Gender inequalities explain why prevention is failing to contain HIV infection among young women in East and Southern Africa. UNAIDS calls for a major effort to reduce their risk of infection. Credit: Mercedes Sayagues/IPS

By Miriam Gathigah
NAIROBI, Nov 7 2014 (IPS)

Experts are raising alarm that years of HIV interventions throughout Africa have failed to stop infection among young women 15 to 24 years old.

“Prevention is failing for young women,” says Lillian Mworeko, HIV expert with International Community of Women Living with HIV in Eastern Africa, based in Uganda.

Among women in East and Southern Africa, four out of ten new HIV infections among women aged 15 years and over happen among  those aged 15 to 24, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Worryingly, HIV infection rates among young women are double or triple those of their male peers. In South Africa, the HIV prevalence of 18 percent among women aged 20-24 is three times higher than in men of the same age. 

Equally alarming are surveys showing that fewer than two in ten young women know their HIV status.

Experts attribute this high HIV prevalence to gender inequalities, violence against women, limited access to health care, education and jobs, and health systems that do not address the needs of youth.

Biology does not help. Teenage girls’ immature genital tract is more prone to abrasions during sex, opening entry points for the virus, Dr Milly Muchai told IPS.

Muchai, a reproductive health expert in Kenya, says it is not just sex that drives HIV infections among young women but the age of the male sexual partner.

“The risk increases steadily with male partners aged 20 years and over,” she explains.

Older men are more likely to have HIV than teenage boys. The Kenya AIDS Indicator Survey 2012 shows that male HIV prevalence remains low and stable until the age of 24, when it shoots up significantly.

Due to intergenerational sex, women in this region are acquiring HIV five to seven years earlier than men, says Muchai, because these relationships are characterised by multiple sexual partners and low condom use. In transactional sex, the young woman receiving gifts or money loses power to negotiate safe sex.

But Kenya is not a unique scenario.

Shocking figures

In Swaziland, Lesotho and Botswana, more than one in 10 females aged 15 to 24 are living with HIV, according to UNAIDS.

Dr Gang Sun, UNAIDS country director in Botswana, says that, in spite of the country’s remarkable progress in reduction of new infections and treatment, HIV is still a girls’ and women’s epidemic due to gender inequality and unequal power dynamics.

Among Batswana youth aged 20 to 24 years, HIV infection among women triples that of men, nearly 15 percent compared to 5 percent, he says.

Mary Pat Kieffer, senior director at Elizabeth Glaser Paediatric AIDS Foundation in Malawi, told IPS that as teenage girls become older, the risk of infection rises.

In Swaziland, HIV prevalence is six percent for girls aged 15 to 17 but rises to a whopping 43 percent by age 24.

Source: UNICEF

A package of interventions

Kieffer says that many of the issues – poverty, lack of secondary education, few jobs, rape and intimate partner violence – that underpin the unacceptably high HIV prevalence among young women are bigger than what HIV programs alone can address.

Mworeko observes major gaps in reproductive and sexual health services for young people, when they are neither children nor adults, in the region.

“Whether it is prevention, treatment, care and support services, young people do not have a youth friendly corner,” she says.

Paska Kinuthia, youth officer with UNAIDS in South Africa, told IPS that sexuality education needs to be strengthened in schools across the region.

“The regional average of comprehensive knowledge of HIV and AIDS stands at 41 percent for young men and 33 percent for young women,” he says.

Experts agree there is no one single solution to protect young women and a combination of interventions is needed.

Addressing restrictive laws on the age of consent for HIV testing and for access to sexual and reproductive health services would be a good place to start, experts say.

Promoting gender equality and providing jobs for young people are part of the solution, says Sun.

In Tanzania, HIV infection among girls more than triples between 15-19 and 20-24 years.

This fact, says Allison Jenkins, chief of HIV/AIDS with the United Nations Children’s Fund in Dar es Salaam, underlines “the importance of orienting HIV prevention and economic livelihoods interventions during her transition to adulthood.”

For all these reasons, UNAIDS is calling for “a major movement to protect adolescent girls and young women from HIV infection.”

Edited by: Mercedes Sayagues

Testing, treating and suppressing viral load in massive numbers could curb the spread of AIDS by 2020. Credit: Mercedes Sayagues/IPS

By Miriam Gathigah
NAIROBI, Oct 17 2014 (IPS)

Although AIDS has defied science by killing millions of people throughout Africa in the last three decades, HIV experts now believe that they have found the magic numbers to end AIDS as a public health threat in 15 years.

The magic numbers are 90-90-90 and are informed by growing clinical evidence showing that HIV treatment equals prevention because putting people on antiretroviral therapy (ART) reduces new infections.

The new treatment targets seek that, by 2020:

• 90 percent of people living with HIV get diagnosed
• 90 percent of people diagnosed with HIV will be on ART
• 90 percent of people on ART achieve durable viral suppression

The 90-90-90 plan, unveiled by the Joint United Nations Programme on HIV/AIDS (UNAIDS) earlier this year, seeks to halt the spread of HIV by 2020 and to end the epidemic by 2030.

While this is the most ambitious strategy to eliminate HIV yet, experts such as Dr Lucy Matu, director of technical services at the Elizabeth Glaser Paediatric AIDS Foundation in Kenya, says that it can be done.

She told IPS that in Kenya 72 percent of the estimated total number of people living with HIV have been tested, and 76 percent of the 880,000 adults and children diagnosed with HIV were on ART by April 2014.

Kenya will get closer to the 90-90-90 target as it implements the 2013 World Health Organisation (WHO) guidelines, which increased the CD4 count threshold to start ART from 350 to 500, says Matu.

As eligibility for ART becomes broader, she explains, “it will push the number of people on ART up by at least 250,000 to 300,000 to at least 90 percent of those in care, and of course more people will continue to enroll in care.”

An attainable goal

The WHO guidelines build on the clinical benefits of starting ART earlier. Patients stay healthier and avoid opportunistic infections, such as pneumonia, meningitis and TB.

Kenya is not the only country on track to achieving the ambitious 90-90-90 targets. In Botswana, which has a very high adult HIV prevalence, surpassed only by Swaziland globally, more than 70 percent of people living with HIV are on ART.

All East and Southern African countries are adopting the new guidelines, says Dr Eleanor Gouws-Williams, senior strategic information adviser with UNAIDS.

Rwanda, Uganda, Zambia, Malawi and Swaziland are “finalising their national guidelines while others like South Africa are planning to implement the new guidelines next year,” she told IPS.

Gouws-Williams believes that the 90-90-90 plan is attainable.

90-90-90: the formula that experts believe could write the final chapter on AIDS in 15 years. Courtesy: UNAIDS

Testing is the first step

Only half of all people living with HIV in sub-Saharan Africa have been diagnosed, says UNAIDS, so getting them to test is the first step.

Studies in Kenya and Uganda show that including HIV testing in multi-disease campaigns drove coverage up by 86 percent and 72 percent respectively.

But experts caution that the targets are more than putting loads of people on ART. Attaining viral suppression is key.

“In Rwanda, 83 percent of people receiving ART were found to be virally suppressed after 18 months of therapy,” says Gouws-Williams.

In Zimbabwe, Dr Agnes Mahomva, country director for the Elizabeth Glaser Paediatric AIDS Foundation, told IPS that 90-90-90 is not too ambitious for the Southern African country.

Already, she told IPS, “HIV positive pregnant and breast feeding mothers are universally eligible for ART for life as well as HIV positive children below five years, regardless of their CD4 count.”

While many experts are optimistic that 90-90-90 targets will be met, Ugandan HIV activist Annabel Nkunda says the targets do not necessarily speak to each other.

Nkunda told IPS that many HIV positive people, “when put on treatment, do not adhere to the treatment because of stigma.”

Without a specific target to reduce stigma, she says, “no amount of intervention will get us to zero HIV/AIDS.”

But some experts like Dr Matu disagree: “If you know your status, you are more likely to be put on HIV care. If you are on ART, you are more likely to stay within the health system for follow up.”

Finding funding

While it is still too early to estimate how much countries will spend to make 90-90-90 work, the consensus is that a lot of resources will be needed. Already, some African countries are exploring innovative financing options such as AIDS tax levies and national HIV trust funds.

Gouws-Williams points out that ART has become far more affordable. In Malawi, it costs less than 100 dollars per person per year.

Nonetheless, donor assistance will still be critical, especially for five poor countries where HIV treatment costs exceed five percent of gross domestic product (GDP) – Malawi, Lesotho, Zimbabwe, Mozambique and Burundi.

Matu says that achieving 90-90-90 requires a combination of factors, including a robust health system, good laboratory capabilities, cheaper viral load testing and a strong health work force.

Mahomva adds that a strong community component is needed, “because this is where several bottlenecks such as stigma happen, compromising adherence to HIV treatment.”

In spite of the uphill task ahead, many are optimistic that 90-90-90 will write the final chapter of the AIDS epidemic.

Edited by: Mercedes Sayagues

By Amy Fallon
KAMPALA, May 7 2014 (IPS)

Every morning at six a.m. before he goes to school, and every night at six p.m. after he gets home from school, Emmanuel, 11, knows what he must do: take his antiretroviral pills.

“They are very sour,” says the shy and gentle boy, who was born with HIV and is cared for by his elderly grandmother, his parents having died from AIDS when he was one year old.

“But I don’t mind taking the medicine. I’m used to it now,” he told IPS.

Emmanuel may be taking his medicine properly, but for many of the 35,500 children in Uganda on HIV treatment, daily ARVs are too much of a bitter pill to swallow, especially if they don’t understand why they need them.

Healing hug: Counsellor Cathy Kakande empowers HIV-positive children with medicine, information and lots of love. Credit: Amy Fallon/IPS

The Young Lives study presented by Ugandan researcher Rachel Kuwuma at a conference in Cape Town in December found that not knowing why they needed medicine was a big reason for non-adherence in young people.

“At first I didn’t know why I was taking drugs and didn’t put much effort into it so sometimes I would just throw it away…in the toilet,” Mika, 11, is quoted in the research, which looked at HIV-positive children in Uganda and Zimbabwe over two years.

In Uganda, in 2012, just one in three children who needed ARVs received them, according to United Nations data.

Cathy Kakande works for Namugongo Fund for Special Children, a Ugandan group providing Emmanuel with the drugs for free. She is also a counsellor to the boy and his grandmother. Kakande told IPS that Uganda’s policy is not to reveal their HIV status to children until they reach 13 years of age.

“We told Emmanuel ‘this is your life, so if you don’t take the medicine you’ll die’,” says Kakande. “He takes it because he’s supposed to.”

But children will be children, and Dr. Edward Bitarakwate, the Uganda director of Elizabeth Glaser Paediatric AIDS Foundation, says not knowing can lead to a child refusing to co-operate.

“Some types of medicine taste horrible and if you’ve not told the child that they have a chronic condition that needs to be treated, that can be a problem,” he says.

Some children living with HIV are told by their carers they have tuberculosis (TB) and other diseases.

“The child is, like, ’man, this TB, I’ve read about it, I can’t have TB for five years,'” Bitarakwate tells IPS.

In Uganda, like in many other African countries deeply impacted by AIDS, children’s drug taking is commonly mediated through carers. If a parent, sibling or guardian is discriminated against or fearful of being shunned for being HIV-positive or having an HIV-positive child, they may be reluctant to give ARVs or not be open about it.

This is but one of many reasons why the scale-up of ARV treatment in Africa is leaving children behind. In 21 high-burden African countries, only 34 percent of eligible children received ARV therapy compared to 68 percent of adults.

“Some mums don’t want to be seen carrying a shopping bag full of medicines,” says Bitarakwate.

It is worse when the child acquired HIV from the parents, he says: “There’s that guilt.”

Like the virus, self-stigmatisation can be transmitted: “The child grows up and finds out ‘I’ve got this terrible disease and my parents won’t even tell me about because it’s a bad thing’,” says Bitarakwate.

Emmanuel’s grandmother fears telling her neighbours near the Kampala house she rents about her HIV-positive grandson, says Kakande.

Not only is she scared, she’s also burdened financially. “She earns just 800 Ugandan shillings (less than a dollar) a day from selling sugarcane and struggles to pay the rent,” says Kakande.“They have only one meal a day. Sometimes Emmanuel takes his medicine just with water.”

ARVS on an empty stomach can cause nausea. Lack of food is listed as one reason why children don’t take drugs in the Young Lives study.

Other factors are not knowing the reason, fear of being seen by others, fear of being scolded, failure to meet expectations of adults, and loss of hope in life among children repeatedly ill.

The study concluded that adherence problems in children were commonly shaped by their social context and implicate their carers.

Waiting for a miracle

“One very, very common challenge” that this and other research ignore is the influence of Uganda’s born-again, Pentecostal churches, says Jacquelyne Alesi, programme director of the Uganda Network of Young People Living with HIV/AIDS.

“We’ve lost over 10 kids that way,” Alesi tells IPS. “They stopped asking for medicine because they believed they were going to be prayed for and they were going to be healed.”

Emmanuel has two more years until he officially learns that he has HIV.

“When we disclose their status, they [children] may segregate themselves,” says Kakande. “It’s our role to empower them. But for young positives, this is really very difficult.”

Dr Solomie Jebessa, a senior technical advisor at the African Network for Care of Children Affected by HIV/AIDS (ANECCA), says the consequences of children not taking their medicine properly can be fatal because the disease progresses much faster in children compared to adults.

“We’re losing a lot of children before getting them into the healthcare system,” she tells IPS.

Stigma can be equally, if not more devastating than the virus, says Dr Jebessa, who has worked with HIV-positive children in Uganda and Ethiopia.

From her experience, school clubs and activities where young people facing the same challenges can interact are crucial.

“There is a high need for organised psycho-social care in Africa,” she says. “A lot has to be done to make these kids comfortable at school and at the community level.”

Excerpt:

Soon parents in rural Kenya will be able to receive the HIV tests results of their infants as soon as the relevant blood tests have been done. Credit: Isaiah Esipisu/IPS

By Isaiah Esipisu
NAIROBI, Feb 20 2012 (IPS)

Jesse Mtembe, a nursing officer at the Akithenesit Health Centre in Teso North, in Kenya’s Western Province, cannot wait for his centre to be connected to a new software system for diagnosing HIV in infants that is being developed in the country’s leading private university.

Soon Mtembe’s patients will be able to receive the HIV tests results of their infants as soon as the relevant blood tests have been conducted at one of the country’s central laboratories some 200 kilometres away. Currently parents in rural health centres wait up to 18 weeks for the blood test results.

Since 2011, students at Kenya’s Strathmore University have been developing and refining software of infant HIV diagnosis. The software has been implemented in 75 health centres in the remotest parts of the country as part of first phase trials.

The software seems simple enough. Once blood samples arrive at one of the country’s four central Kenya Medical Research Institute (KEMRI) Centre for Disease Control and Prevention (CDC) laboratories all samples are logged into the system. Once this is done, the software automatically generates a short message service (SMS) to the rural health centre the sample was sent from to confirm receipt.

Once diagnosis has been completed, the system generates another SMS to confirm this, and if the result is negative, the results are also given. Results are received in rural areas on SMS printers and parents are notified by the clinic that their results are ready.

“On the SMS printers that we have already installed in rural clinics, we only send negative results in real time. This is because as a policy, all positive results on the polymerase chain reaction (PCR) equipment have to be re-run for confirmation in order to avoid false positives that might be due to contamination,” said Oscar Mulondanome a lab technologist at the Alupe Centre, one of the country’s testing laboratories.

Unlike other HIV testing methods such as rapid tests, where a patient receives the results after a few minutes, testing for the virus in infants requires the PCR technique, which is used to amplify the genetic make-up (or DNA) of a single or a few HIV viruses.

In Kenya, early diagnosis in infants is conducted with the support of the National Aids and STIs Control Programme and the United States Army Medical Research Unit. The project is being funded by the Clinton Health Access Initiative.

“The database application has allowed real time analysis of data generated for active interventions and has a wide geographical coverage,” Silvia Kadima, a research scientist at the KEMRI HIV laboratory, told IPS.

“We are projecting that by April this year, the software tool will be customised to Kenya’s local needs, and that is when it will be officially launched and rolled out by the government,” said Kadima.

She said that 50 more facilities would be connected for further trial phases before the product is officially rolled later this year. Kenya has a total of 904 listed public health centres all over the country.

The system is a welcome relief to far-flung places like the Akithenesit Health Centre.

“Given the location of our health centre in a remote area, we have to rely on lifts offered by officers from the nearby military camp to transport the samples to (the Alupe Hopsital in Busia) some 200 kilometres away, where there is an infant HIV testing centre,” Mtembe said.

It is a journey that takes a minimum of 10 hours because of the poor state of the road.

“After a few months, we then go through the same route to collect the results. And if they are not ready, then we have to organise another trip on another day,” said Mtembe, who is also head of the centre, which only has three nurses.

However, in Kitui County in Eastern Province, residents say they are already experiencing the impact of the system.

“For my first two babies, I received their HIV test results 18 weeks after the blood sample had been collected, and this was given during the routine postnatal clinic visits. But for my third born, I received an SMS on my phone five days after the sample collection, asking me to collect the results,” said Elizabeth Mwende a resident of Mutomo village in Kitui.

The 17-week difference in receiving an infant’s HIV results is key to effective treatment.

“Diagnosis of infants within six weeks of birth allows timely initiation of anti-retroviral therapy (ART) of children below two-years-old and can save lives. Without ART, up to 50 percent of children who acquired the virus from their mothers, would usually die before the age of two,” said Dr. Lucy Matu of the Elizabeth Glaser Pediatric AIDS Foundation.

“Early infant diagnosis allows for early and timely intervention. If a kid from an HIV-positive mother turns out to be negative, then proper preventive measures will be put in place to ensure that they do not acquire the virus at all,” added the Prevention of Mother-to-Child Transmission adviser at the foundation.

(END/2012)