling and separate sex-education discussion groups for young girls and boys. Williams says these practices contributed significantly to the drop in teenage pregnancy and HIV infection rates among youth in the area since the Centre’s opening in 2008. This narrative, among others contained in an online article in The Famuan, reflects on the efficacy of national mass-media HIV awareness campaigns as opposed to local, community-orientated efforts. Proactive, direct approaches that “get in with the people” are regarded as more engaging, allowing volunteers to connect experientially with target audiences around self-responsibility.
-In the Western Cape, medicine delivery services have been boosted by a “Mr Delivery” model spearheaded by the provincial Department of Health. The Chronic Dispensing Unit is being used at 43 community health centres, eight local authority clinics, two district hospitals and 19 homes for the elderly in an effort to reduce long queues at health care facilities and pharmacies. ARVs, urinary bags, linen savers and chronic medication is packaged at Tygerberg Hospital and the service has helped patients who would otherwise have to travel long distances and take a day’s leave to receive their medical supplies.
-The launch edition of Hlasela News, official newspaper of the Free State provincial government, reports that a comprehensive turnaround strategy for health has improved basic healthcare services. Aligned with government’s 10-point plan for health, implementation of the strategy was adopted in July 2009 and has seen a record numbers of people testing for HIV, receiving and adhering to HIV and TB treatment, with 73% of HIV-positive pregnant women receiving dual therapy for PMTCT. Provision of basic essential equipment to all clinics and district hospitals, the appointment of 1038 new staff (including 105 permanent cleaning and security staff at Bongani Hospital), and a well-functioning medical depot are among the other achievements described.
-In an effort to improve provision of health services, more than R10-billion has been allocated to rebuild and rehabilitate five major hospitals across the country. Health Minister Dr Aaron Motsoaledi announced that this project is scheduled for completion within five years. The hospitals earmarked for redevelopment are King Edward VIII in Durban, Chris Hani Baragwanath and Dr George Mukhari in Gauteng, Nelson Mandela Academic in the Eastern Cape, and the Limpopo Academic Hospital.
-Staying pure staves off STDs – this was the thread of one article covering the annual Royal Reed Dance that celebrated the virginal status of 26 000 young Zulu women. Speaking of virgins, the maiden edition of The New Age, the ANC’s new national newspaper, featured a piece headlined “Persistently, controversially, Ngobese continues virginity testing”. It describes Dr Nomagugu Ngobese (who holds a PhD in Theology from the University of KwaZulu-Natal) as having defied the views of feminists, children’s rights activists and even the Gender and SA Human Rights Commissions for 12 years in her quest to administer “the ultimate abstinence test among young girls in KZN”. It also presents the arguments against virginity testing as proffered by the Treatment Action Campaign.
Professor Pumla Dineo Gqola, writing in City Press, added her compelling voice to this fray, asking whose culture this was and whose purposes it serves: “Practices that render women’s bodies hyper-visible are dangerous and need to be questioned. Linking and equating a young woman’s value to her virginity makes virginity her duty. The man, on the other hand, has no similar responsibility, so this isn’t an equal partnership … we need to face the possibility that some inheritances do more harm than good, and either adapt them or abolish them … we need to enhance human life and value, not endanger some of our most vulnerable.”
-Also featured in The New Age was a full-page article on South Africa’s medical male circumcision that comprehensively addressed the benefits of this prevention strategy along with drawbacks in its implementation. It offered a well-balanced range of expert perspectives on the social dynamics surrounding the procedure, such as the meanings associated with sexuality and gender sensitivity, as well as cautions about the need for consistent condom use. It also highlighted the dangers of marketing the services before they were ready, and without massively publicising key awareness messages that circumcision does not obviate the need for safe sex practices.
While it was gratifying to see this level of journalism being purveyed in The New Age, the launch of which has been dogged by criticism in a political vein, the editorial board either ditched, or failed to recognise, a golden opportunity to elevate perceptions of both the party and the publication by sponsoring a “first”: HCT campaign promotion.
Reflections on resistance
During a truce between government and public sector strikers brought welcome relief to health services and patients after three weeks of turmoil in August, health ethicist Professor Ames Dhai of Wits University’s Faculty of Health Sciences contends that government must finalise a Minimum (Level) Service Agreement with unions to prevent recurrences of paralysis in service delivery. In a Health-e News report, she also criticised striking nurses, saying that whilst their right to a work environment that would support fulfilment of their oath to serve was infringed, violence and intimidation cannot be condoned, and that they too betrayed patients’ rights, with tragic consequences.
The effects of this dual betrayal constitute deadly resistance in another form: in one instance, with the virtual closure of King George V Hospital – a specialised TB treatment referral facility in Durban – during the strike, most patients with multi-drug-resistant (MDR) and extremely drug-resistant (XDR)-TB were sent home. They, along with thousands of the nation’s patients infected or co-infected with HIV, will have experienced interruptions of their medication, leading to increased drug resistance, and endangering their lives and those in their households and communities.
With drug-resistance testing being unavailable in Africa, and many of South Africa’s treatment programmes for HIV and TB being under-regulated, there is a horrifying prospect of patients with these infections being untreatable in time to come. "Imagine if one out of four [HIV-positive] people … were infected with [drug] resistant viruses, and needed to start second- and third-line treatment immediately," says Prof Tobias Rinke de Wit, programme director of PASER (PharmAccess African Studies to Evaluate Resistance).
Second-line ARVs cost at least five times more than first-line drugs, and funding for AIDS treatment is already diminishing; according to a report in Health-e News, South Africa needs an extra R2-billion a year to monitor and treat the estimated four million people needing ARVs. With the spread of drug-resistant viruses, not only would expansion of treatment access be impossible, but extremely drug-resistant HIV strains would make our existing ARVs obsolete.
PASER is piloting ART-A, a cheap, easy-to-use drug-resistance test, in South Africa and Uganda, but even if it works well in the field, it would only be available for wider use in another two years. This threat is yet another motivation to step up prevention efforts. As health economist Professor Alan Whiteside said to Health-e News: “HIV treatment without prevention is like mopping the floor while the tap is running.”
As we look back on September as Heritage Month, perhaps we should reflect on what we as a nation must resist if we are to bequeath anything worthwhile as a legacy for future generations. Pumla Dineo Gqola reminds us that we are tomorrow’s ancestors. Surely, then, we should resist attitudes and actions that manifest as “we don’t care” and “we won’t care”. The HCT campaign message must be propagated to saturate our collective consciousness: take responsibility – for HIV prevention, testing and treating, and for respecting the rights of all.
The contents of this publication reflect the opinion of the author only and are intended purely for informational purposes. HIVAN accepts no liability for the content of this document, or for the consequences of any actions taken on the basis of the information it provides. If you wish to copy or distribute part or the whole of this document, please acknowledge HIVAN as its source.
Johannesburg- Lay counsellors in South Africa can now legally perform HIV tests, but delays in paying them and shortages of test kits are threatening a national campaign to scale up voluntary HIV testing and counselling (VCT).
Before new regulations came into effect in May 2010 only nurses were allowed to administer finger-prick HIV tests, but AIDS activists had long argued that this not only added to an already heavy work load, but could also hamstring the VCT campaign aiming to test 15 million South Africans by 2011.
"The way it used to work, if I wanted an HIV test, a counsellor would have to sit down and do all the pre-test counselling ... and then that counsellor would have to go hunt down a nurse to do something that takes 10 minutes to teach a diabetic [how to do]," said Dr Francois Venter, president of the Southern African HIV Clinicians Society and head of the HIV management cluster at Johannesburg's Reproductive Health and HIV Research Unit (RHRU).
"It was ridiculous that one of our most important diagnostic tools be held hostage to our human resources crises," he told IRIN/PlusNews.
Task-shifting the prick
South Africa's public health system is struggling to cope with one of the world's worst HIV epidemics, as well as a shortage of doctors and nurses. The South African Nursing Council estimates that the country has about one registered nurse for every 440 patients, but according to the Human Sciences Research Council, up to 20 percent of nurses are not practicing.
Malawi and Zambia, faced with even worse health worker shortages, have put HIV testing in the hands of trained lay counsellors, a strategy known as "task-shifting".
South Africa's new legislation requires counsellors to undergo three hours of training before being added to a database of healthcare providers allowed to perform "the prick". Dr Thobile Mbengashe, chief director of HIV and AIDS in the Department of Health, said they would not be allowed to perform other tasks, such as drawing blood.
The departments of health and social development are partnering with organizations funded by the US President's Emergency Plan for AIDS Relief (PEPFAR) to conduct the training. Venter said a handful of organizations, including RHRU, had started training their lay counsellors, but most clinics had not yet begun.
Civil society groups, including the Southern African HIV Clinicians Society, the Treatment Action Campaign (TAC), a local AIDS lobby group, and the Democratic Nursing Organisation of South Africa, have welcomed the new legislation.
"This is really the second extremely important task-shifting move we've seen this year," said Catherine Tomlinson, a senior researcher at the TAC. The first was the announcement in the new guidelines released in April 2010 of government's goal to trains nurses to initiate and manage antiretroviral (ARV) treatment. "With the new [VCT] campaign, we needed another level of task-shifting and that’s what we’re seeing with this second move."
Tomlinson cautioned that despite the strides made in task-shifting, challenges remain for the VCT campaign. The TAC has documented shortages of HIV testing materials, and counsellors going unpaid in Eastern Cape and Limpopo provinces.
"People are coming in numbers to do HIV testing, but ... we don't have lancets [a pricking needle used to obtain blood for testing], so we are using needles to do the tests," said Noloyiso Ntamehlo, a TAC coordinator in the Eastern Cape district of Lusikisiki.
The payment of monthly stipends for counsellors had also been delayed, and the off-road utility vehicles to take VCT to the district's largely rural population have not arrived.
Mbengashe said the health department was aware of the stipend delays and was working with the South African National AIDS Council to prioritise payment.
Call to Join World AIDS Day “Testing Millions” Campaign. 2009
Dear friends and colleagues,
Today 33 million people are estimated to be living with HIV. We know that the majority do not know their status. We can change that.
If you have not yet joined in support of the World AIDS Day “Testing Millions” Campaign we ask you to do so today. And we thank those of you that have. A global coalition is working hard to make HIV testing free and accessible with linkages to antiretroviral treatment (ART). We urge you to be a part of this worldwide movement to stop HIV/AIDS.
Around the world people are lining up to get tested ~ overcoming stigma and fear. To support their courageous steps to take control of their own health, we commit to making HIV testing faster, easier and more convenient.
From the Asia Pacific region, AIDS Healthcare Foundation’s country leadership has sent you a video message. Please take a moment and hear what they have to say by clicking here. They are on the front lines and are determined to transform HIV testing in their countries. They are fighting to save lives and we ask you to sign on with them.
Last year’s ONE MILLION Tests campaign resulted in 1,603,272 people being tested. 61,399 worldwide were identified as positive as a result of the campaign. This year we are hoping to more than double that.
We need your help. We ask for your endorsement and support in making Testing Millions a reality this World AIDS Day.
Be a part of this wordwide effort.
Terri M. Ford Senior Director of Policy/Advocacy AIDS Healthcare Foundation
FDA Approves Abbott’s New HIV Test. 6/10
Current antibody-only tests miss up to 10% of HIV infections in some high-risk populations because they do not detect antigens.
On June 21, Abbott Laboratories announced that the U.S. Food and Drug Administration (FDA) has approved “an innovative new diagnostic tool, which will allow patients to be diagnosed earlier than ever before.” This marks the fastest approval by the FDA of an automated HIV test to date.
According to the release, “Abbott's ARCHITECT HIV Ag/Ab Combo assay is the first test approved in the United States that can simultaneously detect both HIV antigen and antibodies. HIV antigen is a protein produced by the virus immediately after infection, whereas antibodies are developed days later as the body works to fight off the infection. Studies have demonstrated that Abbott’s new test may detect HIV days earlier than antibody-only tests, which is important in controlling the spread of the virus.”
“Since individuals are most infectious to others shortly after infection, detecting HIV earlier is critical and life-saving,” said Peter Leone, M.D., medical director, North Carolina HIV/STD Prevention and Control Branch, University of North Carolina, Chapel Hill. “A significant percentage of new HIV infections are transmitted by someone with an undetected acute infection, so identifying more people earlier offers a significant opportunity for counseling, which can reduce high-risk behaviors and also initiate antiretroviral treatment for early-stage infection, if appropriate.”
Studies conducted by the Centers for Disease Control and Prevention (CDC) show that current antibody-only tests miss up to 10% of HIV infections in some high-risk populations because they do not detect antigens. However, Abbott’s new assay detects the HIV p24 antigen, or the direct presence of HIV, allowing for diagnosis of early infections days before antibodies emerge.
The Abbott ARCHITECT HIV Ag/Ab Combo assay will be available to consumers in the U.S. later this year.
Governments and Civil Society Expand Access to HIV Testing and Counselling. 30/9/09
A brightly coloured van known as the ‘Tutu Tester’ has become a familiar sight in Cape Town, South Africa, as part of an accelerating drive to persuade people to know their HIV status. More than 10 000 people have been tested and counselled since May 2008 when the mobile clinic from the Desmond Tutu HIV Foundation took to the road.
It is one of many initiatives in sub-Saharan Africa designed to dispel the stigma and fear long associated with AIDS through imaginative campaigns ranging from sex worker advice at truck stops to peer counselling in mining areas to national testing weeks spearheaded by celebrities. The campaigns are part of wider national and international efforts to expand the number of people receiving testing and counselling—which is often referred to as ‘the gateway to HIV prevention, treatment and care’ because it is a precondition for timely access to all three, including antiretroviral therapy which cuts mortality rates.
Ninety percent of low- and middle-income countries last year reported that they have national HIV testing and counselling polices, up from 70% in 2007, according to the 2009 Towards universal access progress report, published by WHO, UNICEF and UNAIDS. Countries hardest hit by the pandemic—Botswana, Kenya, Lesotho, Malawi, Namibia, Rwanda, South Africa, Swaziland, Tanzania and Uganda—are testing and counselling pregnant mothers as the basis for prevention of mother-to-child transmission (PMTCT) to cut the number of infants born with HIV, and to help HIV-negative pregnant women stay negative.
There is encouraging evidence that more countries are adhering to WHO-UNAIDS guidance on provider-initiated testing and counselling in health facilities. This recommends HIV testing and counselling as part of the standard care to all persons with symptoms or medical conditions that could indicate HIV infection, to infants born to HIV-positive women, and in generalized epidemics to all persons attending health facilities. The guidelines are key to facilitating early diagnosis in countries which are struggling with a dual HIV-TB epidemic.
The number of health centres providing HIV testing and counselling is on the increase. In 15 reporting nations in East, South and South-East Asia, the number of such facilities rose from 13 000 to 15 000 between 2007 and 2008; in reporting Latin American and Caribbean countries it doubled, while sub-Saharan Africa boasted a 50% increase. Some countries have made more progress than others. Ethiopia increased its number of facilities from 1005 to 1469 and reported that 4.5 million people received testing and counselling in 2008, up from 1.9 million in 2007. At the other end of the scale, less than 10% of health centres in Nigeria and the Democratic Republic of Congo had testing and counselling facilities.
Cameroon adopted provider-initiated testing and counselling in 2007. This was part of the government commitment to increase the number of people on treatment, up from 600 in 2001 to 60 000 in November 2008, according to WHO’s National Programme Officer for HIV/AIDS in Cameroon, Etienne Kembou. Although much remains to be done to train health professionals to implement the government model at local level, Kembou says about 85% of pregnant women at health facilities agree to be tested, as do growing numbers of men. “AIDS is not stigmatised like it was in the 1990s and many people who are HIV-positive are open about it,” Kembou says, adding that the annual national testing week and peer education projects aimed at 15–25 year-olds have helped enormously.
Uganda and Kenya have expanded coverage through home-based testing and counselling, whereby trained counsellors go from door to door. The advantage is that couples can be counselled together in a familiar environment without the stigma of going into a government facility. As a result, there are fewer disclosure problems which may arise with the male or female partner testing separately. It means that undiagnosed children with the virus can access HIV services and that high-risk areas such as the Kibera slum near Nairobi can be targeted.
In nations like Botswana and Swaziland, the government drive to scale up male circumcision for HIV prevention has led to an upsurge in testing and counselling among males, an often underserved group, as a precondition for the surgical intervention. WHO’s country representative in Botswana, Eugene Nyarko, says intensified prevention campaigns targeting youth are bearing fruit. “Across the board there is an increase in testing because young people know they can benefit from interventions if they know their status.”
In South Africa, which has the highest number of people in the world living with HIV, a national population-based survey in 2008 by the Human Sciences Research Council showed that 50% of respondents over 15 years of age said they had received an HIV test, compared to 20% in 2002. Between 2005 and 2008, the percentage of women and men who reported having an HIV test in the past 12 months more than doubled.
Civil society groups in South Africa, like the Treatment Action Campaign, have mounted high profile ‘Get Tested’ campaigns. There are many local initiatives backed by foreign donor funding and the government, and the message is getting through.
Sweetness Mzoli, runs an organisation called Kwakhanya (‘Light’) which helps care for 300 beneficiaries in Khayelitsha, a poor suburb of Cape Town with high HIV prevalence. She tours minibus taxi ranks trying to persuade men to be tested and counselled and notes there is far less resistance than even a year ago. “It’s coming right. There’s a lot of men out there who want to talk about their status and who want to know their status,” she comments.
The ‘Tutu Tester’ is also a regular visitor to Khayelitsha’s taxi ranks, as well as to shopping malls and other crowded areas. The testing and counselling process is efficient, thorough and friendly. Clients can avoid lengthy queues at public health facilities, while knowing they will receive high quality, confidential service.
“When you make it quick and efficient, people are willing to undergo testing,” says project coordinator Nienke van Schaik. The mobile clinic now offers a package, including testing for hypertension and diabetes “to make it less scary,” she says. “We literally just pitch up. People see us and run off and fetch their partners and family members. People are willing to test.”
HIV Home Test Kits in South Africa
Lyn's Comment: Late in 2009 it was reported that home testing kits for HIV will be piloted in South Africa. The initial response to this was quite positive. However, as organisations and the government reflected on this, more concerns were raised. Some of the issues to consider include:
- the effect of false positive results and the fact that confirmation tests might not be done,
- the lack of counselling,
- incorrect use of kit or interpretation of results,
The national health department and the Treatment Action Campaign (TAC) have added their voices to condemning the use of HIV home testing kits, saying they are risky to use at home and their accuracy cannot be guaranteed.
This follows a warning from the SA Medical Association (Sama), which cautioned that home testing for HIV could leave people devastated.
Sama chairman Norman Mabasa discouraged people from using the kits, urging them to rather get free HIV tests at public health institutions. These came with essential pre- and post-test counselling, he said.
"Let us not create a situation where we wait for disaster to happen by encouraging potentially risky practices where people discover their HIV status at home unmonitored," Mabasa added. TAC general secretary Vuyiseka Dubula warned against the use of the kits. Suicides could result if people tested at home and got a positive result.
"If they are out there, we encourage people not to utilise them. When doing an HIV test it's very important to know why you are doing it, and to have a proper support system.
"The fact is there are a lot of emotions involved, and if there is no proper support system some people may end up committing suicide," she warned.
Dubula also questioned the accuracy of home testing kits, saying there was no confirmation.
"All HIV tests must be confirmed. The worry with self-testing is that it's not always possible to confirm the results. Some people may not be able to afford to buy a second kit to confirm their results," she said, urging people to get free tests at public health facilities.
Mabasa said rapid HIV testing was important in facilitating the diagnosis of HIV infection, but that it was vital that this was conducted in an ethical manner that included pre- and post-test counselling.
Mabasa said he had heard from pharmacies in the country selling the kits that many people feared being recognised by relatives and colleagues at health facilities, so opted for home testing instead.
"While rapid testing may assist in facilitating the diagnosis of HIV infection, improving HIV testing capabilities in facilities without access to laboratories, the tests have important implications for the individual, especially in respect of HIV counselling procedures," he said.
There was also the danger of misinterpretation of the results of the home test kit.
"The danger of tragic incidents happening once people are encouraged to conduct home testing cannot be excluded. Similarly, if a person goes for counselling before they do their own test they might well be assisted in doing the test," Mabasa said.
The national health department also discouraged people from using the kits.
Spokesman Fidel Hadebe that people should rather get tested free at health facilities.
Professor Peter Eagles, chairman of the Medical Control Council, said while the council had not endorsed the use of the product in the country, because it was a medical device and not medicine, he still urged people who used these kits to do so "carefully".
The council is responsible only for the registration of medicines.
Eagles said consumers needed to ensure the product was of a good quality, and registered in its country of origin.
"There is a risk that if the product is not good quality, it could produce incorrect results," he said.
He added that the council encouraged importers of the kits to always consult with the SABS to check that the products met acceptable standards.
This article was originally published on page 9 of Cape Argus on January 22, 2010
South Africans may soon be able to get an HIV home test kit to enable them to find out their HIV status in private.
The kit has the support of celebrity musicians including Jozi’s Bongani Fassie, Leslie and Ishmael.
The test is going to be piloted early next year to people living in Umgungundlovu district (Pietermaritzburg), which has the highest HIV rate in the country.
“Knowing your HIV status is the first step to both prevention and accessing life-saving treatment,” says Dr Krista Dong, who heads iTeach, an HIV/AIDS organisation based in KwaZulu-Natal that will pilot the home tests under the guidance of the University of KwaZulu-Natal’s bioethics committee.
“Everyone knows that testing is free and available at every clinic and hospital, but people don’t want to go to the local clinic where their aunt or cousin might work, or where their neighbour could be standing in line,” says Dong.
“A free HIV self-test, similar to a home pregnancy test, supported by counsellors accessible by cell phone, will empower patients to test in private when they are ready.”
Less than a quarter of South African adults have tested for HIV and only one in 10 people who need treatment are currently receiving it, according to researchers.
The home-test kit, designed by New York-based frog designs, has already won a gold award at the 2009 International Design Excellence Awards (IDEA) competition.
The test will detect whether the person has produced antibodies for the virus. The presence of antibodies means that the person has been exposed to HIV and needs to get medical help.
Encouraging everyone to have an HIV test is a central message of this AIDS Day, and President Jacob Zuma is widely expected to take a public HIV test on World AIDS Day.
However, self-testing for HIV is controversial. In 2005, Pick n Pay recalled a home test kit after complaints by the SA Medical Association that it might be “harmful” to patients as they did not get post-test counselling.
But Johns Hopkins University recently piloted a home test with 400 people in a hospital emergency room in the US and found that most people found the test easy to use and acceptable.
The results of the pilot, presented last month (November) at the annual conference of the Infectious Diseases Society of America, found the test was also 99% accurate.
“Self-testing does raise some serious questions, which require thoughtful analysis and careful planning,” according to the test’s developers. “However, these concerns must be weighed against the ability to achieve wide-scale testing and earlier entry into care through an option that empowers patients and alleviates stigma.”
Meanwhile, Dr Dong is confident that the test will be well received: “Feedback from the community confirms individuals are eager to have access to an HIV self-test, with both patients and healthcare workers preferring counseling via cell phone.”
The development of the self-test is the third phase of Project Masiluleke, an innovative partnership between a variety of organisations as diverse as technology innovators Praekelt Foundation, music label Ghetto Ruff and mobile phone giant MTN.
The first phase of “Project M”, as it is known, was launched in October 2008 with up to a million HIV/AIDS messages a day being sent out as part of “please call me” SMSes donated by MTN.
These messages directed people to the national AIDS Helpline, and resulted in a 300% increase in calls to the line from the month that it launched.
Phase two, which will launch soon, involves sending patients on antiretroviral treatment automated SMS reminders of their scheduled clinic visits.
“We are using the power of mobile technology to penetrate the communities we serve and offer life-saving, vital healthcare information to millions that need our help,” said Eunice Maluleke, General Manager, MTN Foundation recently when she announced that MTN would continue to be part of Project M for another year.
“Together with our partners, we aim to help South Africans access information, get tested and stay on treatment. We are using our core product to eradicate the stigma about HIV AIDS and bring down these numbing statistics.”
HIV Testing More Than Doubles Worldwide in 2008. 30/9/09
HIV testing more than doubled in dozens of countries last year, leading to an upswing in HIV reporting and an increase in people getting treated, according to UNAIDS as reported by The New York Times.
The agency’s 2009 progress report showed that the number of people on antiretroviral medication increased by more than a million people in 2008, raising the total number of people on treatment to more than 4 million. The number of HIV-positive children receiving medication increased from 198,000 to 275,7000 during that same period. More than half of HIV-positive mothers in Africa who need medication to prevent transmission of the virus to their infant received it.
“In the space of one year, you’re seeing a huge ramping up of AIDS services,” said Mark Stirling, regional director for UNAIDS in eastern and southern Africa. “It’s unprecedented. In the acceleration and intensification of reach, 2008 was an extraordinary year.”
However, the report also showed that while more than 1 million positive people were put on treatment in the past year, 2.7 million were newly infected in 2007, the last year data were available.
The SA Medical Association (Sama) has warned that HIV/Aids home testing posed several risks and discouraged people from using it.
"Let us not create a situation where we wait for disaster to happen by encouraging potentially risky practices where people discover their HIV status at home unmonitored," Sama chairman Norman Mabasa said in a statement.
He urged people to go for HIV/Aids tests for free at hospitals and clinics where post-test counselling was done.
But he said many people feared being recognised by a cousin or colleague and rather opted for home testing.
"The tests have important implications for the individual, especially in respect of HIV counselling procedures.
"There is also the danger of people committing suicide after being informed of their HIV positive status, or even following misinterpretation of the results of the home test kit," said Mabasa.
"Sama therefore would discourage home testing, especially in the absence of pre-and post-test counselling, even where the technical quality of the test kits is acceptable." - Sapa
Published on the Web by IOL on 2010-01-21 08:23:07
In Their Minds, Those Boys Do Not Have HIV. 31/7/09
JOHANNESBURG, 31 July (PLUSNEWS) - Jessica Standish-White is a senior student at St Mary's, a prestigious girls' school in one of Johannesburg's more affluent suburbs, where she organized an HIV testing drive. Standish-White, who is going to the University of Cape Town next year, told IRIN/PlusNews that some of her peers still think HIV can't happen to them.
"There is this perception that girls that go to St Mary's don't get HIV, and that's what we wanted to change.
I know in my friendship group we don't talk about condoms. "If girls are on the pill, I don't know how much of an issue the condom is. I know a lot of girls who are on the pill, and if they are on the pill and having sex with their boyfriends, I don't know how often a condom will be used, to be honest.
"It's a continuation of the perception that St Mary's girls are going out with boys who come from the same sort of background they do and, in their minds, those boys do not have HIV. I think it's a continuation of the ... [misperception] that [HIV] doesn't happen to people who live in the Johannesburg suburbs.
"Most girls are aware about HIV and how it works, but I think testing has made it more personal; I think the girls have really had to think about it.
"It's huge for a 15-year-old to take an HIV test - where do school kids get tested? I mean, parents can take you, but are kids speaking to their parents about HIV?
"For the absolute majority of girls, this week was their first time getting tested. It slightly challenged the parents, but I think it's good. The response was incredible - we had to do extra testing.
"It's really nice that the school recognises that some girls are having sex, and if they are not having sex now, they will be in the next few years.
"The school has been great in saying, 'We're quite happy to talk about it, and we're quite happy to educate girls so that when they start entering into that part of their lives they know what's going on and how to protect themselves'. It's really nice that the school doesn't deny that it's happening.
"Next year, if the University of Cape Town runs an awareness programme and says, 'Come test', I'll be, like, 'Sure, no problem, I've done that before'. I know that I'll feel good after - I just know more about it, and I think that makes it easier."
Is HIV Self-Testing The Future? Living with AIDS # 391. 28/5/09
Between 5% - 15% of the South African population has ever tested for HIV. This is despite the fact that testing services are widely available in the public health sector. A recent pilot study in KwaZulu-Natal has shown that South Africans would rather test themselves than go to a clinic.
“We know, despite the fact that things are improving because we have effective treatment, stigma persists. People do not want to go to their local clinic, although testing is available. The messages are ineffective, at best, and offensive, at worst, and that’s common. And we do have inequality in the clinics. You say it should be private. Well, not every clinic has a space where the single counselor can tend to the 80 people queuing to get VCT. So, how is that private?” , said Christa Dong of the Integration of TB and HIV Care (ITEACH) programme at Edendale Hospital in Pietermaritzburg, explaining what they found to be reasons why people were not likely to test for HIV at government clinics.
Women seem to access testing more readily than men in South Africa. Researchers believe that this is due to fears amongst men that if HIV-positive, their status will be disclosed through testing, and that stigmatization will follow. Thus, the pilot programme predominantly recruited a cross-section of men from different settings of KwaZulu-Natal, starting last October. Over a million men were targeted through cell-phone text messages and over 300 000 participated.
The result was that “men wanted a new option to the current method of HIV testing”, says Zinhle Thabethe, one of the researchers. “They said they wanted HIV self-testing”, she said.
Testing for HIV as it’s done through the current Voluntary Counseling and Testing method, includes a compulsory counseling session before and after the test and the actual test is done by a health worker. Participants in Project Masiluleke received self-test kits with instructions on how to use it. The package also contained a number to call to speak to a counselor if they needed further assistance or counseling.
“The counselors, every single one who participated this way, said they preferred it. They said, ‘oh, that was nice. I could tell them everything I needed to’. Not just the patient, but the counselor also said ‘I appreciate this thing. It lets me relax and I can give this information and it’s not so emotionally burdening”, said Christa Dong.
Results of the pilot programme have drawn mixed reactions.
“I’m concerned about this self-testing”, said Lydia, a clinician working in Tembisa, on Gauteng’s East Rand.
“Maybe when this person buys the test kit there should be some accountability about the person who is selling it, so that they can have a counselor calling that person rather than waiting for that person to call the counselor because we have discovered so many people who attempt suicide even after being well counseled”, she added.
But Dr Francois Venter, President of the Southern African HIV Clinicians’ Society, relished the results. I think the worst place to learn your HIV status is in a health care facility; and I really think that we need to be looking for much more creative ways for moving that testing out; and that if the health care facility is our only option - in fact, if it’s our best option - then, we are in deep, deep trouble. We really need better and creative ways and I hope that in two years’ time we won’t be sitting around here and saying ‘most people are still testing themselves through insurance policies and in the health care facility’, but that if it’s self testing, or whatever else it is, there are more creative ways of accessing your HIV status”, he said.
Johannesburg - HIV testing among men has increased considerably over the last 12 months, rising from 24% to 60%, a nationwide survey has found.
"The figures show a dramatic increase in HIV testing, particularly among males," said Dr Saul Johnson, managing director for Health and Development Africa, at a media briefing in Johannesburg on Monday.
He attributed the increase to awareness campaigns and programmes having reached people, who acted on the information and got tested.
He was releasing the findings of the Second National HIV/Aids 2009 survey, which was conducted in all nine provinces between June and August last year. A total of 9 728 people aged between 16 and 55 took part in the survey.
Of those in the 15 to 24 age group in 2006, 17% of men and 38% of women were tested. In 2009 this increased to 31.8% of men and 71.2% of women.
About 75% of young men and 78% of women between 16 and 19 were tested in the last year.
Faithfulness In 2006, the study found 26% of respondents believed faithfulness was a way to prevent the spread of the virus, compared to 39.1% in 2009.
People in stable, long-term relationships were less likely to use condoms.
Half the women interviewed, who were involved in one-night stands, did not use condoms. Most men and women believed cheating was a norm and pervasive.
While there is evidence that the message around the risks of multiple partners is getting through, the message needs to be sustained in the future to further increase knowledge levels and bring about behaviour change," Johnson said.
The survey found stable relationships were uncommon for younger men.
"It takes a long time for people to enter into stable relationships, especially for men. Young men have multiple partners, and have more casual relationships," he said.
Both men and women were more likely to settle into stable relationships in their late 30s.
Alcohol Alcohol was found to be a big problem, as when people got drunk, they didn't worry about HIV. There was also a perception that alcohol consumption would lower the risk of contracting HIV.
Johnson said their HIV/Aids campaigns were working and that knowledge of condom use, ARV treatment and tuberculosis was very high.
About one in 10 people start having sex before the age of 15, which puts young women at high risk of HIV infection.
Condom use was high among young people and those in "casual" relationships, particularly among males.
Johnson estimated that Aids communication programmes reached about 90% of the population - younger people more than older ones.
The survey concluded that information on mother-to-child-transmission was still fairly poor, and male circumcision was not a "top-of-mind" issue. Only a few men knew that male circumcision reduced the risk of contracting HIV.
The campaign still had a long way to go to help reduce multiple partners.
Nearly One In Three People With HIV Do Not Know: EU. 27/10/09
BRUSSELS — Almost one in three people infected with the virus that causes AIDS do not know they have the disease, increasing the risk of infection, the European Commission warned Monday.
In a document on combatting AIDS more than a quarter century after it surfaced, the EU's executive arm said now was not the time for Europe to drop its guard, noting that the figure was up to double in some neighbour nations.
And while efficient treatments exist to slow the evolution of the human immunodeficiency virus (HIV), no vaccine or cure has been found.
"We need to continue the political momentum in the fight against HIV/AIDS," EU Health Commissioner Androulla Vassiliou said in a statement.
"We need to encourage people to take responsibility for themselves and their partners by talking about and practicing safe sex and going for HIV testing," she said.
According to commission figures, the number of people living with HIV or AIDS in the 27 EU countries and its neighbours rose from 1.5 million in 2001 to 2.2 million in 2007, around 730,000 of whom live in the bloc.
Some 50,000 new cases of HIV were diagnosed in the EU and its neighbours in 2007.
The percentage of adults, ranging in age from 15 to 49, infected with HIV vary widely, from less than 0.1 percent in some countries to more than 1.0 percent in others.
France, Italy, Spain and Portugal have relatively high infection rates -- ranging from 0.4 percent to 0.5 percent -- but the number roughly triples in Estonia, which has a rate of 1.3 percent.
In Russia, around 1.1 percent of the population is HIV positive, while the figure climbs to 1.6 percent in Ukraine.
Abbott's Architect HIV Ag/Ab Combo assay has been approved by the U.S. Food and Drug Administration.
Traditional HIV diagnostics have detected HIV antibodies, which are developed days after an infection as a sign that the body is working to fight the invading virus. The Architect assay also detects the HIV p24 antigen, which is a protein produced by the virus immediately after infection, Abbott said in a news release.
The risk of HIV transmission is highest just after infection with the AIDS-causing virus, the company said.
Since the new test could detect HIV infection days earlier than antibody-only diagnostics, people could be alerted before unknowingly spreading the infection and be treated earlier, Abbott said.
Some 56,000 new cases of HIV infection are diagnosed each year in the United States, the Illinois-based company said, citing the U.S. Centers for Disease Control and Prevention.
Only 2% of SA Citizens have been Tested for HIV. 28/03/08
The billions spent on failed biological tools to stop HIV infection, such as microbicides, should rather have been spent on "human behavioural stuff", according to the president of the Southern African HIV Clinicians Society, Francois Venter.
"We have to fix human behaviour. The solution to the HIV crisis is probably in our social values," Venter said in a hard-hitting talk in Cape Town on Wednesday night.
It was estimated that half of all South Africans will eventually be infected with HIV and this showed how the prevention policy had failed.
The failure was due to healthcare workers not offering patients what they needed, but preaching "a moral message" of stopping smoking, better nutrition and "believing in Jesus".
Consequently, three-quarters of those who tested positive were lost to follow-up, until their white blood cell counts dropped to a critical point and they returned desperately ill. "When are we going to start offering something that patients value?"
Since anti-retroviral therapy (Art) rollout, there had been 1.8 million new infections. There were four new infections for every one person starting on Art.
"What is going on that we will be treating in 10 years someone who is infected tonight? We need an emergency approach to prevention. There is not a single hint at the moment that the HIV rate is going down, except maybe in teenagers," he said.
In South Africa, half of all deaths a year were Aids-related. By 2025, the best forecast for life expectancy would be 59 years and the worst 50 years.
The fact that there would be two million Aids orphans by 2010 was an "absolute national catastrophe and crisis by itself" - especially considering there was no social welfare system in place to deal with it.
While promoting the use of condoms was the major thrust of the HIV prevention campaign in South Africa, people were still not registering that they had to use them every time they had sex.
And there was no focus on the high risk groups: married women and widows.
"We do not understand the sexual dynamics of this country," Venter said.
Only two percent of the population have tested for HIV.
"Everybody thinks they're immune," he added. Four-fifths of those with HIV in the world lived in southern Africa and one-fifth in South Africa.
A World Health Organisation report recently warned that the world "must be scared" if South Africa does not get its HIV problem right, he said.
Another future problem was that while medicine took care of tuberculosis, pneumonia and gastroenteritis - the top three killers in South Africa apart from Aids - there would be "a flood" of cardiovascular diseases from the fourth and fifth top killers - the lifestyle diseases, hypertension and diabetes.
Screening Tool for HIV in Children Not Being Used Effectively. 15/10/09
Incorrect use in routine practice of a World Health Organization (WHO)/UNICEF HIV screening tool for children at primary health care clinics in Limpopo and KwaZulu Natal provinces, South Africa leads to the failure of life saving interventions, Christiane Horwood and colleagues reported in a study in the September 22 2009 edition of BMC Pediatrics. Forty per cent of trained health workers failed to identify HIV in any child and not one was able to classify every child correctly for HIV.
In South Africa where HIV prevalence rates among pregnant women remain at 29% the burden of paediatric HIV disease continues to grow. Limpopo with a mostly rural population of 5.5 million has high rates of poverty and poor access to basic services. While KwaZulu Natal has less poverty, half of the 10 million population lives in rural areas and antenatal HIV prevalence in 2006 was close to 40%.
Insufficient testing and follow-up of HIV-exposed children leads to high mortality rates with over half of untreated children dying within the first two years of life. Few children who need antiretroviral treatment receive it in spite of it being free. Improved follow-up of HIV exposed children, increased early identification of children with symptomatic HIV and improved access to ART for children are urgently needed.
New guidelines from WHO recommend that where virological testing is unavailable children should be started on antiretroviral treatment based on clinical diagnosis alone followed by quick confirmation of HIV status.
WHO and UNICEF developed the Integrated Management of Childhood Illnesses (IMCI) strategy to improve child survival in resource-poor settings. Focusing on the well-being of the whole child, the aim is to reduce death, illness, disability, and to promote improved growth and development among children under five years of age. South Africa adopted these guidelines as the standard of care for children at the primary level in 1997.
Multi-country evaluations of the IMCI strategy indicate, when used correctly, improved health worker performance and quality of care as well as a reduction in under-five mortality and improved nutritional status.
The guidelines have been adapted to incorporate a validated HIV component (including an algorithm) to identify and manage HIV infected (at risk for early death) and exposed (symptomatic) children. The IMCI course includes comprehensive training on this component.
For effective use of the algorithm, health care workers are expected to ask every mother bringing a sick child to a health care facility whether she has been tested for HIV, so that children may be classified as HIV-exposed, and all children should be assessed for clinical symptoms suggestive of HIV. The presence of three or more symptoms should trigger further investigation and the carer should be advised of the need for the child to be tested for HIV.
In this first known evaluation of the IMCI/HIV guidelines the study was designed to show how the guidelines are used by IMCI trained health workers, the validity of the HIV algorithm when used by expert IMCI practitioners in routine practice and the burden of HIV disease among under-fives attending primary health care facilities in Limpopo and KwaZulu Natal provinces.
Between May 2006 and January 2007 seventy-seven randomly selected IMCI trained health workers were observed by IMCI experts in 74 primary health care facilities in Limpopo and KwaZulu Natal provinces.
All sick children between the ages of two months and five years were eligible. Consultations with a total of 1357 sick children were observed. A different IMCI expert reassessed each child to confirm correct findings.
Consent for HIV testing for all children who attended was requested from parents or legal guardians with them. Positive rapid tests were confirmed with HIV polymerase chain reaction (PCR) in children under 18 months of age. HIV-positive children had CD4 counts and HIV clinical staging done.
Each health worker was observed for a mean of 2.2 days and 17.7 consultations. The average age of the observed children was 19.6 months of which 40.7% (552) were under one year of age. A third of all consultations were observed in Limpopo and the remaining two-thirds in KwaZulu Natal.
Of the 1064 children with available HIV test results 76 tested positive giving an HIV prevalence rate of 7.1% (CI: 5.7%-8.9%) among children in primary health care clinics. Of these 76, one was on antiretroviral treatment. Following CD4 counts or if unavailable WHO clinical staging, ART was indicated for 84% (63/75) of the remaining.
When compared to the HIV test results IMCI experts skilled at using the HIV algorithm correctly identified 90.8% (69/76) of HIV-infected children as either suspected symptomatic HIV or HIV-exposed and therefore in need of further investigation. This shows that when used correctly the HIV algorithm is an effective screening tool and can lead to improved access to life-saving treatment for HIV infected and exposed children.
In comparison over 40% of IMCI-trained health workers failed to identify HIV in any child because of poor or incomplete use of the HIV component. And, nine did not classify the disease stage of any child with HIV correctly.
Even when health workers classified children with suspected symptomatic HIV the need for testing, cotrimoxazole prophylaxis and feeding advice was only communicated to 64%, 31% and 43% of carers, respectively.
The authors suggest several reasons for poor use of the algorithm:
* Inadequate training
* Lack of a clear understanding that the HIV algorithm is a screening tool and not a diagnostic test. IMCI training must clearly explain that most children will test negative and provide appropriate counselling messages. Even with a sensitivity of over 90% in this high prevalence population it has a low positive predictive value (PPV) which would be lower still when used in low prevalence settings.
*Poor use of the algorithm may be reflective of an overall poor use of IMCI due to: heavy workloads, lack of time for consultation, absence of clinical supervision and support
*Poor application of prevention of mother-to-child transmission (PMTCT) programmes. Even though many mothers reported testing positive few HIV-exposed children had been tested and most clinics did not test children under five. 73% of mothers had been tested for HIV, of which 24% (221) tested positive. Of the 221 HIV-exposed children only 35% (78) had been tested for HIV within routine services.
The authors recommend the strengthening of PMTCT and linkage with IMCI as well as improved access to HIV PCR for exposed children. This may reduce the need for the algorithm to identify symptomatic HIV. However, it will remain important for children whose mothers do not disclose their status, become infected during pregnancy and breastfeeding, and in settings where virological testing is not available.
The authors note that these findings show that undiagnosed HIV infection is common in primary health care clinics among under-five year olds and most have advanced disease. Current recommendations suggest that antiretroviral treatment is begun in children under one year of age as soon as HIV status is confirmed. They also note that their findings support the IMCI recommendation to check all children for possible HIV infection.
The authors highlight the study’s strengths. The IMCI experts were all highly experienced and pr0vided a “reliable gold standard”; observation of large numbers of children and health workers made it possible to describe performance using the health worker as the unit of analysis. Health workers had no notice of the observation and observation of large numbers over several days reduced bias.
The authors note several limitations. The observer’s presence may have influenced performance and led to bias. For example, health workers may have worked out what to do during the observation. Evaluation of individual ability to identify specific signs did not take place to avoid interference during the consultation. Evaluation of the sensitivity of HIV rapid tests in children under 18 months of age remains incomplete. They did not get CD4 results for all HIV infected children.
The authors conclude that IMCI and the correct use of the current guidelines can identify HIV-infected and exposed children and provide increased and earlier access to care in South Africa to reduce under-five mortality.
However, poor use of the guidelines limits its potential. The authors suggest further study to understand poor health worker performance “to provide evidence-based interventions to address poor IMCI implementation”.
Reference Horwood C et al. Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV. BMC Pediatrics 9:59, 2009.
South Africa: HIV Testing and Mental Illness. 17/03/10
People suffering from HIV-related mental disorders is growing, but mental health remains an ethical, legal and clinical minefield, where many doctors and nurses fear to tread - and fear to test.
Johannesburg — As more HIV-positive people access treatment and live longer, the number of people suffering from HIV-related mental disorders is growing, but mental health remains an ethical, legal and clinical minefield, where many doctors and nurses fear to tread - and fear to test.
"We're moving away from seeing patients on their death beds towards patients who are living longer, and are being affected by mental disorders that have real impacts on their life and work," said Dr Greg Jonsson, a psychiatrist at the Luthando Psychiatric HIV Clinic at the Chris Hani Baragwanath Hospital, in Johannesburg.
Various studies have shown a higher than average prevalence of mental illness among people living with HIV. A 2005 study by South Africa's Human Sciences Research Council found that about 44 percent of the 900 HIV-positive individuals surveyed suffered from a mental disorder.
The links between HIV and mental illness are complex, but factors include the effects of the virus on the central nervous system, as well as difficulties in dealing with HIV-related stigma and discrimination.
South Africa has the world's largest ARV programme to counter an HIV prevalence rate of about 18 percent, according to UNAIDS, and about 920,000 people are on ARV treatment.
No easy choices
Doctors and nurses in clinics often find it daunting to test mental health patients for HIV. "People who are not trained in psychiatric disorders are scared of getting consent from patients with mental disorders," Jonsson told IRIN/PlusNews. "People should not assume that mentally ill or even psychotic patients are incapable of understanding [testing] and consenting."
But Jonsson added that there would be times where doctors would need to make tough calls about testing severely mentally ill patients who could not consent to HIV testing and whose families may not be approachable to consent on their behalf.
Psych is hard because the 'three ticks equal this' approach doesn't really work, and that's why people are so scared of it.
"If you can't obtain informed consent, you need to weigh up the potential harm and benefit to the patient - ask yourself whether this test is going to change your diagnoses or your treatment," he suggested to health workers at an annual symposium held by the Aurum Institute, a non-profit medical research organization.
"I think if the answer is 'yes' to either, then go for it. It is really the right of the patient to be offered effective HIV treatment," said Jonsson, who pointed out that doctors should be aware of possible interactions between mental health medications and antiretroviral (ARV) drugs.
He advised doctors to document the process and counsel patients throughout, especially about how to reduce risk, given the prevalence of substance abuse among mental health as well as HIV patients.
"Psych is hard because the 'three ticks equal this' approach doesn't really work, and that's why people are so scared of it," Jonsson told IRIN/PlusNews.
No right answers
Once a mental health patient started taking ARVs, healthcare providers would have to evaluate whether mandating a "treatment supporter" - a friend or family member to help the patient adhere to treatment - would be appropriate. Again, there may not be a right answer.
"We need to draw up protocols and put them in primary healthcare, but the problem with protocol-based system is that people don't think outside the box - with mental health patients it really is on a case-by-case basis," Jonsson told the symposium audience.
"I tell most of my patients, 'If you can get treatment support, go for it', but I don't insist on it - disclosing to a patient's family is difficult and ... at my clinic, our patients on treatment are already so stigmatized and victimized."
The Luthando Psychiatric HIV Clinic has a treatment default rate - patients who discontinue ARVs - that is the same as institutions in Johannesburg that mandate treatment supporters, Jonsson added.
JOHANNESBURG, 26 June 2009 (PlusNews) - It has become a given – test more people for HIV and you'll get more people on treatment earlier, plus cut down on risky sex. But recent research on the behaviour of people who test HIV negative, has led some doctors to question the testing gospel.
Speaking at the monthly meeting of the South African HIV Clinicians society, Dr Francois Venter said what seemed a strong relationship between increased testing, treatment and behaviour change is not necessarily valid in the South African context. This, coupled with worrying research that has shown a negative HIV test can actually increase risky behaviour, means more work needs to be done before countries look to adopt models like 'provide initiated testing and counselling' (PITC) - in which health workers offer tests to clients rather than waiting for a request.
More testing, better patient outcomes? "It's absolutely phenomenal how testing has been escalated over the last five years, but the argument that more testing will lead to more people on treatment earlier is not coming to fruition," said Venter.
He added that CD4 counts - which measure the strength of the immune system - in patients initiating antiretroviral (ARV) treatment remained low, often 100 or less in the public sector. "Donor projects want to know how many people tested and know their status," Venter told IRIN/PlusNews. "Who cares if they tested and know their status if they don't do anything with the information. The people who run those testing programmes must be able to demonstrate that those people entered into system of care or it's pointless."
The need to re-examine testing comes amid on-going calls for countries with generalised epidemics like South Africa to adopt PITC. In 2006, the World health Organisation and UNAIDS released draft guidelines on the PITC model, arguing that it would mean more people tested and therefore began treatment.
Venter said he was sceptical that more testing would lead to bigger numbers on ARVs, and in any case PITC might be unfeasible given the public sectors limited resources.
A massive scaling up of testing, he stressed, could also do more harm than good if not done right.
The good, the bad and the ugly Venter cited new research from Uganda that has shown a 50 percent reduction in condom use in participants who tested negative for HIV. It's a finding that he said echoed those out of a recent TB study in Zimbabwe that showed that a negative HIV test increased not only risky behaviour, but the number of sexual partners as well.
The counterpoint is research from the United States about the overwhelmingly positive affects of testing positive, he told IRIN/PlusNews.
"In fact, testing positive is a huge HIV prevention tool," Venter said. "Findings have shown that those who test positive take fundamental steps to protect others whether that is increased condom use, increased disclosure to their sexual partners or abstinence."
In the meantime, he urged a re-examination of what we think we know about testing, and how to roll it out. "We might be doing a whole lot of harm and we have to think very hard as clinicians about people who test negative," Venter said. "We also need to fix our healthcare system so when people test positive, they want to seek treatment within the system".
WHO Recommends New Early HIV Detection Ways. 9/6/10
The World Health Organisation has come up with new ways to enhance early detection of HIV and ensure quick access to anti-retroviral therapy.
Harare — The World Health Organisation has come up with new ways to enhance early detection of HIV and ensure quick access to anti-retroviral therapy.
WHO team leader for HIV and Aids programmes Dr Bryan Pazvakavambwa said this at a recent stakeholders’ workshop in Harare. He said the new recommendations followed extensive research accumulated over the years.
"The updated recommendations are aimed at promoting earlier diagnosis of HIV and earlier anti-retroviral treatment initiation, use of less toxic and more patient-friendly regimens, and early initiation of prophylaxis or treatment as medically indicated for prevention of mother-to-child transmission," he said.
WHO also revised paediatric HIV care and treatment guidelines.
However, Dr Pazvakavambwa said the new recommendations presented challenges to country interventions.
"As more people will now be eligible for treatment and the role of the laboratory in patient management expanded, the financial implications could be huge for low income countries.
"Early ARV for treatment and PMTCT initiation will prolong the duration of ART use and ensuring adherence may be a challenge.
"Increased ART care and the need for close follow-up with counselling, family and community support for breastfeeding HIV-infected mothers may challenge the health systems," he said.
ZAMBIA: HIV Testing Services Missing the Mark. 5/01/10
LUSAKA, 5 January 2010 (PlusNews) - New research has found that Voluntary Counselling and Testing (VCT) services in Zambia are squandering the opportunity to reach clients with information about how to reduce their HIV risk.
The study, conducted by Private Sector Partnerships–One, (PSP-ONE), a USAID project aimed at increasing the private sector's capacity to provide quality health services in developing countries, looked at VCT services offered by the private, non-governmental, government and faith-based sectors in one urban and one rural province of the country - Copperbelt and Luapula.
In a report compiling the study findings, the researchers emphasise that VCT services form a critical opportunity to provide risk reduction counselling and HIV prevention information and to act as a gateway to HIV/AIDS services for clients who test positive.
Zambia has an adult HIV prevalence of 14.3 percent, but the infection rate is as high as 20 percent in some urban areas. New HIV infections rose from an estimated 70,000 in 2007 to 82,000 in 2008 - the majority of them through heterosexual sexual contact.
"In a generalized HIV epidemic where multiple concurrent sexual partnerships are a significant driver of new infections, discussion of risk-reduction methods should be a main focus of pre-test and post-test counselling," comment the researchers.
However, the study found that across all sectors, while condom use was emphasized, only one in three clients received counselling on reducing their number of sexual partners and even fewer were advised on how to disclose their HIV test results to partners.
Pre-test counselling tended to over-emphasise the risk of contracting HIV through blood exchange, which is not a major driver of Zambia's HIV epidemic, and of living positively with HIV, even before a client's status was known.
The research also found that VCT services across all sectors were mainly accessed by the most educated segments of the population, and were largely failing to reach the 65 percent of women and 51 percent of men in Zambia who have no or only primary school education.
The study found the quality of VCT services provided by private sector clinics was on a par with or better than those provided by public and NGO clinics, despite the lack of HIV prevention training opportunities offered to private providers. This raised the question of how beneficial those trainings were and whether their cost was justified.
One positive finding that emerged from the study was that most people sought VCT services close to their homes indicating they did not fear being stigmatized by their communities. This is in contrast to other studies from the region in which clients reported choosing VCT and treatment sites far from home to avoid detection and stigma from neighbours.
Although most of the clients reported being satisfied with the qualify of VCT services they received, this often had more to do with the friendliness of counsellors than their technical competence at emphasizing risk reduction and behaviour change.
The researchers conclude: "A renewed focus on adapting counselling topics to the realities of Zambia’s HIV epidemic will improve the efficacy of VCT across all sectors."