Ending pediatric AIDS and achieving a generation born HIV-free

In the 30 years of the AIDS pandemic, the devastating effects of HIV on infants and young children have often been overlooked and neglected. However, the ability to prevent mother-to-child transmission of HIV (PMTCT), or vertical transmission, has been one of the most significant prevention success stories in the global AIDS response. New HIV infections in children have been virtually eliminated in high-income countries and programmatic efforts have shifted to low-income and middle-income countries, particularly in sub-Saharan Africa, home to the vast majority of pediatric AIDS cases.Over the past decade, the dramatic scale-up of PMTCT programs has saved millions of lives and has provided a foundation for HIV prevention and care and treatment programs that are integrated within maternal and child health services. Although some countries in sub-Saharan Africa are now approaching universal PMTCT coverage, global access to PMTCT for HIV-positive pregnant women remains at nearly 50%. Recently, a new global plan has focused efforts and resources to keep HIV-positive mothers healthy and to virtually eliminate new pediatric infections by 2015.What programmatic and technical innovations will be necessary to overcome current service gaps and implementation barriers? How can countries continue the current momentum with sustainable locally-led programs that address the epidemic in women and children? And how can the vital perspectives of communities and people living with HIV help drive these efforts? Successfully addressing these and other issues will be key to ending HIV infections in children and creating an AIDS-free generation within the next decade.     

Challenges of a hidden epidemic: HIV prevention among women in the United States

HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two-thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk and by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.     

Intergrating health research with socio-cultural systems in the fight against HIV/AIDS

The rapid spread of AIDS in Africa has brought into focus the need to integrate medical science with socio-cultural beliefs and practices. The scientific knowledge on HIV, immune systems and drugs is well established. However, the drugs which are in use in the developed countries are too expensive for the great majority of the persons with HIV/AIDS in Africa. On the other hand, Africa is rich in socio-cultural traditions which have served their respective communities well. However, because of poverty and ignorance, many of the socio-cultural systems are helping in HIV/AIDS to spread increasingly fast. This therefore means that the most important weapon that Africa has for fighting HIV/AIDS is education through our socio-cultural systems. In this connection, for example, it is necessary to make the people understand that malnutrition will help the HIV to destroy the immune systems faster than it would do in a well-nourished person. This means therefore that the people need to be educated on the types of foods they must eat in order to get the necessary vitamins, proteins and calories. This is turn has implications on agricultural practices. It is also vital to make the people understand that other diseases do help HIV in suppressing immunity and that they should seek medical help as soon as they feel unwell. HIV/AIDS is a very expensive public health crisis. Families and health services are finding it difficult to meet all the needs of persons with AIDS. It is because of this that the rich African tradition of mutual social responsibility can play a major role in ameliorating the suffering and sharing the responsibility. A very major component of mutual social responsibility is co-operation and co-operative education among members of the community. Since the young persons constitute the most affected population , an educational system based on socio-cultural tradition of mutual social responsibility will help the young persons to acquire socially acceptable values and ethics which they need for survival. What has been said about HIV/AIDS is applicable to all health problems such as malaria and mother to child health (MCM). Health research and publications are important in making health policies precise and relevant. The application of those precise policies in solving health problems in Africa will in turn be more cost-effective and cost-beneficial if they are integrated with the socio-cultural systems.     

HIV/AIDS' spread and impact on other health-related millennium development goals--secondary publication

HIV/AIDS threatens the development of countries with high HIV prevalence. This article focuses on the magnitude of the impact of HIV/AIDS on the millennium development goals (MDGs) for health. The article is based on a literature survey on the impact of HIV on child health, maternal mortality, tuberculosis (TB) and malaria. At global level 10% of child mortality is related to HIV/AIDS but the impact of HIV/AIDS on child mortality is much higher in high HIV prevalence countries being measured in the range of 27-42%. The impact on maternal mortality is difficult to estimate since the majority of pregnant women are not tested for HIV, but studies in a number of HIV high prevalence countries indicate an increasing negative impact on maternal mortality. The impact of HIV/AIDS on TB is significant. 9% of the TB cases are related to HIV/AIDS at the global level, but for the WHO African region alone, the impact of HIV/AIDS is estimated at 31%. There is evidence that HIV infections increase the risk for the progression of malaria in children and the risk of severe and complicated malaria in adults in stable malaria areas. However, the most evident effect of HIV on malaria is related to pregnant women. It is concluded that strategies to reach the MDGs for health must include a comprehensive and coordinated approach to fight the major health problems including a more suitable resource allocation and organisation of health services taking into account the many inter-linkages between diseases.     

Managing HIV/AIDS in correctional settings

Approximately one quarter of people living with HIV/AIDS in the United States pass through the correctional system, resulting in a burden of infection on the correctional health care system that has challenged correctional and public health officials. The HIV epidemic behind bars results from the high prevalence of HIV risk behaviors among those incarcerated: illicit drug use, untreated mental illness, prostitution, homelessness, and poverty. Challenges to HIV care in correctional settings include management of comorbid conditions, remoteness from HIV care sites, organizational constraints, and access to effective therapies. Despite these challenges, prisoners with HIV have derived considerable benefit from HIV detection and treatment. In order to achieve parity in HIV outcomes among vulnerable populations, effective prison-release programs that incorporate effective case management with effective drug treatment and adherence strategies are required to extend the benefit of highly active antiretroviral therapy as prisoners transition back to community settings.     

Nonstigmatizing ways to engage HIV-positive African-American teens in mental health and support services: a commentary

This commentary illustrates a hospital/adolescent-clinic based model for providing support services and for increasing medical adherence among HIV positive inner city African-American adolescents. This commentary reviews the racial/ethnic disparities in HIV disease among adolescents and describes a successful program model for overcoming stigma. Traditional support groups were rejected by youth with HIV/AIDS. Seven elements common to successful programs were identified. Successful programs built on designs described in the research literature. Focus groups composed of HIV-positive adolescents identified what they wanted and needed. Stigmatizing labels were avoided in naming programs. Practical barriers to access, such as transportation and childcare, were eliminated. Programs were skills oriented, culturally sensitive, and life affirming, focusing on healthy living. HIV-positive inner city African-American youth can be successfully recruited and engaged in hospital based programs. Although these programs were qualitatively evaluated by youth as successful and attrition was low and attendance averaged 50%, rigorous quantitative research is needed to evaluate the effectiveness of such programs. We need quantitative research to successfully advocate for government funding. Stigma needs to be addressed openly in public health. Future research is needed to evaluate interventions to overcome the health consequences of stigma on utilization of available medical and mental health services.     

Poverty reduction and the HIV / AIDS epidemic in Kenya:What are the core issues

The government of Kenya has recently attempted to develop a national budget that gives priority to two pertinent constraints to national development efforts. These are poverty and HIV/AIDS. The poor are those members of society that are unable to afford minimum basic human needs comprising food and non-food items. Slightly over 50% of Kenyans live bellow poverty line. Also, about 700 Kenyans are lost to the HIV/AIDS epidemic everyday. 75% of those infected live in the rural areas and the majority of those are aged 15-39 years. Any efforts to reduce poverty and contain the epidemic will require an integrated approach because of the interplay between the effects of HIV/AIDS and poverty. Both poverty and HIV/AIDS are direct, non-selective and universal, both affects males, females and children ,reduce the labour force as well as food production, strain medical services and generally aggravate the performance of the economy. There is therefore an absolute need to protect the poor from infection and re-infection especially those located in the rural areas and the youth who are at risk. An essential component of this protection is public education of these groups, accompanied by economic empowerment through creation of self-employment opportunities. The recently developed Poverty Reduction Strategy paper (PRSP) clearly identifies these lines of attack. What remains is the translation of these noble ideas into concrete implementable projects and programmes with the participation of all stakeholders.     

Poverty and child mortality in different contexts: can Mozambique learn from the decline in mortality at the turn of the 19th century in Stockholm?

Child mortality has declined in many low-income countries. However, in Sub-Saharan Africa, childhood mortality is still a major public health problem, which is worsening with some countries experiencing new increases in mortality due to HIV /AIDS. This lack of success in reducing child mortality is not only due to HIV /AIDS, but also to high numbers of deaths in other causes of death such as diarrhoea, pneumonia and neonatal causes, for which there are effective curative and preventative interventions. One problem seems to be in the access, coverage and implementation of these interventions, particularly among the poorer sections of the population. A related problem is the interventions that sometimes, when implemented, take place in environments in which they can only be expected to have limited effects. On the other hand in many developed countries infant and child mortality declined as social and economic changes of modernisation took place. However, the mechanisms that did bring about the decline are still not well understood. This paper discuss whether analyses of the historical decline of mortality in industrialised countries could contribute to knowledge in reducing the high child mortality in poor countries today, based on studies of child mortality in different social contexts in Mozambique 1973-1997 and Stockholm 1878-1925.     

Be our guest. Meals for people with HIV

Good nutrition is vital to people with HIV/AIDS, and four New York-based meal programs providing services to people with HIV are described. Each program's history, resources, and clientele served are discussed. An overview is provided of how the programs operate and how they have become more sophisticated since their inception, including health code compliance, menu planning, and food preparation. Social work and counseling services are also described. Final comments address what the future may hold for these programs.     

Scale-up of HIV treatment through PEPFAR: a historic public health achievement

Since its inception in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems.     

The 2004 International AIDS Conference and how to globally counter HIV/AIDS

This article reports noteworthy HIV/AIDS clinical trials presented at the XVth International AIDS Conference, Bangkok, July 2004, and also outlines goals of comprehensive prevention, care, treatment, and monitoring plans. The Bangkok conference theme was "Access for All." Outlined are goals of comprehensive prevention, care, and treatment programs: increased education and prevention efforts, greater involvement of national health authorities, reduction of new HIV infections, increased use of voluntary counseling and testing, increased acceptance and use of condoms, acceptance of an individual's right to be protected against HIV infection during sexual activity, increased support of NGOs, reduction of sexual partners, increased sexual fidelity, availability of antiretroviral medication, prevention of mother-to-child transmission, reduction of AIDS deaths, improved surveillance of sexually transmitted infections, improved blood supply security, increased coordination with tuberculosis and malaria treatment, equity for urban and rural persons, increased orphan services, reduction of orphan rate, greater involvement of local leaders, increased media involvement, reducing HIV/AIDS discussion taboo, reduced injecting drug user needle sharing, and continuing education for health care professionals. Monitoring parameters include incidence and prevalence of HIV infections, use of voluntary counseling and testing, condom use and attitudes to right of protection, AIDS deaths, orphan rate, public advertisements, leadership participation, antiretroviral use and availability, public awareness of services, blood supply security, and professional education.     

Strategies for greater impact in developing countries

Effective AIDS education programs are needed to prevent AIDS. They must integrate HIV/AIDS messages into basic health care services and adapted them to cultural norms and values. They should eliminate the mystery surrounding human sexuality. Effective AIDS education programs must examine control of communicable diseases and the relationship between gender issues and effective health care treatment. The infrastructure and resources to direct vertical HIV/AIDS programs generally do not exist in developing countries. All too often senior professionals accept positions in these vertical programs, which limits their ability to lobby for integrated HIV/AIDS programs. Donor organizations should make sure that all projects which they support have an AIDS component and work with other organizations to ensure that prevention and control of sexually transmitted diseases (STD)/HIV/AIDS is completely integrated into health care delivery services. All health workers should undergo AIDS prevention and control training. Supervisors should make sure that subordinates practice AIDS control. Benefit packages should not be offered to attract health workers. Just because nationals may make up an information, education, and communication (IEC) program does not mean that they will adapt the program to cultural values. Donors must provide appropriate educational strategies and programs to developing countries. Social change evolves from the culture. Health care workers must help find culturally appropriate education strategies. IEC has not reached its objectives in prevention and control of STDs. Communication mechanisms that allow human sexuality to be a subject of every day discussion without causing embarrassment, uneasiness, and outrage are needed.     

Examining geographic and temporal variations of AIDS mortality: evidence of racial disparities

BACKGROUND: There is little literature on spatiotemporal trends of AIDS mortality among different race and gender groups. The purpose of the present study is to describe AIDS mortality geographically and temporally, and to determine if detected trends vary by race and gender. METHODS: The Spatial Scan Statistic was employed to examine the geographic excess of AIDS mortality by race and gender in 24 Maryland jurisdictions between 1987 and 2003. Spatial analysis was conducted to identify clusters of excess mortality. The temporal scan statistic was used to explore time trends of AIDS mortality. Prospective space-time analysis was also conducted to verify if detected clusters persisted into the present. RESULTS: Among 10,887 AIDS deaths, 77.5% occurred in African Americans. Geographic excesses of AIDS mortality were detected in Baltimore city, and Howard, Montgomery, Anne Arundel, Prince Georges and Baltimore counties. Over the study period, AIDS mortality peaked in 1995 and then sharply dropped until 1998, when it stabilized. However, the AIDS mortality of African-American women started oscillating upward in 1998. CONCLUSION: This study quantitatively described geographic and temporal variations of AIDS mortality in Maryland by gender and racial groups. The results may inform development of programs to address HIV/AIDS while considering the groups most affected differentially by geographic area.     

A public health approach to rapid scale-up of antiretroviral treatment in Malawi during 2004-2006

BACKGROUND: Approximately 1 million people are infected with HIV in Malawi, where AIDS is the leading cause of death in adults. By December 31, 2007, more than 141,000 patients were initiated on antiretroviral treatment (ART) by use of a public health approach to scale up HIV services. METHODS: We analyzed national quarterly and longitudinal cohort data from October 2004 to December 2006 to examine trends in characteristics of patients initiating ART, end-of-quarter clinical outcomes, and 6- and 12-month survival probability. FINDINGS: During a 27-month period, 72,666 patients were initiated on ART, of whom about two-thirds were women. The percentage of patients initiated on ART who were children and farmers increased from 5.5% to 9.0% and 23% to 32%, respectively (P < 0.001 for trends). Estimated survival probability ranged from 85% to 88% at 6 months and 81% to 84% at 12 months on ART. INTERPRETATION: In Malawi, a public health approach to ART increased treatment access and maintained high 6- and 12-month survival. Resource-limited countries scaling up ART programs may benefit from this approach of simplified clinical decision making, standardized ART regimens, nonphysician care, limited laboratory support, and centralized monitoring and evaluation.     

PEPFAR's evolving HIV prevention approaches for key populations--people who inject drugs, men who have sex with men, and sex workers: progress, challenges, and opportunities

In most countries, the burden of HIV among people who inject drugs, men who have sex with men, and sex workers is disproportionately high compared with that in the general population. Meanwhile, coverage rates of effective interventions among those key populations (KPs) are extremely low, despite a strong evidence base about the effectiveness of currently available interventions. In its first decade, President's Emergency Plan for AIDS Relief (PEPFAR) is making progress in responding to HIV/AIDS, its risk factors, and the needs of KPs. Recent surveillance, surveys, and size estimation activities are helping PEPFAR country programs better estimate the HIV disease burden, understand risk behavior trends, and determine coverage and resources required for appropriate scale-up of services for KPs. To expand country planning of programs to further reduce HIV burden and increase coverage among KPs, PEPFAR has developed a strategy consisting of technical documents on the prevention of HIV among people who inject drugs (July 2010) and prevention of HIV among men who have sex with men (May 2011), linked with regional meetings and assistance visits to guide the adoption and scale-up of comprehensive packages of evidence-based prevention services for KPs. The implementation and scaling up of available and targeted interventions adapted for KPs are important steps in gaining better control over the spread and impact of HIV/AIDS among these populations.     

Integrating Human Immunodeficiency Virus and Reproductive,Maternal and Child,and Tuberculosis Health Services Within National Health Systems

Joint United Nations Programme on HIV/AIDS (UNAIDS) established 90–90–90 HIV treatment targets for 2020 including the following: 90 % of HIV-infected people know their HIV status, 90 % of HIV-infected people who know their status are on treatment, and 90 % of people on HIV treatment have a suppressed viral load. Integration of HIV and other programs into the national health system provides an important pathway to reach those targets. We examine the case for integrating HIV and other health services to ensure sustainability and improve health outcomes within national health systems. In this non-systematic review, we examined recent studies on integrating HIV, tuberculosis (TB), maternal-child health (MCH), and sexually transmitted infection (STI) programs. Existing evidence is limited about the effectiveness of integration of HIV and other services. Most studies found that service integration increased uptake of services, but evidence is mixed about the effect on health outcomes or quality of health services. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. Research on how best to maximize benefits, including sustainability, of integrated services is necessary to help inform international and national policy. We recommend additional interventions to test how best to integrate HIV and MCH services, HIV and TB services, HIV testing and treatment, and STI testing and treatment.     

Building a durable response to HIV/AIDS: implications for health systems

The remarkable rise in investments for HIV control programs in 2003-2010 enabled an unprecedented expansion of access to HIV services in low-income and middle-income countries. By the end of 2010, more than 5.2 million people were receiving antiretroviral therapy (ART), which transformed HIV infection, once a death sentence, into a long-term illness. The rapid expansion in the number of persons receiving ART means that health systems must continue to provide acute life-saving care for those with advanced HIV/AIDS although also providing chronic care services to expanding cohorts of more stable patients who are doing well on ART. This expansion also means a transition from an emergency response to the epidemic, characterized by a public health approach, to a more integrated and durable approach to HIV prevention, care, and treatment services that fosters individualized care for those requiring long-term antiretroviral treatment. Yet most low-income and middle-income countries, which have weak health systems, are poorly prepared to make this transition. In this article, we highlight the challenges health systems face in developing a sustained and durable response to HIV/AIDS. The article analyses the readiness of health systems to combine rapid expansion of ART access with long-term treatment and continuity of care for a growing cohort of patients. We argue that effective management of a transition from an emergency AIDS response to long-term programatic strategies will require a paradigm shift that enables leveraging investments in HIV to build sustainable health systems for managing large cohorts of patients receiving ART although meeting the immediate needs of those who remain without access to HIV treatment and care.     

AIDS in Africa: a public health priority

AIDS and HIV infection are now endemic in many parts of Africa. The infection is mainly transmitted by heterosexual activity, as illustrated by a 1:1 female to male case ratio and high HIV seroprevalence rates in people at risk for sexually transmitted diseases and female prostitutes. Transmission by blood transfusions, contaminated injections and from mother to child is occurring more frequently than in Europe. AIDS will probably have a profound impact on health care programmes and economic development in the continent, and its control should be a public health priority.     

AIDS and racism in America.

Institutionalized racism affects general health care as well as acquired immunodeficiency syndrome (AIDS) health intervention and services in minority communities. The overrepresentation of minorities in various disease categories, including AIDS, is partially related to racism. The national response to the AIDS epidemic in minority communities has been slow, showing an insensitivity to ethnic diversity in prevention efforts and AIDS health services.     

What's care got to do with it? Responding to the AIDS pandemic

In some regions of Mali, 20% of the adult population is estimated to be infected with HIV. However, despite such a high prevalence of infection, only a limited effort has been mounted to provide HIV/AIDS care and treatment programs in the country. The US Agency for International Development (USAID) gives several million dollars annually to AIDS prevention efforts in Mali, making it the largest contributor to HIV/AIDS-related programs in the country. Half of USAID funds are channeled through private voluntary organizations such as Plan International, Africare, and World Vision. USAID's current mandate allows the provision of funds solely for HIV/AIDS prevention education and condom social marketing. Care and treatment cannot be funded. Caring for and supporting those infected with HIV, however, is a key element in the fight to control the spread of HIV. Addressing HIV/AIDS demands a prevention-to-care continuum which includes prevention as well as medical care, traditional care, nursing care, counseling, and social support services. USAID's global HIV/AIDS efforts will implement care strategies as formal complements of their objectives beginning in 1997.