tag:blogger.com,1999:blog-52028867455110947802024-03-13T06:33:20.048-07:00AIDS - HIVInformation about HIV infection, testing, prevention and treatment, plus pages about AIDS in specific countries, statistics, and personal stories...Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.comBlogger38125tag:blogger.com,1999:blog-5202886745511094780.post-40166243225512241312010-07-07T07:53:00.000-07:002010-07-07T07:53:13.033-07:00Alternative, complementary and traditional medicine and HIV<div class="box bFull"> Alternative and complementary medicine is quite popular among people living with HIV. For example, around a half of HIV positive Americans report recent use.<sup>1</sup> Many HIV positive people say they feel better after using alternative and complementary medicine, and it is likely that some of these treatments are indeed beneficial, although unproven according to conventional Western medicine.<br />
</div><div class="box bFull"> <h2>What are alternative and complementary medicines?</h2>Alternative and complementary medicine is the name generally given to those medical and health care systems, practices, and products that are not presently considered to be part of conventional Western medicine. Well known examples include herbal and other nutritional supplements, acupuncture, aromatherapy and homeopathy.<br />
<ul><li>Alternative medicine is used in place of conventional medicine</li>
<li>Complementary medicine is used together with conventional medicine.</li>
</ul>The more ancient forms of complementary and alternative medicine are also known as traditional medicine.<br />
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<h2>What are these therapies used for?</h2><div class="photo_r"> <img alt="Aromatherapy blends" border="0" src="http://www.avert.org/media/photos/2423.jpg" width="300" /> <div style="width: 300px;">Aromatherapy blends</div></div>In relation to HIV, <i>alternative </i>therapies are most commonly used in areas where it is difficult to access Western medicine. In the absence of antiretroviral treatment, people seek other ways to delay the onset of AIDS, or to treat opportunistic infections. In sub-Saharan Africa, for example, traditional healers outnumber medically qualified doctors eighty-to-one.<sup>2</sup> Traditional healers also usually provide immediate treatment, whereas clinics may have lengthy waiting lists and tests for eligibility.<br />
Most people living with HIV in developed countries have ready access to antiretroviral therapy and conventional treatments for opportunistic infections. Because these treatments are so effective, there is less demand for alternative HIV medicine, except perhaps for addressing relatively minor infections, or when antiretroviral treatment cannot any longer be taken, for example because of drug resistance. Many instead look to <i>complementary </i>medicine as a way to prevent or relieve aids treatment side effects, some of which are not easily treatable with conventional medicine. There is also demand for complementary therapies that might boost immunity, relieve stress, or improve general health and wellbeing.<br />
The people who distrust and avoid Western medicine for HIV include not only individuals, but also some governments. For example, senior politicians in South Africa have promoted unproven therapies while at times disparaging antiretroviral drugs. In Gambia, the president himself has treated patients with a herbal mixture he claims is an AIDS cure.<br />
<h2>Do alternative and complementary therapies for HIV and AIDS work?</h2>Western medicine embraces all approaches shown to be safe and effective in rigorous scientific trials. By definition, complementary and alternative medicine consists of therapies that are unproven, at least by the standards of Western medicine. Given the many therapies in existence, there can be little doubt that some of them do what they are supposed to. Many others are likely to be ineffective or can even be harmful. In the absence of good scientific trials, it is impossible to be certain which is which.<br />
<div class="photo_l"> <img alt="Acupuncture" border="0" src="http://www.avert.org/media/photos/2424.jpg" width="250" /> <div style="width: 250px;">Acupuncture</div></div>Still it can be argued that, from a scientific point of view, some things are more likely to work than others. Acupuncture, for example, appears to alter brain activity,<sup>3</sup> and there is quite good evidence that it can help relieve post-operative nausea.<sup>4</sup> <sup>5</sup> Herbal medicines, too, are scientifically plausible: some 25% of modern drugs were derived from plants first used traditionally.<sup>6</sup> Scientists have already identified one plant extract that acts like an antiretroviral drug;<sup>7</sup> it is entirely possible that there are others.<br />
At the other end of the scale are therapies that seem to defy the known laws of science. The most notorious of these is homeopathy, which few scientists see as credible and the World Health Organization recommends should not be used to treat HIV.<sup>8</sup> Homeopathic remedies are so diluted that none of the active ingredient remains.<br />
Yet even if a medicine has no specific effects on an illness, this doesn’t necessarily mean it is worse than nothing. It is widely accepted that patients’ beliefs about a treatment, and the quality of the doctor-patient relationship, can influence health outcomes. This is what is known as the placebo effect. For example, one trial<sup>9</sup> divided irritable bowel syndrome sufferers into three groups: the first received no treatment, the second underwent sham acupuncture (placebo), and the third got fake acupuncture plus a 45-minute consultation with a friendly doctor. The proportions of patients reporting moderate or substantial improvement were 3% (no treatment), 20% (placebo only) and 37% (placebo plus interaction). This effect may well account for some of the reported benefits of alternative and complementary medicine, as suggested in an editorial that accompanied the study:<br />
<blockquote class="longquote">“Is it possible that the alternative medical community has tended historically to understand something important about the experience of illness and the ritual of doctor-patient interactions that the rest of medicine might do well to hear? … The meanings and expectations created by the interactions of doctors and patients matter physically, not just subjectively.”<cite> <sup>10</sup></cite></blockquote>Even if it fails to ease symptoms, the treatment experience may have non-specific effects such as boosting self-confidence and relieving anxiety. Group therapies – such as yoga – are particularly good for meeting new people, who may be able to share knowledge of other treatment options.<br />
<h2>Why is there such a lack of evidence?</h2>Supporters of complementary and alternative medicine propose a number of reasons why their therapies have not been subjected to thorough testing. For one thing, major medical trials are highly expensive; if there is no prospect of a patent then there is less of an incentive to invest in research. Reliable, ethical trials also require a considerable amount of expertise. Many scientists with the necessary skills are reluctant to investigate therapies they think are implausible.<br />
Yet it is misleading to suggest that no research takes place. The US government has an agency (NCCAM) dedicated to complementary and alternative medicine, and in 2008 allocated nearly $300 million to this field (around 1% of all federal funding for medical research). Potential HIV therapies investigated in government-sponsored trials include acupuncture, yoga, Reiki and distant healing.<sup>11</sup><br />
Although practioners of complementary and alternative medicine generally voice support for scientific research, they are often unwilling to accept negative findings. In 2005, medical journal The Lancet published the most thorough review of homeopathy trials ever conducted.<sup>12</sup> Having analysed more than one hundred trials related to a wide range of illnesses, the authors concluded,<br />
<blockquote class="longquote">“there was no convincing evidence that homeopathy was superior to placebo.”</blockquote>Homeopaths united in objecting to the methodology of both the trials and the review. <sup>13</sup> Some even suggested that placebo-controlled randomised trials (regarded as the gold-standard of medical science) were inappropriate for testing their system of healing.<sup>14</sup><br />
<h2>Potential for harm</h2>Some forms of complementary and alternative medicine can cause harmful side effects. Words like “natural” and “traditional” are certainly no guarantee of safety.<br />
Herbal or nutritional therapies (notably St John’s Wort) may also interact with other medications, making them less effective or worsening their side effects.<br />
In general, herbal remedies and dietary supplements are not covered by the strict regulations that govern pharmaceutical drugs. Quality is inconsistent even among popular commercial formulations; tests have shown that the concentrations of active ingredients can vary greatly from the amounts listed on the packaging.<sup>15</sup><br />
The standard of complementary and alternative practioners is similarly uneven. Although some countries regulate certain types of practioners (such as osteopaths in the US and UK), many people practise without any formal qualifications.<br />
Even if a therapy carries little risk of direct physical harm, it may still turn out to be a waste of time and money. Relying on alternative medicine instead of scientifically proven treatment can have very serious consequences. Once HIV has severely weakened the immune system, antiretroviral drugs are less likely to be life-saving.<br />
<h2>Advice for those seeking complementary medicine</h2>HIV positive people have a long history of taking control of their own healthcare decision-making. Those interested in complementary medicine can take steps to maximise their chances of success.<br />
The Canadian AIDS Treatment Information Exchange (CATIE) suggests ten questions for assessing a new therapy:<sup>16</sup><br />
<ul><li>What am I hoping to get out of this therapy?</li>
<li>Do other HIV positive people use it?</li>
<li>Am I able to talk to any of these other people about their experiences?</li>
<li>Is there any research or additional information about this therapy?</li>
<li>What are the side effects, if any?</li>
<li>What sort of commitment do I have to make to use this treatment?</li>
<li>Where can I get this treatment, and will it be regularly available?</li>
<li>How much of this treatment is too much and what are the early signs of taking too much?</li>
<li>Does this treatment interact with anything else I’m taking?</li>
<li>How much does it cost?</li>
</ul>Careful research is needed to answer these questions. Good sources of information include reference books on complementary medicine (available in many libraries), medical journals (which can be searched using the PubMed website), and the publications of reputable health organisations. Many AIDS organisations and other bodies, including NCCAM, will answer enquiries over the phone or online.<br />
As already discussed, all forms of complementary medicine are unproven; each individual must make their own assessment of likely risks and benefits based on the available data. The most reliable evidence comes from large human trials – preferably randomised trials in which the treatment is compared to a placebo. Personal testimonies and laboratory findings should be given less weight, especially if they appear only in promotional material. Anyone who makes sensational claims (such as being able to cure many unrelated diseases with a single therapy), or who attacks conventional treatment, is probably a quack and best avoided.<br />
If you have done your research and wish to try a complementary therapy, the next step is to talk to your personal doctor or HIV specialist. This is important because there may be a risk of interactions with other medications.<br />
Some medical doctors have received training in complementary medicine. If your doctor lacks such expertise then it may be sensible to also find a complementary practioner, ideally one with experience in treating people with HIV. Help finding a practioner may be obtained from your doctor, an AIDS service organisation, or a professional body such as the Institute for Complementary Medicine in the UK, or the American Holistic Medical Association in the US. There are many practioners available; it is worth taking the time to find one you trust and feel comfortable with. Look for experience, qualifications and references you can verify.<br />
When purchasing a herbal medicine or nutritional supplement, try to choose a reputable seller and manufacturer. Large, long-established companies are generally the most trustworthy because they have more to lose from selling poor quality goods. If possible, look for a company that submits its products for independent quality testing.<br />
Having started a new treatment, it is a good idea to keep a diary of your symptoms. This will help you assess whether the therapy is having the desired outcome, or whether it may be causing unwanted side effects.<br />
<h2>List of common complementary and alternative therapies</h2>Complementary and alternative therapies can be divided into five main categories. The list below contains a few of the most popular examples.<br />
<b>Whole medical systems</b><br />
<ul><li>Naturopathic medicine (mostly practised in the West; includes diet modification, herbal medicine, acupuncture and massage)</li>
<li>Traditional Chinese medicine (includes herbal medicine, acupuncture and massage)</li>
<li>Ayurveda (ancient Indian healing system; includes diet modification, herbal medicine, cleansing therapies, massage, meditation and yoga)</li>
<li>Homeopathy (most commonly prescribes extremely diluted solutions of natural substances)</li>
</ul><b>Mind-body medicine</b><br />
<ul><li>Relaxation techniques, meditation and visualization</li>
<li>Spirituality and prayer</li>
<li>Yoga (may incorporate spirituality, meditation and body postures)</li>
<li>Tai Chi (a Chinese martial art incorporating meditation and breathing exercises)</li>
<li>Qi gong (includes meditation, body postures and breathing exercises)</li>
<li>Aromatherapy (uses remedies derived from plants that are inhaled, applied to the skin or used internally)</li>
</ul><b>Biologically based practices</b><br />
<ul><li>Vitamins and minerals</li>
<li>Herbal remedies</li>
<li>Animal-derived extracts</li>
<li>Prebiotics and probiotics (aim to encourage the growth of beneficial microbes)</li>
</ul><b>Manipulative and body-based practices</b><br />
<ul><li>Massage</li>
<li>Chiropractic (invented in America; manipulates the spine)</li>
<li>Osteopathy (invented in America; manipulates the spine, joints and muscles; American osteopathic physicians are also trained in conventional medicine)</li>
<li>Shiatsu (traditional form of Japanese massage therapy) </li>
<li>Reflexology (invented in America; applies pressure to the feet, hands or ears)</li>
<li>Rolfing (named after American Ida Pauline Rolf; manipulates soft tissue)</li>
</ul><b>Energy medicine</b><br />
<ul><li>Acupuncture (involves inserting fine needles into the body)</li>
<li>Reiki (practioners claim to channel healing energy through their palms)</li>
<li>Therapeutic touch and distant healing (practioners claim to manipulate energy “biofields” with their hands)</li>
<li>Bioelectromagnetic-based therapies (involve unconventional use of sound, light, magnetism, and other forms of electromagnetic radiation)</li>
</ul><h2>African traditional healers and HIV</h2><div class="photo_r"> <img alt="Traditional medicine for sale in Malawi" border="0" src="http://www.avert.org/media/photos/1647.jpg" width="300" /> <div style="width: 300px;">Traditional medicine for sale in Malawi</div></div>Sub-Saharan Africa is the region worst affected by AIDS; it is also a region in which most people turn first to traditional healers when they fall ill. There is potential for traditional healers to play an important role in responding to the epidemic.<br />
Although few have been scientifically tested, there can be little doubt that some of the remedies given by traditional healers are effective in treating HIV-related opportunistic infections and drug side effects. However, in common with all forms of medicine, these therapies may also do harm through side effects, drug interactions, or delaying use of conventional treatment. In addition, the reuse of implements for rituals such as scarification, tattooing and circumcision can transmit infections, including HIV. Some African healers blame illness on witchcraft, which can lead to ostracism of those accused.<br />
Collaboration between traditional healers and Western doctors has the potential to improve safety, for example by encouraging better hygiene. Training can also assist traditional healers in identifying illnesses beyond their capacity to treat, hastening referral to a clinic when necessary. In South Africa, The Traditional Health Practitioners Act includes a council to oversee and provide training to traditional health practitioners to protect the interests of the patient. As yet, the Act has not been fully enforced; there have been calls to implement the Act alongside a robust system of scientific testing of 'remedies'. <sup>17</sup><br />
Traditional healers are respected within their communities, and know how to convey health information in a culturally appropriate manner. They are ideally placed to teach HIV prevention, distribute condoms, conduct counselling, encourage HIV testing, and set up support groups for affected people.<br />
Yet although traditional healers are generally eager to learn from other health workers, experience has shown it is not easy to establish successful collaboration.<sup>18</sup> Traditional theories of disease causation are very different to those of Western science. Traditional healers – suppressed during the colonial era, and often demonised in the media – are understandably suspicious of authority. Many are reluctant to reveal details of their remedies for fear that their ideas will be stolen. Likewise, conventional doctors are inclined to be prejudiced against treatments that lack scientific foundation. These are not the only difficulties:<br />
<blockquote class="longquote">“How can healers give their clients a diagnosis of AIDS when it means possibly losing their business? How can a traditional healer – the traditional advocate of a clan’s fertility – counsel an HIV-positive woman who wants to have a child? And how can a traditional healer turn away a sick patient who has become dependent on his or her care and support?”<cite> <sup>19</sup></cite></blockquote>It may take months or even years to establish mutual trust, confidence and respect. Success depends on being sensitive to the local context, and cooperation must be on equal terms, regardless of level of education. Rather than trying to change traditional belief systems, research has shown it is better to stress what is common to both forms of medicine, and to establish a common language.<sup>20</sup><br />
The best way to maximise the reach of training is to first identify and train a group of the most influential and respected healers, who can each then train many others. This method, however, requires ongoing support if it is to be sustainable.<sup>21</sup><br />
Despite the challenges, a number of organisations – such as THETA in Uganda and TAWG in Tanzania – have demonstrated the benefits of collaborating with traditional healers in HIV prevention and care.<sup>22</sup> Much could be gained from replicating these programmes more widely.<br />
<br />
<div class="box bFull" id="footnote"> <h2>References</h2><ol><li>Hsiao A.F. et al (1 June 2003) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/12794548" target="blank">Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients</a>”, JAIDS 33(2)</li>
<li>Mills E. et al (17 June 2006) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16734953" target="blank">The challenges of involving traditional healers in HIV/AIDS care</a>” Int J STD & AIDS 17(6)</li>
<li>Lewith G.T. et al (September 2005) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16136210" target="blank">Investigating acupuncture using brain imaging techniques: the current state of play</a>” Evidence-based complementary and alternative medicine 2(3)</li>
<li>Lee A and Done M.L. (2004) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15266478" target="blank">Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting</a>” Cochrane Database of Systematic Reviews</li>
<li>Lee A et al (September 2006) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16895822" target="blank">Publication bias affected the estimate of postoperative nausea in an acupoint stimulation systematic review</a>” Journal of Clinical Epidemiology 59(9)</li>
<li>World Health Organisation (May 2003) “Fact Sheet No. 134: Traditional Medicine”</li>
<li>Eiznhamer D.A. et al (November-December 2002) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/12501127" target="blank">Safety and pharmacokinetic profile of multiple escalating doses of (+)-calanolide A, a naturally occurring nonnucleoside reverse transcriptase inhibitor, in healthy HIV-negative volunteers</a>” HIV Clinical Trials</li>
<li>Mashta, O (2009, 24th August), '<a ,="" href="http://www.bmj.com/cgi/content/extract/339/aug24_2/b3447" target="_blank">WHO warns against using homeopathy to treat serious diseases</a>' British Medical Journal 339(b3447).</li>
<li>Kaptchuk T.J. et al (3 May 2008) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18390493" target="blank">Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome</a>” BMJ 336(7651)</li>
<li>Spiegel D. and Harrington A. (3 May 2008) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18390494" target="blank">What is the placebo worth?</a>” BMJ 336(7651)</li>
<li>NCCAM: <a ,="" href="http://nccam.nih.gov/clinicaltrials/alltrials.htm" target="blank">All Clinical Trials</a></li>
<li>Shang A. et al (27 August 2005) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16125589" target="blank">Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy.</a>” Lancet 366(9487)</li>
<li>The Society of Homeopaths press release (19 September 2005) “Universal Condemnation for The Lancet's Stance on Homeopathy”</li>
<li>Chatfield K. and Relton C. (September 2005) “Are the clinical effects of homeopathy placebo effects? - A full critique of the article by Shang et al”</li>
<li>Harkey M.R. et al (June 2001) “<a ,="" href="http://www.ajcn.org/cgi/content/full/73/6/1101" target="blank">Variability in commercial ginseng products: an analysis of 25 preparations</a>” American Journal of Clinical Nutrition 73(6)</li>
<li>CATIE (2004) “<a ,="" href="http://www.catie.ca/comp_e.nsf/table+of+contents" target="blank">A Practical Guide to Complementary Therapies for People Living With HIV</a>”</li>
<li>TAC (Dec 2009) '<a ,="" href="http://www.tac.org.za/community/node/2784" target="_blank">Equal Treatment Magazine</a>'</li>
<li>Kayombo E.J. et al (26 January 2007) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/17257409" target="blank">Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania</a>” Journal of ethnobiology and ethnomedicine 3:6</li>
<li>UNAIDS (2000) “<a ,="" href="http://data.unaids.org/Publications/IRC-pub01/JC299-TradHeal_en.pdf" target="blank">Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa – A Literature Review</a>” [PDF]</li>
<li>UNAIDS (2006) “<a ,="" href="http://data.unaids.org/Publications/IRC-pub07/JC967-TradHealers_en.pdf" target="blank">Collaborating with Traditional Healers for HIV Prevention and Care in sub-Saharan Africa: suggestions for Programme Managers and Field Workers</a>” [PDF]</li>
<li>Mills E. et al (June 2006) “<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16734953" target="blank">The challenges of involving traditional healers in HIV/AIDS care</a>” Int J STD & AIDS 17(6)</li>
<li>UNAIDS (2000) “<a ,="" href="http://data.unaids.org/Publications/IRC-pub01/JC299-TradHeal_en.pdf" target="blank">Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa – A Literature Review</a>” [PDF]</li>
</ol></div><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-32035270592568451732010-07-07T07:42:00.000-07:002010-07-07T07:42:49.203-07:00AIDS: Fear and Anxiety<div class="box bFull"> This page is designed to help those who feel anxious about HIV and AIDS. It could be a fear that they are infected with HIV, or it could be a fear of being at risk of HIV infection.<br />
If the first section does not answer your worries then the idea is to keep on reading.<br />
</div><div class="box bFull"> <h2>Are you anxious or worried because you have been diagnosed HIV positive?</h2>Being diagnosed HIV positive can be devastating to have to deal with but it is not necessarily a death sentence, nor something you need to cope with on your own. Being anxious or fearful of having HIV and all that it entails is perfectly natural. Fear and anxiety are just a couple of many emotions you will inevitably feel, and both you will have to manage. How you respond to the feelings you will experience is a personal thing but it is not something that has to be done alone.<br />
There are many sources of help and advice available to people diagnosed with HIV and a good place to start would be looking at AVERT's pages on learning you are HIV positive.<br />
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<h2>Are you worried you <i>have</i> been infected?</h2>It can be perfectly natural to worry about HIV/AIDS. It is a virus that, given the right circumstances, can spread from one person to another. It is important however not to let natural worry or fear stop you from being rational about the reality of infection. HIV is a virus that cannot just appear from two people who do not have it. If you have been involved in an activity that is deemed risky or feel you may have been exposed to HIV then it is important to know how you can and cannot be infected. There are very specific ways of becoming infected and often many of the ways people think they have been infected are wrong.<br />
If you are worried you have been exposed to possible transmission then read our page on how you can and cannot be infected. This page will tell you clearly if you are at possible risk or not.<br />
<h2>Are you <i>still</i> worried you have been infected?</h2>If you have read the ways in which you can and cannot be infected then you should be able to work out whether or not you are genuinely at risk of having been infected. If it still all seems vague then take a look at our HIV symptoms page. Although there are no obvious symptoms of HIV this page may help in answering some of your worries.<br />
If you believe you are at risk from having been exposed to possible infection then it is very important you go and get tested.<br />
All the information you will need regarding testing can be found on our HIV testing page.<br />
<h2>Are you worried you could get infected?</h2>If you are someone who feels they are at risk of possible exposure to HIV then there is nothing wrong with having a healthy worry about the risks of transmission. It is likely that you either worry about exposure due to your personal lifestyle (you engage in unprotected sex or use intravenous drugs), or because you are exposed to blood through the nature of your job. Many people who work in the health sector or with ‘at risk’ groups worry about infection. Having this worry is a rational and totally logical worry and one that should not be ignored. If you are in a job where exposure to HIV is likely then make sure that not only your employer, but also you, take the appropriate measures to protect yourself against infection by employing the system of Universal Precautions.<br />
It is very common also for people to worry about infection through general contact in everyday life. There are always rumours and myths surrounding AIDS and it is important to remember that scenarios of deliberate infection are normally myths, often circulated on the Internet and made to look very legitimate. The problem with these myths is that no matter how much they are dismissed and exposed as hoaxes, the damage is done. The fear has already been instilled. It is extremely important to remember these are just myths though. They are not fact.<br />
For the people who have a genuine worry that they are at risk of potential exposure due to the nature of their job or personal lifestyle, take appropriate precautions and again be fully aware of how HIV can be transmitted.<br />
<h2>Do you have a constant fear of infection?</h2>It is not uncommon to be afraid and scared of being infected with HIV/AIDS and for many it can be very debilitating and can take over and control that person’s life. There are many reasons why HIV/AIDS can generate such a fear among people.<br />
AIDS is a relatively new disease that only came to the attention of scientists in the early 1980s. Because of this there is still much people don’t know about the nature of the virus. Lack of knowledge about anything is often a likely cause for worry in people. The media has also played its part with often sensationalist stories serving only to heighten people's fear and worry. It is very easy for the press to exacerbate the problem in order to create a good story. A combination of little actual fact and sensationalist story writing is a potent cocktail for creating fear.<br />
There also seems to be an assumption that only certain people get infected. It is true that the occurrence of HIV is higher amongst drug users and homosexuals, and these are groups that are often looked down on or stigmatised in some societies. Because of this an irrational fear can develop where a person believes the virus will be passed on if contact with anyone from these certain affected groups is made. An emotional assumption is then being made not based on any fact at all. People can also develop a fear through doing something that is often deemed bad or wrong, having sex with a prostitute for example, and that because of this they have been cursed or are now being punished in some way for doing something that through their own upbringing or culture is deemed unacceptable.<br />
If you do have a constant worry about being infected it may be best to get yourself tested. This should then settle your worries and reassure you. Look at our HIV testing page for more information.<br />
<h2>Are you convinced you will be infected or feel you are at constant risk of infection?</h2>If you are convinced that either you have been, or will be infected, despite what you have been told to the contrary, then it could be possible that your anxiety and fear of HIV is actually something that has nothing to do with HIV or AIDS.<br />
People who suffer from anxiety can often have persistent concerns about harm or risk to themselves. This is a type of anxiety disorder that can cause people to become obsessed with germs or dirt, and in some cases HIV. This can result in certain rituals such as repetitive hand washing or the need to check things repeatedly, like how you can and can’t become infected.<br />
If you think you might be in this situation then try speaking to your doctor about it.<br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-7538634409572172342010-07-07T07:35:00.000-07:002010-07-07T07:35:36.163-07:00Criminal transmission of HIV<div class="box bFull"> For the vast majority of people living with HIV, preventing others from becoming infected with the virus that they carry is a primary concern. HIV positive individuals are, after all, only too aware of just how difficult it can be to live with the illness, and few would wish it on anybody else.<br />
This said, not all HIV positive people take the precautions that they perhaps should. Scare stories of people 'deliberately' or 'recklessly' transmitting HIV to others have appeared in the media since the epidemic first began, and some of the individuals concerned have even been criminally charged and imprisoned for their actions. But while at first it might seem obvious to prosecute someone for recklessly or intentionally infecting another with an ultimately fatal virus, this assumption, and its consequences, can present numerous problems.<br />
So what are the issues that must be addressed when prosecuting someone for transmitting HIV? Is it right to try and criminalise HIV positive people in this way? And what can past cases teach us?<br />
</div><div class="box bFull"> <h2>Intentional, reckless or accidental?</h2>Before looking at the complexities of prosecuting people for infecting others with HIV, it is first necessary to understand the different types of transmission that can take place. The definitions below are based on general categories and are not specific to any particular country or legal system.<br />
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<h3>Intentional</h3>Intentional (or deliberate or wilful) transmission, is considered the most serious form of criminal transmission. Some cases have involved individuals (both HIV positive and HIV negative) who have used needles or other implements to intentionally infect others with HIV. Others have been based on HIV positive people who have had sex with the primary intent of transmitting the virus to their partner.<br />
Intentional transmission can also take place when a negative partner has an active desire to become infected with HIV. This is unlikely to lead to prosecution however, as both parties consent.<br />
<h3>Reckless</h3>This is where HIV is transmitted through a careless rather than deliberate act. If for example a person who knows they have HIV has unprotected sex with a negative person, but fails to inform them of the risk involved, this could be classed as reckless transmission in court. "Reckless" here implies that transmission took place as part of the pursuit of sexual gratification rather than because the HIV positive person intended to give their partner HIV (HIV is of course not 'automatically' transmitted every time someone has unprotected sex).<br />
<h3>Accidental</h3>This is the most common way that HIV is passed on. A person is generally said to have accidentally transmitted HIV if:<br />
<ul><li>They were unaware that they had the virus, and therefore did not feel the need to take measures to protect their partner.</li>
<li>They were aware of their HIV positive status and they used a condom during sex, but the condom failed in some way (although there is some debate over whether this should in fact be classed as a reckless act, as we shall see later).</li>
</ul><h2>The complexities of prosecution</h2>Unfortunately deciding if someone has intentionally, recklessly or accidentally transmitted HIV is not as simple as the explanations above may suggest. The divisions between each of the three categories can be very blurred, and depend largely on individual interpretation. Even after a decision has been made on what grounds to prosecute, a court may still have a hard time deciding whether to find someone guilty or not. Some of the most problematic issues include:<br />
<h3>Proof</h3>It might appear that proof is a straightforward issue, but proving that an individual has transmitted HIV can be exceedingly difficult.<br />
Firstly it needs to be proven that the accused (let's call them A) was definitely the source of the accuser's (B) HIV. This would involve a range of evidence including sexual history, testing history and scientific evidence in the form of phylogenetics. This compares the DNA of the virus that A and B are infected with (see the Richard D. Schmidt case study, below, for application in US courts). If they are completely different then it means B almost certainly did not acquire HIV from A, and the case would probably be thrown out. If the strains are very similar, however, it is possible, though not conclusive, that A infected B. Phylogenetics can not reliably estimate the direction of transmission and therefore it is possible that B infected A. Furthermore, both could have been infected by the same third party, or different third parties who shared similar strains of HIV. Due to its shortcomings, advocates recommend phylogenetic evidence should only be considered in the context of all other evidence.<br />
<div class="photo_l"><img alt="A diagram illustrating the pitfalls in the use of HIV phylogenetic analysis for forensic purposes" height="195" src="http://www.avert.org/media/content/diagrams/phylogenetic-analysis.jpg" width="400" /> <div style="width: 614px;">The different ways two people, 'A' and 'B', could be infected with similar HIV strains.</div></div>Often, the only definitive proof would be a negative test on B that was performed after A received a positive test. Even so, if the complainant had had multiple sexual partners, pinning responsibility on a particular individual could be very difficult.<br />
In cases where intentional transmission needs to be proven, evidence needs to be found that A actively intended and wanted to infect B. Unless there is physical proof of this (e.g. a syringe filled with HIV positive material, a note, or a written confession), it can often just be one person's word against another. With cases of sexual transmission, proving intention can be virtually impossible as the very nature of sexual HIV transmission means there are no witnesses: what happens in the bedroom is essentially private. If no evidence of intentional transmission could be found therefore, a charge of reckless or careless transmission would probably be chosen. Whether someone can be legally charged with reckless (as opposed to intentional) transmission depends entirely on an individual country's laws and courts. In some places there is no differentiation between the two.<br />
<h3>Consent and disclosure</h3>Almost all criminal convictions involving sexual transmission are brought about because an HIV positive person has failed to inform their negative partner about their status. In some cases, the positive person may have actively lied in response to a direct question in order to persuade their partner to have unprotected sex. In others, they may simply not have mentioned their status. A prosecution involving deception might carry a more severe penalty than a simple failure to disclose, because it affects a person's choice to consent to sex. But again, this depends on local laws.<br />
Consent is an important issue in all criminal prosecutions. If the accused had simply not mentioned they are HIV positive, then the prosecution would probably argue that they had been reckless by not disclosing their status and not informing their partner of the risks involved in intercourse. However, the defence could well counter this by saying that the balance of responsibility is 50:50, and that by agreeing to having unprotected sex, the ‘victim’ effectively consented to all the risks involved, including that of HIV. This argument was used in the appeal trial of Mohammed Dica, the first person in England to be accused of recklessly transmitting HIV (see below).<br />
If the accused had actively deceived their partner, and told them they were negative when they were not, then the prosecution could quite easily argue that the 50:50 balance of responsibility had been taken away, making the accused more liable to prosecution.<br />
The argument that non-disclosure equals guilt could potentially even be applied if the person on trial had used a condom. Some say that sex with a condom, but without disclosure of status should also count as reckless transmission. This is because condoms are not always 100% effective. If a condom fails, and an individual becomes infected with HIV, there is potential for that person to accuse their partner of being 'reckless' for having withheld information that may have influenced their decision to have sex.<br />
<h3>Assumed status and trust</h3><div class="photo_r"> <img alt="A New Zealand HIV prevention poster" border="0" src="http://www.avert.org/media/photos/309.jpg" width="300" /> <div style="width: 300px;">A New Zealand HIV prevention poster</div></div>Disclosing one's HIV status to an intimate partner can be extremely difficult. Many people have difficulty coming to terms with having HIV and remain in denial of their condition. The fear of rejection and stigma can also prevent people from being honest, particularly if they are worried about friends, colleagues or members of their family finding out. Likewise, asking about someone else's status can be hard because of the risk of offending them, or 'spoiling the moment'. In such circumstances, many people choose to make assumptions instead.<br />
Ironically, this is particularly true in high-prevalence areas or among high-risk groups where virtually everyone has heard of HIV. A positive person who engages in casual sex with a negative person may, for example, assume that by failing to suggest the use of a condom or failing to ask about status, the negative partner is either already positive themselves or does not care about the risks of HIV. Likewise, a negative person may assume that by not using a condom and not talking about status, their partner must be negative too:<br />
<blockquote class="longquote">“If she was HIV positive, she'd ask me to use a condom...” or “He's not using a condom, so he must be HIV positive, like me”</blockquote>There is also the issue of trust. Most would agree that a relationship can only work if both partners have faith in each other to be honest and truthful. But when one partner consistently lies or deceives the other, where does the blame lie - with the person who has been deceptive, or with the person who has been naive enough to trust them?<br />
<h3>Police investigations</h3>There have been cases in the UK (such as the Sarah Jane Porter case below) and abroad, where police have assumed that because HIV transmission can now be a criminal offence, it is acceptable to fully investigate any HIV positive person about whom they receive a complaint. In some cases, this will involve actively raiding the accused’s home for evidence of HIV positive status or demanding medical records from HIV clinics. Police have also been known to track down past partners to inform them of their risk, or even to persuade them to testify against the accused individual.<br />
How such activities fit in to national laws about privacy and confidentiality needs to be assessed very carefully, and HIV positive people need to be aware of their rights if ever they undergo such an investigation. It also needs to be made very clear who should be traced, which previous partners should be contacted, and how this should be done to ensure proper counselling and help is provided. Questions about whether anyone has the right to trace and contact previous partners if the person concerned does not give consent for this to happen also need to be addressed.<br />
<h3>Reasons for prosecuting</h3>Sometimes a lack of knowledge regarding HIV-associated risk and what a prosecution may entail could lead to someone making a formal complaint before they later realise it is not in their interest to do so. An impulsive overreaction upon being diagnosed, due to a misunderstanding of transmission risk, or acting out of vengeance against a former partner following a bad break-up, for example, could lead someone in the heat of the moment to try and take legal action. Poor advice by solicitors or, as mentioned, police may encourage a complainant to believe they have a solid case when it is unlikely to lead to conviction. Furthermore, they may later doubt that the defendant was the source of their infection. Complainants may also be led to believe they are entitled to complete anonymity only to find their entire sexual history dragged publicly through the courts in a case that was unlikely to end in conviction anyway.<br />
<h2>Criminal prosecution: right or wrong?</h2>Given the ambiguities and difficulties outlined above, it is apparent that any form of legislation on the issue needs to be clear about what forms of transmission are and are not covered. There are generally three broad schools of thought on how this should work:<br />
<h3>No criminalisation at all</h3>A few people argue that criminal charges should never be brought for transmitting HIV, no matter what the circumstances. HIV is a virus that acts under its own rules of nature, they say, and therefore the laws of man should not apply. Banning any prosecution for HIV transmission would therefore make the whole issue a lot simpler. Many would consider this rule to pose a threat to public health by leaving individuals who wish to do harm immune to prosecution.<br />
<h3>Criminalisation for intentional transmission only</h3>Generally this is the sort of policy that most AIDS organisations, public health officials and civil rights groups favour<sup>1</sup> <sup>2</sup> <sup>3</sup>. They argue that by restricting the law to cases of intentional rather than reckless transmission, it would greatly reduce the confusion amongst HIV positive people over what is legal and what is not. It would also cut down on the number of HIV positive people being criminalised unfairly, while allowing those who truly deserve prosecution to be brought to trial. In cases of reckless or accidental transmission, most agree that education and counselling is a more effective prevention method than imprisonment or fines.<br />
Furthermore, it has been argued that even in cases of intentional transmission the wording of laws used to prosecute should not be HIV-specific. Instead, existing criminal law should be used so as not to further stigmatise people with HIV as a whole.<br />
<h3>Criminalisation for all forms of transmission</h3>As the list of trials at the end of this page demonstrates, many states and countries now allow the prosecution of HIV-positive people for all forms of transmission, including reckless and accidental, and even for exposure where no transmission has taken place. Some have specific laws permitting this, others use more general criminal laws to obtain a conviction. As with any type of criminal trial, once one prosecution is successfully achieved, it sets a precedent for future trials, and makes lawyers more likely to take on similar cases. This growing trend is of particular concern for many organisations trying to advocate on behalf of HIV positive people around the world. Below is a short summary of some of their arguments for the criminalisation of HIV transmission, and the counter arguments against such legislation:<br />
<table><tbody>
<tr> <th>FOR CRIMINALISATION</th> <th class="table_special">AGAINST CRIMINALISATION</th> </tr>
<tr> <td>If you are HIV positive, failing to use protection is wrong, and people who do wrong should be brought to justice through the law regardless of their health status or background.</td> <td>Criminalising HIV positive people does not address the complexities involved in disclosure and increases HIV stigma, particularly when positive people being brought to trial are demonised by the press.</td> </tr>
<tr> <td>Giving someone HIV is akin to murder.</td> <td>HIV is an unpleasant virus to live with, but it is no longer a death sentence, and with modern antiretroviral drugs, HIV positive people can live a healthy life for many years.</td> </tr>
<tr> <td>If you are HIV positive, it is your duty to use protection. The idea of 'shared responsibility' is based on ideals that came about when HIV was still a 'gay' illness. With heterosexual relationships, it is not always a practical reality. Many women, even in the West, do not necessarily have the power to force their partners to wear a condom.</td> <td>The more cases that come to court, the more people will believe that the responsibility for having safe sex should lie solely with positive people. This could in turn lead to more incidents of unprotected intercourse, with people believing it to be a legal responsibility for their partner to disclose any infection. Safe sex should always be a shared concern.</td> </tr>
<tr> <td>Criminalising people for reckless transmission will act as a deterrent and will make HIV positive people think twice before having unprotected sex.</td> <td>The law has little effect on people's sexual behaviour, as is clear from the number of teens who have illegal underage sex. Criminalisation of transmission does however enable lovers to use the law as a way of exacting revenge. In such cases, the original HIV positive partner would always be at a natural disadvantage.</td> </tr>
<tr> <td>To ensure that people don't believe they are immune from prosecution just because they haven't taken an HIV test, it should be possible to call an HIV positive person 'reckless' even if they have never actually had an HIV test - knowledge that they have put themselves at risk in the past should be enough to make them aware of their HIV risk and thus legally obliged to use a condom in the future.</td> <td>Prosecuting positive people for reckless transmission could well leave many afraid to be tested, believing that if they do find out their status, they could be liable to all sorts of criminal charges. Avoiding this problem by telling people they should be 'aware' of their risk even if they haven't tested for HIV is entirely unfair. It is also impossible to assess or judge how 'aware' of past risk of infection any one person is or should have been.</td> </tr>
<tr> <td>Putting people in prison will stop them from spreading HIV and endangering the community.</td> <td>In the short term, this may be true, but imprisonment does nothing to help people come to terms with their HIV and take a safer attitude towards sex. Education and psychological counselling would be a more appropriate course of action in many cases. The sharing of needles for injecting drugs and the high incidence of male rape and sex between men in prisons also mean that HIV transmission is still perfectly possible, even behind bars.</td> </tr>
<tr> <td>Criminal cases help to uncover and warn lots of HIV positive people who might not otherwise learn their status.</td> <td>Criminal cases give police licence to investigate the background of anyone they suspect of having passed on HIV. This can represent a serious invasion of privacy as well as a potential breach of confidentiality and anonymity, and it may well be entirely unjustified.</td> </tr>
<tr> <td>Laws on the transmission of diseases do not necessarily apply just to HIV. Many laws relating to HIV could potentially be used to prevent people spreading many other fatal illnesses.</td> <td>No other illnesses are treated with the same hysteria as HIV, and few people are ever criminalised for transmitting them. It is for example very unlikely that anyone would think to prosecute an employee of a residential care home for coming into work with the flu and giving it to the residents, even if several of those residents subsequently died. HIV is only singled out in criminal cases because of its association with stigmatised groups and promiscuity.</td> </tr>
<tr> <td>HIV positive people can easily be divided into legal definitions of "guilty" (people who 'bring HIV upon themselves' and recklessly give it to others) and "innocent" (victims who were infected through no fault of their own, and would never put anyone else at risk).</td> <td>These categorisations are far from clear cut, and most HIV positive people have at some point in their lives belonged to both. After all, everyone who transmits HIV was once a 'victim' of someone else with the virus.</td> </tr>
<tr> <td>Vulnerable women who do not have control over their sexual relations will find protection in laws that would prosecute reckless male partners.</td> <td>Women will face a greater risk of prosecution as they more often know their status through attending health clinics more frequently. A HIV positive man may accuse his female partner of infecting him, because she was diagnosed first, even if he infected her and was not diagnosed until much later.</td> </tr>
</tbody> </table><h2>How does criminalisation affect the lives of HIV positive people?</h2>While most HIV positive people practice very safe sex, and would never have cause to be taken to court, many say that the issue of criminalisation still affects them. A recent survey by researchers from the Sigma research team at Portsmouth University for example<sup>4</sup>, found that 90% of the HIV positive people they interviewed were critical of the growing trend for criminalisation of reckless HIV transmission. Most said this was because they believed that the responsibility for protected sex should be shared, or because they thought criminalisation increased the stigma they faced. A number also said they believed that criminalisation was a step back towards the culture of ‘blame’ that surrounded the early years of the epidemic.<br />
Right or wrong however, criminalisation does mean there is now an extra concern for any HIV positive person who decides to have a sexual relationship, and many HIV organisations are finding that they have to take the issue into consideration when giving out advice.<br />
<h2>What trials for criminal transmission have there been?</h2>Criminal transmission trials have been held in many countries around the world, but most have occurred in the West. Below are some of the better-known trials to have taken place in recent years:<br />
<span class="highlight_color">Dr Richard J. Schmidt</span>, 1998<sup>5</sup>,<sup>6</sup>: Richard Schmidt was a doctor from Louisiana, USA, who was accused of infecting his lover, a nurse called Janice Trahan, by injecting her with HIV infected blood. Trahan alleged that Schmidt had injected her with the blood of one of his positive patients in an act of vengeance after she tried to end their relationship. DNA samples of the virus in Trahan's blood and that of the positive patient in question were found to be very similar, but Schmidt's defence team insisted that 'very similar' was not scientifically accurate enough. HIV rapidly mutates and changes its DNA structure once it enters another person's body meaning comparisons can be difficult. However, using a new technique called ' phylogenetics' (or 'evolutionary analysis'), scientists were able to determine that Schmidt's patient was extremely likely to have been the source of the virus found in Trahan. Schmidt was found guilty and sentenced to 50 years.<br />
This was the first time that phylogenetics had been used in a criminal transmission trial, but it is now the standard way of determining the source of HIV infection in trials. Incidentally, phylogenetics was also used in the early 90s to determine the cause of infection of five patients treated by the HIV positive Florida dentist, Dr. David Acer. Acer died before any criminal charges were brought, but following testing, he was found to be the source of all five infections.<br />
<span class="highlight_color">Brian Stewart</span>, December 1998<sup>7</sup>: Stewart was a medical technician from Illinois who was sentenced to life in prison after deliberately injecting his son with HIV infected blood, allegedly in an effort to kill him and avoid paying child support. He was found guilty after all other suggested sources for the boy's infection were ruled out. On one occasion Stewart allegedly told the boy's mother not to bother seeking child support because the child would not live beyond the age of five. On another, he told colleagues that he had "the power to destroy the world… I would inject them with something and they would never know what hit them."<br />
<span class="highlight_color">Christophe Morat</span>, June 2004<sup>8</sup>: Morat was sentenced to six years in a French prison under legislation designed to be used in cases of poisoning (France has no specific anti-HIV transmission laws). He was found guilty of failing to disclose his status to two women, Isabelle and Aurore, both of whom subsequently became infected with HIV. Aurore later committed suicide and Morat's appeal against his sentence was subsequently rejected. Isabelle is now a member of a major HIV action group known as Femmes Positives, whose mission is to get the French government to create a specific HIV transmission-related law that will give them the right to prosecute former lovers. The case, and the demands of Femmes Positives, has opened up a debate in France over whether HIV positive people should ever be divided into 'victims' and 'criminals' in the eyes of the law, or whether the conventional doctrine of 'shared responsibility' in contraception should remain.<br />
<span class="highlight_color">Hans-Otto Schiemann</span>, November 2004<sup>9</sup>: A 56-year-old German who lived in Thailand, Schiemann allegedly tried to infect nearly 100 Thai women (including his wife) during the 10 years he lived in the country. As Thailand deliberately has no laws that outlaw unprotected sex or its consequences, he was eventually sentenced to two months in jail for overstaying his visa, and was deported back to Germany. Schiemann was reported to have a pathological hatred of Thai women, and referred to them as 'witches' and 'monkeys', but claimed he had done nothing wrong. He was deported for a second time in November 2005 after he was found to have re-entered the country.<br />
<span class="highlight_color">Anthony E. Whitfield</span>, December 2004<sup>10</sup>: An African-American from Lacey in the USA, Whitfield was sentenced to an unprecedented 178 years in prison by a court in the state of Washington after exposing 17 women to HIV and infecting his wife and four others. He was found guilty on 17 counts of first-degree assault with sexual motivation, two counts of witness tampering and three counts of violating a court protection order. His conviction spawned a racist leafleting campaign in the state capital, Olympia, with flyers proclaiming "Don't Have Sex With Blacks; Avoid AIDS" delivered to more than 100 homes. Whitfield is one of around 150 people to have been convicted of criminal HIV transmission in the US.<br />
<span class="highlight_color">Mohammed Dica</span>, March 2005<sup>11</sup>: Kenyan-born with family in Somalia, Dica lived in Mitcham, SW London. In the first ever HIV transmission conviction in England and Wales, he was found guilty of reckless (rather than deliberate) Grievous Bodily Harm against two women and was sentenced to 8 years in prison in November 2003. However, in March 2004 he appealed, claiming that he had not been allowed to give evidence that suggested the women had fully consented to the risks of unprotected sex with him. A retrial was ordered and began in June 2004, but was later halted due to questions over the validity of documents submitted by one of the complainants. This woman subsequently withdrew her complaint and dropped out of the trial. In December 2004, a third hearing was held, this time with only one complainant, but the jury failed to reach a verdict. A fourth and final hearing in March 2005 however found him guilty on one count of GBH and he was jailed for four and a half years.<br />
The trial caused concern among many AIDS and human rights organisations in Britain, as UK Law Commission guidelines recommend that only cases of deliberate transmission ever be brought to trial. However, the prosecution believed it had a case, as Dica was alleged to have actively persuaded one of the women not to use condoms, even though he knew he was HIV positive. He also led the other to believe he was HIV negative and a rich single lawyer, when in fact he was HIV positive, unemployed and married with children.<br />
Other trials in the UK include:<br />
<b>England</b><br />
<ul><li>Feston Konzani: an asylum seeker from Malawi, jailed for 10 years.</li>
<li>Kouassi Adaye: an asylum seeker from South Africa, jailed for 4 years.</li>
<li>Christopher Walker: pleaded not guilty and was sectioned under the Mental Health Act.</li>
<li>Paulo Matias from Leicester: jailed for three years</li>
<li>Derek Hornett: sentenced to three years for transmitted HIV to an 82-year old women</li>
<li>Unnamed man from Bournemouth: Zimbabwean man sentenced to three and a half years</li>
<li>Mark James from West Sussex: Gay man sentenced to 40 months in prison in his absence after he went missing while on bail. His whereabouts are still unknown.</li>
<li>Sarah Jane Porter (see below) from London: jailed for 32 months.</li>
<li>Unnamed gay man from London: not convicted – the trial ended in an unprecedented ‘not guilty’ verdict after the defence claimed that phylogenetic analysis could not prove that the defendant had definitely infected the complainant.</li>
<li>Clive Rowlands from Merseyside: jailed for two and a half years in November 2006.</li>
</ul><b>Wales </b> <ul><li>An unnamed woman from Cardiff: jailed for two years.</li>
</ul><b>Scotland </b> <ul><li>Stephen Kelly: Tried in Scotland in 2001, he was the first ever person to be convicted in the UK. He was jailed for 5 years.</li>
<li>Giovanni Mola: sentenced to nine years in jail in April 2007 for 'recklessly infecting his Edinburgh lover with HIV and Hepatitis C'.</li>
<li>Mark Devereaux: Convicted of 'culpable and reckless conduct' in February 2010 and sentenced to ten years in prison </li>
</ul><span class="highlight_color"></span> <span class="highlight_color">Justin Dalley</span>, June 2005<sup>12</sup>: Dalley, a New Zealander, was convicted of criminal nuisance after having unprotected sex with his girlfriend and failing to disclose his status. Unusually, his girlfriend remains HIV negative, but initially told Dalley's family she was positive. She later admitted she had lied, but charges were still brought due to the alleged mental stress and trauma she had suffered on discovering her boyfriend's status. Dalley was sentenced to 300 hours' community work, six months supervision and $1000 reparation to cover his girlfriend's counselling and other expenses.<br />
The case is also unusual because of a second woman, who on hearing of the trial, tried to prosecute Dalley for having sex with her with a condom but without disclosure. She too remains HIV negative. Dalley was however found not guilty of this charge in October 2005, because he had used a condom.<br />
<span class="highlight_color">Canadian Red Cross Society</span>, June 2005<sup>13</sup>: In the first case of an entire organisation being prosecuted for HIV transmission, the Canadian Red Cross was taken to court after more than 1,000 Canadian citizens acquired HIV from infected blood products in the late 1980s and early 1990s. The Red Cross had run the country's national blood donor scheme for decades before the scandal, but failed to properly implement HIV and hepatitis screening for a number of years after tests for the diseases became available. Originally accused of "distributing an adulterated drug", official charges were dropped after the organisation admitted they were guilty, issued a full apology and agreed to compensate the victims. As well as a $5,000 fine, they was asked to donate $1.5 million of money not sourced from public donations to fund scholarships for the children affected by the tragedy and to finance research into medical errors.<br />
<span class="highlight_color">Bulgarian medics on trial in Libya</span>; February 1999 - July 2007<sup>14</sup> <sup>15</sup>: The Bulgarian medics trial began in 1999 after a number of children treated at the al-Fateh paediatric hospital in Benghazi, Libya were discovered to have AIDS. Hospital officials and parents accused a group of medics, which included six Bulgarians (five women nurses and a male doctor), a Palestinian doctor and nine Libyans, of having collaborated to deliberately infect the children. However, the foreign health workers' defence lawyer insisted that the infections were caused by poor hygiene and the multiple use of contaminated syringes within the hospital, and that they began long before the medics arrived.<br />
The case was initially dismissed by the Libyan People's Court, but was then passed to an ordinary criminal court. At the second hearing in 2003, Prof. Luc Montagnier, the co-discover of HIV, was called in to give an impartial expert opinion. He suggested that the tragedy had probably taken place due to negligence rather than deliberate intent, and that the children had been infected at least a year before the medics arrived. Despite his report, the five Bulgarian nurses and Palistinian doctor were found guilty and sentenced to death in May 2004. The Libyans and Bulgarian doctor were freed.<br />
After appealing against the conviction on the grounds that false confessions had been extracted from two of the nurses by torture, the case was reopened, and the death sentences were quashed in late 2005 by the Supreme court. A retrial in December 2006 again sentenced the seven to death. The medics once again appealed, but were given a third death sentence on 11 July 2007. This was commuted to life imprisonment on 18 July. After many months of negotiations with the European Union (of which Bulgaria became a part in January 2007) the medics were finally released on 24 July 2007.<br />
The trial caused a major international incident, with many nations saying it was an attempt to divert attention away from the poor conditions in Libya's state-run hospitals. The families of the infected children refused to drop the case until they had been paid sufficient 'blood money' - compensation that would allow the death sentence to be commuted under Islamic law. Both the EU and Bulgaria refused to pay this, arguing it would imply that the medics were guilty. However, they did set up a fund designed to support the infected children, and donated money to the hospital concerned to improve the facilities and conditions. Eventually, after much international pressure and a number of deals with the EU, the demands for blood money were met by Libya itself, and the medics were released to serve the remainder of their life sentences in Bulgaria. All five nurses and the Palestinian doctor, who was given Bulgarian citizenship shortly before his release, were acquitted as soon as they returned to Bulgaria.<br />
<span class="highlight_color">Sarah Jane Porter</span>; June 2006<sup>16</sup>: Sarah Jane Porter was a woman from London in the UK who was charged with Grievous Bodily Harm through the reckless transmission of HIV. Her case is a good example of some of the reasons why many AIDS organisations are against the criminalisation of reckless HIV transmission.<br />
Firstly, her accuser, a former boyfriend, was not the man who made the original complaint to the police - he remains HIV negative – but someone the police tracked down in the course of their investigations, and persuaded to file charges. These investigations lasted over a year, and involved Sarah’s home being raided and her medical records being seized. Some have accused the Metropolitan Police Force of wasting police time in trying to secure a conviction, and Sarah’s legal team have made an official complaint about the conduct of police officers in the case.<br />
The psychologist in the case told the court that Sarah was in complete denial about her HIV infection because she was convinced that she would be rejected by her friends and lovers if she disclosed her status. She was terrified of the stigma attached to HIV. However, on being found guilty, she was not offered counselling, but was imprisoned for 32 months, separating her from her young son. She also faced deep hostility from much of the tabloid press, who labelled her “pure evil” and an “AIDS avenger”, so perpetuating the stigma and idea of ‘blame’ that caused Miss Porter not to disclose her status in the first place.<br />
Finally, no mention was made of the fact that her lovers also failed to use condoms when having sex with Miss Porter – which it was of course their equal responsibility to do.<br />
<span class="highlight_color">Willie Campbell</span>; May 2008.<sup>17</sup> The HIV positive 42 year-old Texan was sentenced to 35 years in prison for harassing a public servant with a 'deadly weapon' after he spat in the face of a police officer who was arresting him for public intoxication in 2006. None of the three officers who arrested him became infected with HIV, in line with the fact that contact with saliva, tears or sweat has never been shown to transmit HIV. Campbell must serve half his sentence before being eligible for parole.<br />
Campbell’s case was highlighted by South African judge, Edwin Cameron, in his speech on criminal transmission at the International AIDS Conference in 2008.<br />
<blockquote class="longquote">"[I]t stuns the mind that someone who has actually not harmed anyone, who has not actually damaged any property (or otherwise spoiled the world) could be locked away in these circumstances for 35 years. The inference that his HIV status played a pivotal role in sending him away for so long is unavoidable. In short: the man was punished not for what he did, but for the virus he carried." - <cite><sup>18</sup></cite></blockquote><span class="highlight_color">Unnamed man</span>; June 2008<sup>19</sup> - In the first ruling of its kind, the Swiss federal court judged a man criminally liable for passing on HIV to his partner, despite the fact that he had not been tested for HIV at the time of having sex. Since he had a history of unprotected sex, and had been aware of the HIV positive diagnosis of another previous partner, the court decided he should have suspected that he was HIV positive, and that his behaviour was risky.<br />
Whilst only applicable in Switzerland, the ruling could set an important legal precedent. It could mean that those who do not disclose past unprotected sex to new partners can be held criminally liable in the event of HIV transmission.<br />
On the other hand, the fact that someone who had never tested for HIV has been convicted for criminal transmission could make the lack of an HIV test no longer an effective defence against prosecution. This is a potentially beneficial development for the impact of criminal HIV transmission on public health, as it removes the deterrent to HIV testing at the individual level.<br />
<span class="highlight_color">Cecelia Sliker</span>; October 2008.<sup>20</sup> <sup>21</sup> An HIV-positive Florida mother became the first US women to be successfully prosecuted for mother-to-child transmission after she was found to have not taken steps to minimise the risk of her second son, born in 2004, becoming infected. In pleading guilty, Sliker was sentenced to two years' probation, avoiding a maximum 15-years in prison, as it was deemed imprisonment would prevent her caring for her son in future.<br />
Authorities say she did not undertake preventive measures as she did not want her son’s father to know her status. Sliker had known she was HIV positive before the birth of her first son in 2001, and had taken steps to prevent him becoming infected.<br />
<span class="highlight_color">Unnamed man</span>; February 2009.<sup>22</sup> A Switzerland-based man received a 34 month suspended sentence for exposing a woman to HIV without disclosing his status, and was imprisoned in December 2008. Geneva’s deputy public prosecutor, Yves Bertossa, appealed to the Geneva Court of Justice for the case to be dropped, following testimony from Professor Bernard Hirschel of the Swiss Federal Commission for HIV/AIDS. Prof Hirschel, co-authored the ‘Swiss Statement’ that claimed an undetectable viral load, due to effective ARV treatment, minimized the risk of onward transmission during unprotected sex. Based on this testimony, which claimed his conduct carried a 1 in 100,000 risk of onward transmission, the man’s prison sentence was overturned.<br />
<span class="highlight_color">Unnamed man</span>; December 2009.<sup>23</sup> In New Zealand, a 35-year-old man living with HIV admitted to deliberately infecting his wife the virus. The man had pricked his wife, while she slept, with a sewing needle tainted with his blood. It is believed the man infected her so she would have sex with him again. For a year, the woman had refused to have sex, for fear of becoming infected. She had tested HIV-negative four times before her period of abstinence.<br />
<h2>Criminalisation laws around the world</h2>Many countries criminalise the transmission of HIV, and have used either general laws relating to assault or have introduced HIV-specific legislation. Different nations and states/territories within nations have different requisite criteria for prosecutions and convictions, as well as varying degrees of punishment. Furthermore, the language of the laws are not necessarily an indicator of how they are administered. Some countries may be far more punitive than others despite prohibiting similar offences.<br />
<h3>United States</h3>As of the end of 2008, 36 states in America had prosecuted HIV positive individuals for criminal transmission or HIV exposure, with many having laws specifically mentioning HIV.<sup>24</sup> Some states punish those convicted of offences such as prostitution or rape more severely if the person knows they have HIV. Spitting or emitting HIV-infected bodily fluids at another person while in prison is also an offence in some states. At least nine HIV-positive individuals in the US have been sentenced for spitting with sentences ranging from 90 days to 25 years.<sup>25</sup> A sample of the laws are below:<sup>26</sup> <br />
<br />
<b>Alabama</b> – Engaging in activities likely to transmit an STD is a class C misdemeanour.<br />
<b>California</b> – Engaging in uninformed, unprotected sexual activity (exception for consent) with the intent to infect the other person is a felony punishable by up to 8 years in prison.<br />
<b>Colorado</b> – Committing or soliciting prostitution with knowledge of being HIV positive are class 5 and 6 felonies.<br />
<b>Florida</b> – Unlawful for person with HIV, with knowledge both of their infection and risk of sexual transmission, to have sex without disclosure and consent having taken place.<br />
<b>Michigan</b> – It is a felony to engage in sexual penetration, however slight and regardless of whether semen has been emitted, without informing the other of his/her HIV status.<br />
<b>Missouri</b> – It is a class B felony to expose a person to HIV if defendant knowingly acted in a reckless manner without knowledge and consent through oral, anal or vaginal sex. If complainant becomes infected, the charge is a class A felony. The use of a condom is not a defence.<br />
<b>New York</b> – The applicable part of the law is reckless endangerment in the first degree for engaging in ‘conduct which creates a grave risk of death to another person’.<br />
<b>Pennsylvania</b> – The state Superior Court ruled in a 2006 case involving oral sex that HIV positive people who do not disclose their status to their sexual partners can be charged with reckless endangerment. It follows that any kind of unprotected sex without disclosure could be prosecuted.<br />
<b>Texas</b> – HIV transmission cases have been brought to court under aggravated assault laws whereby a person “intentionally, knowingly, or recklessly… uses or exhibits a deadly weapon as part of an assault”. Saliva is considered a deadly weapon.<br />
<h3>United Kingdom</h3>Cases successfully prosecuted in England and Wales have been under Section 20 of the Offences Against the Person Act (OAPA) 1861, with the charge being ‘recklessly inflicting grievous bodily harm’. This carries a maximum five-year sentence. It must be proved that:<br />
<ul><li>The defendant did in fact infect their partner.</li>
<li>The defendant was aware of the risk of transmission. In theory they may not have had a positive test, but they will have ‘known’ they were infected.</li>
<li>The complainant did not explicitly give informed consent to sex with an individual they knew had HIV.</li>
<li>The defendant did not take steps to protect their partner – consistent condom use is a defence.</li>
</ul>No one has been prosecuted for intentional grievous harm (Section 18, OAPA). This is because the burden of proof is very high – sex would be an ineffective way of transmitting HIV if someone was intent on doing so.<br />
In Scotland the likely offence is ‘culpable and reckless conduct’. Theoretically, a person could be prosecuted under ‘reckless endangerment’ where transmission does not occur.<sup>27</sup> There have been three convictions for 'reckless conduct' since 2001 in Scotland with the maximum jail sentence so far ten years. These sentences do not affect English or Welsh law in any way.<br />
<h3>West Africa </h3>Several nations in West Africa have adopted HIV laws based on a ‘model law’ formulated in 2004 by Action for West Africa Region – HIV/AIDS (AWARE–HIV/AIDS). Article 36 creates an offence of willful HIV transmission <i>“through any means by a person with full knowledge of his/her HIV/AIDS status to another person”</i>. This definition is considered very broad and disregards whether disclosure or reasonable precautions took place. Some of the countries’ laws are listed below.<br />
<ul><li>Benin law does not require transmission to have taken place.</li>
<li>Togo law prohibits people with HIV having unprotected sex regardless of their partner’s status or whether consent has been given.</li>
<li>Guinea law criminalises exposing others to substances that could cause transmission, regardless of the consequences, and disregards circumstances such as whether the defendant took precautions, knew their status and risk of transmission, disclosed their status, and whether or not the defendant had control over the sexual relationship.</li>
<li>Mother-to-child transmission (MTCT) can be prosecuted in several countries either by specific reference to MTCT or as a mode of transmission through blood. Sierra Leone explicitly mentions pregnant mothers as a group required <i>“to take all reasonable measures and precautions to prevent transmission”</i>. It is believed this violates the right to medical treatment with voluntary informed consent. Also “reasonable measures and precautions” is not defined so it is not clear whether an act such as breastfeeding could be criminalised.<sup>28</sup></li>
</ul><h3>Australia</h3>Criminal HIV transmission in Australia is considered by both public health laws and criminal laws. Most states have public health laws relating to reckless or deliberate HIV transmission, or the risk of doing so. Only New South Wales makes illegal any sexual intercourse without disclosure.<br />
Australian state criminal laws that would likely apply to HIV transmission include criminalising acts that transmit, or risk transmitting, a serious disease (including HIV), recklessly endangering another person’s life or causing grievous bodily harm. Sentences in different states range 10 years maximum imprisonment, to a life sentence.<sup>29</sup><br />
<h2>Conclusions</h2><div class="photo_r"> <img alt="HIV prevention poster promoting condom use, Malawi" border="0" src="http://www.avert.org/media/photos/2793.jpg" width="200" /> <div style="width: 200px;">'No Condom - No Way!' - HIV prevention poster in Malawi</div></div>The criminalisation of people who have transmitted HIV is both a moral and a practical minefield. The very fact that the sentences received by the individuals listed above vary from a small fine to life in prison reflects just how difficult it can be to legislate and deliver a ruling on an issue where individual viewpoints, emotions, stigma and the good of public health are so inextricably mixed.<br />
According to UNAIDS there is no evidence to suggest that criminalising HIV transmission is an effective means to prevent the further spread of the virus or achieve criminal justice.<sup>30</sup> If governments wish to make a dent in their countries’ epidemic, far more effective prevention programmes exist such as testing, counselling and general awareness campaigns. Where criminalisation laws have been proposed as a means of protecting vulnerable women and girls from their HIV-positive partners, a more effective approach would be to address gender-related violence, inequality and sexual coercion, as well as stigma and discrimination.<br />
While it is perhaps an understandable reaction on the part of individuals to want to seek redress through the courts for becoming infected, on an epidemic-wide scale criminalisation could do more harm than good. The potential disincentive to testing, stigmatisation of HIV, misapplication of the law, prosecuting people unaware of their status, as well as other possible pitfalls mean criminalisation may be counterproductive.<br />
What should ultimately be remembered is that HIV is an infectious disease - every single person who is accused of sexually transmitting the virus by whatever means, will at some point have been the victim of a 'transmitter' themselves. Replication and infection is the primary objective of any virus. The real criminal is perhaps not the human host therefore, but HIV itself.<br />
<br />
<div class="box bFull" id="footnote"> <h2>References:</h2><ol><li><a ,="" href="http://www.nat.org.uk/Our-thinking/Law-stigma-and-discrimination/Criminal-prosecutions.aspx" target="_blank">"<span class="externallink">Criminal prosecutions: Why NAT opposes prosecution for reckless HIV transmission</span>"</a>, National AIDS Trust</li>
<li>" <a ,="" class="externallink" href="http://www.actoronto.org/website/research.nsf/pages/crimsanct" target="_blank">Policy on the Use of Criminal Sanctions as a Response to the Transmission of HIV</a>": AIDS Committee of Toronto</li>
<li>" <a ,="" class="externallink" href="http://www.seattleweekly.com/2004-12-01/news/hiv-criminal-intent.php" target="_blank">HIV: Criminal Intent,</a>", Seattle Weekly, 1-7 December 2004</li>
<li><a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16643681" target="_blank">"Criminal Prosecutions for HIV Transmission: people living with HIV respond"</a>, International Journal of STD & AIDS, Vol. 17, No. 5, May 2006</li>
<li>"If I cannot have you", Night & Day, 12th January 1997</li>
<li><span class="externallink">www.GenomeNewsNetwork.org</span> <a ,="" href="http://www.genomenewsnetwork.org/articles/01_03/hiv.shtml" target="_blank">"Guilty Sequence"</a> 24th January 2003</li>
<li>"Man injected son with HIV to save cash", The Guardian, 7th December 1998</li>
<li>"Fighting Femmes" by David Thorpe; POZ magazine, June 2005</li>
<li><a ,="" href="http://www.aegis.com/news/re/2004/RE041138.html" target="_blank">"Thailand to deport German accused of spreading HIV"</a>, Reuters Foundation Alert Net, 19th November 2004</li>
<li>"Serial HIV assault convict sentenced to 178 years in prison", The Associated Press, 22 December 2004</li>
<li><a ,="" href="http://news.bbc.co.uk/1/hi/england/london/4375793.stm" target="_blank">"HIV man guilty of infecting lover"</a>, <span class="externallink">bbc.co.uk</span>, 4th May 2005</li>
<li>"HIV positive man facing new charges", <span class="externallink">www.tvnz.co.nz</span>, 26th November 2004</li>
<li>"Victims move judge to tears", Toronto Star, 1st July 2005</li>
<li>"<a ,="" href="http://www.ft.com/cms/s/f2a95246-3445-11dc-8c78-0000779fd2ac.html" target="_blank">Timeline: Foreign medics trial in Libya</a>", Financial Times, 17th July 2007</li>
<li>"<a ,="" href="http://news.bbc.co.uk/1/hi/world/europe/6912965.stm" target="_blank">HIV medics released to Bulgaria</a>", BBC.co.uk, 24th July 2007</li>
<li><a ,="" href="http://www.dailymail.co.uk/news/article-391418/Woman-jailed-deliberately-infecting-lover-HIV.html" target="_blank">"Woman jailed for deliberately infecting lover with HIV"</a>, The Daily Mail, 20th June 2006 & <a ,="" href="http://www.independent.co.uk/news/uk/crime/sarah-was-no-aids-avenger-405403.html" target="_blank">"Sarah was no AIDS avenger"</a>, The Independent on Sunday, 25th June 2006</li>
<li><a ,="" href="http://www.nytimes.com/2008/05/16/us/16spit.html?_r=2&ref=health&oref=slogin&oref=slogin" target="blank">"Prison for Man With H.I.V. Who Spit on a Police Officer"</a>, The New York Times, May 16, 2008</li>
<li>Edwin Cameron (2008, 8th August), <a ,="" href="http://www.tac.org.za/community/node/2399" target="_blank">"HIV is a virus, not a crime: Criminal statutes and criminal prosecutions – help or hindrance?"</a>, XVII International AIDS Conference</li>
<li><a ,="" href="http://www.swissinfo.ch/eng/news/social_affairs/Condom_only_solution_to_risky_sexual_behaviour.html?siteSect=204&sid=9284918&cKey=1214935548000&ty=nd" target="_blank">"Court rules in HIV case"</a>, SwissInfo, July 1, 2008</li>
<li>HeraldTribune.com (2008, 2nd October), <a ,="" href="http://www.heraldtribune.com/article/20081002/BREAKING/810020238/2055/NEWS?Title=Mother_who_gave_HIV_to_newborn_gets_probation" target="_blank">'Mother who gave HIV to newborn gets probation'</a></li>
<li>HeraldTribune.com (2008, 11th January), <a ,="" href="http://www.heraldtribune.com/article/20080111/NEWS/801110356/-1/newssitemap" target="_blank">'Officials: Woman with HIV did not seek care for baby'</a></li>
<li>aidsmap.com (2009, 25th February) <a ,="" href="http://www.aidsmap.com/en/news/CEFD90F2-34F1-4570-B9CF-1F0DB462AC9D.asp" target="_blank">'Swiss court accepts that criminal HIV exposure is only 'hypothetical' on successful treatment, quashes conviction'</a></li>
<li>Sunday Star Times (2009, 12th June), <a ,="" href="http://www.stuff.co.nz/sunday-star-times/news/3130245/Man-injects-sleeping-wife-with-HIV" target="_blank">'Man injects sleeping wife with HIV'</a></li>
<li>GNP+, <a ,="" href="http://www.gnpplus.net/criminalisation/index.php?option=com_content&task=view&id=388&Itemid=45" target="blank">‘Global Criminalisation Scan’</a> website, accessed 4th December 2008</li>
<li>aidsmap.com (2008, 16th May) <a ,="" href="http://www.aidsmap.com/en/news/57E118E4-CC57-4C0E-A200-E7709A67AF1F.asp" target="blank">'Texas jury concludes saliva of HIV-positive man a ‘deadly weapon’, sentenced to 35 yrs jail</a>'</li>
<li>GNP+, <a ,="" href="http://www.gnpplus.net/criminalisation/index.php?option=com_content&task=view&id=388&Itemid=45" target="blank">‘Global Criminalisation Scan’</a> website, updated 1st December 2008</li>
<li>Terrence Higgins Trust website, <a ,="" href="http://www.tht.org.uk/informationresources/prosecutions/whatthelawsays/" target="_blank">‘A guide to the law on criminal prosecutions’</a>, accessed 5th December 2008</li>
<li>Canadian HIV/AIDS Legal Network (2007, December), <a ,="" href="http://www.aidslaw.ca/publications/publicationsEN.php?t_id=3&l_id=1&sort=date" target="_blank">‘Legislation contagion: the spread of problematic new HIV laws in Western Africa’</a>, HIV/AIDS Policy and Law Review 12(2/3)</li>
<li>Australian Federation of AIDS Organizations (2006), <a ,="" href="http://www.afao.org.au/view_articles.asp?pxa=ve&pxs=103&pxsc=127&pxsgc=139&id=561#_ftn8" target="_blank">‘HIV Australia – Legal section, Vol. 5, No. 1’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/policyandpractice/humanrights/humanrights_criminalization.asp" target="_blank">‘Policy Brief: Criminalization of HIV Transmission’</a></li>
</ol><h2>Other Sources</h2><ul><li><a href="http://www.unaids.org/en/policyandpractice/humanrights/humanrights_criminalization.asp" target="_blank">‘Policy Brief: Criminalization of HIV Transmission'</a> UNAIDS, 2008</li>
<li>"<a class="externallink" href="http://data.unaids.org/Publications/IRC-pub02/JC733-CriminalLaw_en.pdf" target="_blank">Criminal Law, Public Health and HIV Transmission: A Policy Options Paper</a>" [PDF] UNAIDS, 2002 </li>
<li>" <a class="externallink" href="http://www.undp.org/hiv/publications/issues/english/issue11e.htm#Conclusion" target="_blank">The Role Of The Law In HIV and AIDS Policy</a>", HIV and Development Programme, UNDP</li>
<li>"<a href="http://www.sigmaresearch.org.uk/files/report2005b.pdf" style="font-weight: normal;" target="_blank">Grievous Harm: Use of the Offences Against the Person Act 1861 for sexual transmission of HIV</a>" [PDF], Sigma Research, 2005</li>
</ul></div><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-13586915206178629402010-07-07T07:26:00.000-07:002010-07-07T07:33:57.214-07:00HIV & AIDS symptoms<div class="box bFull"><h2>What are the symptoms of HIV and AIDS?</h2>It is not possible to reliably diagnose HIV infection or AIDS based on symptoms alone.<b> </b>HIV symptoms<b> </b>are very similar<b> </b>to the symptoms of other illnesses<b>. So the only way to know for sure whether a person is infected with HIV is for them to have an HIV test.</b><br />
People living with HIV may feel and look completely well but their immune systems may nevertheless be damaged. It is important to remember that once someone is infected with HIV they can pass the virus on immediately, even if they feel healthy.<br />
HIV is the virus that causes AIDS. If a person infected with HIV does not take effective antiretroviral treatment, over time HIV will weaken their immune system, which will make them much more vulnerable to opportunistic infections.<br />
<a name='more'></a><br />
</div><h2>Symptoms caused by opportunistic infections</h2>Opportunistic infections are caused by germs that are around us all the time but which can normally be fought off by a healthy immune system. Once the immune system is sufficiently weakened, such infections will develop and produce any of a wide range of symptoms. Some of these symptoms can be very severe. Certain cancers also become more common when the immune system is weakened.<br />
Such symptoms, however, cannot themselves be interpreted as definite signs of HIV infection or AIDS. A diagnosis of AIDS requires signs of severe immune deficiency, which cannot be explained by any factor except HIV. This generally requires an HIV test.<br />
<h2>Symptoms following HIV infection</h2>Some people who become infected with HIV do not notice any immediate change in their health. However, some suffer from a brief flu-like illness within a few weeks of becoming infected, or develop a rash or swollen glands. These symptoms do not indicate the development of AIDS, and the symptoms usually disappear within a few days or weeks.<br />
<h2>"I have flu-like symptoms/swollen glands - could it be HIV?"</h2><div class="photo_r"> <img alt="Joza community centre's free HIV rapid test service" border="0" src="http://www.avert.org/media/photos/413.jpg" width="300" /> <br />
<div style="width: 300px;">A free HIV rapid test service</div></div>Many illnesses have flu-like symptoms or cause swollen glands. You cannot have HIV unless you have been directly exposed to the virus. HIV can be transmitted during sexual intercourse with an infected person, through contact with infected blood or breastmilk, or during unsafe injections or medical procedures. If you are not sure whether or not you have been at risk of HIV then read our page about how you can and can't be infected with HIV.<br />
The only way you can find out whether or not you have been infected is to have an HIV test.Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-21162051909473482202010-06-26T08:44:00.000-07:002010-06-26T08:44:26.599-07:00AIDS vaccine<div class="box bFull"><h2>Is there an AIDS vaccine?</h2>An AIDS vaccine does not yet exist, but efforts to develop a vaccine against HIV and AIDS have been underway for many years. Since 1987, more than 30 vaccine candidates have been tested.<sup>1</sup><br />
An AIDS vaccine is not the same thing as a cure for AIDS.</div><div class="box bFull"><h2>Why do we need an AIDS vaccine?</h2>Even a partially effective AIDS vaccine could save millions of lives. Experts have calculated that an AIDS vaccine that is 50% effective, given to just 30% of the population could reduce the number of HIV infections in the developing world by more than half over 15 years. An AIDS vaccine that was more than 50% effective could cut the infection rate by more than 80%.<sup>2</sup><br />
An AIDS vaccine would have a number of key advantages over today’s HIV prevention options. In particular, the protection offered by a vaccine during sex would not depend on the consent of both partners (unlike condom use), and would not require behaviour change (unlike abstinence). An AIDS and HIV vaccine would also be invaluable for couples wishing to conceive a child while minimising the risk of HIV transmission.<br />
Children could be given an HIV and AIDS vaccine before ever being exposed to the HIV virus, and ideally this would subsequently protect them from all routes of HIV transmission. Vaccinating large numbers of people would probably require relatively little equipment and expertise, and would be much simpler and cheaper than providing antiretroviral treatment for those already infected.<br />
<h2>How might an AIDS vaccine work?</h2><div class="photo_r"><img alt="an antibody in
contact with an HIV protein" border="0" src="http://www.avert.org/media/photos/1453a.jpg" width="213" /> <br />
<div style="width: 213px;">This image shows an antibody (green) in contact with an HIV protein (yellow & red), which is a possible target for AIDS vaccine developers.<br />
<a name='more'></a></div></div>An AIDS vaccine could be effective in either of two ways. A “preventive” vaccine would stop HIV infection occurring altogether, whereas a “therapeutic” vaccine would not stop infection, but would prevent or delay illness in people who do become infected, and might also reduce the risk of them transmitting the virus to other people. Although a preventive vaccine would be ideal, a therapeutic vaccine would also be highly beneficial.<br />
The basic idea behind all AIDS vaccines is to encourage the human immune system to fight HIV. The immune system works using a combination of cells and chemicals called antibodies. Early vaccine research focused on teaching the immune system to produce antibodies that would block HIV entering human cells. However, products designed to work this way failed in clinical trials because the antibodies worked only against lab-cultured HIV, not against the wild strains of the virus.<br />
Recent research has focused on encouraging the immune system to produce cells to fight HIV. Nevertheless, many scientists believe such “cell-mediated” approaches will not be very effective on their own, even as therapeutic vaccines. It seems likely that a really effective vaccine will have to take a two-pronged approach involving both cells and antibodies.<br />
<h2>Why is it difficult to develop an AIDS vaccine?</h2>Developing an AIDS vaccine is a very difficult challenge for scientists. There are many reasons for this, including:<br />
<ul><li>Nobody has ever recovered from HIV infection, so there is no natural mechanism to imitate</li>
<li>HIV destroys the immune system cells that are meant to fight against it</li>
<li>Soon after infection, HIV inserts its genetic material into human cells, where it remains hidden from the immune system</li>
<li>HIV occurs in several subtypes, each of which is very different from the others</li>
<li>Even within each subtype, HIV is highly variable and constantly changing</li>
<li>There are no good animal models to use in experiments</li>
</ul>There are though reasons to be optimistic about the search for an AIDS vaccine, despite the difficulties and the slow progress so far. Vaccines against other diseases took many decades to develop, and HIV was only discovered in the mid 1980s. It is therefore much too early to give up hope, especially given the current speed of scientific progress.<br />
One particular reason for remaining hopeful is that most people remain healthy for several years after becoming infected with HIV, and a small minority have survived as long as 20 years without developing AIDS, even though they never entirely rid themselves of the virus. Also it appears that a few people have some kind of natural resistance to HIV infection, meaning they never become infected despite repeated exposure to the virus. These facts suggest that the immune system can be quite effective at controlling HIV.<br />
<h2>AIDS vaccine research and development</h2>In 2008, the public, philanthropic and private sectors invested around $868 million in preventive AIDS vaccine research and development.<sup>3</sup> The public sector provided around 84 percent, the philanthropic sector accounted for 12 percent, and the commercial sector accounted for the remaining 4 percent. Although funding for vaccine research has increased substantially since 2000, the 2008 contributions were a 10 percent decrease from 2007.<sup>4</sup><br />
The quest for an AIDS vaccine is aided by the not-for-profit International AIDS Vaccine Initiative (IAVI), which helps to support and coordinate vaccine research, development, policy and advocacy around the world. In addition an alliance of organisations called the Global HIV/AIDS Vaccine Enterprise exists to coordinate research and promote scientific cooperation and collaboration.<br />
<h2>How is a potential AIDS vaccine tested?</h2>Any potential AIDS vaccine must pass through three phases of clinical trials before being judged safe and effective. The first phase usually lasts from twelve to eighteen months, whereas the last phase can take three or four years to complete. In most cases volunteers taking part in the trial must be HIV-negative at the start of the trial, though it is important also to test safety in those who are already infected. Some therapeutic vaccine candidates may be tested on HIV-positive people to see if they can delay disease progression.<br />
<ul><li><b>Phase I</b> involves a small number of volunteers to test the safety of various doses</li>
<li><b>Phase II</b> involves hundreds of volunteers to further assess safety and, in some cases, positive responses</li>
<li><b>Phase III</b> involves thousands of volunteers to test safety and effectiveness</li>
</ul>A recent innovation is the Phase IIb trial, a larger form of the Phase II trial that provides some indication of effectiveness.<br />
Trials of AIDS vaccines are made more difficult by the ethical obligation to provide condoms and prevention counselling to all those who take part. Providing such services lowers the overall rate of HIV transmission, which increases the number of volunteers required to produce a significant result.<br />
<h2>What AIDS vaccine trials have already taken place?</h2><h3>The AIDSVAX vaccine trials</h3>The first AIDS vaccine candidate to undergo Phase III trials was called AIDSVAX. Two separate studies were conducted. One had around 5,400 participants - mostly gay American men - while the other involved around 2,500 injecting drug users in Thailand. The vaccine was made from a single HIV protein and was meant to stimulate a protective antibody response. The trials began in 1998 and 1999 respectively, and ended in 2003. No beneficial effect was found in either population group.<sup>5</sup><br />
<h3>The STEP and Phambili vaccine trials</h3>Two Phase IIb trials of a vaccine candidate created by the pharmaceutical company Merck were halted in September 2007. The studies - known as STEP and Phambili - had been expected to produce their first results by 2010. The trials were stopped when researchers found people receiving the vaccine were no less likely to become infected with HIV than those given the placebo - the version that had no medicinal properties. The STEP trial had started in 2004 in the USA, Canada, Australia, Peru and the Caribbean; the Phambili trial had begun in January 2007 in South Africa.<sup>6</sup> <sup>7</sup><br />
There is some concern that slightly more HIV infections occurred among people who received the Merck vaccine than among those who took a placebo. The vaccine was delivered using adenovirus type 5, which causes the common cold. It has been suggested that the vaccine may have provoked a different immune response among people who already had some immunity to the adenovirus strain, and that this may have made them more susceptible to HIV infection. This hypothesis - which is supported by laboratory evidence<sup>8</sup> - raises questions about the use of adenovirus in future vaccines.<sup>9</sup> It has also been noticed that uncircumcised men were four times more likely to become infected with HIV if they received the vaccine than if they received the placebo.<sup>10</sup><br />
Following the failure of the trial several other trials were delayed to ensure the design of the trail took into account what had been learnt from the Merck vaccine study.<br />
Leading vaccine researcher Dr. Gary Nabel described the results of the Merck vaccine trial as “a big blow to the field”.<sup>11</sup> Nevertheless, Dr. Seth Berkley, President and CEO of the International AIDS Vaccine Initiative, has stressed that the outcomes are not all negative:<br />
<blockquote class="longquote">“Though the Merck candidate failed, the trial did not. The contribution of the volunteers was not in vain. As a result of their dedication, the field will have new data that will inform future vaccine design, help with the prioritization of candidates in the pipeline and guide decisions on how to best proceed with ongoing and upcoming trials.”<sup>12</sup></blockquote><h3>The ALVAC / AIDSVAX vaccine trial</h3>In 2006 AIDSVAX was used in another Phase III trial in combination with ALVAC.<sup>13</sup> It was hoped that a trial combining AIDSVAX, which promotes the production of antibodies to HIV, and ALVAC, which is designed to stimulate a cellular response to the virus, would prove more effective than the previous AIDSVAX trial.<sup>14</sup> The trial recruited 16,402 young adults in Thailand.<br />
The results, published in late 2009, showed that 74 trial candidates who received a placebo became infected with HIV, compared to 51 who had received the vaccine candidate.<sup>15</sup> Although further examination produced mixed results, the analysis which the authors claimed was most relevant showed the vaccine prevented HIV infection by 31.2%. Drawing on this statistically significant result, the authors concluded that the trial showed a "modest protective effect of vaccine".<sup>16</sup><br />
Opinion differed over the significance of the study. Seth Berkley, of the International AIDS Vaccine Initiative was optimistic:<br />
<blockquote class="longquote">“The outcome is very exciting news and a significant scientific achievement. It’s the first demonstration that a candidate AIDS vaccine provides benefit in humans. Until now, we’ve had evidence of feasibility for an AIDS vaccine in animal models. Now, we’ve got a vaccine candidate that appears to show a protective effect in humans, albeit partially.” - <cite><sup>17</sup></cite></blockquote>However, Dr. Otto Yang, an immunologist at University of California, LA, said:<br />
<blockquote class="longquote">"the results are weak enough that we need to be very careful about assigning too much optimism to them... It seems not so likely that the vaccine really did what it was intended to do". - <cite><sup>18</sup></cite></blockquote><h2>What AIDS vaccine trials are now underway?</h2>By 2009, twenty-nine human trials of preventive HIV/AIDS vaccines were taking place worldwide.<sup>19</sup> This number included one Phase II trial; three Phase I/II trials and twenty-five Phase I trials.<br />
<h2>How soon could we have an effective AIDS vaccine?</h2><blockquote class="bigquoteright"><div class="bigquotebody">“The path forward is not clear. I think there is agreement on that. Anybody who talks about a timeline for a vaccine is being silly and uninformed.”</div><div class="bigquotecite">- Professor John Mellors</div></blockquote>In 1984, at the press conference arranged to announce the discovery of HIV, the US Health and Human Services Secretary Margaret Heckler said she hoped a vaccine against AIDS would be ready for testing in about two years.<sup>20</sup><br />
Unfortunately, the problem has turned out to be much more challenging than Secretary Heckler expected. Today’s researchers agree that the quest for an AIDS vaccine still has a long way to go. It is possible that the search could last decades.<br />
<blockquote class="longquote">“HIV infection has never provided scientists with a proof of concept of predictable protection, which historically has been the guiding principle for successful vaccine development.” – <cite>Dr Anthony S. Fauci, Director of NIAID<sup>21</sup></cite></blockquote>The failure of the STEP trial in 2007 in particular has led some scientists to question whether the current approach to AIDS vaccine development has much chance of success, given that it favours products that work in a similar way to the failed Merck candidate.<br />
<blockquote class="longquote">“The path forward is not clear. I think there is agreement on that. Anybody who talks about a timeline for a vaccine is being silly and uninformed. It will require an incremental process of knowledge, and experimentation, and testing of ideas.” - <cite>Professor John Mellors<sup>22</sup></cite></blockquote>The news media regularly announce a new “breakthrough” in AIDS vaccine research. However, most of these stories refer to products in Phase I or Phase II trials, where there has been no evidence of the product actually working in humans. Such stories are realistically talking only about potential breakthroughs.<br />
Few if any vaccines are 100% effective. Most probably the first AIDS vaccines to succeed in trials will offer only partial protection, and these may need to be improved or combined with other products before being suitable for widespread use. Vaccine development is likely to proceed by small, incremental steps; we are unlikely to see an immediate “miracle breakthrough”.<br />
<h2>Reaching people in need</h2>If trials conclusively find a particular AIDS vaccine to be safe and effective then the next challenge is to distribute it and help people access it. In addition both governments and individuals will need to be convinced that the product is worth investing in. The process of getting a vaccine to all the hundreds of millions of people in need could take many years.<br />
An important consideration is whether a vaccine could undermine the popularity of existing HIV prevention methods, such as condoms. If a product is only partially effective (as is almost inevitable) then experts will have to weigh up the potential risks and benefits very carefully before considering distribution. Upon release of any product, awareness-raising and prevention efforts will need to be redoubled to counter the risk of complacency.<br />
<h2>Should the development of an AIDS vaccine be a priority?</h2>It is very unlikely that HIV and AIDS will ever be eradicated without new scientific developments. Eventually, unless great progress is made in prevention, the number of people living with HIV will outstrip the resources available for treatment. Many people therefore believe that the search for an effective AIDS vaccine must be one of the highest priorities for scientific research.<br />
However, it is not realistic to expect such research to produce a major breakthrough for some time yet, and it is important to be wary of news stories suggesting otherwise. Any new discovery needs to undergo trials lasting years, and must then be distributed around the world before its full benefits will be seen. There is also a danger that too much emphasis on the development of an AIDS vaccine will diverted both attention and resources away from existing successful initiatives such as HIV prevention and antiretroviral treatment programmes.<br />
<blockquote class="longquote">“The world is jumping into a flurry of excitement about a possible solution many years down the line – nobody seems to be in a similar flurry about the fact that, right now, two out of three people who need ART to stay alive aren’t receiving it.” – <cite>Paula Akugizibwe, AIDS and Rights Alliance for Southern Africa<sup>23</sup></cite></blockquote></div><br />
<div class="box bFull" id="footnote"> <h2>References:</h2><ol><li>Ross, A.L, Bråve, A, Scarlatti, G, Manrique, A & Buonaguro, L (2010) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/20417413" target="_blank">'Progress towards development of an HIV vaccine: report of the AIDS Vaccine 2009 Conference'</a>, Lancet Infectious Diseases, Vol 10, May 2010</li>
<li>International AIDS Vaccine Initiative (2006) <a ,="" href="https://www.iavi.org/publications-resources/pages/PublicationDetail.aspx?pubID=1365" target="blank">‘Estimating the impact of an AIDS vaccine in developing countries’</a>. </li>
<li>HIV Vaccines and Microbicides Resource Tracking Working Group (2009, July) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/PressCentre/PressReleases/2009/20090720_PR_Funding.asp" target="blank">‘Adapting to Realities: Trends in HIV prevention research funding, 2000 to 2008’</a>.</li>
<li>HIV Vaccines and Microbicides Resource Tracking Working Group (2009, July) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/PressCentre/PressReleases/2009/20090720_PR_Funding.asp" target="blank">‘Adapting to Realities: Trends in HIV prevention research funding, 2000 to 2008’</a>.</li>
<li>BBC (2003, 12th November) <a ,="" href="http://news.bbc.co.uk/1/hi/health/3265089.stm" target="blank">‘HIV vaccine trial ends in failure’</a>.</li>
<li>HIV Vaccine Trials Network (2007, 8th February) <a ,="" href="http://www.hvtn.org/media/pr/phamfr.html" target="blank">‘Africa’s first large-scale HIV vaccine study launches’</a>.</li>
<li>BBC (2007, 21st September) <a ,="" href="http://news.bbc.co.uk/1/hi/health/7007734.stm" target="blank">‘Merck abandons HIV vaccine trials’</a>.</li>
<li>Perreau, M, Pantaleo, G & Kremer, E.J (2008) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18981239?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum" target="blank">‘Activation of a dendritic cell-T axis by Ad5 immune complexes creates an improved environment for replication of HIV in T cells’</a>, The Journal of Experimental Medicine, 2008 Nov 24;205(12):2717-25.</li>
<li>The New York Times (2007, 8th November) <a ,="" href="http://www.nytimes.com/2007/11/08/health/08hiv.html?_r=1" target="blank">‘In tests, AIDS vaccine seemed to increase risk’</a>.</li>
<li>HIV Vaccine Trials Network <a ,="" href="http://www.hvtn.org/science/step_buch.html" target="blank">‘Step study results’</a>.</li>
<li>Baltimore Sun (2007, 14th November) ‘AIDS vaccine’s failure deals big blow’.</li>
<li>EurekAlert! (2007) <a ,="" href="http://www.innovations-report.com/html/reports/studies/report-95965.html" target="blank">‘IAVI statement on new analysis of STEP large-scale AIDS vaccine trial’</a>.</li>
<li>ClinicalTrials.gov (Updated 22nd June 2009) <a ,="" href="http://www.clinicaltrials.gov/ct/show/NCT00223080" target="blank">‘HIV vaccine trial in Thai adults’</a>.</li>
<li>AVAC (2009) <a ,="" href="http://www.avac.org/ht/d/sp/i/2510/pid/2510" target="_blank">‘Piecing together the HIV prevention puzzle’</a>.</li>
<li>Rerks-Ngarm, S et al (2009) <a ,="" href="http://content.nejm.org/cgi/content/full/NEJMoa0908492" target="_blank">'Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand'</a>, The New England Journal of Medicine, October 2009;361, Massachusetts Medical Society</li>
<li>Rerks-Ngarm, S et al (2009) <a ,="" href="http://content.nejm.org/cgi/content/full/NEJMoa0908492" target="_blank">'Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand'</a>, The New England Journal of Medicine, October 2009;361, Massachusetts Medical Society</li>
<li>IAVI (2009, 24th September) <a ,="" href="http://www.iavi.org/news-center/Pages/PressRelease.aspx?pubID=3158" target="_blank">'IAVI statement on results of Phase III ALVAC-AIDSVAX trial in Thailand'</a></li>
<li>Los Angeles Times (2009, 20th October) <a ,="" href="http://www.latimes.com/news/nationworld/nation/la-sci-aids-vaccine20-2009oct20,0,5109656.story" target="_blank">'Results of AIDS vaccine trial 'weak' in second analysis' </a></li>
<li>AVAC (2009) <a ,="" href="http://www.avac.org/ht/d/sp/i/2510/pid/2510" target="_blank">‘Piecing together the HIV prevention puzzle’</a>.</li>
<li>The New York Times (1984, 24th April) <a ,="" href="http://www.nytimes.com/1984/04/24/science/new-us-report-names-virus-that-may-cause-aids.html?sec=health&&scp=1&sq=heckler+aids&st=nyt" target="blank">‘New U.S. report names virus that may cause AIDS’</a>.</li>
<li>News24 (2009) <a ,="" href="http://www.news24.com/Content/SouthAfrica/News/1059/cd68cc5e02f84d898ebe8beee4785b2e/22-07-2009%2011-07/Aids_vaccine_no_magic_cure" target="blank">‘AIDS vaccine ‘no magic cure’</a>.</li>
<li>Bay Area Reporter (2008, 7th February) <a ,="" href="http://www.aegis.org/news/bar/2008/BR080202.html" target="blank">‘NIH HIV vaccine program criticized’</a>.</li>
<li>News24 (2009) <a ,="" href="http://www.news24.com/Content/SouthAfrica/News/1059/cd68cc5e02f84d898ebe8beee4785b2e/22-07-2009%2011-07/Aids_vaccine_no_magic_cure" target="blank">‘AIDS vaccine ‘no magic cure’</a>.</li>
</ol></div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-71421661425548032142010-06-26T08:30:00.000-07:002010-06-26T08:31:26.686-07:00President's Emergency Plan for AIDS Relief<div class="box bFull"><h2>What is PEPFAR?</h2>The President's Emergency Plan for AIDS Relief, also known as PEPFAR, is America's initiative to combat the global HIV/AIDS epidemic.</div><div class="box bFull"><h3>When did PEPFAR start?</h3><div class="photo_r" style="width: 318px;"><img alt="President Bush
signs the Leadership Act of 2003" border="0" height="215" src="http://www.avert.org/media/photos/521.jpg" width="318" /> <br />
<div style="width: 318px;">President George W. Bush signs the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003</div></div>In his State of the Union Address in January 2003, President George W. Bush made a commitment to substantially increase US support for addressing HIV/AIDS worldwide.<sup>1</sup><br />
<blockquote class="longquote">"I ask the Congress to commit $15 billion over the next five years, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean"<cite> President George W. Bush</cite><br />
<a name='more'></a></blockquote>In May 2003, the US Congress approved, and President Bush signed into law, the "United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003".<sup>2</sup> This legislation approved expenditure of up to $15 billion over 5 years and it provided the legal and policy framework for the expenditure.<br />
The first "new" money of $350 million was made available by Congress in January 2004.<sup>3</sup> Full implementation of PEPFAR began in June 2004.<br />
PEPFAR was reauthorised for a further five years when President Bush signed the “Tom Lantos and Henry J Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008”, in July 2008.<sup>4</sup> The act authorised up to $48 billion for PEPFAR for fiscal years (FY) 2009-2013. It was named in honour of two late congressmen, one Republican and one Democrat, who authored the original 2003 act.<br />
<h3>Is this the total US Government expenditure on HIV/AIDS?</h3>The sum of $48 billion is the proposed expenditure of the US Government for combating HIV/AIDS, malaria and tuberculosis outside of the US over a five-year period. The bulk of this money, $39 billion, is for HIV/AIDS, with $4 billion going towards tuberculosis, and $5 billion for tackling malaria. The act also doubled the US contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria to $2 billion yearly. This is in addition to domestic HIV/AIDS expenditure for which $18.2 billion was requested for FY 2009.<sup>5</sup><br />
<h3>How is the money to be divided between different areas of work?</h3>Under the original 2003 act Congress required that PEPFAR money should be divided in the following way:<sup>6</sup><br />
<ol><li>55% for the treatment of individuals with HIV/AIDS</li>
<li>15% for the palliative care of individuals with HIV/AIDS</li>
<li>20% for HIV/AIDS prevention (of which at least 33% is to be spent on abstinence until marriage programmes)</li>
<li>10% for helping orphans and vulnerable children.</li>
</ol>The 2008 reauthorisation act does not specify in such detail how the money should be spent, though there are still some guidelines:<sup>7</sup><br />
<ol><li> Over half of the funds are to be spent on treatment programmes, including antiretroviral treatment, care for associated opportunistic infections and nutritional support for people living with HIV/AIDS.</li>
<li>In countries with generalised HIV epidemics, at least half of all money directed towards preventing sexual HIV transmission should be for ‘activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction’. If this is not complied with then the Global AIDS Coordinator must report to Congress within 30 days on the reasons behind the shortfall.</li>
<li>The 10% figure directed towards helping orphans has remained. </li>
</ol><h3>Who is in charge of PEPFAR?</h3>The US Global AIDS Coordinator is responsible for coordinating all US Government HIV/AIDS activities. He or she is based in the Department of State and is directly responsible to the Secretary of State.<br />
Dr Eric Goosby was appointed US Global AIDS Coordinator in June 2009.<sup>8</sup> He replaced Dr Mark Dybul, who was asked to step down soon after the inauguration of President Barack Obama.<br />
<h3>Was the US involved in tackling HIV/AIDS overseas prior to PEPFAR?</h3>Prior to the implementation of PEPFAR in 2004 the US Government was already spending significant sums on combating HIV/AIDS outside of the US. However, spending has greatly increased under PEPFAR with $6 billion enacted for PEPFAR in FY 2008 compared with $1.5 billion in FY 2003.<sup>9</sup> Before PEPFAR most expenditure was through bilateral agreements (agreements between the US and one other country). Most of these agreements - including the Mother to Child Prevention Initiative - continued and became part of PEPFAR.<br />
<h3>Which countries benefit from PEPFAR?</h3>The Leadership Against HIV/AIDS Act of 2003 refers to funding relating to combating HIV/AIDS focusing on fourteen specific countries, now usually referred to as “focus” countries:<br />
<span class="highlight_color">Botswana</span>, <span class="highlight_color">Cote d'Ivoire</span>, <span class="highlight_color">Ethiopia</span>, <span class="highlight_color">Guyana</span>, <span class="highlight_color">Haiti</span>, <span class="highlight_color">Kenya</span>, <span class="highlight_color">Mozambique</span>, <span class="highlight_color">Namibia</span>, <span class="highlight_color">Nigeria</span>, <span class="highlight_color">Rwanda</span>, <span class="highlight_color">South Africa</span>, <span class="highlight_color">Tanzania</span>, <span class="highlight_color">Uganda</span> and <span class="highlight_color">Zambia</span>.<br />
When Congress appropriated the funding for FY 2004, they required that a 15th focus country should be added, and that it should be outside of Africa and the Caribbean.<sup>10</sup> <span class="highlight_color">Vietnam</span> was added as an additional focus country in June 2004.<br />
<blockquote class="bigquoteright"><div class="bigquotebody">“An example of non-focus country PEPFAR expenditure is the substantial funding that is being provided for HIV/AIDS work in India.”</div></blockquote>The acronym PEPFAR, or the longer name, the "President's Emergency Plan", are often used confusingly as though they refer solely to the focus countries. However PEPFAR and the President's Emergency Plan refer to all HIV/AIDS expenditure and activities that the US government provides to all countries outside of the US. An example of non-focus country PEPFAR expenditure is the substantial funding that is being provided for HIV/AIDS work in India.<br />
American recognition of the global scale of the epidemic is demonstrated by amendments made to the Foreign Assistance Act of 1961 during PEPFAR's reauthorisation. The amended act specifically names Central Asia, Eastern Europe and Latin America as regions in which ‘the alarming spread of HIV/AIDS … is a major global health, national security, development, and humanitarian crisis’.<sup>11</sup> previously, only sub-Saharan Africa, the Caribbean and 'other developing countries' were mentioned.<br />
<h3>How much money has been enacted (provided by Congress) for PEPFAR so far?</h3>For FY 2004, President Bush requested $1.9 billion for combating global HIV/AIDS, TB and Malaria, suggesting that the annual expenditure would increase from then onwards in order to meet the overall $15 billion target. Congress increased President Bush's figure by $500 million, and in January 2004 appropriated $2.4 billion for HIV/AIDS, tuberculosis and malaria. Of this total, $850 million was "new" money.<sup>12</sup><br />
Funding for HIV/AIDS increased steadily to reach $3.3 billion in FY 2006 and $6.0 billion in FY 2008, which brought the total for the first five-year period to $18.8 billion - exceeding the original commitment of $15 billion. $6.6 billion was enacted for PEPFAR in FY 2009. <sup>13</sup><br />
In 2009 Obama pledged $48 billion for HIV/AIDS over a five-year period, as part of the Global Health Initiative.<sup>14</sup> The total funding request for FY2010 for global HIV/AIDS was $6.7 billion. <sup>15</sup> Funding for 2009-2010 was effectively flat-lined in contrast to the much higher previous year-on-year increases in funding, especially from 2006-2009. In effect, 2010 was the first year US funding for PEPFAR did not increase. Obama's proposed 2011 budget includes almost $7 billion for PEPFAR, representing a 2.2% increase.<sup>16</sup> However, according to some AIDS activists this slight increase is actually a 'step backwards' due to inflation and increasing demand for treatment.<sup>17</sup> The flat-lining of the PEPFAR budget means, so far, the proposed $48 billion target is far from being reached.<br />
<h2>How is PEPFAR changing?</h2>PEPFAR II is a term sometimes used to refer to PEPFAR after it was renewed in 2008. The distinction arises from various changes that were introduced by the reauthorisation act and changes that have occurred since reauthorisation, which have transformed PEPFAR significantly from what it was in its initial five years. In particular, there are a few key factors that will have a strong influence over the future of PEPFAR.<br />
<h3>A new president</h3>In 2009, Barack Obama replaced George Bush as President of the United States. PEPFAR is upheld as one of the most significant accomplishments of Bush’s presidency, and some PEPFAR recipients worried that his departure would mean the end of “the Bush fund”.<sup>18</sup> Although it is certain that PEPFAR will continue under the new president, there has been much speculation about the way in which it will continue.<br />
Many AIDS organisations have welcomed the new administration as an opportunity for change regarding the more controversial aspects of PEPFAR, specifically in terms of prevention. Obama’s election pledge of “best practice, not ideology”, and his decision to overturn the controversial 'global gag rule' have encouraged hopes for positive changes to PEPFAR policy. The 'global gag rule' prevented US funds from going to any organisation that either offered abortions or provided information and counselling on abortions.<br />
<blockquote class="bigquoteright"><div class="bigquotebody">“The lack of new funds means clinics are now being forced to stop enrolling patients.”</div></blockquote>During the election campaign Obama pledged to increase PEPFAR funding to provide $50 billion to fight global HIV/AIDS by 2013, including an increase of $1 billion in new money each year.<sup>19</sup> The President's Global Health Initiative, announced in May 2009, has been criticised for undermining this commitment by extending the time frame of its delivery to six years rather than five. Furthermore, Obama's first budget proposes just $366 million in new money for PEPFAR in FY 2010.<sup>20</sup> It is feared that a lack of political commitment in the enduring economic downturn could jeopardise PEPFAR funding.<sup>21</sup> Indeed, for the majority of recipient countries PEPFAR funding flatlined in 2009, rather than increasing as was expected at the time of reauthorisation.<sup>22</sup> International AIDS activists have expressed concern that shortfalls in funding will have severe health consequences, including significantly reduced numbers of people receiving vital HIV and AIDS treatment.<sup>23</sup><br />
The experiences of many of PEPFAR’s partners indicate that budget uncertainty is already having a detrimental effect. Dr Mugyenyi, Executive Director of the Joint Clinical Research Centre in Uganda, has said that the lack of new funds means clinics are now being forced to stop enrolling patients.<sup>24</sup> The importance of fulfilling PEPFAR’s funding commitments is even greater during the global economic crisis. Peter Piot, former Executive Director of UNAIDS, has warned that rising food and energy costs could exacerbate the spread of HIV and AIDS by increasing vulnerability to the disease. Margaret Chan, Director General of the World Health Organization, has emphasised the danger that the economic crisis poses for national health systems, and the limitations this would create for PEPFAR’s progress.<sup>25</sup><br />
<h3>Partnership Frameworks </h3>Partnership Frameworks were introduced as part of the 2008 reauthorisation act, establishing new guidelines which redefine the roles of the US government and PEPFAR’s partners. PEPFAR promotes the new Partnership Framework model as part of a necessary transition from an emergency response to an approach that ensures sustainability by “strengthening country capacity, ownership, and leadership”.<sup>26</sup><br />
The guidelines focus on several key principles, which had already been raised as suggested improvements in the Institute of Medicine’s report on PEPFAR’s progress.<sup>27</sup> A primary emphasis is on increasing 'host country' autonomy in decision making, in order to promote ‘harmonization’ with national AIDS plans. Another focus is on policy reform, particularly in terms of addressing gender issues and expanding human resources.<sup>28</sup><br />
PEPFAR has proposed Partnership Frameworks with all 15 focus countries, as well as a number of others.<sup>29</sup> As of May 2010, eight Partnership Frameworks had been signed.<sup>30</sup> The Partnership Frameworks must be established before any new funding above FY 2008 levels can be allocated.<sup>31</sup><br />
<h3>Governments - changing roles and increasing responsibilities</h3>Historically, PEPFAR has worked largely through well-established American NGOs, utilising their experience and capacity.<sup>32</sup> This method was seen as the most efficient for an emergency response. As a result, the proportion of PEPFAR funds allocated to governments during its first five years was relatively small. In 2005 just 13% of the money obligated by PEPFAR went to host country governments.<sup>33</sup><br />
The new Partnership Frameworks emphasise the role of host country governments in ensuring an effective and sustainable response to the epidemic.<sup>34</sup> Matias Gomez, Global Fund Fund Portfolio Manager for Latin America and the Caribbean, highlights the positive impact that this change in PEPFAR's focus could have on human resources for health.<sup>35</sup> A 2008 study in Zambia showed that perks gained from working on PEPFAR supported programmes (such as higher salaries, paid overtime, and training opportunities) combined with limited incentives to remain in the public sector (particularly the lack of opportunities for career progression) leads to an "internal brain drain" in which government workers leave their jobs to work for PEPFAR implementing organisations, creating critical shortages in the public sector.<sup>36</sup> Greater investment and coordination with host country governments could help to address the 'brain drain' effect.<br />
Although it is likely that PEPFAR’s funding channels will change as a result of the new partnership agreements, the guidelines do not indicate whether governments will receive a greater proportion of PEPFAR funds than in the past. Integral to PEPFAR's principle of country ownership is the increased financial accountability of host country governments. One of the goals stated in the guidance on Partnership Frameworks is for host countries to increase their share of financial contributions and to rely more on financing from the Global Fund.<sup>37</sup> Although the guidance specifies that increases in host country financial commitments should be relative to the country’s means, there could be repercussions for people on the ground, principally the many NGOs, companies and institutions who rely on PEPFAR funding.<br />
<h2>PEPFAR targets and results</h2><h3>What are the goals of PEPFAR?</h3>President Bush talked about the goals when he made the first announcement of PEPFAR:<br />
<blockquote class="longquote">"This comprehensive plan will prevent 7 million new AIDS infections [sic], treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS." </blockquote>Later it was decided that care should be provided to 10 million people, completing the so-called "2-7-10" goals to be met by 2008.<sup>38</sup><br />
The goals set out for PEPFAR's second phase greatly expand the initial five-year targets set in 2003. Objectives to be achieved by 2014 include:<sup>39</sup><br />
<ul><li>Treating at least 4 million people</li>
<li>Preventing 12 million new HIV infections worldwide</li>
<li>Providing care for 12 million people living with or affected by HIV/AIDS, including 5 million orphans</li>
<li>Providing at least 80% of the target population with services including counselling, testing and treatment to prevent mother-to-child transmission of HIV </li>
<li>Ensuring the proportion of children receiving treatment for HIV/AIDS is relative to the overall infected proportion</li>
<li>Training at least 140,000 new health care workers</li>
</ul>The reauthorisation act of 2008 expanded the range of prevention initiatives that PEPFAR will fund including the diagnosis and treatment of other sexually transmitted infections; engaging vulnerabilities of women and girls; and addressing the stigma and discrimination that can hinder prevention efforts.<br />
The new act also calls for a wider range of initiatives to support communities affected by HIV/AIDS. These include providing nutritional support and counselling, safe drinking water and sanitation, and legal services; a greater integration of HIV/AIDS programmes with those addressing gender-based violence; ‘opt-out’ HIV testing; and a strengthening of national responses to HIV/AIDS and stronger national health systems in general.<sup>40</sup><br />
<h3>What progress is being made towards these goals?</h3>Initially, progress was slow due to an eight month delay between the enactment of PEPFAR and the first money issued by Congress. Full implementation of the programme did not start until June 2004.<sup>41</sup> Consequently, the programme was supporting antiretroviral treatment for 24,900 HIV infected individuals in nine countries by July 2004 - well below the original target set by Congress in the 2003 act.<br />
Once PEPFAR had been fully implemented, rapid results began to be seen with regards to treatment. By the end of September 2005, some 401,000 people were receiving treatment with PEPFAR support in the focus countries, and around 70,000 were benefiting in other countries through US bilateral programmes.<sup>42</sup> The focus country number rose to 822,000 by the end of September 2006,<sup>43</sup> and 1.36 million by the end of September 2007.<sup>44</sup><br />
<blockquote class="bigquoteright"><div class="bigquotebody">“By the end of September 2008 PEPFAR was supporting treatment for over 2.1 million people around the world, exceeding its 2 million target.”</div></blockquote>By the end of September 2008 PEPFAR was supporting treatment for over 2.1 million people around the world, exceeding its 2 million target. This includes 2,007,800 people in the programme’s 15 focus countries. Treatment figures in some countries, however, have fallen short of their intended targets. In Nigeria, for example, 211,500 people were receiving treatment by the end of September 2008 compared to the goal of 350,000. The number on treatment in Ethiopia fell short of the 210,000 target by over 90,000.<sup>45</sup><br />
With regard to prevention, PEPFAR will measure its achievements in 2010 using US Census Bureau statistical models of country-level prevelance trends.<sup>46</sup> To date, the only estimates of prevented infections are those averted through the prevention of mother-to-child transmission. It is estimated that almost 240,000 infant infections were averted over PEPFAR’s first five years.<sup>47</sup><br />
In FY 2004 around 125,500 women were provided with antiretroviral therapy to prevent infection of their unborn children, and as a result an estimated 23,700 infant infections were averted. The figures for FY 2005 were slightly lower and the target of a 20% reduction in infant infections was not met.<sup>48</sup> Results were much better in FY 2006, with around 285,600 pregnant women receiving the preventive drugs, improving again to 294,000 in 2007. The proportion of HIV-positive, pregnant women in focus countries receiving antiretroviral drugs rose from 9% in FY 2004 to 21% in FY 2006.<sup>49</sup><br />
By the end of September 2008, PEPFAR had supported treatment for more than 2.1 million people. Nearly 9.7 million people in PEPFAR’s focus countries had received care (10.1 million, globally) including nearly 4 million orphans and vulnerable children. PEPFAR has also supported 57 million counselling and testing sessions.<sup>50</sup><br />
<h3>What progress is being made towards treatment targets in individual focus countries?</h3>The table below shows the number provided with treatment by July 2004<sup>51</sup>, September 2004<sup>52</sup>, September 2005<sup>53</sup>, September 2006<sup>54</sup>, September 2007<sup>55</sup> and September 2008.<sup>56</sup><br />
<table><tbody>
<tr> <th>Country</th> <th>Provided treatment by July 2004 (direct US support)</th> <th>Provided treatment by end September 2004</th> <th>Receiving treatment end September 2005</th> <th>Receiving treatment end September 2006</th> <th>Receiving treatment end September 2007 </th><th>Receiving treatment end September 2008</th> </tr>
<tr> <td class="row_title">Botswana</td> <td><br />
</td> <td>32,900</td> <td>37,300</td> <td>67,500</td> <td>90,500</td> <td>111,700</td> </tr>
<tr> <td class="row_title">Côte d'Ivoire</td> <td>400</td> <td>4,500</td> <td>11,100</td> <td>27,600</td> <td>46,000</td> <td>50,500</td> </tr>
<tr> <td class="row_title">Ethiopia</td> <td><br />
</td> <td>9,500</td> <td>16,200</td> <td>40,000</td> <td>81,800</td> <td>119,600</td> </tr>
<tr> <td class="row_title">Guyana</td> <td><br />
</td> <td>500</td> <td>800</td> <td>1,600</td> <td>2,100</td> <td>2,300</td> </tr>
<tr> <td class="row_title">Haiti</td> <td><br />
</td> <td>2,800</td> <td>4,300</td> <td>8,000</td> <td>12,900</td> <td>17,700</td> </tr>
<tr> <td class="row_title">Kenya</td> <td>2,700</td> <td>17,100</td> <td>44,700</td> <td>97,800</td> <td>166,400</td> <td>229,700</td> </tr>
<tr> <td class="row_title">Mozambique</td> <td><br />
</td> <td>5,200</td> <td>16,200</td> <td>34,200</td> <td>78,200</td> <td>118,000</td> </tr>
<tr> <td class="row_title">Namibia</td> <td>2,500</td> <td>4,000</td> <td>14,300</td> <td>26,300</td> <td>43,700</td> <td>56,100</td> </tr>
<tr> <td class="row_title">Nigeria</td> <td>500</td> <td>13,500</td> <td>28,500</td> <td>67,100</td> <td>126,400</td> <td>211,500</td> </tr>
<tr> <td class="row_title">Rwanda</td> <td>100</td> <td>4,300</td> <td>15,900</td> <td>30,000</td> <td>44,400</td> <td>59,900</td> </tr>
<tr> <td class="row_title">South Africa</td> <td>3,700</td> <td>12,200</td> <td>93,000</td> <td>210,300</td> <td>329,000</td> <td>549,700</td> </tr>
<tr> <td class="row_title">Tanzania</td> <td>100</td> <td>1,500</td> <td>14,700</td> <td>44,300</td> <td>96,700</td> <td>144,100</td> </tr>
<tr> <td class="row_title">Uganda</td> <td>7,300</td> <td>33,000</td> <td>67,500</td> <td>89,200</td> <td>106,000</td> <td>145,000</td> </tr>
<tr> <td class="row_title">Vietnam*</td> <td><br />
</td> <td>0</td> <td>700</td> <td>6,600</td> <td>11,700</td> <td>24,500</td> </tr>
<tr> <td class="row_title">Zambia</td> <td>1,500</td> <td>13,600</td> <td>36,000</td> <td>71,500</td> <td>122,700</td> <td>167,500</td> </tr>
<tr> <td class="table_special">Total</td> <td class="table_special">18,800</td> <td class="table_special">155,000</td> <td class="table_special">401,000</td> <td class="table_special">822,000</td> <td class="table_special">1,358,500</td> <td class="table_special">2,007,800</td> </tr>
</tbody> </table>* Vietnam was designated a focus country on 23rd June 2004 and was not included in the reporting period to the end of September 2004.<br />
These numbers refer only to people receiving antiretroviral treatment supported by PEPFAR (for data on the total number of people receiving treatment from all sources, see our treatment access table [PDF]).<br />
<h3>What do these numbers really mean?</h3>There are a few issues worth bearing in mind when interpreting PEPFAR treatment figures.<br />
In most cases PEPFAR provides only part of the support needed to enable people to access treatment. In particular, many thousands of people are on treatment supported by both PEPFAR and the Global Fund. In FY 2007 the Global Fund supported treatment for around 864,000 people in the fifteen focus countries, and the US government believes that the vast majority of these people also received some support from PEPFAR. Therefore most, if not all, of these people are counted by both organisations.<sup>57</sup><br />
PEPFAR's numbers include not only those assisted through site-specific support of treatment centres, but also those supported by PEPFAR through contributions to national, regional or local "system strengthening" (including such activities as staff training, laboratory support, logistics, and curriculum development). Of the 1.64 million on treatment in March 2008, some 1.29 million (79%) received direct, site-specific support.<sup>58</sup><br />
In some countries such as Botswana, a small contribution to clinic costs by PEPFAR funding is resulting in all of the people attending certain clinics being credited to PEPFAR.<sup>59</sup> Some Botswanan health officials have argued that in fact zero patients in Botswana have been put on treatment because of PEPFAR.<sup>60</sup> It is unclear exactly how much PEPFAR needs to contribute to someone's treatment in order to include them in its treatment figures.<br />
PEPFAR, the Global Fund, and indeed the WHO do seem to be attaching great importance to the number of people receiving antiretroviral treatment, and who is credited with achieving this. It is indeed excellent news that in countries such as Kenya and Zambia, an increasing number of people are receiving treatment. However, there also needs to be great importance paid to the quality of treatment, because if insufficient attention is given to such matters as adherence then not only will people die despite receiving treatment, but also a great deal of money will be wasted.<br />
This sudden but very welcome increase in numbers may also obscure some of the real difficulties which exist with the scaling up of treatment.<br />
<h3>What are some of the critical issues in the scaling up of treatment?</h3>A number of major difficulties have been identified as hampering the efforts to expand access to antiretroviral treatment in the focus countries.<sup>61</sup> These difficulties include:<br />
<ol><li>coordination difficulties amongst both US and non US agencies</li>
<li>US government policy constraints</li>
<li>shortages of qualified focus country health workers</li>
<li>focus country government restraints</li>
<li>weak infrastructure, including data collection and reporting systems, and drug supply systems.</li>
</ol><h2>PEPFAR policies</h2><h3>Can generic drugs be purchased with PEPFAR money?</h3>PEPFAR money is used to purchase a wide range of supplies. These include such diverse items as soap and non-sterile gloves (for home care kits), laboratory equipment for CD4 counts, other laboratory supplies such as fridges, and breast-milk substitutes (for the prevention of mother-to-child transmission). Several billion dollars of PEPFAR money is spent on the purchase of HIV antiretroviral drugs.<br />
PEPFAR guidance has never directly prohibited the use of PEPFAR money to purchase lower priced generic drugs. However, the purchase of most generic drugs was initially excluded by PEPFAR’s policy that all drugs had to be approved by the US Food and Drug Administration (FDA) or a regulatory agency in Canada, Japan or Western Europe.<sup>62</sup> Most generic antiretrovirals were only pre-qualified by the World Health Organisation (WHO), which was not sufficient under PEPFAR regulations despite being a widely trusted system among other donors and national governments. Furthermore, the policy totally excluded the purchase of Fixed Dose Combinations (FDCs), none of which were approved by the FDA.<sup>63</sup><br />
<div class="photo_r"><img alt="Protesting over
the resistance of the US govt to the widespread use of generic ARVs" border="0" src="http://www.avert.org/media/photos/1184.jpg" width="300" /> <br />
<div style="width: 300px;">2004 demonstration against US policies on generic AIDS drugs.</div></div>In May 2004 the FDA announced an accelerated review process for FDCs and generic drugs, and it was agreed that drugs approved through this process could then be purchased with PEPFAR money "where international patent agreements permit them to be purchased’.<sup>64</sup> But although FDA approval can be provided in as little as six weeks after submission of an application, the first drugs received "tentative" FDA approval through this route only in December 2004.<sup>65</sup><br />
By August 2005, nine generic drugs had won FDA approval. However none could be distributed by PEPFAR because several African countries refused to trust the FDA, and insisted the drugs be approved by the WHO before allowing them to be imported. To solve this unforeseen problem, FDA officials agreed to share with the WHO its files about the drugs, so that the WHO could quickly add them to its list of approved medicines.<sup>66</sup> PEPFAR eventually began distributing generics towards the end of 2005, by which time 15 such drugs had been approved by the FDA, including two FDCs.<sup>67</sup><br />
By December 2007 the FDA had approved 57 generic antiretroviral drugs, including eight FDCs and 14 paediatric formulations.<sup>68</sup> In FY 2006 generics accounted for only 27% of spending on drug procurement in focus countries,<sup>69</sup> but in FY 2007 some 73% of all antiretroviral drugs delivered by PEPFAR were generics.<sup>70</sup> Critics say that unnecessary bureaucracy has slowed the transition to using generics.<sup>71</sup><br />
A complete list of all PEPFAR approved antiretroviral drugs can be found on the U.S Food and Drug Administration website.<br />
<h3>How important is it that generics and FDCs are made available through PEPFAR?</h3>The inclusion of FDCs is potentially very important because of the beneficial effect FDCs have on adherence.<sup>72</sup> <sup>73</sup> FDCs are not only very important for developing countries but could also be very useful for some people in more developed countries such as the USA and UK.<br />
Generic copies of AIDS drugs are usually cheaper than brand-name versions, so potentially enable more people to receive treatment. Purchasing generics in FY 2007 saved PEPFAR partners an estimated $64 million.<sup>74</sup><br />
<h3>Is it proposed that a very significant amount of PEPFAR money be spent on promoting "abstinence until marriage"?</h3>The 2008 act states that in countries with generalised HIV epidemics, at least half of all money directed towards preventing sexual HIV transmission should be for activities promoting abstinence, monogamy and partner reduction. Failing this the Global AIDS Coordinator is required to report to Congress within 30 days justifying the shortfall. It is not yet clear what possible steps would follow the coordinator's report.<br />
Unlike in the 2003 act, the proportion of funds designated for prevention efforts as a whole is not stated.<br />
<h3>What was the allocation for abstinence programmes under the first PEPFAR act?</h3>In the original PEPFAR legislation HIV prevention was allocated 20% of total expenditure, and Congress specified that at least a third of this money should be spent on abstinence until marriage programmes. In late 2005, PEPFAR introduced a new rule that at least two-thirds of all funds for preventing sexual transmission of HIV should be spent on promoting abstinence and being faithful (known as "AB" strategies). The remaining one third of money for preventing sexual transmission was supposed to be spent on "condoms and related activities".<br />
These spending requirements were the focus of considerable discussion; many people questioned the effectiveness of promoting abstinence at the apparent expense of other initiatives such as the distribution of condoms.<br />
<h3>What condom programmes does PEPFAR fund?</h3>The original PEPFAR five-year strategy document mentioned condom provision and promotion only for those who practice high-risk behaviours. Those who practice high-risk behaviours include "prostitutes, sexually active discordant couples [in which one partner is known to have HIV], substance abusers, and others". Condoms were not mentioned as a strategy for helping young people in general.<sup>75</sup> This approach differed significantly from previous US policy and the policies of other donors including the Global Fund and the European Union.<br />
It is unclear whether this policy will be retained over PEPFAR's second five-year term.<br />
<h3>What are the effects of these prevention policies?</h3>There have been some reports of organisations refusing US funding because they believe condoms should be promoted beyond "high risk" groups. Such groups fear that PEPFAR's approach will lead to re-stigmatisation of condoms, and will promote the notion that condoms don't work as a form of HIV prevention.<sup>76</sup> However Dr Mark Dybul, the previous Global AIDS Coordinator, has claimed that,<br />
<blockquote class="longquote">"It is impossible for a site to be told to stop distributing condoms, or to close because of condom distribution... it would be directly contravening the stated policy of the U.S. government to say that because someone distributes condoms, they cannot receive resources from the U.S. government."</blockquote>Dr Dybul has also insisted that,<br />
<blockquote class="longquote">"The notion that there's an excessive focus on abstinence is just untrue... The policy both in the guidance we issue and in the programs we support is fully ABC - abstain, be faithful, and correct and consistent use of condoms."<cite><sup>77</sup></cite></blockquote>In April 2006, the Government Accountability Office (GAO) released the results of an extensive investigation of PEPFAR's policies for preventing sexual HIV transmission. Seventeen of the twenty country teams interviewed by the GAO said that fulfilling the spending requirements set by PEPFAR presented "challenges to their ability to respond to local prevention needs." Some said that they had had to scale down efforts to prevent mother-to-child transmission or to improve blood safety in order to try to meet the one-third AB requirement, and many said that not enough emphasis was being placed on condoms. In one country, the budget for outreach work with high-risk groups such as sex workers, sexually active youth and discordant couples was cut from $8 million to $4 million in order to meet AB requirements.<sup>78</sup><br />
Moreover the official funding rules may not be the only constraints on the type of work that is carried out. According to one of PEPFAR's implementing partners in Nairobi:<br />
<blockquote class="longquote">"There are perceived restrictions in PEPFAR about what you can discuss with whom, so everyone is being very cautious... People are afraid to discuss family planning, condoms, abortion - so many groups don't address them at all."<cite><sup>79</sup></cite></blockquote>This opinion is echoed by Canon Gideon, an HIV-positive Anglican minister from Uganda:<br />
<blockquote class="longquote">"The policy is making people fearful to talk comprehensively about HIV, because they think if they do, they will miss funding. Although they know the right things to say, they don't say them, because they fear that if you talk about condoms and other safe practices, you might not get access to this money."<cite><sup>80</sup></cite></blockquote>A study of the impacts of PEPFAR in Zambia found that several PEPFAR funded organisations had not only stopped promoting condoms, but had eliminated any reference to condoms in their programmes out of fear that they would lose their funding. The programme implementers believed that these measures were required by PEPFAR.<sup>81</sup><br />
Such reports have led many to criticise PEPFAR for disproportionately funding abstinence and fidelity programmes. Critics have included the HIV Medicine Association (HIVMA) and the Infectious Diseases Society of America (IDSA);<sup>82</sup> prominent American HIV prevention experts;<sup>83</sup> <sup>84</sup> and non-governmental organisations such as ActionAid International, CARE and the Elizabeth Glaser Pediatric AIDS Foundation.<sup>85</sup> <sup>86</sup><br />
In a statement widely viewed as a criticism of PEPFAR policy, the European Union has said it is "profoundly concerned about the resurgence of partial or incomplete messages on HIV prevention which are not grounded in evidence and have limited effectiveness."<sup>87</sup><br />
<h3>Other funding restrictions</h3>PEPFAR sets other funding restrictions that are not necessarily based on evidence of what is most effective in combatting HIV/AIDS.<br />
<span class="highlight_color">Needle exchange programmes</span><br />
The First Annual Report states that, "Emergency Plan funds will not support needle or syringe exchange".<sup>88</sup> Many people have objected to this because needle exchange programmes have been proven to help reduce the spread of blood-borne HIV by providing injecting drug users with sterile syringes, without encouraging drug use. In some areas, this may be part of a wider harm reduction strategy, whereby users are given a safe, monitored place to inject and/or pure uncontaminated drugs to reduce the risk of overdose. However, the US government is opposed to such measures as it believes they make drug use seem more acceptable, and facilitate continued drug use.<br />
<span class="highlight_color">Sex workers</span><br />
The "Leadership" act of 2003 states that, "No funds made available to carry out this Act, or any amendment made by this Act, may be used to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking."<sup>89</sup> This condition (sometimes called the "Prostitution Loyalty Oath") led to Brazil refusing $40 million of PEPFAR funds in May 2005. The director of Brazil's HIV/AIDS programme explained, "Brazil has taken this decision in order to preserve its autonomy on issues related to HIV/AIDS as well as ethical and human rights principles".The Brazilian government and many organisations believed that adopting the PEPFAR condition would be a serious barrier to helping sex workers protect themselves and their clients from HIV.<sup>90</sup><br />
<blockquote class="bigquoteright"><div class="bigquotebody">“Numerous non-governmental organisations and public health experts believe that the anti-prostitution clause is harmful and should be removed.”</div></blockquote>In January 2006, the BBC World Service Trust abandoned a USAID-funded, multi-million-dollar AIDS awareness campaign in Tanzania because it refused to comply with this anti-prostitution clause. The Trust said it did not want to inhibit its ability to make television and radio programmes that discuss sex workers in a non-judgmental way.<sup>91</sup> As a result Tanzania was left without any mass media programme to combat HIV.<br />
Numerous non-governmental organisations and public health experts believe that the anti-prostitution clause is harmful and should be removed.<sup>92</sup> <sup>93</sup> Some have tried to challenge its legality under the First Amendment of the US constitution, which guarantees the right to free speech. In May 2006, two American judges ruled in two separate cases that the clause did indeed violate the First Amendment and so could not be applied to the US-based organisations that brought the cases, though all overseas groups wishing to receive US Government funding, whether directly or indirectly, would still have to comply.<sup>94</sup> In February 2007 a higher court overturned one of these rulings.<sup>95</sup> It is therefore likely that the clause will continue to be imposed unless and until it is repealed by new legislation.<br />
<span class="highlight_color">Safe abortion services</span><br />
The 'Global Gag Rule', also known as the 'Mexico City Policy', denied US international family planning funding to foreign non-governmental organisations that provide safe abortion services, counselling, referral, or information about safe abortion, advocate for changes in abortion law in their own country, conduct research on the effects of unsafe abortion, or otherwise work on safe abortion issues.<br />
In August 2003, President Bush released an Executive Order specifically exempting HIV/AIDS funds from restrictions under the Global Gag Rule. However, the restriction appeared twice in Kenya's $193 million Request for Application (RFA) for HIV/AIDS prevention, treatment and care, released by USAID in November 2005.<sup>96</sup> The inclusion seems to have been due to administrative error, and the document was later retracted. Nevertheless, there remained confusion about how the Global Gag Rule related to HIV/AIDS funding, and some organisations may have been denied funds as a result. Moreover, the policy was a significant obstacle to the integration of HIV prevention with reproductive health services.<br />
President Obama rescinded the Global Gag Rule very soon after assuming office in January 2009, hopefully ending any doubts or confusion over whether organisations with particular abortion policies could receive PEPFAR funding.<br />
In pursuit of rapid results, PEPFAR is in some cases taking over established projects that already had sufficient (though perhaps less generous) funding from other donors. In order to qualify for US support, the organisations running such projects are compelled to sign documents setting out what activities they may and may not perform. Successful programmes may be terminated if they do not comply with PEPFAR conditions. Organisations that have previously relied on large amounts of US money may have great difficulty securing alternative funding should they refuse to comply with the new "morality clauses".<br />
<h3>Are there any other controversial areas?</h3>Another controversial area has been the circumventing of the Global Fund to Fight AIDS, Tuberculosis and Malaria, by directing the bulk of resources to a separate initiative. Nevertheless, the US Government is still the greatest sponsor of the Global Fund. Under the 2008 PEPFAR reauthorisation act, America doubled its yearly contribution to $2 billion.<br />
The controversial areas of PEPFAR have at times overshadowed what has already been achieved, which is the channelling of hundreds of millions of newly appropriated funds to treatment programmes for tens of thousands of AIDS patients around the world.<sup>97</sup><br />
<blockquote class="longquote">"Since I started medication and I realized that I'm strong, I can do other things, my feelings are coming back. That's why I went back to school. What I was planning, I can now do it. So when you talk of PEPFAR, that's my life, because without it, I could have not lived."<cite>John Robert Ongole, the first recipient of PEPFAR-supported antiretroviral treatment.<sup>98</sup></cite></blockquote></div><br />
<div class="box bFull" id="footnote"><h2>References</h2><ol><li>CNN (2003, 29th January), '<a ,="" href="http://edition.cnn.com/2003/ALLPOLITICS/01/28/sotu.transcript/" target="_blank">Bush's state of the union speech</a>'.</li>
<li><a ,="" href="http://thomas.loc.gov/cgi-bin/bdquery/z?d108:h.r.01298:" target="_blank">United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003</a><span class="externallink"></span>.</li>
<li>United States General Accounting Office (2004, July), '<a ,="" href="http://www.gao.gov/docsearch/locate?searched=1&o=0&order_by=rel&search_type=publications&keyword=GAO-04-784&Submit=Search" target="_blank">U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain</a>'.</li>
<li><a ,="" href="http://www.thomas.gov/cgi-bin/bdquery/z?d110:h.r.05501:" target="_blank">Tom Lantos and Henry J Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008</a><span class="externallink"></span></li>
<li>The Henry J Kaiser Family Foundation (2008, April), '<a ,="" href="http://www.kff.org/hivaids/7029.cfm" target="_blank">US federal funding for HIV/AIDS: fiscal year 2009</a>'.</li>
<li><a ,="" href="http://thomas.loc.gov/cgi-bin/bdquery/z?d108:h.r.01298:" target="_blank">United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003</a><span class="externallink"></span></li>
<li><a ,="" href="http://www.thomas.gov/cgi-bin/bdquery/z?d110:h.r.05501:" target="_blank">Tom Lantos and Henry J Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008</a><span class="externallink"></span></li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2009, 19th June), '<a ,="" href="http://www.pepfar.gov/press/releases/2009/125208.htm" target="_blank">Confirmation of Dr. Eric Goosby to be Ambassador at Large and Global AIDS Coordinator</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, May), "<a ,="" href="http://www.pepfar.gov/press/80064.htm" target="_blank">Making a Difference: Funding</a>".</li>
<li>PL108-199 (FY 2004 Consolidated Appropriations Bill)</li>
<li><a ,="" href="http://www.thomas.gov/cgi-bin/bdquery/z?d110:h.r.05501:" target="_blank">Tom Lantos and Henry J Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008</a><span class="externallink"></span></li>
<li>US Department of State (2004, February), '<a ,="" href="http://2001-2009.state.gov/s/gac/plan/c11652.htm" target="_blank">U.S. Five Year Global HIV/AIDS Strategy</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, November), '<a ,="" href="http://www.pepfar.gov/press/80064.htm" target="_blank">Making a difference: funding</a>'.</li>
<li>[PDF] www.theglobalhealthinitiative.org (2009, October)<a ,="" href="http://www.theglobalhealthinitiative.org/documents/report.pdf" target="_blank"> 'The Future of Global Health: Ingredients for a Bold and Effective U.S Initiative'.</a></li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, November), '<a ,="" href="http://www.pepfar.gov/press/80064.htm" target="_blank">Making a difference: funding</a>'.</li>
<li>Bloomberg (2010, 1st Feb) <a ,="" href="http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aznIEv0H74Jw" target="_blank">'Obama boosts World Health Programs 9% to $8.5 billion'</a>.</li>
<li>IPS (2010, 12th March) '<a ,="" href="http://ipsnews.net/news.asp?idnews=50651" target="_blank">U.S AIDS Fund Flat-lining, Groups Complain</a>'</li>
<li>The New York Times (2008, 5th January) '<a ,="" href="http://www.nytimes.com/2008/01/05/washington/05aids.html?fta=y" target="_blank">In Global Battle on AIDS, Bush Creates Legacy</a>'.</li>
<li>The Body (2009, 6th May), '<a ,="" href="http://www.thebody.com/content/govt/art51625.html" target="_blank">Obama Proposes $63 Billion Global Health Initiative Over Six Years</a>'.</li>
<li>The White House (2009, May), '<a ,="" href="http://www.whitehouse.gov/omb/budget/" target="_blank">The President's Budget for Fiscal Year 2010</a>'.</li>
<li>The Lancet (2009, 18th April), '<a ,="" href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960755-8/fulltext" target="_blank">Obama administration may flat-line funding for PEPFAR</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, June), '<a ,="" href="http://www.pepfar.gov/about/c30152.htm" target="_blank">Fiscal year 2009: PEPFAR country operational plan</a>'.</li>
<li>Global AIDS Alliance (2009, 7th May), '<a ,="" href="http://www.globalaidsalliance.org/index.php/1219/" target="_blank">President Obama’s FY10 Budget Breaks His Campaign Promises on Global Issues</a>'.</li>
<li>Dr Peter Mugyenyi (2009, 16th March), '<a ,="" href="http://csis.org/multimedia/audio-last-decade-mobilization-against-hivaids-uganda" target="_blank">The Last Decade: Mobilization Against HIV/AIDS in Uganda</a>' [conference].</li>
<li>The Henry J Kaiser Family Foundation (2008, 29th October), '<a ,="" href="http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=55247" target="_blank">Global financial crisis could harm HIV/AIDS funding</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, December), '<a ,="" href="http://www.pepfar.gov/strategy/" target="_blank">PEPFAR: Five Year Strategy</a>'.</li>
<li>The Institute of Medicine (2007) ‘<a ,="" href="http://www.nap.edu/catalog.php?record_id=11905" target="_blank">PEPFAR Implementation: Progress and Promise</a>’.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, 11th march) '<a ,="" href="http://www.pepfar.gov/guidance/framework/index.htm" target="_blank">Draft Guidance for PEPFAR Partnership Frameworks and Partnership Framework Implementation Plans: Version 1</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, May) '<a ,="" href="http://www.pepfar.gov/press/121652.htm" target="_blank">Partnering in the fight against HIV/AIDS</a>'.</li>
<li>The U.S President's Emergency Plan for AIDS Relief (2010) '<a ,="" href="http://www.pepfar.gov/frameworks/index.htm" target="_blank">Partnership Frameworks</a>'</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, 11th March) '<a ,="" href="http://www.pepfar.gov/guidance/framework/index.htm" target="_blank">Draft Guidance for PEPFAR Partnership Frameworks and Partnership Framework Implementation Plans: Version 1</a>'.</li>
<li>Center for Global Development (2007, October), '<a ,="" href="http://www.cgdev.org/content/publications/detail/14569" target="_blank">Following the funding for HIV/AIDS</a>'.</li>
<li>Center for Global Development (2008), '<a ,="" href="http://www.cgdev.org/content/publications/detail/15799" target="_blank">The numbers behind the stories: PEPFAR funding for fiscal years 2004-2006</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, December), '<a ,="" href="http://www.pepfar.gov/strategy/" target="_blank">PEPFAR: Five Year Strategy</a>'.</li>
<li>Matias Gomez (2009, 12th May), 'Disease of Poverty: Current Progress Towards MDG 6 in Latin America' [Seminar].</li>
<li>Hanefeld J. & Musheke M. (2009, 10th February), '<a ,="" href="http://www.human-resources-health.com/content/7/1/8" target="_blank">What impact do global health initiatives have on human resources for antiretroviral treatment roll-out? A qualitative policy analysis of implementation processes in Zambia</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009. 11th March) '<a ,="" href="http://www.pepfar.gov/guidance/framework/index.htm" target="_blank">Draft Guidance for PEPFAR Partnership Frameworks and Partnership Framework Implementation Plans: Version 1</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2005, March), '<a ,="" href="http://www.state.gov/s/gac/rl/c14961.htm" target="_blank"><span class="externallink">Engendering Bold Leadership: First Annual Report to Congress on PEPFAR</span></a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2009, December), '<a ,="" href="http://www.pepfar.gov/strategy/" target="_blank">PEPFAR: Five Year Strategy</a>'.</li>
<li><a ,="" href="http://www.thomas.gov/cgi-bin/bdquery/z?d110:h.r.05501:" target="_blank">Tom Lantos and Henry J Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008</a><span class="externallink"></span></li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2004, August), '<a ,="" href="http://www.pepfar.gov/progress/" target="_blank"><span class="externallink">Bringing Hope and Saving Lives: Building Sustainable HIV/AIDS Treatment</span></a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2006, February), '<a ,="" class="externallink" href="http://www.state.gov/s/gac/rl/c16742.htm" target="_blank">Action Today, A Foundation For Tomorrow: Second Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2006, December), '<a ,="" href="http://www.pepfar.gov/press/c19592.htm" target="_blank"><span class="externallink">Latest Treatment Results</span></a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2007, December), '<a ,="" href="http://2006-2009.pepfar.gov/press/95911.htm" target="_blank">World AIDS Day 2007: The Power of Partnerships</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, 1st December), '<a ,="" href="http://www.pepfar.gov/about/c19785.htm" target="_blank">Celebrate Life: Latest PEPFAR Results</a>'.</li>
<li>Institute of Medicine (2007) ‘<a ,="" href="http://www.nap.edu/catalog.php?record_id=11905#toc" target="_blank">PEPFAR Implementation: Progress and Promise</a>’.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, 1st December), '<a ,="" href="http://www.pepfar.gov/about/c19785.htm" target="_blank">Celebrate Life: Latest PEPFAR Results</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2006, February), '<a ,="" class="externallink" href="http://www.state.gov/s/gac/rl/c16742.htm" target="_blank">Action Today, A Foundation For Tomorrow: Second Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2007, March), '<a ,="" class="externallink" href="http://www.pepfar.gov/press/c21604.htm" target="_blank">The Power of Partnerships: Third Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2009, 1st December), '<a ,="" href="http://www.pepfar.gov/progress/" target="_blank">Celebrate Life: Latest PEPFAR Results</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2004, August), '<a ,="" href="http://www.pepfar.gov/progress/" target="_blank"><span class="externallink">Bringing Hope and Saving Lives: Building Sustainable HIV/AIDS Treatment</span></a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2005, March), '<a ,="" href="http://www.state.gov/s/gac/rl/c14961.htm" target="_blank"><span class="externallink">Engendering Bold Leadership: First Annual Report to Congress on PEPFAR</span></a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2006, February), '<a ,="" class="externallink" href="http://www.state.gov/s/gac/rl/c16742.htm" target="_blank">Action Today, A Foundation For Tomorrow: Second Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2006, December), '<a ,="" href="http://www.pepfar.gov/press/c19592.htm" target="_blank"><span class="externallink">Latest Treatment Results</span></a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2007, December), '<a ,="" href="http://2006-2009.pepfar.gov/press/95911.htm" target="_blank">World AIDS Day 2007: The Power of Partnerships</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, 1st December), '<a ,="" href="http://www.pepfar.gov/about/c19785.htm" target="_blank">Celebrate Life: Latest PEPFAR Results</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, February), '<a ,="" href="http://www.pepfar.gov/press/fourth_annual_report/" target="_blank">The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, 1st December), '<a ,="" href="http://www.pepfar.gov/about/c19785.htm" target="_blank">Celebrate Life: Latest PEPFAR Results</a>'.</li>
<li>The Henry J Kaiser Family Foundation (2004, 20th October), '<a ,="" href="http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=26324" target="_blank">Harvard School of Public Health Behind in Administering PEPFAR Grant for HIV/AIDS Treatment Programs</a>'.</li>
<li>Washington Post (2005, 1st July), '<a ,="" href="http://www.washingtonpost.com/wp-dyn/content/article/2005/06/30/AR2005063002158.html" target="_blank">Botswana's Gains Against AIDS Put U.S. Claims to Test</a>'.</li>
<li>United States General Accounting Office (2004, July), <span class="externallink">'<a ,="" href="http://www.gao.gov/products/GAO-04-784" target="_blank">U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain</a>'.</span></li>
<li>Baker B. (2004, 1st March) "<a ,="" href="http://lists.essential.org/pipermail/ip-health/2004-March/005996.html" target="_blank">U.S. Drug Quality Smokescreen Subsidizes Big Pharma</a>"<a ,="" href="http://lists.essential.org/pipermail/ip-health/2004-March/005996.html" target="_blank"><span class="externallink"></span></a>.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2004, August), '<a ,="" href="http://www.pepfar.gov/progress/" target="_blank"><span class="externallink">Bringing Hope and Saving Lives: Building Sustainable HIV/AIDS Treatment</span></a>'.</li>
<li>US Department of Health and Human Services (2004, 16th May), '<a ,="" href="http://www.hhs.gov/news/press/2004pres/20040516.html" target="_blank">HHS Proposes Rapid Process For Review of Fixed Dose Combination and Co-Packaged Products</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2005, 25th January), '<a ,="" href="http://www.aegis.org/news/USIS/2005/US050101.html" target="_blank">South African Generic Drug Eligible for Use in Emergency Plan</a>'.</li>
<li>The Boston Globe (2005, 14th August), '<a ,="" class="externallink" href="http://www.boston.com/news/world/articles/2005/08/14/accord_could_speed_distribution_of_generic_aids_drugs?mode=PF" target="_blank">Accord could speed distribution of generic AIDS drugs</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2006, February), '<a ,="" class="externallink" href="http://www.state.gov/s/gac/rl/c16742.htm" target="_blank">Action Today, A Foundation For Tomorrow: Second Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, February), '<a ,="" href="http://www.pepfar.gov/press/fourth_annual_report/" target="_blank">The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2007, March), '<a ,="" class="externallink" href="http://www.pepfar.gov/press/c21604.htm" target="_blank">The Power of Partnerships: Third Annual Report to Congress on PEPFAR</a>'.</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, February), '<a ,="" href="http://www.pepfar.gov/press/fourth_annual_report/" target="_blank">The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR</a>'.</li>
<li>The Center for Public Integrity (2006, 13th December), '<a ,="" class="externallink" href="http://www.publicintegrity.org/aids/report.aspx?aid=836" target="_blank">PEPFAR Policy Hinders Treatment in Generic Terms</a>'.</li>
<li>MSF (2004, 19th April), '<a ,="" href="http://www.who.int/3by5/en/untanglingtheweb.pdf" target="_blank"><span class="externallink">Untangling the web of price reductions, 6th edition</span></a>' [PDF].</li>
<li>'<a ,="" href="http://lists.essential.org/pipermail/ip-health/2004-March/006181.html" target="_blank"><span class="externallink">Interchurch Medical Assistance document</span></a>' (2004).</li>
<li>Office of the U.S. Global AIDS Coordinator, U.S. Department of State (2008, February), '<a ,="" href="http://www.pepfar.gov/press/fourth_annual_report/" target="_blank">The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR</a>'.</li>
<li>US Department of State (2004, February), '<a ,="" href="http://2001-2009.state.gov/s/gac/plan/c11652.htm" target="_blank">U.S. Five Year Global HIV/AIDS Strategy</a>'.</li>
<li>"News from home", African HIV Policy Network Issue 7 (vol3.no2), Summer 2005</li>
<li><a ,="" class="externallink" href="http://www.whitehouse.gov/news/releases/2005/11/20051130-13.html" target="_blank">Press Briefing by Conference Call with Dr. Mark Dybul</a>, 30 November 2005</li>
<li>Government Accountability Office (2006, 4th April), '<a ,="" class="externallink" href="http://www.gao.gov/docsearch/abstract.php?rptno=GAO-06-395" target="_blank">Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief</a>'.</li>
<li>Center for Strategic and International Studies (2006, July), '<a ,="" href="http://www.pepfarwatch.org/index.php?option=com_content&task=view&id=99&Itemid=98" target="_blank"><span class="externallink">Integrating Reproductive Health and HIV/AIDS Programs - Strategic Opportunities for PEPFAR</span></a>'</li>
<li><cite>The American Prospect (2007, 10th July), </cite><cite>'<a ,="" href="http://prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans" target="_blank">How Bush's AIDS Program is Failing Africans</a>'.</cite></li>
<li>Sexuality Information and Education Council of the United States (2009), '<a ,="" href="http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&FeatureID=1767" target="_blank">Making Prevention Work: Lessons from Zambia on Reshaping the U.S. Response to the Global HIV/AIDS Epidemic</a>'.</li>
<li>HIVMA and IDSA Joint Policy Statement (2005, March), '<a ,="" href="http://www.hivma.org/Content.aspx?id=2784" target="_blank">Preventing HIV and other Sexually Transmitted Infections: A Call for Science-Based Government Policies</a>'.</li>
<li>Baltimore Sun (2005, 10th December), '<a ,="" href="http://www.globalhealth.org/news/article/6923" target="_blank">More HIV funds to promote abstinence</a>'.</li>
<li>Washington Post (2006, 20th May), '<a ,="" class="externallink" href="http://www.washingtonpost.com/wp-dyn/content/article/2006/05/19/AR2006051901533.html" target="_blank">Where AIDS Funding Should Go</a>'.</li>
<li>PEPFAR Watch '<a ,="" href="http://www.pepfarwatch.org/index.php?option=com_content&task=view&id=101&Itemid=101" target="_blank">National, State, and Local, Endorsing Organizations of the PATHWAY Act of 2006</a>'.</li>
<li>'<a ,="" href="http://www.care.org/newsroom/articles/2006/09/20060906_gayle_testimony.asp" target="_blank"><span class="externallink">Testimony of Dr. Helene Gayle, President and Chief Executive Officer, CARE USA</span></a>' (2006, 6th September).</li>
<li>The Guardian (2005, 1st December), '<a ,="" class="externallink" href="http://www.guardian.co.uk/christmasappeal2005/story/0,16796,1654865,00.html" target="_blank">Europeans reject abstinence message in split with US on Aids</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State (2005, March), '<a ,="" href="http://www.state.gov/s/gac/rl/c14961.htm" target="_blank"><span class="externallink">Engendering Bold Leadership: First Annual Report to Congress on PEPFAR</span></a>'.</li>
<li><a ,="" href="http://thomas.loc.gov/cgi-bin/bdquery/z?d108:h.r.01298:" target="_blank">United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003</a><span class="externallink"></span>.</li>
<li>The Guardian (2005, 4th May), '<a ,="" href="http://www.guardian.co.uk/world/2005/may/04/brazil.aids" target="_blank">Brazil spurns US terms for AIDS help</a>'.</li>
<li>The Guardian (2006, 23rd January), '<a ,="" href="http://www.guardian.co.uk/media/2006/jan/23/mondaymediasection" target="_blank">BBC backs off from Bush in Africa</a>'.</li>
<li>'<a ,="" class="externallink" href="http://www.nswp.org/safety/usaid-letter.html" target="_blank">Letter Regarding the U.S. Global AIDS Act</a>' (2005, 17th May).</li>
<li>'<a ,="" href="http://www.care.org/newsroom/articles/2006/09/20060906_gayle_testimony.asp" target="_blank"><span class="externallink">Testimony of Dr. Helene Gayle, President and Chief Executive Officer, CARE USA</span></a>' (2006, 6th September).</li>
<li>Washington Post (2006, 19th May), '<a ,="" href="http://www.washingtonpost.com/wp-dyn/content/article/2006/05/18/AR2006051801857.html" target="_blank">Prostitution Clause in AIDS Policy Ruled Illegal</a>'.</li>
<li>United States Court of Appeals for the District of Columbia Circuit (2007, 27th February), '<a ,="" href="http://bulk.resource.org/courts.gov/c/F3/477/477.F3d.758.06-5225.html" target="_blank">DKT International, Inc., v. United States Agency for International Development No. 06-5225</a>'.</li>
<li>Center for Health and Gender Equity (2005, 23rd November), '<a ,="" href="http://www.religiousconsultation.org/News_Tracker/global_gag_rule_expanded_to_HIV_funding.htm" target="_blank">Global Gag Rule Expanded to HIV Funding</a>'.</li>
<li>Holly Burkhalter (2004, 27th October), '<a ,="" href="http://www.foreignaffairs.com/articles/64228/holly-burkhalter/trick-or-treat" target="_blank">Trick or treat?</a>'.</li>
<li>Office of the Global AIDS Coordinator, U.S. Department of State<cite> (2006), </cite><cite>'<a ,="" href="http://2006-2009.pepfar.gov/press/76024.htm" target="_blank">Voices of Hope Documentary</a>'.</cite></li>
</ol></div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-32429929685545894672010-06-26T08:11:00.000-07:002010-06-26T08:11:58.424-07:00AIDS & prostitution<div class="box bFull"> For years, ‘prostitution’ has been a major theme in discussions about the global AIDS and HIV epidemic. The media often run stories about HIV that focus on individuals who sell sex, and both governments and HIV related organisations frequently talk about prostitutes and prostitution in the context of AIDS.<br />
</div><div class="box bFull"> <h2>Why is ‘AIDS and prostitution’ an issue?</h2>This topic is significant for several reasons:<br />
<ul><li>High rates of HIV have been found amongst individuals who sell sex in many different and diverse countries. Even where HIV prevalence is low amongst this group, it is usually higher than the rate found amongst the general adult population.</li>
<li>Sex workers usually have a high number of sexual partners. This means that if they do become infected with HIV, they can potentially pass it on to multiple clients.</li>
<li>Preventing HIV infections amongst those involved in the sex trade has been proven to be an instrumental part of many countries’ fight against AIDS. We discuss this issue in our HIV prevention and sex workers page.<a name='more'></a></li>
</ul><h2>‘Prostitutes’ or ‘sex workers’?</h2>Although the word ‘prostitution’ can be used to describe the act of selling sex, it can also mean ‘using a skill or ability in a way that is considered unworthy’. It seems to include a moral judgement, by implying that individuals who sell sex are somehow ‘unworthy’, or involved in a practice that is corrupt. A far more neutral and respectful alternative is the term ‘sex work’.<br />
This issue may not matter so much in the context of everyday conversations or casual debates, but in serious discussions on the topic it is important that words are chosen carefully. Since this article seeks to discuss the issue of HIV and sex work in an open and non-judgemental way, we refer to sex workers rather than prostitutes.<br />
Some authorities continue to talk about prostitutes, but they often do so because they wish to make a moral comment about the sex trade. In addition, some people talk about sex workers ‘fuelling the spread of HIV’. Not only is this an example of poorly chosen wording, but it is also a claim that is questionable in its accuracy.<br />
<h2>What role do sex workers play in the global AIDS epidemic?</h2>Sex workers, along with other marginalised groups such as men who have sex with men and injecting drug users, are often labelled a 'key risk group' in the context of HIV and AIDS. But the debate about sex workers’ wider role in the global AIDS epidemic often polarises opinion. Some argue that sex workers are being wrongly portrayed as ‘spreaders’ of HIV, while others claim that HIV transmission through paid sex is ‘driving’ the epidemic.<br />
In truth, the situation differs vastly between different countries and regions. While HIV prevalence is high amongst sex workers in some areas, in others it is relatively low, and they seem to play a fairly minor role in the spread of HIV. For instance, in most parts of Western Europe and North America, HIV transmission through paid sex is not considered to be a major issue. In other regions, however, notably parts of Asia, large numbers of sex workers are living with HIV, and this is influencing the overall pattern of the AIDS epidemic.<br />
<div class="photo_r"><a href="" id="1" name="1" title="1"></a><img alt="A sex worker
stands in a doorway at Shipha House, a brothel in Northern Thailand " border="0" height="195" src="http://www.avert.org/media/photos/1363.jpg" width="300" /> A sex worker stands in a doorway at a brothel in Northern Thailand.<br />
</div>The factors that put sex workers at risk also vary between countries. In some places, sex workers commonly use drugs and share needles. The overlap between sex work and injecting drug use is linked to growing HIV epidemics in a number of countries, such as China, Indonesia, Kazakhstan, Ukraine, Uzbekistan and Vietnam.<sup>1</sup> Studies often find higher rates of HIV infection amongst sex workers who inject drugs than amongst those who do not. For example, in Ho Chi Minh City, Vietnam’s largest city, a 2003 study found that 49% of sex workers who injected drugs were HIV-positive, compared to 8% of those who did not use any drugs.<sup>2</sup><br />
As well as regional differences between sex workers, the picture is further blurred by a general lack of information on this group. Sex workers are a marginalised and often criminalised population, and are therefore very difficult to track and monitor. <sup>3</sup><br />
Due to the lack of certainty, some people argue that labelling sex workers as a ‘high risk group’ is not helpful, and is simply used an excuse to further stigmatise sex workers by those who are morally opposed to their profession:<br />
<blockquote class="longquote">“Apart from the stigma already attached to [sex workers], society has further marginalised them as core transmitters of the HIV infection. It fails to understand and recognise that they are but links in the broad networks of heterosexual transmission of HIV. And that they constitute a community that bears and will continue to bear the greatest impact of the HIV epidemic.” <cite>Meena Seshu, SANGRAM (a project working with sex workers in India)<sup>4</sup></cite></blockquote>It is certainly true that sex workers are simply one part of the wider network of HIV transmission, and that ‘blaming’ them for the spread of HIV is misguided. Those who do blame sex workers seem to take an ‘us and them’ approach to the issue, and talk about sex workers as if they are somehow inferior to other population groups. Ultimately, whatever moral stance you take on sex work, no one deserves to become infected with HIV.<br />
While it is important that sex workers are protected from discrimination, and that their role in the global AIDS and HIV epidemic is not overstated, it is equally important that high rates of infection amongst sex workers are not overlooked. There is evidence that commercial sex is a significant factor in many countries’ AIDS epidemics.<br />
<h2>HIV and sex work around the world</h2><h3>Asia</h3>In Asia, which contains some of the fastest growing AIDS epidemics in the world, it is believed that a high proportion of new HIV infections are transmitted during paid sex.<sup>5</sup><br />
Historically, the AIDS epidemic in India was first identified amongst sex workers and their clients, before other sections of society became affected.<sup>6</sup> The same is true in Thailand, although the Thai government were faster to act on this problem. In the early 1990s, they implemented the now famous ‘100% condom programme’, enforcing mandatory condom use in brothels throughout Thailand, which helped to significantly reduce the spread of HIV.<br />
High HIV infection rates continue to be detected in India. The government estimates that 8% of sex workers nationally are infected with HIV, which is almost nine times higher than the overall HIV prevalence rate for Indian adults.<sup>7</sup> What is more, studies of sex workers in individual areas have found much higher HIV prevalence rates, such as 44% in Mumbai, and 26% in Mysore.<sup>8</sup> AVERT has more about HIV and sex workers in India.<br />
In South and South-East Asian countries outside India, the United Nations estimates that sex workers and their clients accounted for almost half of all people living with HIV in 2005.<sup>9</sup><br />
There are also fears that commercial sex is having an increasing influence on the AIDS epidemic in China. China’s AIDS epidemic is expanding, and at the same time, it is thought that the demand for commercial sex is growing.<sup>10</sup> The Chinese government estimates that in 2005, sex workers and their clients accounted for just under 20% of people living with HIV nationally.<sup>11</sup><br />
<h3>Sub-Saharan Africa</h3>More so than in many other regions, women in sub-Saharan Africa often turn to sex work because they are desperately poor and have no other way of earning an income. In some cases, women or girls are not involved in sex work as a long-term occupation, but may exchange sexual services for money as a temporary measure – for instance, to pay school tuition fees, or to provide food for their family at a time of crisis.<sup>12</sup><br />
The spread of HIV through commercial sex is a major issue in parts of West Africa. In Senegal, for instance, the AIDS epidemic appears to be driven by commercial sex, with around 27.1% of sex workers in the country’s capital, Dakar, found to be infected with HIV in 2005. Similarly, commercial sex seems to be a significant factor in Ghana’s AIDS epidemic. Studies of sex workers in 2005 also found high HIV prevalence rates in the West African nations of Togo (53.9%) and Burkina Faso (20.8%).<sup>13</sup><br />
In other parts of Africa, past studies of urban areas have found levels of HIV infection as high as 73% among sex workers in Ethiopia, and 68% among those in Zambia.<sup>14</sup><br />
<h3>The Caribbean</h3>The Caribbean’s thriving sex industry, which serves both local clients and many tourists, features prominently in the AIDS epidemics of certain countries, such as the Dominican Republic and Jamaica.<sup>15</sup> A handful of countries in the region have established creative HIV prevention campaigns aimed at sex workers; in Haiti, for example, a non-governmental organisation called FOSREF offer professional salsa dancing lessons to sex workers who are interested in leaving the sex trade and becoming dancers. In general, though, sex workers are being overlooked in the Caribbean, and this is holding back the region’s fight against AIDS.<sup>16</sup><br />
<h3>Latin America</h3>Information about the role of sex workers in Latin America’s AIDS epidemic is sparse, and shows a varied picture. In 2005, it is thought that sex workers and their clients accounted for almost one in six people living with HIV in Latin America as a whole,<sup>17</sup> and UNAIDS has reported that some of the AIDS epidemics in Central America are ‘strongly related’ to sex work.<sup>18</sup><br />
However, HIV prevalence rates amongst sex workers in South America seem to be relatively low. A study released in 2006, which analysed sex workers in nine South American countries over a thirteen-year period, concluded that <i>“consistently low HIV seroprevalences were detected among female commercial sex workers in South America, particularly in the Andean region”.</i><sup>19</sup><br />
<h3>Eastern Europe/ Central Asia</h3>The number of sex workers in Eastern European and Central Asian countries has risen dramatically in recent history. This is due to social, economic and political changes that led many to turn to sex work as a means of income.<br />
HIV prevalence rates generally seem to be low amongst sex workers in the region. Levels of sexually transmitted infections, however, are high, suggesting that few sex workers are practising safer sex, and that there is scope for HIV to become more common among sex workers in coming years. Commercial sex is playing an increasingly prominent role in the AIDS epidemics of many countries in the region.<sup>20</sup><br />
In Russia, sex workers commonly become infected with HIV through injecting drug use rather than sex. In the city of St Petersburg, 48% of sex workers were found to be living with HIV in 2003, and this high prevalence is attributed to the fact that most sex workers in the city also inject drugs.<sup>21</sup> By contrast, in the capital city of Moscow, where the sex industry is more organised and actively discourages drug use, only 3% of sex workers were thought to be infected with HIV in 2005.<sup>22</sup><br />
<h3>Western Europe and North America</h3>In Western Europe, levels of HIV infection seem to be relatively low amongst sex workers who do not inject drugs. For sex workers who do inject drugs, the risk is often significantly higher. In many areas, it also seems that male and transgender sex workers are more vulnerable to HIV than female sex workers.<sup>23</sup> As with other regions, however, there is a lack of recent data available on HIV infections among sex workers in Western Europe.<br />
The same is true in the United States, where the government takes a strong stance against sex work, as demonstrated by its refusal to grant overseas aid to any HIV/AIDS projects that do not ‘explicitly oppose’ the practice. Domestically, sex work is illegal in the U.S. (with the exception of a few counties in the state of Nevada), and very little information is gathered about workers and their clients. As with Western Europe, many of the HIV cases that do occur amongst sex workers in the U.S. are attributed to injecting drug use rather than sex.<sup>24</sup><br />
<h2>The way forward</h2>It is clear that sex workers are not ‘universally’ at high risk of becoming infected with HIV, and that the situation varies widely between regions. However, it is also apparent that in many of the countries where AIDS is taking its heaviest toll, large number of sex workers are being affected by HIV, and this is a major issue.<br />
Improving the situation will require greater efforts by governments, groups, and individual members of society to help sex workers. It is particularly important that sex workers gain access to HIV prevention and treatment programmes. Such programmes not only save sex workers’ lives; they can also help to stem the wider impact that HIV is having on societies around the world.<br />
To read a detailed account of what needs to be done, and to find out about some of the most famous examples of campaigns that have reduced the impact of AIDS on sex workers, see our HIV prevention and sex workers page.<br />
<br />
<div class="box bFull" id="footnote"> <h2>References</h2><ol><li><a ,="" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">UNAIDS/WHO 2006 Report on the Global AIDS Epidemic</a>, Chapter 5</li>
<li><a ,="" href="http://www.mapnetwork.org/" target="_blank">MAP</a> (2005). Sex work and HIV/AIDS in Asia.</li>
<li>UNAIDS (2009, February), '<a ,="" href="http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/SexWorkers/" target="_blank">UNAIDS guidance note on HIV and sex work</a>'.</li>
<li>UNDP (2007, 7th February),<a ,="" href="http://newsgrist.typepad.com/visualaids/sex_work/" target="_blank">Interview - Meena Seshu, director, Sangram</a></li>
<li><a ,="" href="http://www.unaids.org/en/HIV_data/epi2006/default.asp" target="_blank">UNAIDS/WHO AIDS Epidemic Update: December 2006</a></li>
<li>Kakar D.N. and Kakar S.N. (2001), 'Combating AIDS in the 21st century Issues and Challenges', Sterling Publishers Private Limited, p.31</li>
<li>NACO (April 2006), HIV/AIDS epidemiological Surveillance & Estimation report for the year 2005</li>
<li>NACO, Observed HIV Prevalence Levels State Wise: 1998-2004</li>
<li><a ,="" href="http://www.unaids.org/en/HIV_data/epi2006/default.asp" target="_blank">UNAIDS/WHO AIDS Epidemic Update: December 2006</a></li>
<li>Tucker J. D. et al. (2005), 'Surplus men, sex work, and the spread of HIV in China', <a ,="" href="http://www.aidsonline.com/" target="_blank">AIDS</a> 2005 (19:539)</li>
<li>Ministry of Health People’s Republic of China/UNAIDS (2005). Update on the HIV/AIDS epidemic and response in China. Beijing.</li>
<li><a ,="" href="http://www.unaids.org/" target="_blank">UNAIDS</a> (2002, June), 'Sex Work and HIV/AIDS, UNAIDS Technical Update'</li>
<li>UNAIDS/WHO Report on the Global AIDS Epidemic, May 2006</li>
<li><a ,="" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">UNAIDS/WHO Report on the Global AIDS Epidemic, May 2006</a></li>
<li><a ,="" href="http://www.unaids.org/en/HIV_data/epi2006/default.asp" target="_blank">UNAIDS/WHO AIDS Epidemic Update: December 2006</a></li>
<li>Cohen, J. (2006, 28th July), ‘HIV/AIDS: Latin America and the Caribbean’, Science Vol. 313 Issue 5786</li>
<li><a ,="" href="http://www.unaids.org/en/HIV_data/epi2006/default.asp" target="_blank">UNAIDS/WHO AIDS Epidemic Update: December 2006</a></li>
<li>UNAIDS/WHO <a ,="" href="http://www.unaids.org/DocOrder/OrderForm.aspx" target="_blank">AIDS Epidemic Update: December 2005</a></li>
<li>Bautista C. T. et al. (2006), <a ,="" href="http://sti.bmj.com/cgi/content/abstract/82/4/311" target="_blank">'Seroprevalence of and risk factors for HIV-1 infection among female commercial sex workers in South America'</a>, Sexually Transmitted Infections 82:311</li>
<li><a ,="" href="http://www.unaids.org/" target="_blank">UNAIDS</a> (2006), 'HIV and sexually transmitted infection prevention among sex workers in Eastern Europe and Central Asia'</li>
<li>Smolskaya T et al. (2005), “Sentinel sero-epidemiological and behavioural surveillance among female sex workers, St Petersurg, Russian Federation, 2003”</li>
<li>UNAIDS/WHO Report on the Global AIDS Epidemic, May 2006</li>
<li>Hamers F. F. and Downs A. M (2004), 'The changing face of the HIV epidemic in western Europe: what are the implications for public health policies?', The Lancet 364(83)</li>
<li>World Health Organisation (2004), <a ,="" href="http://who.arvkit.net/sw/en/index.jsp" target="_blank">Sex Work Toolkit</a></li>
</ol></div><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-60239337922091125052010-06-24T08:38:00.000-07:002010-06-24T08:38:42.503-07:00AIDS education and young people<div class="box bFull"> <h2>Why is AIDS education for young people important?</h2>AIDS education for young people plays a vital role in global efforts to end the AIDS epidemic. Despite the fact that HIV transmission can be prevented, each year millions of people become infected with the virus; in 2008 alone, there were 2.7 million new HIV infections. Almost 1-in-6 of these new infections were among people under 15 years old.<sup>1</sup><br />
<blockquote class="bigquoteright"> <div class="bigquotebody">“In 2008 alone, there were 2.7 million new HIV infections. Almost 1-in-6 of these new infections were among people under 15 years old.”</div></blockquote>Providing young people with basic AIDS education enables them to protect themselves from becoming infected. Young people are often particularly vulnerable to sexually transmitted HIV, and to HIV infection as a result of drug-use. Acquiring knowledge and skills encourages young people to avoid or reduce behaviours that carry a risk of HIV infection.<sup>2</sup> <sup>3</sup> <sup>4</sup> Even for young people who are not yet engaging in risky behaviours, AIDS education is important for ensuring that they are prepared for situations that will put them at risk as they grow older.<sup>5</sup><br />
AIDS education also helps to reduce stigma and discrimination, by dispelling false information that can lead to fear and blame. This is crucial for prevention, as stigma often makes people reluctant to be tested for HIV. Somebody who is not aware of their HIV infection is more likely to pass the virus on to others. AIDS education can help to prevent this, halting stigma and discrimination before they have an opportunity to grow.<sup>6<a name='more'></a></sup><br />
</div><h2>Why is AIDS education for young people an issue?</h2>Educating young people about HIV and AIDS necessitates discussions about sensitive subjects such as sex and drug use. Many people believe that it is inappropriate to talk to young people about these subjects and fear that doing so will encourage young people to indulge in risky behaviours. Such attitudes are often based on moral or religious views rather than evidence, and severely limit AIDS education around the world. Substantial evidence shows that educating young people about safer sex and the importance of using condoms does not lead to increases in sexual activity.<sup>7</sup><br />
<blockquote class="longquote">“I did not go to school and learn about the civil war and decide to start a civil war, nor would I have had sex because of a class in school.” - <cite>Mark</cite></blockquote>The belief that young people should only be taught about sex and drugs in terms of them being ‘wrong’ also perpetuates stigmatisation of people who are living with HIV. By teaching young people that indulging in ‘immoral’ sex and drugs will lead to HIV infection, educators imply that anyone who has HIV is therefore involved in these ‘immoral’ activities.<br />
In order to prevent becoming infected with HIV, young people need comprehensive information about how HIV is transmitted and what they can do to stop themselves from becoming infected. This information should be delivered without moral judgement.<br />
<h2>AIDS education at school</h2><div class="photo_r"><img alt="Sex education in a
school in India" border="0" src="http://www.avert.org/media/photos/1249.jpg" width="300" /> <div style="width: 300px;">Sex education in a school in India</div></div>Schools play a pivotal role in providing AIDS education for young people. Not only do schools have the capacity to reach a large number of young people, but school students are particularly receptive to learning new information. Therefore schools are a well-established point of contact through which young people can receive AIDS education.<br />
At the same time, in many countries HIV and AIDS are significantly weakening the capacity of the education sector, and greater investment in education is vital for the provision of effective HIV prevention for young people.<sup>8</sup> <sup>9</sup> <sup>10</sup><br />
<h3>Different approaches to AIDS education at school</h3>Opinion is divided between education providers who take an abstinence-only approach to sex education and those who advocate a more comprehensive approach. Which approach is favoured significantly affects how young people are educated about HIV and AIDS.<br />
Sex education that focuses on abstinence is based on the belief that encouraging young people not to have sex until marriage is the best way to protect against HIV infection. This approach limits AIDS education by not providing information about how young people can protect themselves from HIV infection if and when they do chose to have sex. It is vital for HIV prevention that schools provide comprehensive sex education, which educates about the importance of condom use as well as promoting delayed initiation of sex.<sup>11</sup><br />
<h3>Teacher training</h3>AIDS education requires detailed discussions of subjects such as sex, death, illness and drug use. Teachers are not likely to have experience dealing with these issues in class, and require specialised training so they are comfortable discussing them without letting personal values conflict with the health needs of the students.<sup>12</sup><br />
Teacher training is fundamental to the successful delivery of AIDS education in schools, and yet efforts to train teachers are often inadequate, if in place at all. For example, teachers in Malawi report not receiving any training on HIV and AIDS, and in Kenya many teachers have opted out of teaching about HIV and AIDS as a result of inadequate training.<sup>13</sup><br />
<h2>AIDS education outside of school</h2>Although offering AIDS education at school is a principal method of reaching large numbers of young people, there are 75 million children around the world who are either unable to go to school or choose not to.<sup>14</sup> In order to ensure that all young people are reached with basic AIDS education, programmes that target young people outside of school are essential. Young people who are in school also benefit from receiving further information about HIV and AIDS from other sources, adding to and reinforcing what they learn in school.<br />
Families, friends, the wider community, mass media and popular culture all influence young people, and it is important that they convey accurate educational information about HIV and AIDS.<br />
<h3>The media</h3>Using the media is a powerful way of reaching large numbers of young people with HIV and AIDS information and prevention messages.<br />
<div class="photo_l"><img alt="LoveLife billboard
in South Africa" border="0" src="http://www.avert.org/media/photos/1526.jpg" width="300" /> <div style="width: 300px;">LoveLife campaign billboard in South Africa</div></div>Many countries have tried some form of AIDS education advertisements, films, or announcements. LoveLife is a prominent campaign in South Africa, which uses a variety of media to educate young people about HIV and AIDS. The LoveLife campaign has produced eye-catching posters and billboards. It has also educated through TV soaps that are popular with young people, and used rap and kwaito music to get its message across.<sup>15</sup><br />
However, it is difficult to measure the extent to which media-based AIDS education reaches young people, and the effect that it has. In 2005, The Global Fund withdrew its funding of LoveLife on the basis that the campaign was not reaching the majority of young South Africans, and that its contribution to HIV and AIDS prevention was unclear.<sup>16</sup> <sup>17</sup><br />
<h3>Peer education</h3>Peer education is the process by which a group is given information by someone who is a member of the same group or community, and who has already been trained in the subject. Peer education programmes are important for HIV prevention, as they are a cost-effective means of influencing the knowledge and attitudes of young people.<sup>18</sup> <sup>19</sup><br />
<div class="photo_r"><img alt="Young people
learning about HIV and AIDS at a youth centre in Angola" border="0" src="http://www.avert.org/media/photos/1787.jpg" width="300" /> <div style="width: 300px;">Young people learning about HIV and AIDS at a youth centre in Angola</div></div>Young people are strongly influenced by the attitudes and actions of others their age, and for many young people much of their existing knowledge of sex and HIV is based on information they have received from friends. This information can often be distorted. Peer education harnesses this method of sharing knowledge to convey accurate information about HIV and AIDS to young people.<br />
Peer education is a particularly effective way of targeting difficult to reach groups, such as young people who do not attend school, with vital AIDS education.<sup>20</sup> Many young people who do not attend school are marginalised in other ways, and may distrust or not take in information given to them by an authority figure. The same information is more likely to be effective if it is provided by someone that young people identify with and see as credible.<sup>21</sup> <sup>22</sup><br />
<blockquote class="longquote">“Peer education works very well for students and young people. Sharing a conversation with people of the same age or social group you can be more relaxed, and, for example, you can ask questions that would be difficult to ask to an adult.” - <cite>Selma, HIV and AIDS peer educator</cite><sup>23</sup></blockquote><h2>Making AIDS education effective</h2><h3>When should young people start to be taught about AIDS?</h3>There is no set age at which AIDS education should start, and different countries have different regulations and recommendations. Often young people are denied life-saving AIDS education because adults consider the information to be too ‘adult’ for young people. These attitudes hinder HIV prevention, as it is crucial that young people know about HIV and how it is transmitted before they are exposed to situations that carry a risk of HIV infection.<br />
AIDS education should begin as early as possible. Information can be adapted so that awareness of AIDS can begin from an early age whilst still ensuring that topics are age-appropriate. For example, UNESCO guidelines advise that basic education on human reproduction should begin as early as age five. This information provides the foundation on which children can build AIDS specific knowledge and skills as they develop; education about condoms and how they can protect from HIV infection can be introduced from around age nine.<sup>24</sup><br />
<h3>Active learning</h3><div class="photo_l"><img alt="Young people taking
part in group work as part of AIDS education programme in Thailand" border="0" src="http://www.avert.org/media/photos/980.jpg" width="300" /> <div style="width: 300px;">Young people doing group work as part of an AIDS education programme in Thailand</div></div>Simply providing young people with information about HIV and AIDS is not enough to ensure that they will absorb and retain that information. Effective AIDS education encourages young people to participate and engage with the information that is being presented to them by offering them the opportunity to apply it.<sup>25</sup> Group-work and role-play are particularly important methods in which students might discover the practical aspects of the information they are given. These methods also allow pupils an opportunity to practise and build skills – saying “No” to sex, for example.<br />
Active learning approaches are widely considered to be the most effective way for young people to learn health-related and social-skills.<sup>26</sup> Furthermore, active learning offers an opportunity to make AIDS education lessons fun. AIDS education classes can be constructed to involve quizzes, games, or drama, for example – and can still be very effective learning sessions.<br />
Avert.org has a selection of educational quizzes and an AIDS game to test young people's knowledge in a fun and interactive way.<br />
<h3>Making it cross-curricular</h3>Effective AIDS education encompasses both scientific and social aspects of HIV and AIDS. Knowledge of the basic science of HIV and AIDS is important for understanding how the virus is passed on and how it affects the body, for example. But AIDS education that deals only with medical and biological facts, and not with the real-life situations that young people find themselves in, does not provide young people with adequate AIDS awareness.<sup>27</sup> Developing life skills and discussing matters such as relationships, sexuality and drug use, are fundamental to AIDS education. Knowing how HIV reproduces won’t help a young person to negotiate using a condom, for example.<br />
<h3>What needs to be considered?</h3>When planning an AIDS education lesson or curriculum, it is important to be aware of local guidelines, as many places have legislation that dictates what sex or AIDS education can or should be given. Local cultures also need to be taken into consideration, as views between cultures differ on issues that are a necessary part of AIDS education, for example human sexuality. Awareness of cultural and religious beliefs enables AIDS education to sensitively, yet effectively, deal with issues in a way that does not conflict with the values of young learners.<br />
When educating a group of young people, the personal circumstances of students need to be taken into account. Some of the students may have been personally affected by HIV or, particularly in high prevalence areas, may themselves be infected with HIV.<sup>28</sup> <sup>29</sup> The sexuality of students and their families is something else that needs to be considered. AIDS education needs to include information about and for people of all sexualities.<br />
The best place to start when planning AIDS education for young people is to talk to the young people themselves. Allowing learners to ask questions and encouraging their input will enable young people to express what they want from their AIDS education. Speaking to the class also ensures that educators are aware of the current knowledge of the students, so that AIDS education can be more effectively targeted towards areas of informational need.<br />
<h2>AIDS education for young people around the world: Case studies</h2>There is no single model of AIDS education that is appropriate to every country; different situations call for different responses. However, the experiences of AIDS education programmes around the world can provide important insights when designing and implementing AIDS education for young people.<sup>30</sup><br />
<h3>Kenya</h3>Kenya has witnessed a declining HIV prevalence in recent years – in 1997/98 the prevalence was estimated at 10 percent; by 2006 this figure had almost halved to 5.1 percent.<sup>31</sup> The decline has been attributed to a number of factors, including a reduction in risky behaviours.<sup>32</sup> Kenya’s education sector has taken an active role in the country’s response to the AIDS epidemic, having a particularly positive effect on HIV and AIDS awareness and leading to a reduction of risk behaviour among young people.<sup>33</sup><br />
Kenya has integrated AIDS education into all subjects at school, and introduced a weekly compulsory HIV and AIDS lesson into all primary and secondary curricula. An evaluation of 2000 schools found that AIDS education is effectively promoting healthy behaviours and reducing the risk of infection.<sup>34</sup><br />
One particularly successful initiative has been the Primary School Action for Better Health Kenya (PSABH). PSABH began in October 2001 in Nyanza Province with the aim of creating positive behaviour change among upper primary school pupils to reduce their risk of exposure to HIV.<sup>35</sup> The programme involves training the head teacher, a senior classroom teacher and one parent/community representative from each participating school, on a week-long course. One term later, two additional teachers are trained. Topics that are covered include:<br />
<ul><li>Information on the routes of HIV transmission and prevention strategies</li>
<li>Skill-building for resisting the social, cultural and interpersonal pressures to engage in sexual intercourse</li>
<li>Adolescent health and sexuality</li>
<li>Issues related to HIV stigma and discrimination</li>
<li>The care of people living with AIDS</li>
</ul>Teachers are then taught how to train their colleagues at school and how to integrate HIV education within classroom subjects. With the aim of a national roll-out, around 11,000 out of 19,000 Kenyan schools had implemented PSABH by June 2006.<sup>36</sup><br />
Evaluations of the programme revealed positive results – an increase in condom use among boys was reported and girls were more likely to decrease or delay sexual activity.<sup>37</sup><br />
<h3>India</h3>In India, where young people represent a large proportion of the country’s population, an estimated 2.4 million people are infected with HIV.<sup>38</sup> In phase II of the country's National AIDS Control Programme, the Adolescent Education Programme (AEP) was launched. The programme aimed to train teachers and peer educators to educate the student community both in and out of school about life skills, HIV prevention and HIV related stigma and discrimination. Under the initiative 112,000 schools were covered and 288,000 teachers were trained.<sup>39</sup><br />
However, there is a discrepancy between the large amount of effort invested in HIV/AIDS curricula and training packages on a national level, and the lack of actual education being carried out in many schools. In the states of the country where there is a relatively low HIV prevalence, officials have been reluctant to encourage AIDS education, claiming that the problem is not significant enough in these areas to warrant a widespread educational response.<sup>40</sup> In reality, it is crucial that young people learn about AIDS in areas with a low prevalence so that the prevalence stays low.<br />
In 2007 it was reported that a number of states had decided not to implement the Adolescence Education Programme in its present form, rejecting the material that had been supplied.<sup>41</sup> Many young people across India are still not receiving information about HIV/AIDS.<br />
“We had a session on AIDS in school once, but it was sketchy. I still do not know the difference between HIV and AIDS. We could not ask any questions, because the boys in our class would tease us later... At home, my mother knows even less, and my father would not allow such a conversation”. - <cite>Chaudhury, an arts undergraduate in Alwar, India<sup>42</sup></cite><br />
<br />
<h2>References</h2><ol><li>UNAIDS (2009, November), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp" target="_blank">'AIDS epidemic update'</a></li>
<li>UNESCO (2009, May), '<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=45615&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">A strategic approach: HIV & AIDS and education</a>'.</li>
<li>Paul-Ebhohimhen V.A. et al (2008), '<a ,="" href="http://www.biomedcentral.com/1471-2458/8/4" target="_blank">A Systematic Review of School-based Sexual Health Interventions to Prevent STI/HIV in sub-Saharan Africa</a>' BMC Public Health 8(4).</li>
<li>Bankole A. et al (2007), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18458741" target="_blank">'Knowledge of Correct Condom Use among Adolescents in sub-Saharan Africa'</a> African Journal of Reproductive Health 11(3).</li>
<li>UNESCO, Director-general (2008), '<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=43224&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">Why are we still failing our young people?</a>'.</li>
<li>UNDP Iran (2008) ‘<a ,="" href="http://www.washingtontimes.com/news/2008/aug/06/the-stigma-factor/" target="_blank">The Stigma Factor by Ban Ki-Moon</a>'.</li>
<li>UNESCO (2009, June) ‘<a ,="" href="http://unesdoc.unesco.org/ulis/cgi-bin/ulis.pl?catno=183281&set=4A5EF7B6_3_66&gp=1&lin=1&ll=1" target="_blank">International Guidelines on Sexuality Education: An evidence informed approach to effective sex, relationships and HIV/STI education</a>’.</li>
<li>The World Bank (2002), ‘<a ,="" href="http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTEDUCATION/0,,contentMDK:20756195%7EmenuPK:613702%7EpagePK:148956%7EpiPK:216618%7EtheSitePK:282386%7EisCURL:Y%7EisCURL:Y,00.html" target="_blank">A window of hope</a>’.</li>
<li>UNESCO (2009) ‘<a ,="" href="http://www.unesco.org/en/efareport" target="_blank">Overcoming inequality: why governance matters</a>’.</li>
<li>UNESCO (2006), ‘<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=35444&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">Good policy and practice in HIV and AIDS education: overview</a>’.</li>
<li>UNAIDS (2008), ‘<a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp" target="_blank">Report on the global AIDS epidemic</a>’.</li>
<li>UNESCO (2009, May), ‘<a ,="" href="http://www.unescobkk.org/education/hivaids/aids-news/hivaids-news-details/article/teachers-and-hiv-aids-reviewing-achievements-identifying-challenges/" target="_blank">Teachers and HIV & AIDS: Reviewing achievements, identifying challenges</a>’.</li>
<li>UNESCO (2008), ‘<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=35444&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">Good policy and practice in HIV & AIDS and education: effective learning</a>’.</li>
<li>UNESCO (2009) ‘<a ,="" href="http://www.unesco.org/en/efareport" target="_blank">Overcoming inequality: why governance matters</a>’.</li>
<li>LoveLife, '<a ,="" href="http://www.lovelife.org.za/corporate/index.html" target="_blank">LoveLife: about us</a>'.</li>
<li>IRIN Plus News (2005), '<a ,="" href="http://www.plusnews.org/Report.aspx?ReportId=39240" target="_blank">Global Fund withdraws support for LoveLife</a>'.</li>
<li>Pettifor A.E. et al (2007, August), ‘Challenge of evaluating a national HIV prevention programme: the case of LoveLife, South Africa’ Sexually Transmitted Infections 83(suppl 1).</li>
<li>UNAIDS (1999), ‘<a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=Publications/IRC-pub01/jc291-peereduc_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d2530%26query%3dpeer%2520education%2520concepts%26hiword%3dconcepts%2520education%2520peer%2520%26PV%3d1" target="_blank">Peer education and HIV/AIDS: Concepts, uses and challenges</a>’.</li>
<li>Youth Peer Education Network (2005), ‘<a ,="" href="http://www.gdnet.org/cms.php?id=research_paper_abstract&research_paper_id=12551" target="_blank">Youth peer education tool kit: Standards for peer education programmes</a>’.</li>
<li>UNAIDS, '<a ,="" href="http://www.unaids.org/en/PolicyAndPractice/Prevention/Education/" target="_blank">Education: in and out of school settings</a>'.</li>
<li>UNESCO & UNAIDS (2001, 1st January), ‘<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=35997&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">HIV/AIDS and human rights: young people in action</a>’.</li>
<li>United Nations ESCAP (2003), ‘<a ,="" href="http://www.unescap.org/publications/detail.asp?id=785" target="_blank">Young people: partners in HIV/AIDS prevention</a>’.</li>
<li>UNESCO & UNAIDS (2001, 1st January), ‘<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=35997&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">HIV/AIDS and human rights: young people in action</a>’.</li>
<li>UNESCO (2008), ‘<a ,="" href="http://unesdoc.unesco.org/ulis/cgi-bin/ulis.pl?catno=183281&set=4A5EF7B6_3_66&gp=1&lin=1&ll=1" target="_blank">International Guidelines on Sexuality Education: An evidence informed approach to effective sex, relationships and HIV/STI education</a>’.</li>
<li>UNESCO (2008), ‘<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=35444&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">Good policy and practice in HIV & AIDS and education: effective learning</a>’.</li>
<li>UNICEF (2009, May), '<a ,="" href="http://www.unicef.org/publications/index_49574.html" target="_blank">Child-friendly schools manual</a>', chapter 2: Dynamics of theory in practice.</li>
<li><span class="person_name">Campbell C. & </span><span class="person_name">MacPhail C.</span> (2002), '<a ,="" href="http://eprints.lse.ac.uk/385/" target="_blank">Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth</a>'<i> </i>Social Science and Medicine 55(2).</li>
<li>UNESCO (2008, December), '<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=44269&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">Supporting the educational needs of HIV-positive learners: lessons from Namibia and Tanzania</a>'.</li>
<li>UNESCO (2008, February), '<a ,="" href="http://portal.unesco.org/en/ev.php-URL_ID=42001&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">School-centred HIV and AIDS care and support in Southern Africa: consultation report</a>'.</li>
<li>The World Bank (2008), ‘<a ,="" href="http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTEDUCATION/0,,contentMDK:20756195%7EmenuPK:1342884%7EpagePK:210058%7EpiPK:210062%7EtheSitePK:282386%7EisCURL:Y,00.html" target="_blank">A sourcebook of HIV/AIDS prevention programs: vol. 2</a>’.</li>
<li>UNGASS (2008, January) '<a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/kenya.asp" target="_blank">Country progress report – Kenya</a>'.</li>
<li>UNGASS (2008, January) '<a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/kenya.asp" target="_blank">Country progress report – Kenya</a>'.</li>
<li>Actionaid (2003), '<a ,="" href="http://www.comminit.com/en/node/211186" target="_blank">Sound of Silence: Difficulties in communicating on HIV/AIDS in schools</a>'.</li>
<li>Kenya National AIDS Control Council (2009, March), ‘<a ,="" href="http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTHIVAIDS/0,,menuPK:376477%7EpagePK:149018%7EpiPK:149093%7EtheSitePK:376471,00.html" target="_blank">HIV prevention response and modes of transmission analysis</a>’.</li>
<li>PSABH '<a ,="" href="http://www.psabh.info/" target="_blank">A snapshot of PSABH as delivered across Kenya</a>'.</li>
<li>Maticka-Tyndale, E, Wildish, J & Gichuru, M (2007) '<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/17689323?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum" target="_blank">Quasi-experimental evaluation of a national primary school HIV intervention in Kenya</a>', Evaluation and Program Planning 30, 172-186.</li>
<li>Maticka-Tyndale, E, Wildish, J & Gichuru, M (2007) '<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/17689323?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum" target="_blank">Quasi-experimental evaluation of a national primary school HIV intervention in Kenya</a>', Evaluation and Program Planning 30, 172-186.</li>
<li>UNAIDS (2008), ‘<a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp" target="_blank">Report on the global AIDS epidemic</a>’.}{!ref: UNGASS (2008, February) ‘<a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/india.asp" target="_blank">Country Progress Report 2008: India’</a>.</li>
<li>National AIDS Control Organisation (2007) '<a ,="" href="http://www.nacoonline.org/Quick_Links/Youth/School_Age_Education_Program_SAEP/" target="_blank">Adolescence Education Programme (AEP)</a>'.</li>
<li>Global Campaign for Education (2005, November) '<a ,="" href="http://www.actionaidusa.org/news/publications/hiv_aids/" target="_blank">Deadly Inertia: A cross-country study of educational responses to HIV/AIDS</a>'.</li>
<li>National AIDS Control Organisation (2007, 13th August) '<a ,="" href="http://www.nacoonline.org/NACO_Action/Media__Press_Release/" target="_blank">Sex education in curriculum</a>'.</li>
<li>The Washington Post (2007, 7th December) '<a ,="" href="http://www.washingtonpost.com/wp-dyn/content/article/2007/12/06/AR2007120602644.html" target="_blank">Getting AIDS education on track in India</a>'.</li>
</ol>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-89276218232785112602010-06-24T08:17:00.000-07:002010-06-24T08:18:33.674-07:00HIV & AIDS treatment for children<div class="box bFull">HIV develops very rapidly among infants and children, and, without treatment, a third of children with HIV will die of AIDS before their first birthday, with half dying before they are two.<sup>1</sup> In 2008, there were 280,000 deaths attributed to HIV in under-15s, most of which could have been prevented through early diagnosis and effective treatment.<sup>2</sup> Though the number of children receiving antiretroviral therapy (ART) has increased significantly in recent years, at the end of 2008 less than 40% of the 730,000 children needing ART in lower- and middle-income countries were receiving it.<sup>3</sup></div><div class="box bFull"><h2>How effective is antiretroviral treatment for children with HIV?</h2>The most effective treatment for children with HIV is antiretroviral therapy. This requires several antiretroviral drugs (ARVs) be taken every day.<br />
Antiretroviral treatment reduces illness and mortality among children living with HIV in much the same way that it does among adults. In one study in Brazil, three-quarters of HIV-positive children receiving ART were alive after a four-year follow-up period.<sup>4</sup> Positive outcomes were also seen in paediatric ART programmes in Thailand and Kenya.<sup>5</sup> <sup>6</sup> A study released in 2007, which monitored 586 HIV-positive children receiving antiretroviral treatment in 14 countries in Africa and Asia, found that 82% were still alive after two years.<sup>7</sup><br />
Some of the most compelling evidence that treatment works in children does not come from studies or statistics, but rather the stories of those who have witnessed HIV-positive children returning to health after starting treatment:<br />
<blockquote class="longquote">"You see scrawny, rashy, tired, lethargic kids come in, you start them on treatment and within weeks you’ve got bounding, podgy, gorgeous growing children. People often don’t believe, they’re often quite sceptical of the medications, and then you see this transformation and parents are like ‘The child’s got so much energy!’”<cite>Julie, UK nurse working with children living with HIV<sup>8<a name='more'></a></sup></cite></blockquote><h2>Identifying and testing children living with HIV</h2>Providing treatment for children with HIV/AIDS essentially involves three stages: finding a child, testing a child and treating a child. Most children living with HIV become infected through mother-to-child transmission, and these children need to be tested as soon as possible after birth to find out if they are are infected with the virus. If a child living with HIV is only diagnosed once they are ill, it may be too late for antiretroviral treatment to be effective.<br />
<div class="photo_r"><img border="0" height="240" src="http://www.avert.org/media/photos/1244.jpg" width="320" /> <br />
<div style="width: 320px;">Collection of dried blood spots from an infant</div></div>In developed countries, children can be tested soon after birth (sometimes within 48 hours) using polymerase chain reaction (PCR) tests and other specialist techniques. Where this technology is available, the longest a mother will have to wait for an accurate result is usually around six weeks.<br />
In resource-poor countries, where PCR testing is generally unaffordable or unavailable, a mother may have to wait up to 18 months after giving birth before antibody tests (which are used in adults, and are more commonly available) can be used to accurately diagnose her child. During this time the antenatal clinic, where the mother was probably diagnosed, is likely to lose contact with her.<br />
In some resource-poor countries, ‘dried blood spot’ testing has been introduced in recent years. This is where a small sample of blood is taken from a child, dropped onto paper, and sent to a laboratory where it can be tested. Since these samples do not need to be refrigerated and are easy to transport, they can potentially be sent miles away to places where PCR is available. This means that even children living in resource-poor areas can be tested relatively quickly. However, dried blood spot testing can be expensive and it can take a long time for test results to return. There's also evidence that when the drug nevirapine is used to prevent mother-to-child transmission of HIV, dried blood spot testing doesn't always detect HIV in the first few days of the child's life.<sup>9</sup> <sup>10</sup><br />
<h2>Starting antiretroviral treatment in children with HIV</h2>As with adult treatment, there is ongoing debate about when it is best to start antiretroviral treatment in HIV-positive children. There is a complex balance between the immediate benefits of providing treatment to children who are not showing any symptoms of AIDS-related illness, and concerns about long-term resistance and antiretroviral drug side effects if treatment is started too early.<br />
<h3>CD4 counts in children</h3>To judge whether an HIV-positive person requires treatment, a CD4 test is usually carried out. This measures the number of T-helper cells – white blood cells that are attacked by HIV – in an individual’s blood. It can either measure the absolute number of CD4 cells, or the percentage of white blood cells that are CD4 cells, in a sample of blood.<br />
A falling CD4 count is a sign that HIV is progressing, and that the immune system is becoming weaker. In healthy, uninfected adults, absolute CD4 count is usually between 500 and 1500 cells per cubic millimetre of blood. When an HIV-positive adult’s CD4 count falls below 350 it is usually recommended (in economically developed countries) that they start receiving antiretroviral treatment.<br />
For children below the age of five, though, these adult guidelines are generally irrelevant. Absolute CD4 counts vary with age, and younger children usually have a much higher CD4 count than adults. This makes it difficult to judge the health of a child's immune system based on CD4 count. Percentage CD4 count does not vary in the same way as absolute CD4 count, and is therefore recommended for children under five.<br />
In some cases, viral load testing (which measures the amount of HIV in an individual’s blood) is used alongside CD4 testing to guide decisions about treatment.<br />
<h3>Starting treatment based on clinical symptoms</h3>In resource-poor communities, the technology needed for CD4 counts and viral load testing is not always available. In the absence of these facilities, healthcare workers sometimes have to make a presumption that a child should begin treatment based on their stage of HIV infection as defined by a range of cancers and infections that are present.<br />
<h3>When to start treatment</h3>Until recently it was generally agreed across guidelines that a child aged less than one year to 18 months with a percentage CD4 count below 20-25% should be started on treatment, whether symptomatic or not. However, the findings of one study prompted WHO to revise their guidelines and it now recommends that all diagnosed children under 12-months should begin antiretroviral therapy regardless of the infant’s clinical or immunological stage.<sup>11</sup> (Children under 12-months with clinically diagnosed presumptive severe HIV should also begin treatment, but confirmation of infection should be obtained as soon as possible.) The Children with HIV Early Antiretroviral Therapy (CHER) study of infants (aged six-to-twelve weeks) in South Africa compared the outcomes of those starting limited treatment immediately with those deferring treatment until CD4 percentage dropped below certain levels or if symptomatic and severe disease occurred. (The study's criteria for deferred treatment were only slightly different from South African or WHO guidelines.) It found the risk of death for infants who began treatment immediately was 76% lower than the deferred treatment group.<sup>12</sup><br />
<div class="photo_l"><img alt="Doctors at the
Rixile HIV clinic treat an ill HIV child, Tintswalo" border="0" height="263" src="http://www.avert.org/media/photos/1165.jpg" width="350" /> <br />
<div style="width: 350px;">Doctors at the Rixile HIV clinic treat an ill HIV positive child, Tintswalo, South Africa</div></div>The United States has followed the lead of the WHO and now recommends treatment, rather than the consideration of treatment, for all infants with HIV, regardless of CD4 percentage, clinical status or viral load.<sup>13</sup> 2009 guidelines produced by the Paediatric European Network for Treatment of AIDS (PENTA) also advocate treatment for all infected children under 12 months regardless of clinical or immunological stage.<sup>14</sup> Other countries’ guidelines may be revised to reflect the CHER study’s findings.<br />
The effect of planned treatment interruptions at one and two years, on those infants who started immediate treatment, will be revealed after the trial is completed in 2011.<sup>15</sup><br />
While there is an emerging consensus on initiating therapy immediately in infected infants, there is an ongoing debate as to when treatment should begin in young children. Generally for children aged between one and five years, treatment is recommended if significant symptoms are evident or percentage CD4 count has decreased to below 20-25% with this indicator declining with age to around 15-20%.<sup>16</sup> <sup>17</sup> <sup>18</sup><br />
Arguments for earlier treatment include: evidence that disease progression is faster in young children; that there is an association between severe HIV disease and persistent neurocognitive deficits in adolescent long-term survivors of perinatally acquired HIV;<sup>19</sup> and that ART can reduce tuberculosis, encephalopathy and bacterial infections that occur even at high CD4 levels, as well as improve physical growth. Advocates for earlier treatment also point to studies showing that the risk of disease progression is identical between adults and over-5s so it follows that any argument for earlier initiation in adults should also apply to older children. Arguments for deferring treatment include a lack of information on the long term effect of doing so, and the additional cost and burden of adherence due to a longer overall period of treatment.<sup>20</sup><br />
<h2>Which antiretroviral drugs should be used?</h2>As with adults, antiretroviral therapy with at least three drugs is recommended for children as this prevents HIV from becoming resistant to any single drug. It is usually recommended that this therapy should consist of two nucleoside reverse transcriptase inhibitors (NRTIs) combined with either one non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI). <sup>21</sup><br />
There are many factors that can influence the choice of drugs for children. Considerations about medications that the mother may have received during pregnancy, the toxicity of certain drugs, and whether the child is still breastfeeding, all need to be taken into account when choosing a regimen.<br />
<h2>Dosing and drug formulations in children</h2>The dose of antiretroviral drugs given to children is generally based on either weight or body surface area. Children have traditionally been thought of as being ‘mini adults’ but this is not the case. Children’s bodies are constantly changing and developing and often it is vital that drug doses are altered to ensure that a child is not given too much, or too little, of a drug. The study of how a child’s body reacts to medication is called pharmacokinetics (PK) but current paediatric PK studies mostly focus on 6-18 years old, which misses the early stages of development; a period when the human body changes the most. Pharmacokinetic properties such as absorption, distribution, metabolism and excretion of a drug all influence the efficacy, toxicity and dosing regimen required in a child. As such, information is limited on PK for infants and drug manufacturers and expert guidelines use a variety of ways to calculate doses of paediatric ARVs, so there is no uniform dosing system to follow. <sup>22</sup><br />
Dosing is further complicated by the variety of forms that ARVs may take when provided to children, all of which require different measurements. Infants who are too young to swallow tablets ideally need to be provided with drugs that are more child friendly such as syrups, powders, sprinkles or ‘melts’ but these formulations are not widely available and are expensive. <sup>23</sup> <sup>24</sup>. Unfortunately, a lot of HIV medicine has an unpleasant taste, especially in syrups and powder form. This can make it difficult for children to take their ARVs every day, and increases the burden of HIV. In addition, it is critical that children’s medicine has clear and concise labelling to ensure that caregivers are able to give an appropriate dosing and ensure adherence.<br />
<blockquote class="bigquoteright"><div class="bigquotebody">Since there are still no available, easy-to-use triple drug combinations for children, I do what most doctors are doing: I try to show caregivers such as grandparents how to break adult tablets, hoping that the children will get the doses they need.</div><div class="bigquotecite">- Dr Fasineh Samura, Malawi</div></blockquote>An encouraging development is the relatively recent availability of fixed-dose combination therapies (FDCs), which combine multiple ARVs into a single tablet, for children. Tablets consisting of lamivudine, stavudine and nevirapine have been supplied by the Clinton HIV/AIDS Initiative (CHAI), in conjunction with drug purchase facility, UNITAID, to children in 26 nations. In these countries CHAI’s monthly paediatric treatment formerly consisted of 12 bottles of liquid. For those children who can now access FDCs, only a small container of tablets is needed, making the therapy easier to store, transport and administer.<sup>25</sup><br />
In areas where there is a lack of affordable paediatric ARV formulations, clinicians often have no choice but to divide adult fixed-dose combination drugs into measures appropriate for children. There is evidence that dividing tablets carries a risk of under- or over-dosing<sup>26</sup> but equally, a significant 2006 study of eight countries concluded that the use of divided adult FDCs can achieve successful and satisfactory results in children.<sup>27</sup> The World Health Organisation supports this practice in situations where no appropriate paediatric medications are available.<sup>28</sup><br />
<blockquote class="longquote">“Since there are still no available, easy-to-use triple drug combinations for children, I do what most doctors are doing: I try to show caregivers such as grandparents how to break adult tablets, hoping that the children will get the doses they need.” <cite>Dr Fasineh Samura, Malawi<sup>29</sup></cite></blockquote><h2>Side effects of paediatric HIV treatment</h2>Children receiving ARVs can suffer from the same drug side effects that adults experience. Because children’s bodies are still developing, and they are likely to be exposed to treatment for prolonged periods of time, they may be particularly vulnerable to some complications.<sup>30</sup> Side effects can occur at various stages of a child’s course of treatment, and may be acute (occurring directly after drug administration), sub-acute (within one or two days after administration), or late (after prolonged drug administration). It can be difficult to distinguish between adverse events caused by ARVs given to a child and complications caused by HIV itself, so care should be taken to exclude other possible causes of illnesses before it is concluded that they are a result of ARVs.<br />
The impact of side effects may vary from mild to severe and life-threatening. Some moderate or severe side effects may require drug substitution, or even the discontinuation of treatment. In general, mild side effects do not require such changes, and symptomatic treatment for them may be given. If side effects are regarded as life threatening, all ARVs should be stopped until the child has stabilised.<sup>31</sup><br />
<h2>Adherence</h2>Children on HIV treatment need to take three or more types of ARVs every day for the rest of their lives. If drugs are not taken routinely, at around the same time every day, HIV may become resistant to the therapy, causing it to stop working.<br />
A review of 17 studies regarding paediatric HIV treatment adherence found adherence ranging from 49% to 100%. Three-quarters of the studies showed adherence rates of 75%. Most of the studies in lower- and middle-income countries revealed adherence rates above 75%, whereas the opposite was true in higher-income countries.<sup>32</sup><br />
There are a number of factors that commonly cause adherence problems: inadequate dosing; high pill burden; reluctance among young infants to take syrups and powders due to their unpleasant taste; dietary restrictions; and toxic side effects of drugs. Adherence issues can put an enormous strain on the daily lives of parents and caregivers, who are usually responsible for administering treatment. Some ARVs need to be taken with food, so carers may have to perform the often difficult task of providing a meal and administering drugs simultaneously. This is assuming that an adequate supply of food is actually available. If fixed-dose combinations appropriate for use in children became more widely available, it is likely that adherence would generally improve, since it is much easier to take a single dose every day rather than multiple doses.<br />
<h2>Nutritional support whilst on HIV treatment</h2>Malnutrition is common in children living with HIV in developing countries, and is a major cause of death. Ideally, children living with HIV who are asymptomatic need to consume 10% more calories than other children of their age and sex. Children who are symptomatic, or recovering from acute infections, need to consume 20-30% more calories than other children.<sup>33</sup><br />
<div class="photo_r"><img alt="An HIV-positive
child, South Africa" border="0" src="http://www.avert.org/media/photos/171a.jpg" width="300" /> <br />
<div style="width: 300px;">An HIV-positive child, South Africa</div></div>If a child is suffering from malnutrition, it is recommended that they receive treatment to stabilise their condition before HAART is started. In poorer areas, however, this is not always possible. Even where it is possible to treat malnutrition, recovery from this condition is likely to be slow and limited in HIV-positive children. If a child has not been cured of malnutrition after six to eight weeks of special feeding or appropriate treatment, it may be decided that HAART should be started despite their condition.<br />
In the opposite situation, where a child experiences rapid weight gain as a result of ARVs, nutrition also needs to be monitored carefully. As a child’s weight changes, so does the recommended dosage of ARVs that they require, so drug doses need to be constantly reviewed.<sup>34</sup><br />
<h2>Treating children for opportunistic infections</h2>Opportunistic infections, which take advantage of weak immune systems, are a serious threat to children living with HIV. Tuberculosis and PCP (a form of pneumonia) in particular are major causes of illness and death among infected infants.<br />
Children are at particular risk of tuberculosis (TB), particularly if they are suffering from a weak immune system due to HIV infection. Co-infection with HIV and tuberculosis in children is increasingly common in many areas.<sup>35</sup> While the basic principles of TB treatment are the same in HIV-positive children and uninfected children, the situation is complicated by drug interactions between ARVs and drugs that are used to treat TB. The drug rifampicin, which is commonly used to treat TB, can react negatively with NNRTIs such as nevirapine, as well as with protease inhibitors. Such interactions can lead to sub-therapeutic drug levels and an increased risk of toxic side effects. For HIV-positive children who are not yet receiving ARVs, it is recommended that treatment for TB should ideally be initiated some weeks before ARV treatment, allowing the child to stabilise on this therapy. For children who are diagnosed with TB while already receiving treatment, ARV regimens need to be carefully reviewed, and may need to be adjusted in accordance with official guidelines.<sup>36</sup> In order to avoid late diagnosis of HIV, it has been suggested that all TB-infected children should be considered for an HIV test.<sup>37</sup><br />
<h2>Preventing opportunistic infections in children</h2>Due to their weak immune systems, children living with HIV are very vulnerable to opportunistic infections, and need to be provided with drug prophylaxis to prevent such illnesses. For example, prophylaxis against PCP (one of the most common opportunistic infections in children living with HIV) is recommended for all children born to HIV-positive mothers, starting from about one month after birth.<sup>38</sup> For children who have no access to ARVs, treatment for opportunistic infections may delay the need for antiretroviral treatment.<br />
Co-trimoxazole, an antibiotic that is included in PCP prophylaxis and can help to prevent other infections such as TB, was shown to reduce AIDS-related mortality by 43% and hospital admission rates by 28% among children with HIV in a major trial in Zambia.<sup>39</sup> Based on this trial and other evidence, experts agree that co-trimoxazole should be widely provided to all children living with HIV, especially where ARVs are not available. It is also recommended that all children born to HIV-positive mothers should be provided with co-trimoxazole until tests confirm that they are HIV-negative. Co-trimoxazole prophylaxis can be given to a child from 4 to 6 weeks of age.<sup>40</sup> As well as being effective, co-trimoxazole is cheap, costing as little as US$0.03 a day to provide. However, provision is extremely low with just 8% of infants born to pregnant women with HIV in 2008 initiating co-trimoxazole prophylaxis by two months of age.<sup>41</sup><br />
Another important intervention is vaccination or immunisation against common infections. There are some risks associated with providing routine vaccines to children living with HIV, but these risks are far outweighed by the benefits of immunisation. In general, routine vaccines are safe to administer in HIV-positive children, and are recommended.<sup>42</sup> <sup>43</sup> However, it should be noted that ‘live vaccines’ are often not considered safe for use in HIV-positive children.<br />
<h2>Barriers to child testing and treatment</h2>Unless barriers to HIV testing and treatment are addressed children will continue to die in their hundreds of thousands each year. The unavailability of paediatric HIV drugs means effective treatment for children is often elusive. Furthermore, stigma and discrimination directed towards people living with HIV are conducive to low levels of testing, and can contribute to poor adherence to ART where it is available.<br />
<h3>Problems with testing</h3>In 2008, less than 1-in-6 children born to women with living with HIV were tested within two months of birth.<sup>44</sup><br />
A number of factors may prevent children from being tested. Health authorities’ lack of technical ability, poor systems for laboratory analysis, problems with transportation of specimens and results, and little confidence in caring for children are all significant factors.<sup>45</sup><br />
Furthermore, parents may be unwilling to take their child for an HIV test for fear that the child will face prejudice once diagnosed. A lack of knowledge about testing and the fact HIV can be effectively treated could also lead to poor testing rates. Mothers who have not yet been tested may too be fearful of discovering their child is infected as this would likely mean they are infected also. Hospitals or clinics that provide testing may not be accessible and will lose contact with HIV-exposed children for follow-up tests. A mother may have to travel long distances to reach the nearest health service that can test her child, and this may be impractical and expensive.<sup>46</sup><br />
<h3>Lack of appropriate treatment</h3>Many of the drugs that are conventionally used to treat adults living with HIV are not available in an appropriate form, or licensed/approved for use in children. Those that are available are often unaffordable in the areas where they are most needed. The paediatric formulations that are available can be significantly more expensive than adult equivalents and therefore an expansion of the development of cheap, fixed-dose combinations for children is greatly needed.<br />
<div class="photo_r"><img border="0" height="225" src="http://www.avert.org/media/photos/2015.jpg" width="300" /> <br />
<div style="width: 300px;">Children performing a play about the benefits of antiretroviral medication</div></div>As more groups speak out about the unacceptably high cost of these formulations, some progress is being made. In December 2006, The Clinton HIV/AIDS Initiative (CHAI), founded by former US president Bill Clinton, announced that it had negotiated reductions in paediatric drug prices made by two Indian pharmaceutical companies. Under this agreement, 19 different ARVs that can be used in children were scheduled to be made available for an average 16 cents per day. This is 45% cheaper than previously available drugs.<sup>47</sup> This agreement has probably contributed considerably in increasing child access to ART in recent years. Since CHAI and UNITAID partnered in 2006, they claim to have reduced the cost of leading child treatments by 64 percent in low income countries.<sup>48</sup><br />
Even though many governments have increased efforts to distribute co-trimoxazole, financial and logistical barriers still stand in the way of its provision. It is estimated that in 2007 just 4% of the four million children who could be benefiting from the drug had access to it.<sup>49</sup> Increasing the numbers of children receiving this relatively low-cost drug would save many lives.<br />
<h3>Problems with adherence</h3>As well as the unavailability of appropriate drugs, stigma surrounding HIV can also lead to adherence problems if parents and caregivers are unwilling to make it publicly known that the child in their care is HIV-positive. For instance, carers may be reluctant to fill out prescriptions in their local community, or may not make a child’s school aware of their condition, which can lead to them missing out on drug doses during the school day.<sup>50</sup> They may also hesitate to administer ARVs if other people are present when a child is due to receive them. For children who are old enough to administer their own ARVs, it can be hard to fit their treatment routine in with their increasingly active social lives:<br />
<blockquote class="longquote">“There are days when I can't be bothered [to take my medications] like when I am tired or if I am at someone else's house and have to hide it or whatever, then it's hard.”<cite>13 year old HIV-positive girl<sup>51</sup></cite></blockquote><h2>Improving testing and treatment for children</h2>While stepping up efforts to prevent mother-to-child-transmission would decrease the need for paediatric treatment, it is likely that HIV will continue to infect many thousands of children for years to come. Given this situation, testing and treatment facilities for children need to be improved, and ARVs that can be used in children need to be made much more widely available.<br />
The wider provision of cheaper, simplified drug formulations, fixed-dose combination tablets and low-cost generic versions of paediatric drugs would all have immense benefits. While there have been welcome increases in recent years in the number of children receiving ART, the vast majority go untreated. Governments, international organisations and donors need to focus on achieving much wider treatment coverage.<br />
The degree to which HIV-related stigma can affect poor levels of testing and adherence to therapy indicates how negative attitudes towards those living with HIV need to be tackled. Efforts to maximise adherence should be strengthened and delivered before and alongside treatment.<br />
General improvements in the health systems of developing countries would allow for greater resources to be allocated towards treating children. Many countries lack the resources and capacity needed to help children living with HIV, and suffer from a shortage of healthcare workers that are trained to test and treat children.<br />
If such improvements are made, the problems of HIV and AIDS among children could potentially be minimised. At present, though, progress is not happening fast enough. Greater advocacy, funding and effort are required if the challenges surrounding HIV treatment for children are to be overcome.<br />
<br />
<div class="box bFull" id="footnote"><h2>Sources:</h2><ol><li>Newell, M. et al (2004), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15464184" target="blank">‘Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis’</a>, The Lancet 364:9441</li>
<li>UNAIDS (2009, November), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp" target="_blank">'AIDS epidemic update'</a></li>
<li>WHO/UNAIDS/UNICEF (2009), <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector'</a></li>
<li>Matida, L.H. et al (2004), <a ,="" href="http://www.scielo.br/scielo.php?pid=S1413-86702004000600005&script=sci_arttext" target="blank">‘Improving survival among Brazilian children with perinatally acquired AIDS’</a>, Brazilian Journal of Infectious Diseases 8:6</li>
<li>Puthanakit, T. et al (2005), <a ,="" href="http://cat.inist.fr/?aModele=afficheN&cpsidt=16960653" target="blank">‘Efficacy of highly active antiretroviral therapy in HIV-infected children participating in Thailand’s national access to antiretroviral program’</a>, Clinical Infectious Diseases 41:1</li>
<li>Wamalwa D.C. et al (2007), <a ,="" href="http://cat.inist.fr/?aModele=afficheN&cpsidt=18907015" target="blank">‘Early response to highly active antiretroviral therapy in HIV-1 infected Kenyan children’</a> Clinical Infectious Diseases 45:3</li>
<li>O'Brien D.P. et al. (2007), <a ,="" href="http://fieldresearch.msf.org/msf/handle/10144/18270" target="blank">‘Treatment outcomes stratified by baseline immunological status among young children receiving non-nucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in resource-limited settings’</a>, Clinical Infectious Diseases 44:1245</li>
<li>The Guardian (2006, November 22nd), <a ,="" href="http://www.guardian.co.uk/society/2006/nov/22/health.aids2" target="blank">‘It’s difficult to say whether parents or children cope better’</a></li>
<li>Prendergast A. et al. (2007, July), <a ,="" href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2807%2961051-4/abstract" target="blank">‘International perspectives, progress and future challenges of paediatric HIV infection’</a>, The Lancet, vol. 370:9581</li>
<li>Mphatswe et al. (2007), <a ,="" href="http://www.aidsonline.com/pt/re/aids/abstract.00002030-200706190-00004.htm;jsessionid=JZMJMh7z1cDgn2wwMnYDkThDdv9MXwZQybvPcsg2G6hfCBx5XYTD%21-1031399950%21181195629%218091%21-1" target="blank">‘High frequency of rapid immunological progression in African infants infected in the era of perinatal HIV prophylaxis’</a>, AIDS 21:10</li>
<li>World Health Organization, <a ,="" href="http://www.who.int/hiv/pub/meetingreports/art_meeting_april2008/en/index.html" target="blank">‘Report of the WHO Technical Reference Group, Paediatric HIV/ART Care Guideline Group Meeting’</a></li>
<li>National Institute of Health website (2007, 25th July), <a ,="" href="http://www.niaid.nih.gov/news/qa/pages/cher_qa.aspx" target="blank">‘Q&A: Children with HIV Early Antiretroviral Therapy (CHER) Study: Treating HIV-Infected Infants Early Helps Them Live Longer’</a>; and Violari A. et al (2008, 20th November), <a ,="" href="http://content.nejm.org/cgi/content/full/359/21/2233" target="blank">‘Early Antiretroviral Therapy and Mortality among HIV-Infected Infants’</a>, New England Journal of Medicine 359:21</li>
<li>AIDSinfo, U.S. Department of Health and Human Services (2008, 29th July), <a ,="" href="http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=8&ClassID=1" target="blank">‘Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection’</a>,</li>
<li>Paediatric European Network for Treatment of AIDS (2009), <a ,="" href="http://www.pentatrials.org/" target="_blank">'Penta 2009 guidelines for the use of antiretroviral therapy in paediatric HIV-1 infection'</a></li>
<li>National Institute of Health website (2007, 25th July), <a ,="" href="http://www3.niaid.nih.gov/news/QA/CHER_QA.htm" target="blank">‘Q&A: Children with HIV Early Antiretroviral Therapy (CHER) Study: Treating HIV-Infected Infants Early Helps Them Live Longer’</a></li>
<li>AIDSinfo, U.S. Department of Health and Human Services (2008, 29th July), <a ,="" href="http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=8&ClassID=1" target="blank">‘Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection’</a>,</li>
<li>Paediatric European Network for Treatment of AIDS (2009), <a ,="" href="http://www.pentatrials.org/" target="_blank">'Penta 2009 guidelines for the use of antiretroviral therapy in paediatric HIV-1 infection'</a></li>
<li>World Health Organization, <a ,="" href="http://www.who.int/hiv/pub/meetingreports/art_meeting_april2008/en/index.html" target="blank">‘Report of the WHO Technical Reference Group, Paediatric HIV/ART Care Guideline Group Meeting’</a></li>
<li>Wood, S.M et al (2009) '<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/19584705?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum" target="_blank">The impact of AIDS diagnoses on long-term neurocognitive and psychiatric outcomes of survival adolescents with perinatally acquired HIV'</a>, AIDS 23(14):1859-1865</li>
<li>Welch, S.B., Gibb, D., (2008), <a ,="" href="http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050073&ct=1" target="blank">‘When should children with HIV infection be started on antiretroviral therapy?’</a>, PLoS Medicine 5:3</li>
<li>FDA, (2009) '<a ,="" href="http://www.aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=8&ClassID=1" target="_blank">FDA Guidelines for the Use of Antiretroviral Agents in Paediatric HIV Infection</a>'</li>
<li>Menson E. N. et al. (2006), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16709991" target="blank">‘Underdosing of antiretrovirals in UK and Irish children with HIV as an example of problems in prescribing medicines to children, 1997-2005: cohort study’</a>, British Medical Journal 332(1183)</li>
<li>UNICEF and WHO, (April 2010) ‘<a ,="" href="http://www.who.int/medicines/publications/sources_prices/en/index.html" target="_blank">Sources and Prices of Selected Medicines for Children</a>’</li>
<li>The Global Price Reporting Mechanism (Nov. 2009), ‘<a ,="" href="http://www.who.int/hiv/amds/gprm/en/index.html" target="_blank">Transaction prices for Antiretroviral Medicines and HIV Diagnostics from 2008 to October 2009’</a></li>
<li>William J. Clinton Foundation (2008), <a ,="" href="http://www.clintonfoundation.org/what-we-do/clinton-hiv-aids-initiative/information-center-resources" target="blank">‘CHAI Pediatric Program Pamphlet’</a></li>
<li>Corbett A et al. (2005), <a ,="" href="http://www.i-base.info/htb/v7/htb7-1-2/Comparison.html" target="_blank">‘Pharmacokinetics between trade and generic liquid and split tablet formulations of lamivudine, stavudine and nevirapine in HIV-infected Malawian children’</a>, 45th Interscience Conference on Antimicrobial Agents and Chemotherapy, Washington DC, abstract H-1106</li>
<li>O'Brien D. P., Sauvageot D., Zachariah R. and Humblet P. (2006, October), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16988517" target="blank">‘In resource-limited settings good early outcomes can be achieved in children using adult fixed-dose combination antiretroviral therapy’</a>, AIDS 20:15</li>
<li>World Health Organisation (2006), ‘<a ,="" href="http://dosei.who.int/uhtbin/cgisirsi/hydwY8PKxG/127480016/8/179628/ANTIRETROVIRAL+THERAPY+OF+HIV+INFECTION+IN+INFANTS+AND+CHILDREN+TOWARDS+UNIVERSAL+ACCESS+RECOMMENDATIONS+FOR+A+PUBLIC" target="_blank">Antiretroviral Therapy of HIV Infection in Infants and Children in Resource Limited Settings: Towards Universal Access (Recommendations for a Public Health Approach)</a>’</li>
<li>Medicines Sans Frontiers (2006, July), <a ,="" href="http://www.msfaccess.org/resources/key-publications/key-publication-detail/?tx_ttnews%5Btt_news%5D=576&cHash=35bb7f6c0d" target="blank">‘Children and HIV/AIDS’</a>, fact sheet</li>
<li>McComsey G.A., Leonard E. (2004), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15316336" target="blank">‘Metabolic complications of HIV therapy in children’</a>, AIDS, 18:13</li>
<li>World Health Organisation (2006), ‘<a ,="" href="http://dosei.who.int/uhtbin/cgisirsi/hydwY8PKxG/127480016/8/179628/ANTIRETROVIRAL+THERAPY+OF+HIV+INFECTION+IN+INFANTS+AND+CHILDREN+TOWARDS+UNIVERSAL+ACCESS+RECOMMENDATIONS+FOR+A+PUBLIC" target="_blank">Antiretroviral Therapy of HIV Infection in Infants and Children in Resource Limited Settings: Towards Universal Access (Recommendations for a Public Health Approach)</a>’</li>
<li>Vreeman R C et al (2008), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18574439" target="_blank">'A systematic review of pediatric adherence to antiretroviral therapy in low- and middle-income countries'</a></li>
<li>World Health Organisation (2006), ‘<a ,="" href="http://dosei.who.int/uhtbin/cgisirsi/hydwY8PKxG/127480016/8/179628/ANTIRETROVIRAL+THERAPY+OF+HIV+INFECTION+IN+INFANTS+AND+CHILDREN+TOWARDS+UNIVERSAL+ACCESS+RECOMMENDATIONS+FOR+A+PUBLIC" target="_blank">Antiretroviral Therapy of HIV Infection in Infants and Children in Resource Limited Settings: Towards Universal Access (Recommendations for a Public Health Approach)</a>’</li>
<li>World Health Organisation (2006), ‘<a ,="" href="http://dosei.who.int/uhtbin/cgisirsi/hydwY8PKxG/127480016/8/179628/ANTIRETROVIRAL+THERAPY+OF+HIV+INFECTION+IN+INFANTS+AND+CHILDREN+TOWARDS+UNIVERSAL+ACCESS+RECOMMENDATIONS+FOR+A+PUBLIC" target="_blank">Antiretroviral Therapy of HIV Infection in Infants and Children in Resource Limited Settings: Towards Universal Access (Recommendations for a Public Health Approach)</a>’</li>
<li>Chintu C., Mwaba P., (2005, May), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15875917" target="_blank">‘Tuberculosis in children with human immunodeficiency virus infection’</a>, The International Journal of Tuberculosis and Lung Disease, 9:5(477)</li>
<li>Mofenson L.M. et al. (2004, December), <a ,="" href="http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5314a1.htm" target="blank">‘Treating Opportunistic Infections Among HIV-Exposed and Infected Children’</a>, Recommendations from the CDC, the National Institute of Health, and the Infectious Diseases Society of America</li>
<li>Cohen, J.M. et al (2008), ‘<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18331563" target="_blank">Presentation, diagnosis and management of tuberculosis in HIV-infected children in the UK’</a>, HIV Medicine, Vol. 9, Issue 5: 277-284.</li>
<li>Paediatric European Network for Treatment of AIDS (PENTA) (2009), <a ,="" href="http://www.pentatrials.org/" target="_blank">‘PENTA 2009 guidelines for the use of antiretroviral therapy in paediatric HIV-1 infection’</a></li>
<li>Chintu C. et al. (2004), <a ,="" href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2804%2917442-4/fulltext" target="blank">‘Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double-blind randomised placebo-controlled trial’</a>, The Lancet, 364:9448</li>
<li>World Health Organisation (2006), <a ,="" href="http://www.who.int/hiv/topics/paediatric/technical/en/index.html" target="_blank">‘Guidelines on Co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults in resource-limited settings’</a></li>
<li>WHO/UNAIDS/UNICEF (2009), <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector'</a></li>
<li>Obaro S.K. et al. (2004), <a ,="" href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2804%2901106-5/abstract" target="blank">‘Immunogenecity and efficacy of childhood vaccines in HIV-1-infected children’</a>, The Lancet Infectious Diseases, 4:8</li>
<li>UNAIDS (2006), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/Archive.asp" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>WHO/UNAIDS/UNICEF (2009), <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector'</a></li>
<li>UNICEF/WHO (2008, November), <a ,="" href="http://www.who.int/hiv/topics/paediatric/technical/en/index.html" target="_blank">‘Scale up of HIV-related prevention, diagnosis, care and treatment for infants and children: A Programming Framework’</a></li>
<li>Chime J. et al. (2004, July), <a ,="" href="http://www.aegis.com/conferences/iac/2004/B12283.html" target="blank">‘Challenges of testing children for HIV in community and University Teaching Hospital (UTH) and Lusaka Zambia’</a>, 15th International AIDS Conference, abstract no. B12283</li>
<li>International Herald Tribune (2006, 30th November), <a ,="" href="http://www.iht.com/articles/2006/11/30/news/aids.php" target="blank">‘Cost of Treating Children with HIV/AIDS to Plummet’</a></li>
<li>UNITAID (2009), ‘<a ,="" href="http://www.unitaid.eu/en/20090417198/News/UNITAID-and-the-Clinton-HIV/AIDS-Initiative-Announce-New-Price-Reductions-for-key-drugs.html" target="_blank">UNITAID and the Clinton HIV/AIDS Initiative Announce New Price Reductions for Key AIDS Medicines</a>’</li>
<li>WHO (2008), <a ,="" href="http://www.who.int/hiv/pub/2008progressreport/en/index.html" target="_blank">'Towards universal access: scaling up priority HIV/AIDS interventions in the health sector'</a></li>
<li>World Health Organisation (2006), ‘<a ,="" href="http://dosei.who.int/uhtbin/cgisirsi/hydwY8PKxG/127480016/8/179628/ANTIRETROVIRAL+THERAPY+OF+HIV+INFECTION+IN+INFANTS+AND+CHILDREN+TOWARDS+UNIVERSAL+ACCESS+RECOMMENDATIONS+FOR+A+PUBLIC" target="_blank">Antiretroviral Therapy of HIV Infection in Infants and Children in Resource Limited Settings: Towards Universal Access (Recommendations for a Public Health Approach)</a>’</li>
<li>Chintu C., Mwaba P., (2005, May), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15875917" target="_blank">‘Tuberculosis in children with human immunodeficiency virus infection’</a>, The International Journal of Tuberculosis and Lung Disease, 9:5(477)</li>
</ol></div><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-17392049609065942492010-06-24T07:56:00.000-07:002010-06-24T07:56:25.082-07:00Continuing HIV treatmentARV treatment should stop a person from becoming ill for many years. For many people the therapy works without any major problems. However, sometimes there can be difficulties related to drug resistance, drug interactions, side effects and adherence.<br />
This page provides information about the issues that a person may face when continuing their antiretroviral treatment.<br />
The following information continues from the pages introduction to HIV & AIDS treatment and starting HIV & AIDS treatment.<br />
<h1><b>Monitoring treatment success</b></h1><h3>The viral load test</h3>Once ARV treatment has been started, it is important to track how well it is working. This is the purpose of the viral load test.<br />
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Viral load refers to the amount of HIV in the blood. If the viral load is high, T-helper cells tend to be destroyed more quickly. The aim of antiretroviral treatment is to keep the viral load as low as possible.<br />
In places where it is available, a viral load test is carried out shortly after antiretroviral treatment is started. If the treatment is working effectively, the viral load will drop to the undetectable level – below 50 copies/ml. Ideally this will happen within 24 weeks of starting treatment, but for some it can take 3 to 6 months. Some people never reach undetectable.<br />
Viral load tests are then carried out every few months. As some viral load tests can produce slightly different results on the same sample of blood, the results are monitored over a period of time. An increase in viral load may be followed by a fall in CD4 count and a greater risk of developing opportunistic infections.<br />
If viral load is increasing it is important to determine whether the treatment is failing due to drug resistance, poor adherence or drug interactions.<br />
<h3>Other assessments after starting treatment</h3>Once therapy has begun, there should be additional clinical and laboratory monitoring, including:<br />
<ul><li>Assessment for signs/symptoms of potential drug toxicities</li>
<li>Adherence counselling and assessment of adherence</li>
<li>Assessment of response to therapy and signs of treatment failure</li>
<li>Weight measurement</li>
<li>CD4 testing at least every six months (if available)</li>
<li>Haemoglobin monitoring for patients on AZT </li>
</ul>In resource-poor communities it is recommended that this monitoring should take place 2, 4, 8, 12 and 24 weeks after treatment begins and then every six months once the patient has stabilised on therapy.<br />
<h2>Drug resistance</h2>Antiretroviral drugs slow the replication of HIV in the body. However the drugs cannot stop the replication completely, so some HIV is able to survive despite ongoing HIV treatment.<br />
When HIV replicates it often makes slight mistakes, so each new generation of HIV differs slightly from the one before. These tiny differences in the structure of HIV are called mutations. Some of the mutations occur in the parts of HIV that are targeted by antiretroviral drugs. So although there is some HIV that continues to be attacked by the drugs, there are other strains of HIV that are less likely to be affected. This HIV is called drug resistant HIV, and it is able to replicate unaffected by the drugs.<br />
When someone has drug resistant HIV (commonly referred to as drug resistance), the amount of HIV in the blood rises and the risk of the person becoming ill increases. Drug resistance is one of the main reasons why antiretroviral treatment fails. If resistance develops, usually the drug regimen needs to be changed.<br />
<h3>Avoiding and detecting resistance</h3><blockquote class="bigquoteright"><div class="bigquotebody">Taking medication exactly as prescribed is a very important part of avoiding resistance.</div></blockquote>There are certain things that can be done to reduce the risk of developing drug resistant HIV. Ensuring that the drug combination is strong to begin with will lessen the risk of resistance developing. This usually means taking a combination of 3 or 4 drugs.<br />
Taking medication exactly as prescribed is a very important part of avoiding resistance. Missing doses or not taking them on time lowers the amount of antiretroviral chemicals in the body, which means the virus is not properly suppressed. The virus is then able to replicate faster, increasing the chance of it becoming resistant.<br />
Regular viral load testing is also important as the results can indicate whether a drug resistant strain of HIV is developing. If the drug combination is working, the viral load should be undetectable. An increasing viral load can be a sign of growing drug resistance.<br />
<h3>Cross-resistance</h3>Resistance to some ARVs can limit future treatment options. If HIV is resistant to one drug, it will sometimes be resistant to similar drugs in the same group. This is called cross-resistance and it means that some antiretroviral drugs will not work even if they have not been used before.<br />
<h2>Drug interactions</h2>Interactions between certain antiretroviral drugs and other drugs, both pharmaceutical and recreational, can alter the effectiveness of antiretroviral therapy. Interactions may lower the amount of antiretroviral drugs absorbed, allowing low level HIV replication to occur, which may increase the risk of drug resistance.<br />
ARVs may interact with the following types of drugs:<br />
<b>Other antiretrovirals. </b>An ongoing study has found that Invirase (saquinavir) when combined with Norvir (ritonavir) may cause an abnormal heart rhythm by affecting the heart's electrical signals.<sup>1</sup> Symptoms can range from lightheadedness to an abnormal heartbeat with the possibility that more severe side effects will develop such as ventricular fibrillation.<sup>2</sup> This has been found from preliminary data and a review of these findings are ongoing.<br />
<b>Other pharmaceutical drugs.</b> Some other pharmaceutical drugs may cause side effects or decrease the effectiveness of some antiretroviral drugs. For example, it is not recommended that protease inhibitors be taken with drugs such as Cafergot and Migranal, which are used to treat migraine headaches.<sup>3</sup><br />
<b>Herbal and complementary treatments.</b> Garlic capsules, for example, stop saquinavir - a protease inhibitor - from working properly.<br />
<b>Drugs for treating opportunistic infections.</b> For example the tuberculosis treatment rifabutin should usually not be used with the protease inhibitor saquinavir or the NNRTI delavirdine.<sup>4</sup><br />
<b>Recreational drugs.</b> Interactions between recreational drugs and antiretroviral drugs can be dangerous because of the potentiation (boosting) effects that antiretrovirals have on recreational drugs. Minimal research has been carried out in this area and little is known about how the body processes recreational drugs. The safest action is not to mix these drugs with antiretrovirals at all.<br />
Drug interactions are often a concern amongst older people living with HIV, as there is a higher chance they will be taking other medications for age-related illnesses.<br />
It is advised that those taking antiretroviral treatment seek advice from their doctor to avoid any drug interactions.<br />
The University of Liverpool maintains an up-to-date chart of drug interactions.<br />
<h2>Immune Reconstitution Inflammatory Syndrome (IRIS)</h2>IRIS is an illness that occurs for a small number of patients soon after treatment is started. It is caused by an excessive response by the recovering immune system to opportunistic infections that were already present, but were previously dormant and not producing symptoms. Although the symptoms of IRIS are often mild, occasionally they can be life threatening. Generally those who have a severely damaged immune system before starting antiretroviral treatment are more at risk of developing IRIS.<br />
IRIS does not indicate that treatment is failing. Usually the best response to IRIS is to continue treatment; the symptoms normally disappear within a few weeks. In cases involving severe opportunistic infections, such as cryptococcal meningitis or tuberculosis, it may be necessary to stop antiretroviral therapy whilst the infection is treated.<br />
<h2>Side effects</h2>Side effects occur when the drugs affect the body in ways other than those intended. Most of the antiretroviral drugs have known side effects, but this does not mean that everyone who takes the drugs will experience them. Some people only experience mild side effects and find them easily manageable. But for some the side effects occur so strongly that they have to consider alternative drugs.<br />
<blockquote class="bigquoteright"><div class="bigquotebody">The side effects often get better after a person has been on treatment for a while, as the body starts to adjust to the antiretroviral drugs.</div></blockquote>Side effects are often referred to by the grade of the effect, and the grades range from mild to moderate to severe to life-threatening. For example, it is considered a mild side effect if a person has 2-3 vomiting episodes a day. Life-threatening side effects such as extreme limitations in daily activity and hospitalisation are rare, but are still threats to some.<sup>5</sup><br />
The side effects often get better after a person has been on treatment for a while, as the body starts to adjust to the antiretroviral drugs. Doctors can usually prescribe some treatment to help with the most common side effects such as nausea and diarrhoea.<br />
Some people use alternative therapies and medications with combination therapy to ease the side effects. For example, ginger for some may ease nausea.<sup>6</sup> Sometimes the side effects do not diminish over time; in some instances one or more of the drugs in the combination can be changed to reduce the side effects.<br />
<h2>Adherence</h2>The term adherence means taking the drugs exactly as described. This includes taking all of the medication at the right time and exactly as the directions state. It also means ensuring that there will be no interactions with other drugs being taken.<br />
Anything below 95 percent adherence has been associated with increases in viral load and drug resistance.<sup>7</sup> Therefore adherence to antiretroviral treatment is extremely important. This means missing no more than one dose a month, if taking antiretroviral drug treatment once a day.<br />
Often experiencing side effects makes adherence difficult. As adherence is such a vital part of treatment, it is important to monitor closely the impact that side effects may have on adherence. A patient should inform their doctor if side effects are affecting adherence or if it is difficult to stick to a drug regimen.<br />
<h2>Changing HIV treatment</h2>Side effects and treatment failure are the two main reasons why antiretroviral treatment may need to be changed.<br />
<h3>Side effects</h3>Sometimes side effects can be so strong, intolerable or even life-threatening that the treatment must be changed. In such cases it is normally safe to change only the offending drug(s). Antiretroviral drug side effects has more information.<br />
<h3>Treatment failure</h3>A change of treatment is needed when the antiretrovirals fail to slow down the replication of the virus in the body. This can occur as a result of drug resistance, poor adherence, poor drug absorption or a weak combination of drugs. Increased viral load or an HIV-related illness may be signs of failing antiretroviral treatment.<br />
There are different opinions about when to change treatment if viral load is increasing. Some doctors recommend changing as soon as the viral load starts to rise, although this could mean running out of treatment options more quickly. Others recommend monitoring the trend of the viral load before making a decision to change. This latter approach may increase the risk of developing resistance to certain drugs, which can limit future treatment options.<br />
The changes made to the drug regimen will depend on the drugs already being used, the CD4 count and the patient’s general health.<br />
If viral load testing is not available it can be difficult to identify treatment failure. The World Health Organisation (WHO) has developed a staging system for HIV disease based on clinical symptoms, which may be used to guide medical decision making. More information about the four stages of HIV disease can be found in the different stages of HIV infection.<br />
WHO guidelines state that treatment failure may be signified by a new or recurrent Stage IV condition occurring after at least six months of therapy.<sup>8</sup> Conditions occurring before this time often represent immune reconstitution syndrome. The onset or recurrence of certain Stage III conditions such as pulmonary TB and severe bacterial infections after at least six months of treatment may also indicate treatment failure. Some Stage IV conditions, such as lymph node TB, may not be indicators of treatment failure.<br />
Combined with clinical judgement, the following table can guide the decision of whether to switch treatment.<br />
<table class="center"><tbody>
<tr> <th>Treatment failure criteria</th> <th>WHO Stage I</th> <th>WHO Stage II</th> <th>WHO Stage III</th> <th>WHO Stage IV</th></tr>
<tr> <td class="row_title">Clinical (CD4 testing unavailable)</td> <td>Do not switch</td> <td>Do not switch</td> <td>Consider switching</td> <td>Switch</td></tr>
<tr> <td class="row_title">CD4 failure (viral load testing unavailable)</td> <td><ul><li>Do not switch</li>
<li>repeat CD4 test in three months</li>
</ul></td> <td><ul><li>Do not switch</li>
<li>repeat CD4 test in three months</li>
</ul></td> <td>Consider switching</td> <td>Switch</td></tr>
<tr> <td class="row_title">CD4 failure and viral load failure</td> <td>Consider switching</td> <td>Consider switching</td> <td>Switch</td> <td>Switch</td></tr>
</tbody></table>In 2008 a study concluded that these guidelines only effectively detected treatment failure in a minority of patients.<sup>9</sup> The majority of those identified as having treatment failure by clinical criteria or CD4, in fact had adequate viral load suppression and therefore did not need to change treatment. However without viral load testing, these guidelines are the most helpful way of recognising treatment failure.<br />
<h2>Salvage therapy</h2>Salvage therapy is the term often used to describe the treatment for those who are resistant to drugs in the three main drug classes. In this situation it may be difficult to find a drug regimen that suppresses the viral load to undetectable.<br />
Many people start their salvage therapy with a much higher viral load than when they started previous HIV treatments. This puts more pressure on the new combination to work. Each combination used lessens the chance of maintaining a low viral load because of the possibility of developing resistance to the drugs. The choice of new treatment should always depend on what caused the previous one to fail.<br />
The recent introduction of new classes of drugs has meant that there are more alternative combinations for those who were running out of treatment options.<br />
<h2>Structured Treatment Interruptions (STIs)</h2>A Structured Treatment Interruption (STI) is when someone stops taking antiretroviral treatment temporarily. Sometimes people have to stop treatment due to severe side effects, ineffectiveness of the drugs or psychological issues. Taking an STI does not mean skipping or stopping medication randomly, but taking a break from the drug regimen with a planned timescale and close monitoring from a doctor.<br />
UK and American treatment guidelines do not recommend taking planned treatment breaks unless under clinical trial settings. Studies have shown that some types of STI have been associated with an increased short-term risk of HIV disease progression.<sup>10</sup><br />
<h2>HIV transmission and antiretroviral drugs</h2>Although antiretroviral drugs suppress HIV, they have not been proven to stop transmission, even when the viral load is undetectable. Unprotected sex between two HIV positive people is not a risk-free activity; there are many different strains of HIV and it is possible to become infected more than once, which can complicate treatment. Those taking antiretroviral drugs should take as much care to minimise the risk of HIV transmission as they did before starting the treatment.<br />
<br />
<h2>References:</h2><ol><li>FDA (2010, 23rd February) <a ,="" href="http://www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm201543.htm" target="_blank">'Ongoing safety review of Invirase (saquinavir) and possible association with abnormal heart rhythms'</a></li>
<li>FDA (2010, 23rd February) <a ,="" href="http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm201552.htm" target="_blank">'FDA announces possible safety concern for HIV drug combination'</a></li>
<li>www.hiv-druginteractions.org <a ,="" href="http://www.hiv-druginteractions.org/frames.asp?drug/drg_main.asp" target="blank">‘Drug interaction charts’</a>.</li>
<li>CDC (2008) <a ,="" href="http://www.cdc.gov/tb/TB_HIV_Drugs/Introduction.htm" target="blank">‘Managing drug interactions in the treatment of HIV-related tuberculosis’</a>. Accessed 9th July 2008.</li>
<li>Calmy. A. et al (2007, 7th July) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/17617255?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum" target="blank">‘Clinical update: adverse effects of antiretroviral therapy’</a>, The Lancet 370(9581).</li>
<li>Ernst, E & Pittler, M.H (2000) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/10793599" target="blank">‘Efficacy of ginger for nausea and vomiting: a systematic review of randomised clinical trials’</a>. British Journal of Anaesthesia, Mar; 84(3):367-71.</li>
<li>BHIVA guidelines (2001) <a ,="" href="http://www.bhiva.org/cms1192484.asp" target="blank">‘1.0 The role of adherence in HIV disease’</a>.</li>
<li>World Health Organisation (August 2006) <a ,="" href="http://www.who.int/hiv/pub/guidelines/adult/en/index.html" target="blank">'Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access - Recommendations for a public health approach</a><a ,="" href="http://www.who.int/hiv/pub/guidelines/adult/en/index.html" target="blank">'</a>.</li>
<li>Mee, P. et al (2008) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18784460?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum" target="blank">'Evaluation of the WHO criteria for antiretroviral treatment failure among adults in South Africa'</a>. AIDS, Vol. 22, No. 15, p.1971-1977.</li>
<li>El-Sadr, W & Neaton, J (2006) <a ,="" href="http://www.retroconference.org/2006/Abstracts/28085.HTM" target="blank">‘Episodic CD4-guided use of ART is inferior to continuos therapy: results of the SMART study’</a>. CROI 2006 Abstract #106LB, February 2006.</li>
</ol>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-80142999761938266302010-06-15T18:48:00.000-07:002010-06-15T18:48:06.238-07:00Introduction to HIV prevention<b> How can HIV transmission be prevented?</b><br />
<br />
<div class="box bFull"> <a href="http://www.avert.org/aids.htm"> </a>HIV can be transmitted in three main ways:<br />
<ul><li>Sexual transmission</li>
<li>Transmission through blood</li>
<li>Mother-to-child transmission</li>
</ul>For each route of transmission there are things that an individual can do to reduce or eliminate risk. There are also interventions that have been proven to work at the community, local and national level.<sup>1</sup><br />
Wherever there is HIV, all three routes of transmission will take place. However the number of infections resulting from each route will vary greatly between countries and population groups. The share of resources allocated to each area should reflect the nature of the local epidemic - for example, if most infections occur among men who have sex with men then this group should be a primary target for prevention efforts.<br />
<blockquote class="longquote">"Knowing your epidemic in a particular region or country is the first, essential step in identifying, selecting and funding the most appropriate and effective HIV prevention measures for that country or region." - <cite>UNAIDS guidelines for HIV prevention <sup>2</sup></cite></blockquote>HIV prevention should be comprehensive, making use of all approaches known to be effective rather than just implementing one or a few select actions in isolation. Successful HIV prevention programmes not only give information, but also build skills and provide access to essential commodities such as condoms or sterile injecting equipment. It should be remembered that many people don’t fit into only one “risk category”. For example, injecting drug users need access to condoms and safer sex counselling as well as support to reduce the risk of transmission through blood.<br />
<a name='more'></a><br />
</div><div class="box bFull"> <h2>Who needs HIV prevention?</h2>Anyone can become infected with HIV, and so promoting widespread awareness of HIV through basic HIV and AIDS education is vital for preventing all forms of HIV transmission. Specific programmes can target key groups who have been particularly affected by a country’s epidemic, for example children, women, men who have sex with men, injecting drug users and sex workers. Older people are also a group who require prevention measures, as in some countries an increasing number of new infections are occurring among those aged over 50.<sup>3</sup><br />
HIV prevention needs to reach both people who are at risk of HIV infection and those who are already infected:<br />
<ul><li> <span class="highlight_color">People who do not have HIV</span> need interventions that will enable them to protect themselves from becoming infected.</li>
<li><span class="highlight_color">People who are already living with HIV</span> need knowledge and support to protect their own health and to ensure that they don’t transmit HIV to others - known as “positive prevention”. Positive prevention has become increasingly important as improvements in treatment have led to a rise in the number of people living with HIV.<sup>4</sup> <sup>5</sup> <sup>6</sup></li>
</ul>HIV counselling and testing are fundamental for HIV prevention. People living with HIV are less likely to transmit the virus to others if they know they are infected and if they have received counselling about safer behaviour. For example, a pregnant woman who has HIV will not be able to benefit from interventions to protect her child unless her infection is diagnosed. Those who discover they are not infected can also benefit, by receiving counselling on how to remain uninfected.<sup>7</sup> <sup>8</sup> <sup>9</sup><br />
The availability and accessibility of antiretroviral treatment is crucial; it enables people living with HIV to enjoy longer, healthier lives, and as such acts as an incentive for HIV testing. Continued contact with health care workers also provides further opportunities for prevention messages and interventions. Studies suggest that HIV-positive people may be less likely to engage in risky behaviour if they are enrolled in treatment programmes.<sup>10</sup> <sup>11</sup><br />
<h2>Sexual transmission</h2><h3>What works?</h3>Someone can eliminate or reduce their risk of becoming infected with HIV during sex by choosing to:<br />
<ul><li>Abstain from sex or delay first sex</li>
<li>Be faithful to one partner or have fewer partners</li>
<li>Condomise, which means using male or female condoms consistently and correctly</li>
</ul>There are a number of effective ways to encourage people to adopt safer sexual behaviour, including media campaigns, social marketing, peer education and small group counselling. These activities should be carefully tailored to the needs and circumstances of the people they intend to help.<sup>12</sup> <sup>13</sup> <sup>14</sup><br />
Comprehensive sex education for young people is an essential part of HIV prevention. This should include training in life skills such as negotiating healthy sexual relationships, as well as accurate and explicit information about how to practise safer sex. Studies have shown that this kind of comprehensive sex education is more effective at preventing sexually transmitted infections than education that focuses solely on teaching abstinence until marriage.<sup>15</sup> <sup>16</sup><br />
<div class="photo_r"> <img alt="A condom vending machine in Vatican City, less than a block from St. Peter's Basilica" border="0" src="http://www.avert.org/media/photos/1924.jpg" width="250" /> <div style="width: 250px;">A condom vending machine in Vatican City</div></div>Numerous studies have shown that condoms, if used consistently and correctly, are highly effective at preventing HIV infection.<sup>17</sup> Also there is no evidence that promoting condoms leads to increased sexual activity among young people. Therefore condoms should be made readily and consistently available to all those who need them.<sup>18</sup><br />
There is now very strong evidence that male circumcision reduces the risk of HIV transmission from women to men by around 50%, which is enough to justify its promotion as an HIV prevention measure in some high-prevalence areas.<sup>19</sup> However, studies of circumcision and HIV suggest that the procedure does not reduce the likelihood of male-to-female transmission, and the effect on male-to-male transmission is unknown.<sup>20</sup><br />
Some sexually transmitted infections - most notably genital herpes - have been found to facilitate HIV transmission during sex. Treating these other infections may therefore contribute to HIV prevention.<sup>21</sup> <sup>22</sup> Trials in which HIV-negative people were given daily treatment to suppress genital herpes have found no reduction in the rate at which they become infected with HIV. Nevertheless, there is evidence to suggest that treating genital herpes in HIV positive people may reduce the risk of them transmitting HIV to their partners. Further research is ongoing.<sup>23</sup><br />
<h3>What are the obstacles?</h3>It is usually not easy for people to sustain changes in sexual behaviour. In particular, young people often have difficulty remaining abstinent, and women in male-dominated societies are frequently unable to negotiate condom use, let alone abstinence. Many couples are compelled to have unprotected sex in order to have children. Others associate condoms with promiscuity or lack of trust.<sup>24</sup><br />
Some societies find it difficult to discuss sex openly, and some authorities restrict what subjects can be discussed in the classroom, or in public information campaigns, for moral or religious reasons. Particularly contentious issues include premarital sex, condom use and homosexuality, the last of which is illegal or taboo in much of the world. Marginalisation of groups at high risk - such as sex workers and men who have sex with men - can be a major hindrance to HIV prevention efforts; authorities are often unwilling to allocate adequate resources to programmes targeting these groups.<br />
Safe male circumcision demands considerable medical resources and some cultures are strongly opposed to the procedure.<br />
Find out more about preventing sexual transmission of HIV.<br />
<h2>Transmission through blood</h2><h3>What works?</h3>People who share equipment to inject recreational drugs risk becoming infected with HIV from other drug users who have HIV. Methadone maintenance and other drug treatment programmes are effective ways to help people eliminate this risk by giving up injected drugs altogether. However, there will always be some injecting drug users who are unwilling or unable to end their habit, and these people should be encouraged to minimise the risk of infection by not sharing equipment.<sup>25</sup><br />
<div class="photo_l"> <img alt="Used syringes collected by a needle exchange in Puerto Rico" border="0" src="http://www.avert.org/media/photos/2149.jpg" width="300" /> <div style="width: 300px;">Used syringes collected by a needle exchange in Puerto Rico</div></div>Needle exchange programmes have been shown to reduce the number of new HIV infections without encouraging drug use. These programmes distribute clean needles and safely dispose of used ones, and also offer related services such as referrals to drug treatment centres and HIV counselling and testing. Needle exchanges are a necessary part of HIV prevention in any community that contains injecting drug users.<sup>26</sup><br />
Also important for injecting drug users are community outreach, small group counselling and other activities that encourage safer behaviour and access to available prevention options.<sup>27</sup><br />
Transfusion of infected blood or blood products is the most efficient of all ways to transmit HIV. However, the chances of this happening can be greatly reduced by screening all blood supplies for the virus, and by heat-treating blood products where possible. In addition, because screening is not quite 100% accurate, it is sensible to place some restrictions on who is eligible to donate, provided that these are justified by epidemiological evidence, and don’t unnecessarily limit supply or fuel prejudice. Reducing the number of unnecessary transfusions also helps to minimise risk.<sup>28</sup> <sup>29</sup><br />
The safety of medical procedures and other activities that involve contact with blood, such as tattooing and circumcision, can be improved by routinely sterilising equipment. An even better option is to dispose of equipment after each use, and this is highly recommended if at all possible.<br />
Health care workers themselves run a risk of HIV infection through contact with infected blood. The most effective way for staff to limit this risk is to practise universal precautions, which means acting as though every patient is potentially infected. Universal precautions include washing hands and using protective barriers for direct contact with blood and other body fluids.<sup>30</sup><br />
<h3>What are the obstacles?</h3>Despite the evidence that they do not encourage drug use, some authorities still refuse to support needle exchanges and other programmes to help injecting drug users. Restrictions on pharmacies selling syringes without prescriptions, and on possession of drug paraphernalia, can also hamper HIV prevention programmes by making it harder for drug users to avoid sharing equipment.<br />
Many resource-poor countries lack facilities for rigorously screening blood supplies.<sup>31</sup> In addition a lot of countries have difficulty recruiting enough donors, and so have to resort to importing blood or paying their citizens to donate, which is not the best way to ensure safety.<br />
In much of the world the safety of medical procedures in general is compromised by lack of resources, and this may put both patients and staff at greater risk of HIV infection.<br />
Find out more about preventing HIV transmission through blood<br />
<h2>Mother-to-child transmission</h2><h3>What works?</h3>HIV can be transmitted from a mother to her baby during pregnancy, labour and delivery, and later through breastfeeding. The first step towards reducing the number of babies infected in this way is to prevent HIV infection in women, and to prevent unwanted pregnancies.<br />
There are a number of things that can be done to help a pregnant woman with HIV to avoid passing her infection to her child. A course of antiretroviral drugs given to her during pregnancy and labour as well as to her newborn baby can greatly reduce the chances of the child becoming infected. Although the most effective treatment involves a combination of drugs taken over a long period, even a single dose of treatment can cut the transmission rate by half.<sup>32</sup><br />
A caesarean section is an operation to deliver a baby through its mother’s abdominal wall, which reduces the baby’s exposure to its mother’s body fluids. This procedure lowers the risk of HIV transmission, but is likely to be recommended only if the mother has a high level of HIV in her blood, and if the benefit to her baby outweighs the risk of the intervention.<sup>33</sup> <sup>34</sup><br />
Weighing risks against benefits is also critical when selecting the best feeding option. The World Health Organisation advises mothers with HIV not to breastfeed whenever the use of replacements is acceptable, feasible, affordable, sustainable and safe. However, if safe water is not available then the risk of life-threatening conditions from replacement feeding may be greater than the risk from breastfeeding. An HIV positive mother should be counselled on the risks and benefits of different infant feeding options and should be helped to select the most suitable option for her situation.<sup>35</sup><br />
<h3>What are the obstacles?</h3>In much of the world a lack of drugs and medical facilities limits what can be done to prevent mother-to-child transmission of HIV. Antiretroviral drugs are not widely available in many resource-poor countries, caesarean section is often impractical, and many women lack the resources needed to avoid breastfeeding their babies.<br />
HIV-related stigma is another obstacle to preventing mother-to-child transmission. Some women are afraid to attend clinics that distribute antiretroviral drugs, or to feed their babies formula, in case by doing so they reveal their HIV status.<br />
Find out more about preventing mother-to-child transmission (PMTCT) and why PMTCT programmes are failing to reach most women in need.<br />
<h2>Policy measures</h2>To be successful, a comprehensive HIV prevention programme needs strong political leadership. This means politicians and leaders in all sectors must speak out openly about AIDS and not shy away from difficult issues like sex, sexuality and drug use.<br />
An effective response requires strategic planning based on good quality science and surveillance, as well as consideration of local society and culture. All sectors of the population should be actively involved in the response, including employers, religious groups, non-governmental organisations and HIV-positive people. Many of the world's most successful HIV prevention efforts have been led by the affected communities themselves.<br />
HIV epidemics thrive on stigma and discrimination related to people living with the virus and to marginalised groups such as sex workers. Their spread is also fueled by gender inequality, which restricts what women can do to protect themselves from infection. Protecting and promoting human rights should be an essential part of any comprehensive HIV prevention strategy. This includes legislating against the many forms of stigma and discrimination that increase vulnerability.<br />
<br />
<h2>References</h2><ol><li>Mayer K. & Pizer H. (eds) (2009), 'HIV Prevention: A Comprehensive Approach'.</li>
<li>UNAIDS (2007), '<a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/PolicyGuidance/OperationGuidelines/HIV_prev_operational_guidelines.asp" target="_blank">Practical Guidelines for Intensifying HIV Prevention</a>'.</li>
<li>CDC (2007) <a ,="" href="http://www.cdc.gov/hiv/topics/surveillance/resources/reports/index.htm#surveillance" target="_blank">'HIV/AIDS surveillance report: Cases of HIV infection and AIDS in the United States and Dependent Areas, 2007'.</a></li>
<li>GNP+ (2009, April), '<a ,="" href="http://www.gnpplus.net/content/view/1507/34/" target="_blank">Living 2008: The Positive Leadership Summit Report</a>'.</li>
<li>Kalichman S. (ed) (2006), 'Positive Prevention: Reducing HIV Transmission Among People Living with HIV/AIDS' Springer.</li>
<li>International HIV/AIDS Alliance, "<a ,="" href="http://www.eldis.org/go/topics/resource-guides/hiv-and-aids&id=33719&type=Document" target="_blank">Positive Prevention: Prevention Strategies for People with HIV/AIDS</a>", July 2003</li>
<li>Richardson et al, "<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15166533" target="_blank">Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment</a>", AIDS 18(8), May 2004</li>
<li>Voluntary HIV-1 Counseling and Testing Efficacy Study Group, "<a ,="" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10963246&dopt=Abstract" target="_blank">Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial</a>", The Lancet 356(9224), July 2000</li>
<li>UNAIDS, "<a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=Publications/IRC-pub02/jc580-vct_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d3443%26query%3dthe%2520impact%2520of%2520voluntary%2520counselling%2520and%26hiword%3dand%2520counselling%2520impact%2520of%2520the%2520voluntary%2520%26PV%3d1" target="_blank">The impact of Voluntary Counselling and Testing</a>", 2001</li>
<li>Kennedy et al, "<a ,="" href="http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=17573590" target="_blank">The impact of HIV treatment on risk behaviour in developing countries: A systematic review</a>", AIDS Care 19(6), July 2007</li>
<li>Crepaz et al, "<a ,="" href="http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&list_uids=15249572" target="_blank">Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review</a>", JAMA 292(2), 14 July 2004</li>
<li>Lamptey and Price, "<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/9792356" target="_blank">Social marketing sexually transmitted disease and HIV prevention: a consumer-centered approach to achieving behaviour change</a>", AIDS 12 Suppl 2, 1998</li>
<li>Peersman and Levy, "<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/9633003" target="_blank">Focus and effectiveness of HIV-prevention efforts for young people</a>", AIDS 12 Suppl A, 1998</li>
<li>UNAIDS, "<a ,="" href="http://www.who.int/hiv/strategic/surveillance/pubchange/en/index.html" target="_blank">Sexual behavioural change for HIV: Where have theories taken us?</a>", 1999</li>
<li>Santelli et al, "<a ,="" class="externallink" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16387256" target="_blank">Abstinence and abstinence-only education: a review of U.S. policies and programs</a>", J Adolesc Health 38(1), January 2006</li>
<li>See AVERT.org's <a ,="" href="http://www.avert.org/abstinence.htm" target="blank">abstinence page</a></li>
<li>See AVERT.org's <a ,="" href="http://www.avert.org/condoms.htm" target="blank">condoms page</a></li>
<li>UNAIDS, "<a ,="" class="externallink" href="http://data.unaids.org/Publications/Fact-Sheets04/FS_Prevention_en.pdf" target="_blank">HIV Prevention Fact sheet</a>", 2004</li>
<li>NIAID, "<a ,="" class="externallink" href="http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm" target="_blank">QUESTIONS AND ANSWERS: NIAID-Sponsored Adult Male Circumcision Trials in Kenya and Uganda</a>", 13 December 2006</li>
<li>Aidsmap, "<a ,="" href="http://www.aidsmap.com/en/news/CA7B4AB2-765A-4AAC-A08F-A0297B44B030.asp" target="_blank">Circumcising HIV positive men may increase HIV infections in female partners, but fewer STIs seen</a>", 3 February 2008</li>
<li>WHO, "<a ,="" href="http://www.who.int/mediacentre/news/releases/2006/pr40/en/index.html" target="_blank">Treatment for sexually transmitted infections has a role in HIV prevention</a>", 16 August 2006</li>
<li>Hitchcock and Fransen, "<a ,="" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10028974&dopt=Abstract" target="_blank">Preventing HIV-1: lessons from Mwanza and Rakai</a>", The Lancet 353(9152), February 1999</li>
<li>Celum et al, "<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18572080" target="_blank">Effect of aciclovir on HIV-1 acquisition in herpes simplex virus 2 seropositive women and men who have sex with men: a randomised, double-blind, placebo-controlled trial</a>", The Lancet 371(9630), 21 June 2008</li>
<li>Marston and King, "<a ,="" class="externallink" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&list_uids=17084758" target="_blank">Factors that shape young people's sexual behaviour: a systematic review</a>", Lancet 368(9547), 4 November 2006</li>
<li>WHO, "<a ,="" href="http://www.who.int/hiv/pub/idu/e4a-drug/en/" target="_blank">Effectiveness of Drug Dependence Treatment in Preventing HIV Among Injecting Drug Users</a>", March 2005</li>
<li>WHO, "<a ,="" href="http://www.who.int/hiv/pub/prev_care/pubidu/en/" target="_blank">Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users</a>", January 2005</li>
<li>WHO, "<a ,="" href="http://www.who.int/hiv/pub/idu/e4a-outreach/en/" target="_blank">Effectiveness of Community-based Outreach in Preventing HIV/AIDS Among Injecting Drug Users</a>", April 2004</li>
<li>UNAIDS, "<a ,="" class="externallink" href="http://www.unaids.org/DocOrder/OrderForm.aspx" target="_blank">Blood safety and HIV</a>", 1997</li>
<li>WHO, "<a ,="" class="externallink" href="http://www.who.int/bloodsafety/en/" target="_blank">Aide-Memoire for National Blood Programmes</a>", July 2002</li>
<li>WHO, "<a ,="" class="externallink" href="http://www.who.int/topics/injections/en/" target="_blank">Universal Precautions, Including Injection Safety</a>"</li>
<li>Takei T et al (2009), '<a ,="" href="http://journals.lww.com/jaids/Fulltext/2009/12012/Progress_in_Global_Blood_Safety_for_HIV.8.aspx" target="_blank">Progress in Global Blood Safety for HIV</a>' Journal of Acquired Immune Deficiency Syndromes 52.</li>
<li>See AVERT.org's <a ,="" href="http://www.avert.org/pregnancy.htm" target="blank">pregnancy page</a></li>
<li>The European Mode of Delivery Collaboration, "<a ,="" class="externallink" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10199349&dopt=Abstract" target="_blank">Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial</a>", The Lancet 353(9165), March 1999</li>
<li>The International Perinatal HIV Group, "<a ,="" class="externallink" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10099139&dopt=Abstract" target="_blank">The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1--a meta-analysis of 15 prospective cohort studies</a>", NEJM 340(13), April 1999</li>
<li>WHO/UNICEF/UNAIDS/UNFPA, "<a ,="" class="externallink" href="http://www.unfpa.org/publications/detail.cfm?ID=204&filterListType=" target="_blank">HIV and infant feeding: Guidelines for decision makers</a>", 2003</li>
</ol><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-27386976127391130332010-06-15T18:39:00.000-07:002010-06-15T18:39:46.628-07:00HIV & AIDS treatment in the UK<div class="box bFull"> Since anti-HIV treatment has been available in the UK, it has had a profound impact upon the lives of those living with HIV and AIDS. The number of people dying from AIDS has dramatically decreased and HIV is now generally thought of as a chronic disease. However, despite the introduction of free antiretroviral treatment, there are still people dying from AIDS-related illnesses in the UK. Around a third of these AIDS-related deaths occur because people are being diagnosed too late, at a stage when antiretroviral treatment is less likely to work.<sup>1</sup> There is the additional risk that HIV may become resistant to the drugs if treatment is not adhered to.<br />
Issues that will be discussed in this page include:<br />
<ul><li><b>When HAART was introduced in the UK</b></li>
<li><b>How many people are receiving treatment and care for HIV in the UK</b></li>
<li><b>Who is able to receive free treatment and care for HIV/AIDS in the UK</b></li>
<li><b>Treatment for HIV positive pregnant women in the UK</b></li>
<li><b>How to access treatment in the UK</b></li>
<li><b>The cost of antiretroviral treatment in the UK</b></li>
<li><b>'Health tourism'</b></li>
<li><b>Why people still die from AIDS in the UK </b></li>
</ul>For more information on antiretroviral therapy see our Introduction to HIV and AIDS Treatment in our Treatment and Care section.<br />
<a name='more'></a><br />
</div><div class="box bFull"> <h2>When was HIV treatment introduced in the UK?</h2>Before the advent of antiretroviral treatment in the UK, there was little that could be done to stop the onset of AIDS. Lifespan was limited and treatment for opportunistic infections was primarily aimed at controlling pain and other symptoms. This meant that when the first AIDS cases were reported in the UK at the beginning of the 1980s, the majority of AIDS patients died within 2 years.<sup>2</sup> The situation started to improve during the middle of the 1980s when it was discovered that people with AIDS could live for longer if treated with antiretroviral drugs.<br />
AZT (zidovudine), the first drug approved for treatment of HIV, became widely available in the UK in 1987. AZT belongs to a group of drugs called nucleoside analog reverse transcriptase inhibitors (NRTIs). Although in the short-term AZT effectively suppresses HIV, over a period of time HIV tends to become resistant to the drug. Additionally, when it was first introduced, side effects were severe as the dosage was very high. These days AZT is very rarely used on its own and is almost always taken as part of combination therapy. It is also taken in a smaller dose than when first introduced.<br />
<div class="photo_r"> <img alt="Tenofovir tablets - NRTIs that are manufactured by Gilead under the brand name Viread" border="0" src="http://www.avert.org/media/photos/2310.jpg" width="300" /> <div style="width: 300px;">Tenofovir tablets - NRTIs that are manufactured by Gilead under the brand name Viread</div></div>In the early 1990s other NRTIs became available, including didanosine and zalcitabine. These drugs provided more treatment options and were proven to be more effective when taken in combination with AZT. However, it wasn't until protease inhibitors, a second class of drug, became available at the end of 1995, that antiretroviral therapy really began to make a difference.<br />
Protease inhibitors form part of Highly Active Antiretroviral Therapy (HAART) - a combination of three or more different antiretroviral drugs, which significantly delays the onset of AIDS in HIV-positive people. Soon after the introduction of protease inhibitors, a third class of drug - NNRTIs - was approved. As a result of the increase in availability of different classes of drugs, between 1994 and 1998 there was a steep decline in the number of AIDS cases reported each year in the UK.<br />
These days, there are five groups of antiretroviral drugs, and the number of drugs in each class continues to expand. Virtually all HIV-positive people in the UK who are receiving treatment are taking a combination of three or more of these drugs. Treatment is recommended for patients whose CD4 count has dropped below 350 cells (or 200 in acute, or primary, infection).<sup>3</sup><br />
<h2>How many people are receiving treatment and care for HIV in the UK?</h2>Data published by the Health Protection Agency show that since the mid-to-late 1990s, the number of HIV-positive people accessing HIV-related care in the UK has substantially increased. Around 18,000 people were being treated in 1998; this number had more than tripled by 2007. The Heath Protection Agency also reported that of those HIV-positive people receiving antiretroviral therapy, 97% were taking a combination of three or more antiretroviral drugs, with the remained taking one or two.<sup>4</sup> However, among those with a high level of immunosuppression - those with a CD4 count of <200 cells/mm3 - almost one-in-five were not receiving treatment.<sup>5</sup><br />
There are two main reasons why there has been a significant increase in the number of people receiving antiretroviral treatment since 1996. First, there has been a sharp decrease in HIV-related deaths since the introduction of antiretroviral therapy. HIV positive people are living longer and therefore need treatment for longer. Second, the number of new HIV diagnoses has risen, due to continuing transmission, an increase in testing, and immigration of HIV-infected individuals.<sup>6</sup><br />
<h2>Who should be able to receive free HIV/AIDS treatment in the UK?</h2>The question of who should be able to receive free HIV/AIDS treatment in the UK has been a much debated public health issue. Since 2004, free HIV treatment has been available only to those legally living in the UK. This means that people living in the UK illegally, who have had their asylum or immigration claims rejected or have not applied for legal residence, have to pay to receive antiretroviral HIV treatment through the National Health Service.<sup>7</sup><br />
A High Court case in April 2008 however saw a judge declare that refusing free NHS treatment to failed asylum seekers was unlawful and in possible breach of human rights.<sup>8</sup> By March 2009 though this ruling was overturned and the Court of Appeal ruled that failed asylum seekers should not be classified as ordinarily resident in the UK, meaning they are not entitled to free NHS treatment and care. However due to NHS rules, refused asylum seekers currently on treatment, or receiving medical monitoring whilst waiting to go on treatment, are still entitled to continue their treatment for free.<sup>9</sup><br />
In emergency situations, which, in the context of HIV may well mean a CD4 count of below 350, hospitals cannot refuse to provide treatment, even if the patient might be charged at a later stage.<sup>10</sup><br />
AVERT.org has more information about who is entitled to NHS treatment in the UK. For refugees or immigrants who are staying in the UK but don't have official permission to be in the country, The Refugee Council may be able to help with HIV treatment issues.<br />
<h2>Treatment for HIV positive pregnant women in the UK</h2>The rapid scale-up of antenatal HIV testing has meant that at least 9 in 10 HIV-infected pregnant women are diagnosed prior to delivery<sup>11</sup> and the appropriate treatment is given to reduce the risk of mother-to-child transmission. These preventative measures have ensured that the rate of mother-to-child transmission in the UK is very low - less than 5 percent in 2007, compared to 17% in 1998.<sup>12</sup><br />
Even though this treatment is available to all HIV positive pregnant women as it is considered 'immediately necessary treatment', the patient will still be charged afterwards if they are not entitled to free treatment within the UK.<sup>13</sup><br />
<h2>How to access treatment in the UK</h2>People with HIV who are entitled to treatment in the UK may get support and treatment from their own doctor or from a specialist at an HIV clinic or a local Genitourinary Medicine (GUM) clinic.<br />
For more information about how to register with a GP visit our page about NHS treatment in the UK.<br />
<h2>The cost of antiretroviral treatment in the UK</h2><blockquote class="bigquoteright"> <div class="bigquotebody">A report in 2007 found that 13 percent of HIV clinicians in the study had decided not to prescribe specific HIV medications or tests due to financial constraints within their budgets.</div></blockquote>The cost of treating someone with HIV in the UK is estimated at around £16,000 per year.<sup>14</sup> This is thought to be very cost effective, when compared to the amount it would cost to treat someone suffering from an AIDS-related illness in hospital and Accident and Emergency departments.<sup>15</sup><br />
As new, improved drugs are becoming available, the cost of HAART is increasing. A growing number of people are requiring more expensive drugs as they become resistant to previous combinations. A report in 2007 found that 13 percent of HIV clinicians in the study had decided not to prescribe specific HIV medications or tests due to financial constraints within their budgets. Patients are therefore often offered drugs based on cost rather than suitability. Additionally, around 1 in 5 of the clinicians had discussed plans to restrict the prescribing of certain drugs due to their cost.<sup>16</sup> If financial restraints force clinicians to be more selective about the medications they provide, it could become increasingly difficult for people who have become resistant to certain antiretroviral drugs to change their regimens.<br />
<h2>'Health tourism'</h2>There are concerns that HIV positive people from other countries have been migrating to the UK in order to access free antiretroviral treatment from the National Health Service. However there is a lack of evidence demonstrating to what extent 'health tourism' has actually occurred. One study showed that out of all the HIV positive participants, very few migrated to the UK primarily to access HIV treatment; it was only after spending some time within the UK that the participants first went to get tested for HIV.<sup>17</sup> This is not the behaviour of 'health tourists' who are entering the country solely to access free treatment services. Other studies have pointed to the fact that accessing healthcare, specifically HIV healthcare, is not a motivating factor in migration decisions. Furthermore, migration patterns have not evolved with the distribution of the HIV pandemic, nor have they been affected by changes in the law that restrict certain classes of immigrants from accessing care.<sup>18</sup><br />
Nevertheless, the Government argues that 'health tourism' exists in the UK and many HIV positive people wait until they are very ill before arriving in the country and going straight to Accident and Emergency Departments to be treated.<sup>19</sup><br />
<blockquote class="longquote">"The Government remains convinced that deliberate abuse of the NHS by overseas visitors, across a range of services, is not just a potential threat but a very real one and the Government must fulfil its responsibility to ensure that the NHS is protected for those who are entitled to receive it free of charge. That applies as much to HIV treatment as to any other hospital service."<cite> - Government response to the Health Select Committee's Third Report of Session 2004-2005.<sup>20</sup></cite></blockquote><h2>Why do people still die of AIDS in the UK?</h2>Despite the fact that HAART is now prolonging the lives of many HIV positive people, some are still dying of AIDS in the UK. In particular, drug resistance and late diagnosis have affected the survival rates among HIV positive people in the UK.<br />
<h3>Drug resistance</h3>When HIV replicates it often makes slight mistakes, so each new generation of HIV differs slightly from the one before. These tiny differences in the structure of HIV are called mutations. Some of these mutations can make the virus resistant to antiretroviral drugs. When this happens, the amount of HIV in the blood rises and the risk of the person becoming ill increases. Resistant viruses can be passed from one person to another. However, HIV that is resistant to one type of drug may not be resistant to another, so changing drug combinations can help in suppressing viral load.<br />
Findings from the UK HIV Drug Resistance Database suggest that there have been recent declines in both the prevalence of transmitted HIV drug resistance (TDR) and the prevalence of drug resistant HIV in treatment-experienced individuals. <sup>21</sup> <sup>22</sup><br />
<ul type="disc"><li><b>Decline in prevalence of transmitted HIV drug resistance in the UK. </b> Testing HIV positive people who have had no previous exposure to antiretroviral therapy indicates the prevalence of TDR. The prevalence of TDR peaked between 2000 and 2002, when around 12 percent of treatment naïve individuals that were tested were resistant to any drug class. In 2006 this figure had fallen to 6.6 percent, rising slightly in 2007.<sup>23</sup> The general decline could be a result of the increase in testing among drug-naïve patients for resistant mutations. It could also be attributed to the fact that a large number of new HIV diagnoses in the UK are a result of HIV infection acquired in countries where antiretroviral therapy is not widely available and hence drug resistant HIV is not as prevalent. </li>
</ul><ul type="disc"><li><b>Decline in the prevalence of drug resistant HIV in treatment-experienced individuals in the UK.</b> Since 2000 there has also been a decline in prevalence of drug resistant HIV in treatment-experienced individuals. In 1999, prevalence was over three-quarters but this had declined to 44% in 2007.<sup>24</sup> The British HIV Association (BHIVA) attributes the decline to the improved management of antiretroviral therapy and treatment failure.<sup>25</sup></li>
</ul>Despite evidence of decline, the level of transmitted drug resistance and the number of HIV infected people with a drug resistant strain of HIV in the UK remain relatively high. This is not only complicating HIV therapy, but is also contributing to AIDS deaths. The BHIVA annual audit showed that in a survey of 133 clinical centres, of the 263 HIV-related deaths, eleven were due to multiple drug resistance and the reducing number of treatment options.<sup>26</sup><br />
<h3>Late diagnosis</h3>A person is diagnosed late with HIV if their CD4 count is low at diagnosis, making them more likely to develop an infection. When this happens, the person is less likely to respond to antiretroviral drugs than someone who is diagnosed when their CD4 count is high. Among Black Africans and Caribbean people, for example, those who are diagnosed late are 13 times more likely to die within a year than those diagnosed at a CD4 count above 200.<sup>27</sup><br />
Late diagnosis is a major issue within the UK. In 2008, it was estimated that around a third of newly diagnosed, HIV infected adults were diagnosed late. The highest proportion of late diagnoses occurred among heterosexual men, with 44 percent of all diagnoses being late. Around 20 percent of HIV diagnoses among men who have sex with men were late, reflecting a greater awareness of the risk of HIV infection among this group.<sup>28</sup><br />
In order to reduce the number of late diagnoses in the UK, individuals who believe that they are at risk of HIV infection need to be aware of the importance of testing early. Healthcare professionals also need to be more aware of the problem and need to offer HIV testing to anyone who may be at risk.<br />
<blockquote class="longquote">"People are dying because they are not being tested early enough. We need to be in a position where GPs are prepared to discuss HIV risks and offer HIV tests as a matter of course to people from at-risk communities"<cite> - Dr Fiona Burns, Centre for Sexual Health & HIV Research, University College London</cite><cite><sup>29</sup></cite><cite></cite></blockquote><h2>Conclusion</h2><div class="photo_l"> <img alt="Tablets of Isentress (raltegravir), an integrase inhibitor used in HIV treatment" border="0" src="http://www.avert.org/media/photos/2677.jpg" width="300" /> <div style="width: 300px;">Tablets of Isentress (raltegravir), an integrase inhibitor used in HIV treatment</div></div>Since the first antiretroviral drug was introduced, treatment in the UK has come a long way. The majority of HIV positive people are living longer lives and the number of people dying from AIDS has significantly decreased. The NHS provides a variety of free drug combinations for all of the UK's HIV positive legal residents, unlike many other countries.<br />
However, there are still HIV positive people residing in the UK who are not getting treatment - often because they are unaware of their positive status. There is therefore a need for increased HIV testing to prevent late diagnoses and a need for greater awareness of issues such as drug resistance.<br />
<br />
<div class="box bFull" id="footnote"> <h2>References</h2><ol><li>BHIVA (2006, December) <a ,="" href="http://www.bhiva.org/cms1192339.asp" target="blank">'BHIVA clinical audit report 2005-6'</a>.</li>
<li>Pomerantz, R.J & Horn, D.L (2003, July) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/12835707?ordinalpos=26&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum" target="blank">'Twenty years of therapy for HIV-1 infection'</a>. Nature Medicine, vol. 9, no. 7.</li>
<li>British HIV Association (2008), <a ,="" href="http://www.bhiva.org/cms1222226.asp" target="_blank">'British HIV Association Guidelines for the Treatment of HIV-1 infected adults with antiretroviral therapy'</a></li>
<li>SOPHID, Centre for Infections, Health Protection Agency (2009) <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1203064766492" target="blank">'Numbers accessing HIV care: National Overview'</a>.</li>
<li>HPA (2008), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1227515299695" target="_blank">'HIV in the United Kingdom' </a></li>
<li>Health Protection Agency (2006) <a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1196942145471?p=1158945066450" target="_blank">'A complex picture'</a>.</li>
<li>The National Health Service (2004) <a ,="" href="http://www.opsi.gov.uk/si/si2004/20040614.htm" target="blank">'Charges to overseas visitors (Amendment)'</a> Regulations 2004: statutory instrument no. 614.</li>
<li>Guardian (2008, April 12th) <a ,="" href="http://www.guardian.co.uk/uk/2008/apr/12/immigration.publicservices" target="blank">'Asylum seekers have right to full NHS care, high court rules, but government considers appeal'</a>.</li>
<li>Aidsmap (2009, 30th March) <a ,="" href="http://www.aidsmap.com/en/news/85EF1548-264A-4898-A096-77498823A13C.asp" target="_blank">'Court of Appeal says refused asylum seekers not ordinary UK residents, therefore not entitled to free NHS care'.</a></li>
<li>Terrence Higgins Trust, <a ,="" href="http://www.tht.org.uk/howwecanhelpyou/livingwithhiv/healthcare/immigrationandhealthcare/" target="_blank">'Living with HIV: Healthcare: Immigration and healthcare'</a></li>
<li>The Health Protection Agency (2007) <a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">'Testing times'</a>. Accessed 4th April 2008.</li>
<li>HPA (2008), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1227515299695" target="_blank">'HIV in the United Kingdom' </a></li>
<li>The Department of Health (2009, April) <a ,="" href="http://www.dh.gov.uk/en/Healthcare/International/AsylumseekersAndrefugees/index.htm" target="blank">'Table of entitlement to NHS treatment - table correct as of April 2009'</a>.</li>
<li>AIDS Treatment Update (2006, May) <a ,="" href="http://www.aidsmap.com/cms1067337.asp" target="blank">'HIV treatment and care costs £16,000 a year'</a>, issue 156.</li>
<li>National AIDS Trust, Terrence Higgins Trust (200, September), <a ,="" href="http://www.nat.org.uk/Living-with-HIV/Useful-information/Treatment-care-and-support.aspx" target="_blank">'Campaign for access to treatment and care for all'</a></li>
<li>Terrence Higgins Trust (2007, January) <a ,="" href="http://www.tht.org.uk/informationresources/publications?pubid=19008" target="blank">'Disturbing symptoms 5'</a>.</li>
<li>THT & NAT (2006, February) <a ,="" href="http://www.google.com/url?sa=t&ct=res&cd=1&url=http%3A%2F%2Fwww.tht.org.uk%2FContent.aspx%3Fciid%3D13466&ei=s6r8R4D_CKD-mwPRwODRAQ&usg=AFQjCNEc5rmwqEixKya11OHWAE3HcfUIbw&sig2=39-CCFan-lsHkCxCYw8lzQ" target="blank">'Note on access to HIV treatment for undocumented migrants and those refused leave to remain' [pdf]</a></li>
<li>NAT (2008), <a ,="" href="http://www.nat.org.uk/Our-thinking/People-in-greatest-need/Asylum%20and%20migration.aspx" target="_blank">'The Myth of Health Tourism'</a></li>
<li>Crown Copyright (2005) <a ,="" href="http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Sexualhealth/Sexualhealthgeneralinformation/DH_4079794" target="blank">'New developments in sexual health and HIV/AIDS policy: Government response to the Health Select Committee's Third Report of the Session 2004-2005'</a>.</li>
<li>Crown Copyright (2005) <a ,="" href="http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Sexualhealth/Sexualhealthgeneralinformation/DH_4079794" target="blank">'New developments in sexual health and HIV/AIDS policy: Government response to the Health Select Committee's Third Report of the Session 2004-2005'</a>.</li>
<li>The Health Protection Agency (2007) <a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">'Testing times'</a>. Accessed 4th April 2008.</li>
<li>UK Collaborative Group on HIV Drug Resistance (2009, October), <a ,="" href="http://www.hivrdb.org/" target="_blank">'UK HIV Drug Resistance Database 2009 Annual Report 2008/2009'</a></li>
<li>UK Collaborative Group on HIV Drug Resistance, <a ,="" href="http://www.hivrdb.org.uk/" target="_blank">'UK HIV Drug Resistance Database - surveillance'</a>, accessed 14th September 2009</li>
<li>UK Collaborative Group on HIV Drug Resistance, <a ,="" href="http://www.hivrdb.org.uk/" target="_blank">'UK HIV Drug Resistance Database - surveillance'</a>, accessed 14th September 2009</li>
<li>British HIV Association (2008), <a ,="" href="http://www.bhiva.org/cms1222226.asp" target="_blank">'British HIV Association Guidelines for the Treatment of HIV-1 infected adults with antiretroviral therapy'</a></li>
<li>BHIVA (2006, December) <a ,="" href="http://www.bhiva.org/cms1192339.asp" target="blank">'BHIVA clinical audit report 2005-6'</a>.</li>
<li>Health Protection Agency (2007) <a ,="" href="http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1158945066450?p=1158945066450" target="blank">'Testing times'</a></li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>EurekAlert! (2007, 6th December) <a ,="" href="http://www.eurekalert.org/pub_releases/2007-12/wt-dft120607.php" target="blank">'Doctors failing to diagnose HIV early in UK Africans'</a>.</li>
</ol></div><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-28551990284336879512010-06-15T18:28:00.000-07:002010-06-15T18:28:47.234-07:00HIV & AIDS in the UK<div class="box bFull"> The UK has a relatively small HIV and AIDS epidemic in comparison with some parts of the world, with an estimated 83,000 people – or around 0.1% of the population – currently living with HIV.<sup>1</sup> While the number of people living with HIV in the UK is relatively low, it has increased dramatically since the 1990s, alongside a general rise in the prevalence of sexually transmitted infections.<br />
</div><div class="box bFull"> <h2>AIDS & HIV in the UK - the current situation</h2><div class="photo_r"><img alt="A poster which was part of the early campaign by the British government to raise awareness of AIDS" border="0" src="http://www.avert.org/media/photos/288.jpg" width="300" /> <div style="width: 300px;">A poster which was part of the early campaign by the British government to raise awareness of AIDS</div><div style="width: 300px;"></div><a name='more'></a><br />
</div>Although AIDS gets less attention from the media in the UK than it did during the early history of the UK AIDS epidemic, it’s far from a problem of the past. In fact, the epidemic has expanded, with the annual rate of new HIV diagnoses more than doubling between 1999 and 2003, and peaking in 2005 at almost 8,000 diagnoses.<sup>2</sup> Annual diagnoses have slightly declined since then with 7300 people being diagnosed HIV-positive in 2008. HIV prevalence in the UK is relatively low and estimated at 0.1% of the population.<sup>3</sup><br />
The UK AIDS statistics show that at the end of 2008 there were an estimated 83,000 people living with HIV in the UK, of whom approximately 22,400 were unaware of their infection.<sup>4</sup><br />
Relatively low numbers of people in the UK have died from AIDS in recent years thanks to the availability of HAART (Highly Active Antiretroviral Therapy), which dramatically increases the life expectancy of people living with HIV. In 2007, around 540 HIV-infected persons died, compared to 1,726 in 1995, when antiretroviral treatment for HIV/AIDS was not available. The majority of AIDS related deaths occurred because people were diagnosed late and therefore did not start treatment early enough. In 2007, an estimated 31% of newly diagnosed, HIV-infected adults were diagnosed late.<sup>5</sup><br />
Although HIV is often perceived to be a ‘gay’ problem, infections acquired through heterosexual sex account for the largest number of HIV diagnoses in the UK. The majority of people who acquired HIV heterosexually were infected overseas but only became aware of their status after being tested in the UK. In terms of HIV infections actually occurring within the UK, gay men (and other men who have sex with men) accounted for two thirds of new cases.<sup>6</sup><br />
Despite the rising numbers of new HIV infections in the UK, public knowledge of HIV and AIDS appears to have declined. While 91% of people in the UK knew that HIV was transmitted through unprotected heterosexual sex in 2000, by 2007 this figure had fallen to 79%<sup>7</sup>.<br />
Many UK HIV/AIDS organisations are calling for improved sexual health services. The Terrence Higgins Trust, for example, released a 2007 report stating that sexual health services in England remain woefully under prioritised and under funded. It claims that despite the government’s promise of an extra £300 million for sexual health services across the United Kingdom to modernise clinics and reduce waiting times, many GUM (Genitourinary Medicine) clinics remain cramped, out-of-date and understaffed<sup>8</sup>.<br />
<h3>UK regions affected by HIV</h3>In 2008, there were 6,727 HIV diagnoses in England, 331 in Scotland, 148 in Wales and 92 in Northern Ireland.<sup>9</sup><br />
London is the epicentre of the UK AIDS epidemic, accounting for around half of all HIV diagnoses in the UK. However, increasing numbers of diagnoses in England are being reported in areas outside the capital, including many places that were not previously associated with HIV. Yorkshire and The Humber, for example, saw an almost four-fold increase in the number annual diagnoses in 2008 compared to 2000. In Wales, Scotland, and Northern Ireland, HIV diagnoses have tended to rise year on year, although 2008 saw a decline in all countries other than Northern Ireland which saw the largest proportional increase.<sup>10</sup><br />
<h2>HIV transmission routes in the UK</h2>Of all diagnoses to the end of June 2009, 44% resulted from sex between men, 44% from heterosexual sex, 5% from injecting drug use, 2% from mother-to-child transmission, 2% from blood/tissue transfer or blood factor, and 4% from other or undetermined routes.<sup>11</sup><br />
<h3>Heterosexual sex</h3>In 2008, half of all people diagnosed in the UK were infected through heterosexual sex, making this the single biggest exposure category. Of these people just 21% were, or possibly were, infected in the UK. The high rate of HIV amongst Africans in the UK<b> </b>reflects the severity of the AIDS epidemic in sub-Saharan Africa. In total, black Africans represented 36% of newly diagnosed infections in 2008.<sup>12</sup><br />
The increasing number of people infected with HIV through heterosexual sex means that the number of women with HIV is increasing. The male to female ratio of HIV diagnoses made before 1994 was more than 7 to 1, whereas in 2008 the ratio for new diagnoses was around 5 male to 3 female.<sup>13</sup><br />
<div class="photo_r"><img alt="Choose safer sex poster" border="0" src="http://www.avert.org/media/photos/316.jpg" width="250" /> <div style="width: 250px;">Choose safer sex poster</div></div><h3>HIV/AIDS and gay men in the UK</h3>In 2007 the Health Protection Agency (HPA) announced that the number of newly diagnosed HIV infections amongst gay men had risen for the third successive year, to an all time high<sup>14</sup>. 2,433 men who have sex with men were diagnosed with HIV in the UK in 2008, representing one third of all new diagnoses that year.<sup>15</sup> There are currently around 31,100 men who have sex with men living with HIV in the UK<sup>16</sup>.<br />
Since HIV/AIDS treatment became available, the number of gay men dying from AIDS has fallen significantly. In fact the number of AIDS related deaths has decreased by 71% since 1997. The 170 AIDS related deaths amongst gay men represented 34% of all AIDS related deaths in the UK in 2006. The number of AIDS diagnoses was also low at 169 people, 69% of which were made at the same time as their HIV diagnosis<sup>17</sup>.<br />
<h3>Injecting drug use</h3>The level of HIV infection caused by injecting drug use is relatively low in the UK, with IDU prevalence in England and Wales in 2007 at 1.1%, including 3.9% in London. By the end of 2008 injecting drug users (IDUs) accounted for nearly 5% of HIV diagnoses ever reported in the UK. Around half of IDUs with newly diagnosed HIV were probably infected in the UK, with the rest probably having been infected in Southern and Eastern Europe.<sup>18</sup><br />
A lot of early media coverage of AIDS in the UK focused on injecting drug users. During the early Eighties it was a big problem, particularly in Scotland where areas such as Edinburgh and Dundee had a very high prevalence of HIV among IDUs. In 1986 needle exchanges began to operate all across the UK, providing clean needles and giving drug users access to information and support. These schemes were largely effective, and helped to substantially reduce the prevalence of HIV among IDUs in the nineties. From 1990 to 1996 prevalence among this group fell from nearly 6% to 0.6%, rising slightly around 2003 and remaining fairly stable since.<sup>19</sup> Troublingly, infection levels appear to be rising among newer injectors, from 0.25% in 2002 to 1% in 2007.<sup>20</sup> <br />
<h3>Mother to child transmission of HIV in the UK</h3>A high uptake of antenatal HIV testing and the availability of drugs to prevent mother to child transmission of HIV<b> </b>has led to a low level of HIV infections passed from mother to child in the UK. Only 1.3% of diagnosed HIV infections in 2008 were acquired through this HIV transmission route. There has been a total of 1,784 UK diagnoses of HIV in people who acquired the virus from their mothers including 847 who were born in the UK.<sup>21</sup><br />
View UK statistics by transmission route and gender<br />
<h2>HIV and Africans in the UK</h2>Africans in the UK are affected by HIV and AIDS to a far greater extent than other broadly defined ethnic groups. Between 1995 and 2008, Black Africans accounted for 42% of the UK’s total HIV diagnoses, of which the overwhelming majority were attributed to heterosexual sex.<sup>22</sup><br />
<div class="photo_l"><img alt="UK AIDS awareness poster" border="0" src="http://www.avert.org/media/photos/324a.jpg" width="214" /> <div style="width: 214px;">UK AIDS awareness poster</div></div>There are a number of challenges facing African communities affected by HIV and AIDS in the UK. Late diagnosis is a particular problem with over 40% of new diagnoses occurring at a CD4 count below 200 cells/mm3. Late diagnosis greatly increases the risk of mortality, with Black Africans and Black Caribbean adults 13 times more likely to die within a year of a late diagnosis compared with one at a higher CD4 count.<sup>23</sup><br />
To tackle this problem it has been suggested the UK could implement a community-based voluntary counselling and testing service offering rapid tests modelled on a similar service in Kenya. Respondents from a small focus group generally thought such a scheme could work. However, it was believed that a community-based service targeting Africans had the potential to exacerbate stigma and that it would not offer the same level of anonymity as a clinic.<sup>24</sup><br />
It is estimated that 69% of HIV-infected black African and Caribbean people are receiving antiretroviral drugs.<sup>25</sup> However, many live with the threat of deportation to countries where they would not be guaranteed such treatment.<sup>26</sup> Stopping or interrupting treatment can cause HIV to replicate quicker and it may become resistant to therapy.<br />
<h2>HIV/AIDS prevention in the UK</h2><h3>Men who have sex with men</h3>Gay men are currently the focus of a number of HIV prevention campaigns in the UK. An important nationally coordinated campaign is CHAPS, which is funded by the Department of Health and run by a partnership of organisations, led by the Terrence Higgins Trust.<br />
Another broad campaign is The London Gay Men’s HIV Prevention Partnership (LGMHPP) – a collaborative prevention effort implemented by AIDS-related organisations and funded by most London health authorities. Interventions include condom distribution, using media to promote prevention messages, newsletters and booklets, counselling and group work.<br />
Despite campaigns to raise HIV awareness, there is evidence to suggest prevention efforts are insufficient. A study released in 2007 found that 18% of HIV-negative gay men had had unprotected anal intercourse with more than one partner during the previous year. Worryingly, this figure rose to 37% for gay men who were HIV-positive.<sup>27</sup><br />
<h3>Africans in the UK</h3>The National African HIV Prevention Programme (NAHIP) is a country-wide prevention campaign funded by the Department of Health. It is managed by the African HIV Policy Network and collaborates with a number of smaller organisations that aim to prevent HIV among African people in the UK.<br />
Among NAHIP’s most prominent initiatives are the ‘Do It Right – Africans Making Healthy Choices’ campaign which provides information on sexual health, condoms, and where to access help. Its website features a series of soap opera-styled videos encouraging viewers to think about HIV, condom negotiation and testing.<sup>28</sup> The ‘Beyond Condoms’ campaign promotes debate among African communities about a wide range of issues regarding sexual health and ‘building a safer sex culture’. The campaign’s literature targets different religious groups and is available in five different languages.<sup>29</sup><br />
It is important that any prevention work targeting African communities in the UK be supported by parallel activities that aim to reduce the problem of HIV-associated stigma and discrimination.<sup>30</sup> A 2006 study found that fear of discrimination is stopping some people of African origin from accessing HIV testing services for fear of community reaction if their result were to be positive.<sup>31</sup> Encouraging HIV testing uptake is a key part of preventing onward transmission of HIV in all communities. If people know their status they are less likely to pass the virus to others.<br />
<h3>Injecting drug users</h3><div class="photo_r"><img alt="Needle exchange symbol on window of Boots, a UK-based pharmacy." border="0" src="http://www.avert.org/media/photos/3091.jpg" width="300" /> <div style="width: 300px;">Needle exchange symbol on window of Boots, a UK-based pharmacy.</div></div>Needle exchange services are run by hospitals, pharmacies, drug agencies and other organisations. While over 90% of current and former drug users in England, Wales and Northern Ireland have used a needle exchange service, campaigners argue that needle exchange provision in the UK is patchy, out of hours provision is poor and there are disparities in the availability of equipment.<sup>32</sup> Risk taking among this group remains high. In 2007, 23% of injecting drug users in England, Wales and Northern Ireland reported sharing needles or syringes during the four weeks prior to a survey, down from around a third in the early part of the decade.<sup>33</sup><br />
Doctors in the UK are permitted to prescribe methadone as a substitute for injected heroin. Through methadone substitution, users can also be helped to end their dependency on drugs.<br />
<h3>HIV/AIDS education and awareness</h3>HIV education is a vital component of HIV prevention strategies. Educating people about the HIV virus can help them to protect themselves and others, and can reduce the fear and stigma surrounding AIDS.<br />
A 2008 UK survey of peoples’ attitudes to and knowledge of HIV conducted by the National AIDS Trust has found “serious gaps” in people’s knowledge about the virus. The study found that levels of understanding about HIV transmission in the UK have fallen significantly since the year 2000. It was found that in 2007, over 90 percent of the British public did not fully understand the ways that HIV is transmitted, with Scotland and London reportedly being the least knowledgeable regions.<sup>34</sup><br />
Deborah Jack, Chief Executive of the National AIDS Trust, emphasises the need to educate the general UK public about HIV:<br />
<blockquote class="longquote">“Ignorance about HIV increases vulnerability to infection and also contributes to stigma and discrimination. The Government must re-invest in educating the public about HIV.”<sup>35</sup></blockquote>HIV education in schools is one way to target young people with HIV prevention. In England and Wales, the government encourages secondary schools to teach pupils about HIV/AIDS as part of Sex and Relationships Education (SRE), although it is not a statutory subject on the national curriculum. Ofsted – an official body that regulates schools in England – reported in 2007 that:<br />
<blockquote class="longquote">Schools gave insufficient emphasis to teaching about HIV/AIDS. Despite the fact that it remains a significant health problem, pupils appear to be less concerned about HIV/AIDS than in the past.”<sup>36</sup></blockquote>In Northern Ireland and Scotland, HIV/AIDS is not a compulsory part of school education either.<br />
The Terrence Higgins Trust, amongst other organisations, believes that sex and relationships education should be a core part of the National Curriculum in the UK:<br />
<blockquote class="longquote">“The lack of good sex education means many young people are leaving school ignorant about HIV and safer sex. HIV is now the fastest growing serious health condition in the UK, and there is no cure. It’s time to get our facts straight.” - <cite>Nick Partridge, Chief Executive, THT<sup>37</sup></cite></blockquote>In response to such recommendations following an independent review, Personal, Social, Health and Economic (PSHE) education will be made compulsory at primary and secondary schools in the UK from 2011. The age at which parents are allowed to withdraw their children from sex and relationships education will also be reduced from 19 to 15. This means that all young people in the UK will be provided with some sex and relationships education before they leave school.<sup>38</sup><br />
<h3>Prevention of mother-to-child transmission</h3>The UK has been very successful at preventing mother-to-child transmission of HIV. All expectant mothers are offered an HIV test and uptake in 2008 was 95% resulting in at least 90% of infections being identified before delivery.<sup>39</sup><br />
In the UK and Ireland, between 2000 (when screening was first rolled out) and 2006, the transmission rate from diagnosed women to their children was just 1.2%. Even lower transmission rates occurred when women took certain forms of antiretroviral therapy and with planned caesarean or vaginal delivery (as opposed to emergency or unplanned deliveries). This is taken as evidence of the effectiveness of providing choices about treatment and delivery mode in order to reduce MTCT. It also points to a need to achieve even greater levels of HIV testing in antenatal settings.<sup>40</sup><br />
<h2>HIV testing in the UK</h2>According to British guidelines, HIV testing should be offered at GUM clinics as part of routine STD screening, regardless of symptoms of disease or risk factors of infection. The guidelines state that everybody taking an HIV test should have a pre-test discussion, and be offered counselling if requested, or if there is a high risk of a positive result.<sup>41</sup><br />
The number of people being tested for HIV and other STDs at GUM clinics (where the majority of people are tested for HIV) has risen in recent years. Almost half of sexual health screens in 2003 included an HIV test; this proportion increased to two-thirds for England, Wales and Northern Ireland in 2006. Overall, around 950,000 had an HIV test in a GUM clinic in England, Wales and Northern Ireland in 2008.<sup>42</sup><br />
Around two-thirds of MSM in England and Wales have taken an HIV test, a rate which, promisingly, is steadily rising year on year.<sup>43</sup><br />
<blockquote class="bigquoteright"> <div class="bigquotebody">It can be difficult to treat someone with HIV if they are diagnosed late, and in some cases late diagnosis leads to death.</div></blockquote>A major worry is that many people infected with HIV aren’t accessing testing services soon enough. It’s estimated that around one third of HIV-positive adults in the UK are diagnosed late, and for heterosexual men this figure rises to 44%.<sup>44</sup> It can be difficult to treat someone with HIV if they are diagnosed late, and in some cases late diagnosis leads to death. According to the British HIV Association (BHIVA), at least a quarter of deaths reported in HIV-positive people in the UK between 2004 and 2005 may have been avoided if HIV had been diagnosed at an earlier stage<sup>45</sup>.<br />
BHIVA, along with other experts, say that non-HIV clinicians such as General Practitioners (GPs) need to be made more aware of the importance of early diagnosis. They have also called for HIV testing to be made a routine part of more generic healthcare services that aren’t specialised towards HIV or sexual health<sup>46</sup>. Introducing an opt-out testing policy (whereby everybody attending a GUM clinic is given an HIV test unless they specifically ask not to be tested) may be another way to reduce the number of people diagnosed late. Of previously undiagnosed HIV-infected heterosexual men and women attending GUM clinics in 2006, one quarter left the clinic unaware of their HIV infection in 2006<sup>47</sup>.<br />
There are also believed to be a significant number of undiagnosed infected children born to women with HIV. This issue garnered greater attention following the 2008 death of a 10 year-old, known as “SP”, who died within days a positive diagnosis. His parents had both been diagnosed HIV-positive six years earlier.<sup>48</sup><br />
One audit of 297 HIV-positive women attending a GUM clinic found just 58 of their 217 children had received an HIV test. The main reasons for not testing were a perception that the child was well and therefore could not be infected; fear of disclosure; inability to cope; and fear of guilt.<sup>49</sup><br />
The issue raises important questions regarding misconception and stigma of HIV, the level of support for families, the rights of the child and parents, and the stage at which social care and legal authorities become involved.<br />
<h2>AIDS treatment in the UK</h2>All legal UK residents are eligible for free HIV/ AIDS treatment from the NHS. The first antiretroviral drug to treat HIV became widely available in the UK in 1987. Since then, the availability of HIV treatment in the UK has greatly reduced the number of people who die from AIDS related illnesses, and has profoundly improved the quality of life of many people living with HIV.<br />
However, individuals undergoing HAART have to take medication every day for the rest of their lives, and sometimes suffer severe HIV drugs side effects. It has also been found that resistance to antiretroviral treatment can occur, and since HAART is a relatively new form of treatment it is not known how long an individual can continue to benefit from it.<br />
<h2>Other issues</h2><span class="highlight_color">Stigma and discrimination:</span> People living with HIV may face prejudice as a result of their condition, and the social stigma surrounding AIDS can stop people from discussing it. Ignorance of how HIV is transmitted can lead to dicrimination against people who have the virus.<br />
<div class="photo_l"><a href="http://www.avert.org/aids-picture.php?photo_id=1993"><img alt="George House Trust campaigners against HIV-related stigma and discrimination" border="0" src="http://www.avert.org/media/photos/1745.jpg" width="300" /></a> <div style="width: 300px;">George House Trust campaigners against HIV-related stigma and discrimination</div></div><span class="highlight_color">HIV in prisons:</span> In the past it has been found that prisoners in England and Wales are more likely to be infected with HIV than other members of the population, a problem driven by high-risk behaviour, particularly injecting drug use.<sup>50</sup> Campaigners argue that, despite a lack of recent data, this is probably still the case. The government has announced plans to provide disinfectant tablets to prisoners, which can be used to sterilise needles, although some campaigners argue that this does not go far enough and that needle exchanges should be introduced to prisons.<sup>51</sup> AVERT.org has more information about prisons, prisoners and HIV/AIDS.<br />
<span class="highlight_color">Criminal transmission of HIV:</span> There have been several high profile cases in the UK of individuals being prosecuted for reckless transmission of HIV because they have failed to tell sexual partners about their condition. These cases generated a lot of debate about how the law should deal with this issue, and in 2008 the UK Crown Prosecution service released guidelines to clarify the law. As of 2008 a person can only be convicted of reckless sexual HIV transmission if there is “a sustained course of conduct during which the defendant ignores current scientific advice regarding the use of safeguards”. This implies that a single act of unprotected sex is not enough to constitute reckless behaviour. Reckless HIV transmission is only punishable in court if HIV is actually passed on and if the defendant is aware of their HIV status.<sup>52</sup> The new legislation has been commended by various AIDS charities who have generally argued that it is right to prosecute people who deliberately pass on HIV, but that reckless transmission should not be criminalised. Promoting knowledge of status and safer sex are considered far more effective in preventing transmission, than prosecuting those who have transmitted the virus.<sup>53</sup><br />
<span class="highlight_color">Migration and HIV in the UK:</span> As nearly half of all new HIV diagnoses in the UK are amongst Africans, there is a clear link between migration and UK HIV incidence. Africans living with HIV in the UK<b> </b>face significant challenges, both due to stigma and discrimination against them and in relation to their immigration status.<br />
<h2>The way forward</h2>The recent history of AIDS in the UK has been marked by a number of important changes. As the situation continues to shift, government responses need to reflect these changes to minimise the future impact of AIDS in the UK.<br />
Many of those being diagnosed in the UK now come from other countries with high HIV prevalence rates, and so the government’s commitment to tackling AIDS internationally can be seen as a part of its response to the epidemic at home. Commendably, the UK is one of the most significant international contributors of bilateral aid towards funding for the AIDS epidemic in developing countries.<br />
At the same time, campaigners argue that the government also needs to renew its domestic response to HIV. In particular, many feel that there needs to be a greater focus on, and an improvement in, the services aimed at the two groups most affected by HIV in the UK: gay men, and people of African ethnicity.<br />
HIV infection in the UK is not limited to these groups though, and with sexually transmitted infections becoming more widespread amongst the population as a whole, it’s clear that unsafe sexual practices are common in the UK. Sexual health services in general need to be improved, and the declining awareness of HIV amongst the general public needs to be addressed. If such steps aren’t taken, it’s likely that the UK epidemic will continue to expand in coming years.<br />
<br />
<div class="box bFull" id="footnote"> <h2>References</h2><ol><li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>NAT (2008) <a ,="" href="http://www.nat.org.uk/News-and-Media/Press-Releases/2008/January/over-90-percent-of-the-british-public.aspx" target="_blank">‘Over 90 percent of the British public do not fully understand how HIV is transmitted’</a></li>
<li>THT (2007) <a ,="" href="http://www.tht.org.uk/informationresources/publications?pubid=19008" target="_blank">‘Disturbing symptoms 5’</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>HPA Press Release (2007) <a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1238055365942?p=1231252394302" target="_blank">‘New figures show rise in HIV diagnoses amongst gay men in UK’</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>HPA (2007) ‘<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007’</a></li>
<li>HPA (2007) ‘<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007’</a></li>
<li>HPA (2008) <span class="genfile"></span><a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1224833091685" target="_blank">'Shooting up:Infections among injecting drug users in the United Kingdom 2007. An update:October 2008'</a></li>
<li>Hope V.D. et al (2005), <a ,="" href="http://www.aidsonline.com/pt/re/aids/fulltext.00002030-200507220-00016.htm;jsessionid=JdnJG5WqjnlBH8b4nWGQzm6wq0vjwC2fhdC67nYqplQyJsmhCpL9%211285625425%21181195628%218091%21-1#TT1" target="_blank">'HIV prevalence among Injecting Drug Users in England & Wales 1990 to 2003: Evidence for increased transmission in recent years'</a> AIDS 2005:19</li>
<li>HPA (2008) <span class="genfile"></span><a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1224833091685" target="_blank">'Shooting up:Infections among injecting drug users in the United Kingdom 2007. An update:October 2008'</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1252660002826" target="_blank">'United Kingdom HIV New Diagnoses to End of June 2009'</a></li>
<li>Health Protection Agency Centre for Infections (2009), <a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1203084373037" target="_blank">'United Kingdom HIV New Diagnoses to End of December 2008'</a></li>
<li>HPA (2007) ‘<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007’</a></li>
<li>Prost A et al (2007), ‘HIV voluntary counselling and testing for African communities in London: learning from experiences in Kenya’, Sexually Transmitted Infections 83:7</li>
<li>HPA (2007) ‘<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007’</a></li>
<li>African HIV Policy Network (2008), briefing paper, <a ,="" href="http://www.ahpn.org/campaigns/index.php?camp_id=7" target="blank">‘Destination Unknown’</a></li>
<li>Dodds J P et al (2007), <a ,="" href="http://eprints.ucl.ac.uk/6748/" target="_blank">‘A tale of three cities: persisting high HIV prevalence, risk behaviour and undiagnosed infection in community samples of men who have sex with men’</a>, Sexually Transmitted Infections</li>
<li><a ,="" href="http://www.doitright.uk.com/" target="_blank">Do it Right website</a>, accessed 16/08/09</li>
<li>The National African HIV Prevention Programme, <a ,="" href="http://www.nahip.org.uk/campaigns/index.php?page_id=79" target="_blank">Beyond Condoms Campaign website</a>, accessed 16/08/09</li>
<li>HPA (2007) ‘<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007’</a></li>
<li>Elam G et al (2006), <a ,="" href="http://www.aegis.com/conferences/bhiva/2006/O28.html" target="_blank">‘Barriers to voluntary confidential HIV testing among African men and women in England: results from the Mayisha II community-based survey of sexual attitudes and lifestyles among Africans in England’</a>, HIV Medicine 2006; 7(Suppl. 1): 7 (abstract no. O28)</li>
<li>Turning point (2007), ‘At the sharp end: a snapshot of 21st century injecting drug use’</li>
<li>HPA (2008), '<a ,="" href="http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/120211551918" target="_blank">Health Protection Agency 2008, ‘Surveillance Update: 2008 Supplementary data tables of the Unlinked Anonymous Prevalence Monitoring Programme: data to the end of 2007’</a></li>
<li>NAT (2008), <a ,="" href="http://www.nat.org.uk/page/6327" target="_blank">‘Over 90 percent of the British public do not fully understand how HIV is transmitted’</a></li>
<li>NAT (2008), <a ,="" href="http://www.nat.org.uk/page/6327" target="_blank">‘Over 90 percent of the British public do not fully understand how HIV is transmitted’</a></li>
<li>Ofsted (2007, April), <a ,="" href="http://www.ofsted.gov.uk/Ofsted-home/Publications-and-research/Browse-all-by/Education/Curriculum/Personal-social-and-health-education/Primary/Time-for-change-Personal-social-and-health-education" target="_blank">'Time for change? Personal, social and health education’ </a></li>
<li>THT (2007) <a ,="" href="http://www.tht.org.uk/mediacentre/pressreleases/2007/july/july4.htm" target="_blank">‘Press release: Survey highlights shocking ignorance about HIV, 25 years after death of Terry Higgins’ </a></li>
<li>Department for Children, Schools and Families (2009, 5th November), '<a ,="" href="http://www.dcsf.gov.uk/pns/DisplayPN.cgi?pn_id=2009_0208" target="_blank">Ed Balls confirms all young people to learn Personal Social Health and Economic education</a>'.</li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>Townsend C L et al (2008), ‘Mother-to-child transmission of HIV’, AIDS 22:8</li>
<li>HPA (2007) ‘<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007’</a></li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>Sigma Research: <a ,="" href="http://www.sigmaresearch.org.uk/gmss/go.php/final" target="_blank">'Testing Targets: finding from the United Kingdom Gay Men's Sex Survey 2007'</a></li>
<li>HPA (2009), '<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151891866?p=1249920575999" target="_blank">HIV in the United Kingdom: 2009 report</a>'</li>
<li>BHIVA (2006), 2005-6 Full results of mortality audit</li>
<li>BHIVA (2006), 2005-6 Full results of mortality audit. Sullivan K. et al. (2005, June), 'Newly diagnosed HIV infections: review in UK and Ireland', British Medical Journal, 330:1301</li>
<li>HPA (2007) ‘<a ,="" href="http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203084355941?p=1158945066450" target="blank">Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007’</a></li>
<li>British HIV Association, Children's HIV Association, British Association of Sexual Health and HIV (2009), '"Don't Forget the Children": Guidance for the HIV testing of children with HIV-positive parents'</li>
<li>British HIV Association, Children's HIV Association, British Association of Sexual Health and HIV (2009), '"Don't Forget the Children": Guidance for the HIV testing of children with HIV-positive parents'</li>
<li>Weild A et al (1998), <a ,="" href="http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102229138.html" target="_blank"><span style="color: black;">'The prevalence of HIV and associated risk factors in prisoners in England and Wales in 1997: results of a national survey'</span></a> , International Conference on AIDS'</li>
<li>Prison Reform Trust/National AIDS Trust (2005), <a ,="" href="http://www.nat.org.uk/Our-thinking/People-in-greatest-need/Prisons.aspx" target="_blank">'HIV and hepatitis in UK prisons: addressing prisoners' healthcare needs'</a>. Elkins T.</li>
<li>CPS (2008) <a ,="" href="http://www.cps.gov.uk/publications/prosecution/sti.html" target="blank">‘Policy for prosecuting cases involving the intentional or reckless sexual transmission of infection’</a></li>
<li>Terrence Higgins Trust, <a ,="" href="http://www.tht.org.uk/informationresources/policy/ourprosecutionspolicy/policydetails/" target="_blank">Policy on prosecution of HIV transmission</a></li>
</ol></div><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-28569766548386367652010-06-15T18:20:00.000-07:002010-06-15T18:21:10.055-07:00HIV and AIDS in Russia, Eastern Europe and Central Asia<div class="box bFull">Around 1.5 million people in Russia, Eastern Europe and Central Asia were living with HIV in 2008, 110,000 of whom became infected that year, with 87,000 dying of AIDS.<sup>1</sup> It is estimated that over two-thirds of the area’s infected people live in Russia, and combined with Ukraine, these two countries account for 90% of the region’s total infections. Both countries also have some of the highest adult prevalence rates in the region, with 1.6% of Ukrainians and 1.1% of Russians infected. Significant numbers of people with HIV live in Belarus (13,000), Kazakhstan (12,000) and Uzbekistan (16,000) among other countries, with prevalence rates in Latvia (0.8%) and Estonia (1.3%) also being some of the highest in the region.<br />
<br />
Since 2001, HIV prevalence in Russia, Eastern Europe and Central Asia has roughly doubled, making the region home to the world’s most rapidly expanding epidemic. In contrast, over the same period, prevalence in sub-Saharan Africa fell from 5.8% to 5.2%, and stabilised in South and Southeast Asia at 0.3%.<sup>2</sup><br />
This page focuses on the 15 former Soviet republics that constitute the Caucasus (Georgia, Armenia and Azerbaijan), the Baltic states (Estonia, Latvia and Lithuania), Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan), as well as Ukraine, Belarus, Moldova and Russia.<br />
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</div><h2>Affected populations</h2>The regional epidemic is currently concentrated among injecting drug users (IDUs), sex workers and their sexual partners.<br />
<h3>Drug users</h3>The rise in HIV in the region is closely linked with increasing rates of injecting drug use that developed in the mid-1990s during the socioeconomic crisis that followed the break-up of the Soviet Union. At this time, nearby Afghanistan became the world’s largest producer of opium, from which heroin is derived, and drug trafficking increased throughout the region. Initial outbreaks were detected in Ukraine, Russia, Belarus and Moldova.<sup>3</sup><br />
<div class="photo_r"><img alt="Injecting drug use paraphernalia in Russia" border="0" src="http://www.avert.org/media/photos/396.jpg" width="260" /> <br />
<div style="width: 260px;">Injecting drug use paraphernalia in Russia</div></div>Sharing of contaminated drug taking equipment is a highly efficient way to transmit HIV, and over 60% of newly reported HIV cases in 2006 were attributed to injecting drug use. In Russia, which has an estimated 1.5 million to 3 million, mostly male, IDUs, this accounts for 83% of all infections among people who know their infection history, though only 65% of new cases in 2007 were caused this way. Nearly 12% of Russian IDUs are HIV positive.<sup>4</sup> A joint study by UNAIDS, WHO, the International HIV/AIDS Alliance in Ukraine and the Ukrainian Ministry of Health estimated the HIV prevalence among IDUs as somewhere between 17% and 70%.<sup>5</sup> The infection rate among IDUs in Estonia has been estimated as being as high as 90% with around one-fifth to one-quarter of IDUs being infected in Tajikistan, Azerbaijan and Latvia.<sup>6</sup> Georgia, Lithuania, Bulgaria and Kazakhstan have lower rates of IDU infection relative to the rest of the region.<sup>7</sup><br />
While incidences of new HIV infections among IDUs in Russia decreased between 2002 and 2006, many countries in the region experienced rapid increases. Ukraine experienced a 55% increase; Kazakhstan, a 132% rise; with Azerbaijan seeing a 377% increase in the number of new infections among IDUs. On a positive note, significant decreases were seen in Belarus, Estonia, Latvia and Lithuania.<sup>8</sup><br />
<h3>Sex workers</h3>Sex workers are at risk of HIV because of the overlap with injecting drug use as well as unsafe sexual behaviours including low contraception use and multiple sexual partners. Nearly four-in-ten female sex workers in Russia’s Samara region and St Petersburg used injecting drugs.<sup>9</sup> In Ukraine, HIV prevalence among sex workers ranges from 4% in the capital, Kiev, to 24% in Donetsk and 27% in Mikolayev. Uzbekistan has a 10% infection rate among sex workers, similar to the prevalence in Azerbaijan, and likely explained by low condom use. The infection rate among sex workers in Tajikistan’s capital, Dushanbe, and the second city, Khujand, leapt from 0.7% to 3.7% between 2005 and 2006. Other countries in the region have showed relatively low prevalence rates among sex workers.<sup>10</sup><br />
HIV knowledge among Russian sex workers is low with just 36% rejecting popular misconceptions and correctly identifying how sexual transmission can be prevented. The same proportion answered correctly in Kazakhstan, with fewer than a quarter able to do so in Lithuania.<sup>11</sup><br />
<h3>Sexual partners of risk groups</h3><div class="photo_l"><img alt="Posters promoting condom use in Tallinn, Estonia " border="0" src="http://www.avert.org/media/photos/3092.jpg" width="260" /> <br />
<div style="width: 260px;">Posters promoting condom use in Tallinn, Estonia</div></div>Partners of IDUs and sex workers are at risk of becoming infected through sexual transmission. Heterosexual contact, which accounts for nearly two-thirds of infections in women in Russia, accounts for an ever-growing proportion of new infections. In 2000, women comprised 20.6% of new infections; in 2003, this figure was 38.5%; and in 2007, the proportion had grown to 44% or 135,000.<sup>12</sup> In Ukraine, the growth of heterosexual transmission as a proportion of total HIV incidences between 2001 and 2006 (28% to 35%) is largely attributable to unprotected sex with an injecting drug user.<sup>13</sup> Regionally, half of HIV-positive women became infected by drug using partners, with a further 35% infected directly through needle sharing.<sup>14</sup><br />
Fewer than 1 in 200 (0.46%) pregnant women in Russia in 2006 were HIV positive. The proportion of tested pregnant women being diagnosed HIV-positive, which saw a very steep rise between 2000 and 2001, has levelled off and all pregnant women are advised to take a test.<sup>15</sup><br />
UNAIDS states that it is unlikely the regional epidemic will spread independently of transmission among injecting drug users and sex workers.<sup>16</sup> Similarly, another study states that even in countries that have prevalence rates of 1% or more, “the virus is still concentrated among injecting drug users and their sexual partners, and has <i>not </i>‘bridged’ into the general population.”<sup>17</sup><br />
<h2>Other affected groups</h2><h3>Prisoners</h3>As with sex workers HIV levels are prevalent in prison populations because of the over representation of injecting drug users. Furthermore, IDUs in prison are more likely to have HIV than those who inject among the general population, suggesting that risky injecting behaviour is more frequent inside prison.<sup>18</sup><br />
Precise information on patterns of HIV in prisons is hard to obtain, especially from lower and middle-income countries which dominate the region.<sup>19</sup> In Russia, over 10% of all new HIV diagnoses in Russia during 2006-2007 were registered to prison populations. Overall prevalence in prison is estimated at around 5% with the majority of inmates already infected before entering.<sup>20</sup> In Ukraine, 3.5-12% of prisoners are estimated as living with HIV. Once again, this is attributed to high levels of injecting drug use and men who have sex with men.<sup>21</sup> Estonia, which has one of the highest imprisonment rates in the European Union, has a 14% prevalence rate among prisoners.<sup>22</sup> The potential danger that prison conditions pose to drug users is indicated in an HIV outbreak in Lithuania’s Alytus prison in 2002 that infected 263 inmates, almost doubling the nation’s total epidemic.<sup>23</sup> This highlights that although HIV rates in prison are often concentrations of the epidemic among free populations, prison can create fertile breeding grounds for HIV independent of a country’s general trends.<br />
<h3>MSM</h3>Official figures show that men who have sex with men (MSM) are a relatively small proportion of total HIV cases in the region in comparison to Western European and North American nations. Unprotected male-to-male sex accounted for less than 1% of newly registered cases in Russia in 2006, where the route of transmission was known.<sup>24</sup> Prevalence rates among MSM range from 9% in the large city of Nizhni Novgorod to 4.6% in Yekaterinburg, 3.8% in St Petersburg and under 1% in Moscow.<sup>25</sup> An MSM prevalence rate of 11% was reported in Tashkent, Uzbekistan’s capital, and 1% in Kyrgyzstan.<sup>26</sup><br />
However, it is believed that the epidemic is thriving among this group but is being kept hidden and underreported due to a reluctance by MSM to reveal the cause of their infection for fear of stigmatisation.<sup>27</sup> In Ukraine, for example, estimated HIV prevalence among MSM ranges from 4.4% in Kiev to as high as 23% in Odessa despite just 110 cases having been officially reported since 1987.<sup>28</sup> <sup>29</sup> It is believed by some that the underground epidemic among MSM has been allowed to escalate due to very little funds targeting this group:<br />
<blockquote class="longquote">Governments everywhere are reluctant to spend money on sex workers, on drug users, but MSM comes at the top of the reluctance list. It is probably the last programmes that the governments will start. - <cite>Roman Gailevich, UNAIDS Regional Programme adviser</cite><sup>30</sup></blockquote>In a survey of nearly 3,700 MSM in Russia only 31% of those in a monogamous relationship always used condoms, with just 61% of MSM who only have casual sexual partners always using condoms. Just 2.7% had injected drugs – slightly more than the upper estimate of 2% in the general population - highlighting that the spread among MSM is largely, though not completely, separate from injecting drug use.<sup>31</sup><br />
<h2>Prevention</h2>Given that injecting drug use accounts for the overwhelming majority of HIV prevalence and new diagnoses, the availability of needle exchanges and drug substitution therapy is vital if HIV is to be effectively tackled. Additionally, information regarding safer sex is also necessary to ensure the epidemic does not bridge to wider populations. Services to prevent the spread of HIV among IDUs are inadequate and it is estimated that just 9% of injecting drug users at best utilise harm reduction programmes.<sup>32</sup><br />
<h3>Russia</h3>There are just 69 needle exchange programmes in Russia to cover as many as 2 million IDUs and UNAIDS estimated in 2005 that just 5% of all IDUs had access to such preventive measures.<sup>33</sup> <sup>34</sup> Despite this, the government cut its funding for needle exchanges from 15 programmes in 2006 to just 3 in 2007. Of the $289m in state funding for HIV just $7.75m was allocated to prevention. The bulk of what little harm reduction measures there are has therefore been left to bodies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria implemented through NGOs including the Russian Harm Reduction Network and the Global Efforts Against AIDS in Russia (GLOBUS) consortium.<sup>35</sup> Under its normal funding guidelines, the Global Fund would not provide support for prevention programmes in Russia due to the country having attained a certain degree of economic development. However, due to the government's continued refusal to adequately fund prevention programmes for sex workers and injecting drug users, the Fund felt compelled to extend funding for these programmes until 2011.<sup>36</sup><br />
<div class="photo_r"><img alt="Contents of needle exchange pack" border="0" src="http://www.avert.org/media/photos/2776.jpg" width="300" /> <br />
<div style="width: 300px;">There are few needle exchange programmes in Russia.</div></div>Drug users are heavily stigmatised in Russia and often come into contact with the law, driving them away from initiatives that could avert the risk of becoming infected. There are reports that IDUs have been harassed and arrested by police outside needle exchange programmes and pharmacies where they have bought syringes, a practice that further deters other drug users from accessing them.<sup>37</sup> One survey of police attitudes in Togliatti, a city with high HIV prevalence - 2.7% among the general population, with over half of IDUs found HIV positive in 2001 – found the pre-emptive, intensive surveillance approach towards drug users, and the belief that they are potential criminals, undermined the city’s harm reduction initiatives.<sup>38</sup> Another study of the same city found the odds of needle sharing among IDUs increase if they were last arrested for a drug offence.<sup>39</sup><br />
Substitution therapy, which provides IDUs with a legal opiate – methadone or buprenorphine – so users can avoid the risks of injecting, does not exist in Russia. A vigorous debate has occurred over whether this form of harm reduction should be legalised. In 2005, leading figures in the government and scientific community, including the deputy director of the Department of Corrections, the chair of the Russian Society of Psychiatrists and the director of the National Center on Addictions, authored a memorandum entitled “Say No to Methadone Programs in the Russian Federation”. The letter, which presented evidence against the measure, was printed in Russia’s <i>Medical News</i> and <i>Issues in Narcology</i>, and distributed throughout the region. The following year, a rebuttal by over fifty HIV and addiction experts from around the world was sent to the memorandum’s authors highlighting its errors and pointing to the scientific evidence supportive of such treatment:<br />
<blockquote class="longquote">“Methadone is currently being administered to more than 750,000 patients in more than sixty countries, including all twenty-five members of the European Union. The medication has been proven to reduce illicit opiate injection and criminal activity, and to decrease HIV risk and increase adherence to HIV medication. “The errors in your memorandum are all the more alarming since methadone’s effectiveness as an HIV prevention measure is of particular importance in Russia, where eighty-five percent of cumulative registered HIV cases were among injecting drug users. Failure to provide a lifesaving means of drug treatment will mean more HIV infections and lives lost.”<cite><sup>40</sup></cite></blockquote>Substitution therapy’s illegal status can in part be explained by Russia’s attitude towards drug addiction and drug users. Practices to tackle drug use are defined by ‘narcology’, a subspecialty of psychiatry originally developed in relation to alcohol addiction. One heavy critique of this approach is that treatment for drug addiction in Russia is seen only within the bounds of ‘cure’ or ‘failure to cure’. This ignores the most effective practice of pursuing multiple outcomes, not just abstinence, including reductions in injecting and exposure to HIV and other blood-borne viruses.<sup>41</sup> Instead of relying on the scientific evidence of harm reduction measures to treat drug addiction, Russian policy towards drug users emphasises criminalisation. “[A]s in the US, mass incarceration of drug users in Russia, under brutal conditions, produces a set of predictable adverse results for the individuals affected, and enables the continued spread of HIV throughout the general population.”<sup>42</sup><br />
<blockquote class="bigquoteright"><div class="bigquotebody">“Conditions within drug treatment facilities in Russia remind more of prisons than hospitals”</div><div class="bigquotecite">Vitaly Djuma, Executive Director, Russian Harm Reduction Network</div></blockquote>Detoxification and psychotherapy at state-run narcological dispensaries – health centers focusing on problematic drug and alcohol abuse – are the primary methods of treating drug addiction.<sup>43</sup> One study found this to be largely ineffectual with over half returning to drug use after one month, and 96% returning after two years. These poor results are despite the willingness of addicts to quit, with one study showing 91% of IDUs having tried once, and 64% attempting to quit at least five times.<sup>44</sup><br />
In December 2006, a fire at a Moscow treatment unit killed 44 HIV-positive women and two nurses trapped behind barred doors and windows. This was seen by some as reflective of an inhumane and repressive attitude towards drug users.<sup>45</sup> One leading Russian harm reduction advocate went so far as to say, “Conditions within drug treatment facilities in Russia remind more of prisons than hospitals.”<br />
Standard addiction therapy also does not offer sexual behaviour counselling to drug users, a vital component as heterosexual transmission occurs largely between IDUs and their partners. One study found sexual practices were likely to be safer when IDUs were offered sexual behaviour counselling at the same time as receiving addiction treatment.<sup>46</sup><br />
<h3>Ukraine</h3>Ukraine appears to have some of the most developed prevention programmes in the region with 46% of IDUs and 69% of female sex workers accessing at least one prevention service in the previous 12 months.<sup>47</sup><br />
There are an estimated 362 needle exchange sites in Ukraine including fixed, mobile and street-based units. It is also one of only two countries in the region that has both pharmacy-based and non-pharmacy-based needle exchanges. Each year the country distributes 80 sterile needles per IDU, the highest in the region.<sup>48</sup> The Global Fund is aiming for 65% of IDUs to follow safer injecting and sexual practices by 2012, up from 53% in 2006.<sup>49</sup><br />
<div class="photo_l"><img alt="World AIDS Day 2002 activities in the Ukraine" border="0" src="http://www.avert.org/media/photos/1138.jpg" width="300" /> <br />
<div style="width: 300px;">World AIDS Day 2002 activities in the Ukraine</div></div>Provision of opiate substitution therapy began in 2004 with IDUs receiving buprenorphine. In 2007, the Ministry of Health made methadone legal, and relaxed the criteria regarding who could receive such treatment. The Global Fund hopes to reach 11,000 IDUs with substitution therapy by 2011.<sup>50</sup><br />
Despite Ukraine’s generally positive approach to prevention, relative to much of the region, there remain barriers that IDUs face. As in Russia, similar problems exist regarding police harassment and arrests of IDUs trying to access needle exchange services.<sup>51</sup> Furthermore, drug users wishing to receive substitution therapy are placed on an official register that can be used to exclude them from certain professions, and information is often shared between medical and law enforcement institutions.<sup>52</sup> Such problems could deter other IDUs from using available services.<br />
<h3>Central Asia</h3>Little is known about the HIV situation in Turkmenistan, but of the other four countries – Kazakhstan, Tajikistan, Kyrgyzstan and Uzbekistan – all provide needle exchange services, with the latter two providing substitution therapy.<br />
Kyrgyzstan has some of the most developed harm reduction programmes in Eastern Europe and Central Asia with clean needles being provided in prisons and pharmacies.<sup>53</sup> This is facilitated by cooperation between primary health care providers and NGOs to improve access and reduce the stigma of needle exchange programmes. Clean needles can be obtained in prisons as well as pharmacies. The Global Fund is promoting methadone substitution therapy, which is available in eight locations, and in three years has provided this to nearly 500 drug users. A pilot programme offering substitution therapy in prisons was scheduled to begin in 2008.<sup>54</sup><br />
In 2007 over 40% of IDUs in Kazakhstan were reached by HIV prevention programmes, short of the more than 70% of sex workers and nearly half of MSM who were covered.<sup>55</sup> Around 65 syringes are distributed on average per IDU each year.<sup>56</sup> There have been moves towards providing substitution therapy, though as of 2009 there were just two small-scale pilot projects covering 50 people.<br />
Harm reduction in Uzbekistan is fairly limited with needle exchange sites, where available, being under resourced and understaffed. Just over 100 IDUs were receiving substitution therapy – 90 on buprenorphine, 37 on methadone – in November 2007. Fewer than one-in-five IDUs were estimated to be reached by harm reduction services in 2006.<sup>57</sup> Needle exchange is also limited in Tajikistan. Promises to implement needle exchange in prisons, where one-in-five HIV-positive people live, have not been implemented; nor has methadone treatment.<br />
<h3>Eastern Europe</h3>Access to harm reduction services is fairly low in the rest of the region with, for example, around 14% of IDUs accessing needle exchanges in Armenia where injecting drug use accounts for half of all HIV infections. Just 10% had access to clean needles in Azerbaijan at the end of 2006. Only 17% of IDUs in Belarus accessed harm reduction services, with a slightly improved picture in Moldova where over a quarter did so.<sup>58</sup> Some harm reduction programmes, providing methadone maintenance in prisons, have been in place in the Baltic countries (Latvia, Lithuania, Estonia) since 2006 as a result of a United Nations Office on Drugs and Crime (UNODC) project.<sup>59</sup><br />
<h2>Treatment</h2>According to the World Health Organization just 23% of adults and children in need of antiretroviral therapy (ART) in low- and middle-income European and Central Asian countries were receiving it as of December 2008.<sup>60</sup> In 2007, only a handful of countries including Uzbekistan, Kazakhstan and Moldova provided antiretroviral (ARV) drugs to more than 20% of those in need. Ukraine has a particularly poor coverage rate at just 8%.<sup>61</sup> Only 16% of adults and children with advanced HIV in Russia were receiving antiretroviral therapy in 2007, despite the treatment being free, though this figure increased roughly five percentage points each year since 2005.<sup>62</sup> In Latvia, the 2009 financial downturn led the government to cut the HIV and health services budget and introduce a cap on the number of people who are provided with free antiretroviral treatment.<sup>63</sup><br />
This means most countries in the region lag severely behind the 33% global coverage average in low- and middle-income countries and far below several African countries with severe epidemics including Botswana (79%), Zambia (46%) and South Africa (28%).<sup>64</sup><br />
Because of stigma and doubts about adherence to therapy IDUs in Russia were only a quarter of those receiving ARV drugs in 2006, despite accounting for the majority of HIV infected people.<sup>65</sup> It has been projected that a strategy specifically targeting drug users for antiretroviral therapy would actually be a significantly more effective and cheaper method of preventing infection among all people, including non-IDUs.<sup>66</sup> This further highlights the great extent to which drug users will have to be involved in treatment and prevention efforts if HIV is to be tackled.<br />
As Russia does not produce its own generic versions of antiretroviral drugs, unlike other large transitional countries such as Brazil and India, they can be costly to provide. The World Health Organization warned in 2006 that shortages of drugs and breaks in treatment, blamed also on bureaucracy, could lead to drug resistant strains of HIV developing and spreading.<sup>67</sup><br />
One expert on Russian health has pointed to official Russian documents showing the number requiring ARVs is likely to multiply to more than 450,000 by the end of 2010, exceeding by as many as eight times the number requiring it in 2009. This is due to the average eight to ten years it takes for HIV infection to develop into AIDS, and taking into account that 2001 saw the highest number of new infections.<sup>68</sup> The official number of cumulative HIV cases jumped from 31,000 in 1999 to 228,000 in 2002 despite annual testing rates remaining at a fairly constant 15-17% of the population since 1990.<sup>69</sup><br />
Perhaps insufficient levels of treatment should be considered in the context that the region has the world’s fastest growing HIV epidemic and that mechanisms for the provision of ART have not been able to keep pace with such rapid growth. Providing treatment for an ever-growing number of people is, in effect, like chasing a moving target. However, efforts to treat people need to be significantly stepped up if the situation is to be prevented from getting further out of control.<br />
<h2>Attitudes and awareness</h2>As in many regions of the world discrimination exists against people living with HIV. Given that the most at-risk groups in the region – IDUs, sex workers and MSM – are involved in what are viewed as socially unacceptable activities, this stigma is perhaps intensified. Peter Piot, former head of UNAIDS, has said stigma and discrimination against drug users and homosexuality in the region act as deterrents to seeking treatment, and according to the United Nations Development Programme (UNDP), most people living with HIV are more fearful of discrimination than they are of the negative health effects.<sup>70</sup> <sup>71</sup><br />
In 2004 a survey was conducted in Moscow which found that 7-in-10 people felt ‘fear, anger or disgust towards those living with the virus’.<sup>72</sup> Similarly, a survey in Samara Oblast region found that ignorance and discrimination were widespread, even among health workers and family members. Many people were afraid that they could acquire HIV through casual contact; some suggested isolating all infected people from the rest of the population.<sup>73</sup><br />
A United Nations Development Programme (UNDP) study of people living with HIV in the region examined the difficulties encountered in the areas of healthcare, education and employment. In the health sector, stigma and discrimination were borne out by substandard care, hidden expenses and sometimes denial of treatment. Negative attitudes among health professionals were believed to result from inadequate education, training and hospital resources to treat people with HIV. A lack of universal precautions and procedures in medical settings to guarantee staff safety also contributed to an unwillingness to treat people with HIV.<sup>74</sup><br />
Adding to negative attitudes of people with HIV is the fact that, in Russia, patients are treated at AIDS centres which are segregated from the rest of the health care system, further marginalising those in need. This separation has also led to a disparity in HIV knowledge between AIDS specialists and nurses and doctors in the general health system, with the latter “shockingly ignorant of basic facts about the disease,” according to an article in The Lancet.<sup>75</sup><br />
<div class="photo_l"><img alt="'HIV is NOT transmitted through sport' poster" border="0" src="http://www.avert.org/media/photos/376.jpg" width="200" /> <br />
<div style="width: 200px;">'HIV is NOT transmitted through sport' poster</div></div>The UNDP has found that teachers and school officials believe students with HIV would be discriminated against by their peers, and that parents of HIV-negative children would remove their children from the school if an HIV-positive child was enrolled.<sup>76</sup><br />
<blockquote class="longquote">“Yes, they are really dangerous. I think that such children [living with HIV] should not attend neither schools nor kindergartens as the other children will not be safe.” - <cite>Teacher from Georgia</cite><sup>77</sup></blockquote>In the same research, people with HIV said disclosing their status would be a hindrance to finding employment and would result in discrimination at work. Many people had therefore resigned themselves to unemployment or informal employment. Further, people with HIV in low-skilled jobs were considered more vulnerable to discrimination and firing. Adding to the problem is a lack of confidential legal action that could be taken in the event of unfair dismissal or discrimination.<sup>78</sup><br />
<blockquote class="longquote">"I know beforehand my status will certainly hinder the chance to get job or to be promoted… I do not search for a job as I think they will have a negative attitude towards me." - <cite>Person living with HIV from Georgia</cite><sup>79</sup></blockquote>Confronting negative attitudes is vital in order to encourage people to come forward for testing and treatment, and to ensure they do not infect others.<br />
<ul><li>A Miss HIV Positive beauty pageant was held in 2005 to mark World AIDS Day.</li>
<li>A poster campaign was launched by UNAIDS and a Russian community group in 2004 featuring famous paintings alongside slogans such as ‘HIV is NOT transmitted through sport’.</li>
<li>The Russian Media Partnership to Combat HIV/AIDS was launched in 2004, with sponsorship from over 40 media companies, and places public service messages across all Russian media. According to its website, 85% of Russians had seen its StopAIDS brand in 2008, and those who had done so were more likely to take preventive measures and be tested.<sup>80</sup></li>
<li>Ukraine launched its own public information campaign in September 2005 with a World Bank-backed advertisement being broadcast daily for three months highlighting the fact that eight Ukrainians die of AIDS every day.<sup>81</sup></li>
<li>A mass campaign directed towards Ukrainian students in 2008 resulted in 15,000 free and anonymous rapid tests, and 100,000 receiving information on HIV and where they could be tested.<sup>82</sup></li>
<li>Other awareness efforts include that of the UK government’s Central Asia HIV and AIDS Programme (CARHAP) that is providing £5.4 million in Kyrgyzstan, Tajikistan and Uzbekistan. As well as aiming to improve HIV services it is also addressing stigma and discrimination issues to increase access.<sup>83</sup></li>
<li>Three large scale conferences in Moscow addressing HIV and AIDS in Eastern Europe and Central Asia were held in 2006, 2008 and 2009, which could be an indicator the epidemic is receiving more attention.</li>
<li>A touring photo exhibition, Stars against AIDS, launched in May 2008, featuring 25 famous women from Russia and Ukraine, to raise awareness of HIV and tackle discrimination. A calendar of the exhibition will launch on World AIDS Day.<sup>84</sup></li>
<div class="photo_l_nofloat"><img alt="Former Olympic gymnastics champion, Svetlana Khorkina, participates in the Stars Against AIDS awareness campaign" border="0" src="http://www.avert.org/media/photos/2775.jpg" width="509" />
<div style="width: 509px;">Former Olympic gymnastics champion, Svetlana Khorkina, participates in the Stars Against AIDS awareness campaign</div></div></ul><div class="clear-all">The extent to which these messages are getting through is debatable. A 2008 audit by the UN, Global Fund and the USA, found shortcomings in Ukraine’s response to the epidemic with many regions of the country being insufficiently supported despite high levels of funding.<sup>85</sup></div><h2>Recent funding initiatives</h2>Positive steps made by Russia in addressing HIV have included significantly stepping up funding in recent years, and this could be seen as a positive step towards treating the epidemic with the graveness it deserves. The $140m allocated to HIV and viral hepatitis in 2006 was a 20-fold increase on funding for 2005. This was doubled in 2007. Future expansion of funding has been criticised, however, for directing too small a proportion to prevention, projected to be less than 9% in 2010. The country’s global commitments towards HIV funding include $40m for vaccine research and a $217m pledge to the Global Fund by 2010, a figure equal to the grants it has received.<sup>86</sup><br />
Prevention, treatment and care initiatives in Ukraine have been greatly boosted by substantial grants from the Global Fund including nearly $100m in 2003 and $151m in 2007.<sup>87</sup> A bill was passed in September 2008 to greatly expand HIV prevention, treatment and care for the 2009-13 period. The program will require around $730m in funding.<sup>88</sup><br />
<h2>Conclusion</h2>While many areas of the world have kept their HIV epidemics relatively stable, the region encompassing Russia, Eastern Europe and Central Asia is a glaring exception. Although there are signs of a heightened awareness of HIV, demonstrated by funding commitments, conferences and public awareness campaigns, far more needs to be done. Unless, IDUs, the drivers of the regional epidemic, are at the core of HIV prevention and treatment efforts, little headway will be made. Political will to tackle stigma and discrimination directed against people with HIV, injecting drug users and other vulnerable populations is imperative as is the introduction and expansion of universally tried and tested prevention methods.<br />
It has been predicted that Russia will experience the greatest number of AIDS-related deaths between 2009 and 2015, indicating the worst is yet to come.<sup>89</sup> It will be tragic if thousands more AIDS-related deaths are needed in order to prompt the countries of the region to effectively address their epidemics<br />
<br />
<div class="box bFull" id="footnote"> <h2>References</h2><ol><li>UNAIDS (2009), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp" target="_blank">'AIDS Epidemic Update'</a></li>
<li>UNAIDS (2009), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp" target="_blank">'AIDS Epidemic Update'</a></li>
<li>Hamers, F.F., and Downs, A.M. (2003, March), <a ,="" href="http://www.thelancet.com/journals/lancet/article/PIIS0140673603128310/abstract" target="blank">‘HIV in central and eastern Europe’</a>, The Lancet 362:9362</li>
<li>Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressAllCountries.asp" target="blank">‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’</a></li>
<li>Kruglov, Y.V. et al (2008, June), <a ,="" href="http://sti.bmj.com/cgi/content/full/84/Suppl_1/i37" target="blank">‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’</a>, Sexually Transmitted Infections 2008:84 (Supplement 1)</li>
<li>International Harm Reduction Development Program, Open Society Institute (2008, March) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/developments_20080304" target="blank">‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’</a></li>
<li>Kruglov, Y.V. et al (2008, June), <a ,="" href="http://sti.bmj.com/cgi/content/full/84/Suppl_1/i37" target="blank">‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’</a>, Sexually Transmitted Infections 2008:84 (Supplement 1)</li>
<li>European Centre for the Epidemiological Monitoring of HIV and AIDS (2007, December), <a ,="" href="http://www.eurohiv.org/reports/report_76/pdf/report_eurohiv_76.pdf" target="blank">‘HIV/AIDS Surveillance in Europe. Mid-year report 2007’</a> (PDF)</li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp" target="blank">‘2008 Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp" target="blank">‘2008 Report on the global AIDS epidemic’</a></li>
<li>Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressAllCountries.asp" target="blank">‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressAllCountries.asp" target="blank">‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp" target="blank">‘2008 Report on the global AIDS epidemic’</a></li>
<li>Lazarus, J. et al (2006, June), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16830605" target="blank">‘HIV/AIDS In Eastern Europe: More Than a Sexual Health Crisis’</a>, Central European Journal of Public Health 14:2</li>
<li>International Harm Reduction Association (2008), <a ,="" href="http://www.ihra.net/GlobalState2008?searchTerms%5B%5D=Global&searchTerms%5B%5D=state" target="_blank">'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'</a></li>
<li>Dolan, K. et al, <a ,="" href="http://www.thelancet.com/journals/laninf/article/PIIS1473309906706855/abstract" target="blank">‘HIV in prison in low-income and middle-income countries’</a></li>
<li>Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), <a ,="" href="http://data.unaids.org/pub/Report/2008/russia_2008_country_progress_report_en.pdf" target="blank">‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’</a> (PDF)</li>
<li>Kruglov, Y.V. et al (2008, June), <a ,="" href="http://sti.bmj.com/cgi/content/full/84/Suppl_1/i37" target="blank">‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’</a>, Sexually Transmitted Infections 2008:84 (Supplement 1)</li>
<li>Drew, R. et al (2008), <a ,="" href="http://www.euro.who.int/Document/E91264.pdf" target="blank">‘Evaluation of fighting HIV/AIDS in Estonia’</a> (PDF), World Health Organization Europe and United Nations Office on Drugs and Crime</li>
<li>Dapkus, L. (2002, 21st August), <a ,="" href="http://www.aegis.com/news/ap/2002/AP020829.html" target="blank">‘Finding of high number of HIV cases among prison inmates unsettles Lithuania’</a>, Associated Press</li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>UNAIDS (2009, January), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/20090126_MSMUkraine.asp" target="_blank">'Hidden HIV epidemic amongst MSM in Eastern Europe and Central Asia'</a></li>
<li>Kruglov, Y.V. et al (2008, June), <a ,="" href="http://sti.bmj.com/cgi/content/full/84/Suppl_1/i37" target="blank">‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’</a>, Sexually Transmitted Infections 2008:84 (Supplement 1)</li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>UNAIDS (2009, January), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/20090126_MSMUkraine.asp" target="_blank">'Hidden HIV epidemic amongst MSM in Eastern Europe and Central Asia'</a></li>
<li><a ,="" href="http://www.psi.org/resources/research-metrics/publications/hiv/russian-federation-2006-hivaids-trac-study-among-men-who" target="_blank">‘Russian Federation (2006): HIV/AIDS TRaC Study among Men who have Sex with Men’</a> Population Services International (2006)</li>
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<li>International Harm Reduction Association (2008), <a ,="" href="http://www.ihra.net/GlobalState" target="_blank">'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'</a></li>
<li>International Harm Reduction Development Program, Open Society Institute (2008, March) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/developments_20080304" target="blank">‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’</a></li>
<li>International Harm Reduction Development Program, Open Society Institute (2008, March) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/developments_20080304" target="blank">‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’</a></li>
<li>The Global Fund to Fight AIDS, Tuberculosis and Malaria (2009, 13th November), <a ,="" href="http://www.theglobalfund.org/en/pressreleases/?pr=pr_091113" target="_blank">'Global Fund to provide $24 million of new funding to fight HIV/AIDS in Russia'</a></li>
<li>‘<a ,="" href="http://hrw.org/reports/2004/russia0404/" target="blank">Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation’</a> Human Rights Watch (2004)</li>
<li>Rhodes, T., et al (2006, July), <a ,="" href="http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2438598#CR37" target="blank">‘Street Policing, Injecting Drug Use and Harm Reduction in a Russian City: A Qualitative Study of Police Perspectives’</a>, Journal of Urban Health 83:5</li>
<li>Rhodes, T., et al (2004, March) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15076245" target="blank">‘Injecting equipment sharing among injecting drug users in Togliatti City, Russian Federation: maximizing the protective effects of syringe distribution’</a>, Journal of Acquired Immune Deficiency Syndromes 35:3</li>
<li>(2006, 11th May) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/news/methadone_2006" target="blank">‘IHRD Joins Drug Treatment and HIV Experts in Criticizing Russian Memorandum Against Methadone Programs’</a></li>
<li>Elovich R. and Drucker E. (2008), <a ,="" href="http://www.harmreductionjournal.com/content/5/1/23" target="blank">‘On drug treatment and social control: Russian narcology's great leap backwards’</a>, Harm Reduction Journal 2008, 5:23</li>
<li>Elovich R. and Drucker E. (2008), <a ,="" href="http://www.harmreductionjournal.com/content/5/1/23" target="blank">‘On drug treatment and social control: Russian narcology's great leap backwards’</a>, Harm Reduction Journal 2008, 5:23</li>
<li><a ,="" href="http://hrw.org/reports/2007/russia1107/" target="blank">‘Rehabilitation Required: Russia’s Human Rights Obligation to Provide Evidence-based Drug Dependence Treatment’</a> Human Rights Watch, 2007 19:7(D)</li>
<li>International Harm Reduction Development Program, Open Society Institute (2008, March) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/developments_20080304" target="blank">‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’</a></li>
<li>Russian Harm Reduction Network (RHRN) and the International Treatment Preparedness Coalition – Region of Eastern Europe and Central Asia (2006, 11th May), <a ,="" href="http://www.itpcru.org/en/letter_to_hm" target="blank">‘Inhumane conditions in the Russian drug treatment facilities are the roots of Moscow’s tragedy’</a></li>
<li>Samet, J.H. et al (2008, September), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18636998" target="blank">‘Mitigating risky sexual behaviors among Russian narcology hospital patients: the PREVENT (Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment) randomized controlled trial’</a>, Addiction 103:9</li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/" target="blank">‘AIDS epidemic update - Regional Summary’</a></li>
<li>International Harm Reduction Association (2008), <a ,="" href="http://www.ihra.net/GlobalState" target="_blank">'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'</a></li>
<li>International HIV/AIDS Alliance in Ukraine, <a ,="" href="http://www.aidsalliance.kiev.ua/cgi-bin/index.cgi?url=/en/round6/index.htm" target="blank">‘Two year Programme budget. Main targets and Programme indicators, implemented by the Alliance Ukraine’</a></li>
<li>International Harm Reduction Development Program, Open Society Institute (2008, March) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/developments_20080304" target="blank">‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’</a></li>
<li>Human Rights Watch (2006, March), <a ,="" href="http://hrw.org/reports/2006/ukraine0306/" target="blank">‘Rhetoric and Risk: Human Rights Abuses Impeding Ukraine’s Fight against HIV/AIDS’</a>, Human Rights Watch 18:2(D)</li>
<li>International Harm Reduction Association (2008), <a ,="" href="http://www.ihra.net/GlobalState" target="_blank">'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'</a></li>
<li>International Harm Reduction Association (2008), <a ,="" href="http://www.ihra.net/GlobalState" target="_blank">'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'</a></li>
<li><a ,="" href="http://www.theglobalfund.org/en/in_action/kyrgyzstan/hiv1/" target="blank">The Global Fund – Kyrgyzstan website</a>, accessed 15th October 2008</li>
<li>UNAIDS, <a ,="" href="http://cfs.unaids.org/country_factsheet.aspx?ISO=KAZ" target="_blank">Latest UNGASS Data</a>, accessed 15th October 2008</li>
<li>International Harm Reduction Association (2008), <a ,="" href="http://www.ihra.net/GlobalState" target="_blank">'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'</a></li>
<li>International Harm Reduction Development Program, Open Society Institute (2008, March) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/developments_20080304" target="blank">‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’</a></li>
<li>International Harm Reduction Development Program, Open Society Institute (2008, March) <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/developments_20080304" target="blank">‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’</a></li>
<li>International Treatment Preparedness Coalition (2010, April) '<a ,="" href="http://www.itpcglobal.org/index.php?option=com_content&task=view&id=74&Itemid=11" target="_blank">Rationing Funds, Risking Lives: World backtracks on HIV treatment</a></li>
<li>WHO/UNAIDS/UNICEF (2009), <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector'</a></li>
<li>WHO (2008), ‘<a ,="" href="http://www.who.int/hiv/pub/2008progressreport/en/" target="_blank">Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector</a>’</li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp" target="blank">‘2008 Report on the global AIDS epidemic’</a></li>
<li>International Treatment Preparedness Coalition (2010, April) '<a ,="" href="http://www.itpcglobal.org/index.php?option=com_content&task=view&id=74&Itemid=11" target="_blank">Rationing Funds, Risking Lives: World backtracks on HIV treatment</a></li>
<li>UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp" target="blank">‘2008 Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2006) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2006/" target="blank">‘AIDS Epidemic Update: December 2006’</a></li>
<li>Long, E.F. et al (2006), <a ,="" href="http://cat.inist.fr/?aModele=afficheN&cpsidt=18287703" target="blank">‘Effectiveness and cost-effectiveness of strategies to expand antiretroviral therapy in St. Petersburg, Russia’</a>, AIDS 20:17</li>
<li><a ,="" href="http://www.medicalnewstoday.com/articles/45906.php" target="blank">‘Antiretroviral Drug Shortages In Parts Of Russia Could Lead To Drug Resistant HIV Strains, Experts Say’</a>, Kaisernetwork.org, June 23, 2006</li>
<li>Feshbach, M., (2008, August 13), <a ,="" href="http://www.cdi.org/russia/johnson/2008-153-36.cfm" target="blank">‘What’s in a number? A new projection by Pokrovskiy’s Center for HIV prevention and treatment and some consequences for Russia’</a>, Johnson’s Russia List</li>
<li>Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressAllCountries.asp" target="blank">‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’</a></li>
<li>Macauley, J., <a ,="" href="http://europeandcis.undp.org/poverty/show/0346E6C3-F203-1EE9-B09BA72A54265BB7" target="blank">‘HIV/AIDS and UNDP in the Eastern Europe and CIS region’</a>, United Nations Development Programme website, accessed October 16th 2008</li>
<li>New Scientist (2008, 11th May), <a ,="" href="http://www.newscientist.com/channel/health/hiv/mg19826552.800-stigma-helps-aids-flourish-in-russia.html" target="blank">‘Stigma helps AIDS flourish in Russia’</a></li>
<li>BBC News online (2004, 14th May), <a ,="" href="http://news.bbc.co.uk/1/hi/world/europe/3715599.stm" target="blank">‘Russia campaigns against AIDS fear’</a></li>
<li>Balabanova Y. et al. (2006, October), '<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16971297" target="_blank">Stigma and HIV infection in Russia</a>', AIDS Care 18(7)</li>
<li>UNDP (2008, December), <a ,="" href="http://europeandcis.undp.org/rhdr.aids2008/" target="_blank">‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’</a></li>
<li>Brown, H. (2006, 5th August), <a ,="" href="http://www.thelancet.com/journals/lancet/article/PIIS0140673606691344/fulltext" target="blank">‘Russia's blossoming civil society holds the key to HIV’</a>, The Lancet 368:9534</li>
<li>UNDP (2008, December), <a ,="" href="http://europeandcis.undp.org/rhdr.aids2008/" target="_blank">‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’</a></li>
<li>UNDP (2008, December), <a ,="" href="http://europeandcis.undp.org/rhdr.aids2008/" target="_blank">‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’</a></li>
<li>UNDP (2008, December), <a ,="" href="http://europeandcis.undp.org/rhdr.aids2008/" target="_blank">‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’</a></li>
<li>UNDP (2008, December), <a ,="" href="http://europeandcis.undp.org/rhdr.aids2008/" target="_blank">‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’</a></li>
<li>Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria, <a ,="" href="http://www.gbcimpact.ru/projects/?id=60" target="_blank">‘Russian Media Partnership to Combat HIV/AIDS’</a>, accessed 28th September 2009</li>
<li>The World Bank Group (2005, 27th September), <a ,="" href="http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/0,,contentMDK:20657882%7EpagePK:146736%7EpiPK:146830%7EtheSitePK:258599,00.html" target="_blank">'Ukraine Launches Information Campaign Against AIDS'</a></li>
<li>International HIV/AIDS Alliance in Ukraine (2008, 1st August), <a ,="" href="http://www.aidsalliance.org.ua/cgi-bin/index.cgi?url=/en/news/2008/index.htm" target="_blank">'Press release: On the results of the first large-scale HIV prevention campaign among students'</a></li>
<li>Department for International Development (2007, November 27), <a ,="" href="http://www.dfid.gov.uk/casestudies/files/asia/kyrgyzstan-hiv.asp" target="blank">‘Defeating the stigma around HIV and AIDS in Kyrgyzstan’</a></li>
<li>UNAIDS (2008, 19th May), <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080519_eastern_europe_stars_aids.asp" target="blank">‘Stars against AIDS’ in Eastern Europe’</a></li>
<li>Kyiv Post (2008, 7th May), <a ,="" href="http://www.kyivpost.com/nation/28938" target="_blank">‘Ukraine losing HIV/AIDS fight’</a></li>
<li>Transatlantic Partners Against AIDS, <a ,="" href="http://www.hivpolicy.net/topics/?id=40&page=138" target="blank">‘On Russian Federation State Financing of Measures to Prevent and Fight HIV/AIDS, 2007–2010’</a>, accessed 15th October 2008</li>
<li><a ,="" href="http://www.theglobalfund.org/programs/grantdetails.aspx?compid=1448&grantid=586%E2%8C%A9=&CountryId=UKR" target="blank">The Global Fund – Ukraine website</a>, accessed 30th October 2008</li>
<li>Kaiser Network (2008, 2nd October), <a ,="" href="http://www.kaisernetwork.org/Daily_Reports/rep_index.cfm?DR_ID=54778" target="blank">‘Ukraine Parliament Introduces Bill To Increase HIV Prevention, Treatment Efforts’</a></li>
<li>Feshbach, M., (2008, August 13), <a ,="" href="http://www.cdi.org/russia/johnson/2008-153-36.cfm" target="blank">‘What’s in a number? A new projection by Pokrovskiy’s Center for HIV prevention and treatment and some consequences for Russia’</a>, Johnson’s Russia List</li>
</ol></div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-5466742020666866002010-06-10T11:11:00.000-07:002010-06-10T11:12:10.064-07:00East Asia, South Asia<b> East Asia</b><br />
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<div style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img class="Asia_SmallMaps" src="http://www.avert.org/media/photos/Asia-Map-East.gif" /></div><br />
<h2>China</h2>China’s first AIDS case was reported in Beijing in 1985. Today, an estimated 700,000 people in China are living with HIV (0.1% of the adult population), but it’s feared that this number will increase dramatically in future years, as HIV spreads from the groups most at risk to the general population.<sup>1</sup> The most frequent modes of HIV transmission have been injecting drug use in southern and western China and unsafe practices among paid blood donors. Heterosexually transmitted HIV is occurring primarily in the eastern provinces of China, fuelled by an increasing commercial sex trade and by the large number of migrants moving to these provinces in search of labour. HIV has been identified in some urban areas among men who have sex with men but this population is stigmatized and is difficult to survey.<br />
In 2007 an estimated 39,000 people died from AIDS in China.<sup>2<a name='more'></a></sup><br />
<h2>Japan</h2>In 2007, around 9,600 adults and children were living with HIV in Japan.<sup>3</sup> Data released by the Japanese government in February 2007 showed that annual numbers of new HIV infections and AIDS cases had risen to an all time high in 2006, to 914 and 390 people respectively.<sup>4</sup> The most prominent rise occurred among MSM, who account for around 60% of annually reported HIV infections in Japan.<sup>5</sup><br />
<br />
<b> South Asia</b><br />
<br />
<br />
<a href="http://www.avert.org/media/photos/Asia-Map-South.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" class="Asia_SmallMaps" src="http://www.avert.org/media/photos/Asia-Map-South.gif" /></a><br />
<br />
<h2>Afghanistan</h2>There have only been a small number of cases of HIV in Afghanistan, in contrast to the relatively large numbers recorded in neighbouring nations such as Pakistan. Nonetheless HIV and AIDS are growing problems. Conditions are in place for an epidemic to develop, including high numbers of displaced people, high levels of illiteracy, low social status of women, and a shortage of health facilities. Afghanistan is one of the world’s leading producers of opium, and the availability of drugs could lead to increased levels of injecting drug use. A 2006 study found that around one third of IDUs in the capital city of Kabul had shared contaminated injecting equipment, and that 4% were infected with HIV.<sup>6</sup><br />
<h2>Bangladesh</h2>The first HIV/AIDS case in Bangladesh was reported in 1989. Since 1994, HIV infection levels have increased, although the problem is still relatively small scale, with around 12,000 adults – 0.2% of the total population – infected.<sup>7</sup> It is nonetheless predicted that Bangladesh may gradually be heading towards an epidemic, unless a greater response is developed. At the moment HIV is mainly confined to groups such as IDUs, migrant workers and MSM, and it is reported that this focus on risk groups has led to a lack of urgency among policy makers in dealing with the problem.<sup>8</sup><br />
<h2>India</h2><br />
<img alt="The launch of a
mobile HIV testing unit in India" src="http://www.avert.org/media/photos/2953.jpg" width="300" /><br />
The launch of a mobile HIV testing unit in India<br />
<br />
India is experiencing a diverse HIV epidemic that affects states in different ways, and to different extents. The groups most affected include injecting drug users, sex workers, truck drivers, migrant workers, and men who have sex with men. Some have predicted that India will soon be experiencing a ‘generalised’ epidemic, where the HIV prevalence rate – currently 0.3% in India<sup>9</sup> – rises above 1%. Others have played down current estimates of the numbers infected, and have argued that, because HIV transmission in India still largely occurs among risk groups, it is unlikely that HIV will spread widely among the general population.<sup>10</sup> Regardless of the future path of India’s epidemic, it is undeniable that AIDS is having a devastating impact, and that there are still many major issues – including stigma and poor availability of AIDS treatment – that urgently need to be addressed.<br />
<h2>Nepal</h2>An estimated 70,000 people are living with HIV and AIDS in Nepal, which equates to an adult prevalence of 0.5%.<sup>11</sup> HIV is primarily transmitted through injecting drug use and unprotected sex. Seasonal labour migration is an important source of income for many Nepalese, but it is associated with a higher risk of HIV infection. Around 41% of all HIV cases in Nepal are among seasonal labour migrants, 16% are clients of sex workers and 21% are partners or wives of HIV positive men.<sup>12</sup> The Nepalese government have responded to the epidemic despite political instability; in 2009 Prime Minister Madhav Kumar Nepal said the government would increase resources and actions for preventing, treating and controlling the country's epidemic.<sup>13</sup><br />
<h2>Pakistan</h2>Pakistan’s first reported case of HIV occurred in 1987. Until the late 1990s, most subsequent cases occurred in men who had become infected while living or working abroad. The most at risk populations in Pakistan include injecting drug users, sex workers and prisoners.<sup>14</sup> Despite a low overall HIV prevalence (0.1%), social and economic conditions in Pakistan – including poverty, low levels of education, and high levels of risk behaviour among IDUs and sex workers – are likely to facilitate the spread of HIV in coming years.<sup>15</sup> HIV prevalence among IDUs has already significantly increased - from 10.8 percent in 2005 to 21 percent in 2008.<sup>16</sup><br />
<br />
<h2>Sources:</h2><ol><li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>Kyodo news (2007, February 7th), <a ,="" href="http://search.japantimes.co.jp/cgi-bin/nn20070209b3.html" target="_blank">‘Japan reports record new HIV infections, AIDS patients in 2006’</a></li>
<li>UNGASS (2007) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/japan.asp" target="_blank">'Country progress report: Japan'</a></li>
<li>Todd S. (2006) <a ,="" href="http://www.aids2006.org/pag/Abstracts.aspx?AID=5843" target="blank">‘Prevalence of HIV, viral hepatitis, syphilis and risk behaviors among Injection drug users in Kabul, Afghanistan’</a>, Abstract TUAC0304, XVI International AIDS Conference, 13-18th August, Toronto</li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>New York Times (2007, June 8th), <a ,="" href="http://www.nytimes.com/2007/06/08/world/asia/08aids.html" target="blank">‘India, said to play down AIDS, has many fewer with virus than thought, study finds’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNGASS (2008) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/nepal.asp" target="_blank">'Country progress report: Nepal'</a></li>
<li>China View (2009, 27th August) <a ,="" href="http://news.xinhuanet.com/english/2009-08/27/content_11952444.htm" target="_blank">'Nepali gov't to upgrade AIDS preventive measures'</a></li>
<li>UNGASS (2007) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/pakistan.asp" target="_blank">'Country progress report: Pakistan'</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2010, 5th February) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2010/20100204_Pakistan.asp" target="_blank">'Lack of resources could undermine gains made in the HIV response in Pakistan'</a></li>
</ol>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-73656065361514838692010-06-10T11:01:00.000-07:002010-06-10T11:01:56.861-07:00Country profiles - South East Asia<div class="separator" style="clear: both; text-align: center;"></div><div style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img class="Asia_SmallMaps" src="http://www.avert.org/media/photos/Asia-Map-SouthEast.gif" /></div><br />
<br />
<h3>Cambodia</h3>Cambodia’s HIV epidemic can be traced back to 1991. After an initial rapid increase, HIV infection levels declined after the late 1990s and by 2003 HIV prevalence was estimated at 1.2%.<sup>1</sup> Results published in 2009 from the first national population-based survey estimated HIV prevalence at 0.6%.<sup>2</sup> It’s believed that interventions with sex workers, carried out by the government and non-governmental organisations (NGOs), played a role in this decline. The adoption of a ‘100% condom’ policy that enforced condom use in brothels led to a substantial rise in condom use among sex workers and their clients and a drop in HIV infection levels among brothel-based sex workers. However, ongoing concerns include low levels of condom use among MSM, an increase in sex work occurring outside of brothels (making it harder to reach sex workers with interventions), and mother-to-child transmission of HIV – around one third of new infections occur through this route. HIV is mostly transmitted through heterosexual sex in Cambodia, and concerns are growing about the number of married women who are infected through their husband.<sup>3<a name='more'></a></sup><br />
<h3>Indonesia</h3>Around 270,000 people are living with HIV in Indonesia.<sup>4</sup> This number has risen sharply in recent years due to several factors, including: the country’s extensive sex industry; limited testing and treatment clinics and laboratories for sexually transmitted infections (STIs); a highly mobile population; a rapidly growing population of people who inject drugs; and the challenges created by major economic and natural crises that Indonesia has experienced (the Asian financial crisis heavily affected the country in 1997, and the 2004 Tsunami devastated parts of Northern Sumatra, the largest island in Indonesia). High levels of HIV infection are found amongst injecting drug users, sex workers and their clients and to a lesser extent, men who have sex with men.<sup>5</sup> In 2007, 8,700 people died from AIDS in Indonesia.<sup>6</sup><br />
<h3>Lao People's Democratic Republic (Laos)</h3>Despite being surrounded by countries that have relatively high HIV infection levels (Thailand, China, Vietnam, Cambodia and Myanmar), Laos has a comparatively small HIV problem. There are various reasons for this: the government was quick to acknowledge AIDS when it first emerged in the country, and took action to warn people about it; Laos has not seen the same level of large-scale migration that has occurred in other parts of Asia; there are relatively high rates of condom use among sex workers and their clients; and it’s thought that very few people in the country inject drugs.<sup>7 8</sup> However in recent years there has been an increase of HIV infection among the most vulnerable groups, such as sex workers and their clients and MSM.<sup>9</sup><br />
<h3>Malaysia</h3><div class="photo_l"><img alt="An HIV prevention
billboard in Malaysia " src="http://www.avert.org/media/photos/1689.jpg" width="300" /><br />
An HIV prevention billboard in Malaysia</div>HIV and AIDS statistics from Malaysia show that an estimated 0.4 percent of the population are living with HIV.<sup>10</sup> Although most people infected with HIV in the country are male, there has been a steep increase in the number of new cases among women. During the late 1990s women made up around 5 percent of new infections, compared to around 20 percent in 2006.<br />
Malaysia's epidemic is largely driven by injecting drug use, but heterosexual transmission is accounting for an increasing number of new infections. Recent trends have demonstrated a promising decrease in annual HIV infections, from 7,000 in 2002 to 5,830 in 2006.<sup>11</sup> In 2006 the government launched a five-year strategic plan to tackle HIV, which includes drug substitution therapy and needle exchange programmes for drug users.<sup>12</sup><br />
In 2007, 3,900 people died from AIDS in Malaysia.<sup>13</sup><br />
<h3>Myanmar (Burma)</h3>Myanmar is facing a serious epidemic - an estimated 240,000 of the adult population is infected with HIV.<sup>14</sup> Myanmar’s authoritarian military regime is widely condemned for its human rights abuses, and in 2005 these concerns led the Global Fund to Fight HIV, TB and Malaria to withdraw its proposed $98.4 million grants for the country.<sup>15</sup> Prevention services for injecting drug users are severely lacking with needle exchange programmes operating in just a few locations. Drug users are dealt with heavy-handedly and crackdowns on drug production have led to a scarcity of opium and heroin. This has resulted in drug inhalation being replaced by injecting, as a more cost-effective way of drug consumption, carrying with it a higher risk of HIV transmission. In 2006 methadone substitution therapy was introduced in a small number of government locations.<sup>16</sup><br />
<h3>The Philippines</h3>An estimated 8,300 people were living with HIV in The Philippines in 2007.<sup>17</sup> The country has traditionally had a very low HIV prevalence, with under 0.1% of the population infected. Even in groups such as sex workers and MSM that are typically associated with higher levels of HIV, prevalence rates above 1% have not yet been detected.<sup>18</sup> In the case of sex workers, this is possibly due to efforts to screen and treat those selling sex since the early 1990s. However, there are reasons to believe that this situation may not last. In early 2010 the Department of Health in the Philippines stated the country was now on the brink of a "concentrated epidemic", due to a rise in prevalence.<sup>19</sup> Condom use is not the norm in paid sex, drug users commonly share injecting equipment in some areas, and among Filipino youth, there is evidence of complacency about AIDS.<sup>20 21</sup><sup></sup><br />
<h3>Singapore</h3>Although the number of people living with HIV in Singapore is relatively small, the country’s status as an international travel and business hub, along with the high number of infections found in surrounding countries, make it possible that the country will experience a more serious epidemic in the future. In 2006 a record 357 people in Singapore were newly diagnosed with HIV. To combat these rising figures, the government has chosen to focus on preventing mother-to-child transmission, but controversially, has rejected widespread condom promotion.<sup>22</sup> Another controversial policy in Singapore is the strict law banning sex between men, which campaigners argue undermines efforts to promote safe sex among MSM.<sup>23 24</sup><sup></sup><br />
<h3>Thailand</h3><div class="photo_r"><img alt="AIDS education for
young people in Thailand" src="http://www.avert.org/media/photos/980.jpg" width="300" /><br />
AIDS education for young people in Thailand</div>Thailand is an example of a country where a strong national commitment to tackling the HIV and AIDS epidemic has paid off, with widespread access to treatment and an admirable history of HIV prevention efforts. However, some of these past prevention successes are starting to be undermined by a current lack of HIV prevention and rising STD rates. New infections are highest among MSM and women who have become infected by their husbands or sexual partners.<sup>25</sup> An estimated 610,000 people are now living with HIV and AIDS in Thailand.<sup>26</sup><br />
<h3>Vietnam</h3>Around 290,000 people are living with HIV and AIDS in Vietnam.<sup>27</sup> Vietnam's epidemic is still in a concentrated phase; injecting drug users, female sex workers and men who have sex with men are the groups primarily affected.<sup>28</sup> The number of people living with HIV in Vietnam doubled between 2000 and 2005. This rise included a large increase in the number of people who became infected through injecting drug use.<sup>29</sup> There is evidence of HIV increasing among the MSM population with approximately 60% of HIV-positive MSM reporting inconsistent condom use with male partners in the previous month.<sup>30</sup><br />
See our South East Asian statistics page for more data on this region.<br />
<br />
<h2>Sources:</h2><ol><li>UNGASS (2008) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/cambodia.asp" target="_blank">'UNGASS country progress report: Cambodia'</a>, National AIDS Authority, Kingdom of Cambodia</li>
<li>Heng, S., Vonthanak, S., Chhorvann, C. & Knut, F (2009) <a ,="" href="http://journals.lww.com/aidsonline/Abstract/2009/07170/Distribution_of_HIV_in_Cambodia__findings_from_the.12.aspx" target="_blank">'Distribution of HIV in Cambodia: findings from the first national population survey'</a>, AIDS, 17 July 2009; 23, 11; 1389-1395</li>
<li>Heng, S., Vonthanak, S., Chhorvann, C. & Knut, F (2009) <a ,="" href="http://journals.lww.com/aidsonline/Abstract/2009/07170/Distribution_of_HIV_in_Cambodia__findings_from_the.12.aspx" target="_blank">'Distribution of HIV in Cambodia: findings from the first national population survey'</a>, AIDS, 17 July 2009; 23, 11; 1389-1395</li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNGASS (2006-2007) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/indonesia.asp" target="_blank">'Country report on the follow up to the Declaration of Commitment on HIV/AIDS'</a>, National AIDS Commission, Republic of Indonesia</li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>BBC news (2002, October), <a ,="" href="http://news.bbc.co.uk/1/hi/world/asia-pacific/2372307.stm" target="blank">‘Can Laos keep AIDS at bay?’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNGASS (2006-2007) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/lao_peoples_+democratic_republic.asp" target="_blank">'UNGASS country progress report'</a>, Lao People's Democratic Republic - National Committee for the Control of AIDS</li>
<li>UNGASS (2008) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/malaysia.asp" target="_blank">'Country progress report'</a>.</li>
<li>UNGASS (2008) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/malaysia.asp" target="_blank">'Country progress report'</a>.</li>
<li>Associated Press (2007, February), <a ,="" href="http://sfgate.com/cgi-bin/article.cgi?f=/n/a/2007/02/10/international/i222200S20.DTL&type=health#sections" target="blank">‘HIV spreading rapidly in Malaysia’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>Global Fund Press release (2005, August), <a ,="" href="http://www.theglobalfund.org/en/pressreleases/?pr=pr_050819" target="_blank">The Global Fund terminates grants to Myanmar</a></li>
<li>Asian Harm Reduction Network, ‘Civil Society Reflections on 10 Years of Drug Control in Myanmar, Thailand and Vietnam: A Shadow Report’ from International Harm Reduction Development Program, Open Society Institute (2009, March), <a ,="" href="http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/atwhatcost_20090302" target="_blank">'At What Cost?: HIV and Human Rights Consequences of the Global War on Drugs'</a></li>
<li>WHO/UNAIDS/UNICEF (2008, December) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/philippines.asp" target="_blank">'Epidemiological fact sheet on HIV and AIDS'</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>Malaya (2010, 8th April) <a ,="" href="http://www.malaya.com.ph/04082010/news5.html" target="_blank">'Critical point reached on HIV/AIDS'</a></li>
<li>UNGASS (2008) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/philippines.asp" target="_blank">'Country report of the Philippines'</a>, Philippine National AIDS Council</li>
<li>Farr, A.C & Wilson, D.P (2010, 22nd April) <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed?term=An+HIV+epidemic+is+ready+to+emerge+in+the+Philippines&TransSchema=title&cmd=detailssearch" target="_blank">'An HIV epidemic is ready to emerge in the Philippines'</a>, Journal of the International AIDS Society 2010, 13:16</li>
<li>AFP/AEGiS (2007), <a ,="" href="http://www.aegis.com/news/afp/2007/AF070637.html" target="blank">‘Singapore's HIV/AIDS cases rise by record levels in 2006’</a></li>
<li>Medical news today (2004), <a ,="" href="http://www.medicalnewstoday.com/medicalnews.php?newsid=16958" target="blank">'Singapore sees rise in AIDS cases, takes new measures'</a></li>
<li>BBC News (2007, 23rd October) <a ,="" href="http://news.bbc.co.uk/1/hi/world/asia-pacific/7059300.stm" target="_blank">'Singapore retains its gay sex ban'</a></li>
<li>UNGASS (2008) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/thailand.asp" target="_blank">'Country progress report'</a>, National AIDS Prevention and Alleviation Committee</li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNGASS (2008) <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/viet_nam.asp" target="_blank">'The third country report on following up the implementation to the declaration of commitment on HIV and AIDS'</a>, The Socialist Republic of Vietnam</li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
</ol>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-75631351727429984082010-06-10T10:50:00.000-07:002010-06-10T10:51:16.325-07:00HIV prevention and Antiretroviral treatment in Asia<h2>HIV prevention in Asia</h2><div class="photo_l"><img alt="HIV prevention
sign, Ho Chi Minh City, Vietnam" src="http://www.avert.org/media/photos/1552.jpg" width="225" /><br />
HIV prevention sign in Ho Chi Minh City, Vietnam<br />
</div>Asia has been the base for some extremely successful large-scale HIV prevention programmes. Well-funded, politically supported campaigns in Thailand and Cambodia have led to significant declines in HIV-infection levels, and HIV prevention aimed at sex workers and their clients has played a large role in these achievements. In Tamil Nadu, India, HIV prevention initiatives have had a substantial impact.<br />
<a name='more'></a> High-profile public campaigns discouraged risky sexual behaviour, made condoms more widely available, and provided STI testing and treatment for people who needed them. These efforts resulted in a large decline in risky sex.<sup>1</sup><br />
Successes such as these prove that interventions can change the course of Asia's AIDS epidemics. As HIV infection rates continue to grow however, it's clear that more needs to be done. The groups most at risk of becoming infected – sex workers, IDUs, and MSM – are all too often being neglected. For instance, although injecting drug use is one of the most common HIV transmission routes in Asia, it is estimated that less than one in ten IDUs in the region have access to prevention services.<sup>2</sup> Similarly men who have sex with men are overlooked and poorly monitored by most governments, even though it is firmly established that this group play a significant role in some countries’ epidemics.<sup>3</sup><br />
<blockquote class="longquote">"In countries without laws to protect sex workers, drug users, and men who have sex with men, only a fraction of the population has access to prevention. Conversely, in countries with legal protection and the protection of human rights for these people, many more have access to services. As a result, there are fewer infections, less demand for antiretroviral treatment, and fewer deaths. Not only is it unethical not to protect these groups: it makes no sense from a health perspective." - <cite>Secretary-General Ban Ki-moon, speaking at the opening address to the International AIDS Conference<sup>4</sup></cite></blockquote>It is not only legal barriers that are preventing people from accessing effective HIV prevention; problems also arise when prevention programmes do not contain information that will be most useful. For example, young people in Asia are generally not taught about the kinds of behaviours that put this group most at risk: unprotected sex through sex work, injecting drug use, and sex between men. Instead they focus on heterosexual transmission and reproductive health, which have a limited impact on preventing new HIV infections among young people in Asia.<sup>5</sup><br />
The coverage of prevention of mother-to-child transmission (PMTCT) services is also very low in Asia. In East, South and South-East Asia, around 12% of pregnant women were offered an HIV test in 2008 - a very low percentage compared to other regions of the world such as Europe and Central Asia (65%) and sub-Saharan Africa (28%).<sup>6</sup> In 2008 across East, South and South-East Asia, only 25% of HIV-infected pregnant women received ARVs to prevent mother-to-child transmission of HIV.<sup>7</sup><br />
See our HIV prevention around the world page for more about efforts to stem the spread of HIV in Asia and other parts of the world.<br />
Due to the stigma that often surrounds those groups most at risk of HIV infection, coverage of HIV voluntary counselling and testing (VCT) services in South-East Asia remains very low. An estimated 0.1% of the adult population in the region received testing and counselling in 2005.<sup>8</sup> Certain countries are making progress, however; testing services in India have been expanded with about 3600 testing centres now open to the public.<sup>9</sup> Even so, far more needs to be done across Asia to ensure VCT is available to those most at risk of acquiring HIV.<br />
<h2>Antiretroviral treatment in Asia</h2><div class="photo_r"><img alt="HIV Positive man
and antiretroviral medicines" border="0" src="http://www.avert.org/media/photos/979.jpg" width="300" /> An HIV positive man sitting at home in Cambodia<br />
before taking his antiretroviral treatment</div>The availability of antiretroviral treatment more than tripled between 2003 and 2006 in Asia.<sup>10</sup> Although this seems encouraging, only just over a third of people in the region who are in need of HIV treatment are receiving it.<sup>11</sup> In addition, access to HIV treatment varies widely across the region. Cambodia and Thailand have an estimated treatment coverage of between 50-75 percent, whilst estimated treatment coverage in Malaysia and the Philippines ranges between 31-50 percent.<sup>12</sup><br />
A major barrier to treatment access is the high cost of antiretroviral drugs, as both first- and second-line drugs are still unaffordable to many governments. Cheaper generic drugs are now produced by a number of pharmaceutical manufacturers in Asia, and together with the increasing availability of lower-cost branded ARVs, it will be easier for governments to obtain and distribute the drugs. Yet even where drugs are available, the poor state of healthcare in many Asian countries, particularly a shortage of trained doctors, is hindering governments' abilities to organise life-long treatment programmes for millions of people living with HIV.<sup>13</sup><br />
<br />
<h2>Sources:</h2><ol><li>MAP (2004) <a ,="" href="http://www.mapnetwork.org/reports.shtml" target="_blank">'AIDS in Asia: Face the Facts'</a></li>
<li>Reuters (2007, May 14th) <a ,="" href="http://www.alertnet.org/thenews/newsdesk/PEK287254.htm" target="blank">'Asian drug users need more HIV prevention help'</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UN News Centre (2008) <a ,="" href="http://www.un.org/apps/news/infocus/sgspeeches/search_full.asp?statID=297" target="_blank">'Address to the International AIDS Conference',</a> Secretary-General Ban Ki-moon's speech.</li>
<li>UNICEF (2009), <a ,="" href="http://www.unicef.org.uk/publications/pub_detail.asp?pub_id=199" target="_blank">‘Preventing HIV with young people: the key to tackling the epidemic’</a></li>
<li>WHO/UNAIDS/UNICEF (2009) <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector'</a></li>
<li>WHO/UNAIDS/UNICEF (2009) <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector'</a></li>
<li>WHO (2007), <a ,="" href="http://www.searo.who.int/LinkFiles/AIDS_SEARO-Report07.pdf" target="_blank">'HIV/AIDS in the South-East Asia Region'</a> [PDF]</li>
<li>UNAIDS (2007) <a ,="" href="http://data.unaids.org/pub/Report/2008/jc1527_epibriefs_asia_en.pdf" target="_blank">'ASIA; AIDS epidemic update Regional Summary'</a> [PDF]</li>
<li>UNAIDS (2006) <a ,="" href="http://www.unaids.org/en/CountryResponses/Regions/Asia.asp" target="_blank">'Asia factsheet'</a>.</li>
<li>WHO/UNAIDS/UNICEF (2009) <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector'</a></li>
<li>WHO (2008), "<a ,="" href="http://www.who.int/hiv/mediacentre/2008progressreport/en/index.html" target="blank">Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector</a>"</li>
<li>AMFAR/TREAT Asia (2004), ‘<a ,="" href="http://www.amfar.org/world/treatasia/article.aspx?id=3328" target="_blank">Expanded Availability of HIV/AIDS Drugs in Asia Creates Urgent Need for Trained Doctors</a>’</li>
</ol><h2> </h2>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-72054190740952378912010-06-10T10:42:00.000-07:002010-06-10T10:42:42.090-07:00How is HIV transmitted in Asia?<b> In the early to mid-1980s, while other parts of the world were beginning to deal with serious HIV and AIDS epidemics, Asia remained relatively unaffected. By the early 1990s, however, AIDS epidemics had emerged in several Asian countries, and by the end of the decade, HIV was spreading rapidly in many areas of the continent.</b><br />
<br />
<div class="box bFull"><div class="photo_r"><img alt="Activists
campaigning against HIV-related discrimination in India" border="0" src="http://www.avert.org/media/photos/2560.jpg" width="300" /> <br />
<div style="width: 300px;">Activists campaigning against HIV-related discrimination in India</div></div>Today, around 4.7 million people are living with HIV in Asia.<sup>1</sup> Although national HIV prevalence rates in Asia appear to be relatively low, the populations of some Asian countries are so vast that these low percentages actually represent very large numbers of people living with HIV. India, for example, has an estimated HIV prevalence of 0.3%, which seems low when compared to prevalence rates in some parts of sub-Saharan Africa. However, with a population of around one billion, this actually equates to 2.5 million people living with HIV in India.<sup>2<a name='more'></a></sup><br />
Although it is useful to understand the overall impact that AIDS is having on the Asian region as a whole, there is no single ‘Asian epidemic’; each country in the region faces a different situation. Progress has been made in countries such as Cambodia, Myanmar and Thailand, where there has been evidence of a decline in HIV prevalence. On the other hand, in Indonesia, Pakistan and Vietnam the number of people living with HIV has increased.<sup>3</sup><br />
Some have warned that epidemics in Asia could escalate to the extent of rivaling those in some parts of Africa. Others, however, argue that Asia's epidemics are on a different trajectory to those found in Africa, as HIV infection in Asia is still largely concentrated among members of 'high-risk' groups.</div><br />
<b>There are three main HIV transmission routes in Asia:</b><br />
<ul><li><span class="highlight_color">Unprotected paid (and unpaid) sex.</span> Unprotected sex, both paid and unpaid, accounts for a significant share of new HIV infections in many Asian countries. A large number of men buy sex regularly and the level of condom use during paid sex in many countries is still low. These factors have contributed to a high HIV prevalence among sex workers and their clients across Asia. In addition, an increasing number of women who are married and considered ‘low-risk’ of HIV infection are becoming infected with HIV.<sup>4</sup> Estimates suggest that around 25-40 percent of new HIV infections in several Asian countries are among wives and girlfriends of men who became infected through paid sex, having sex with other men or injecting drugs.<sup>5</sup></li>
</ul><ul><li><span class="highlight_color">Injecting drug use.</span> Injecting drug use is a major driving factor in the spread of HIV throughout Asia, notably in China, Indonesia, Malaysia and Vietnam. In China, nearly half of all people infected with HIV are believed to have become infected through injecting drug use, and in North-East India injecting drug use is the most common HIV transmission route.<sup>6</sup> There is often an overlap between communities of IDUs and communities of sex workers in Asia, as those who sell sex may do it to fund a drug habit, or they may have become involved in sex work first before turning to drug use.</li>
</ul><ul><li><span class="highlight_color">Sex between men.</span> Sex between men accounted for some of the earliest recorded cases of HIV in Asia, and transmission through this route is still a prominent feature of many countries’ epidemics. Most men who have sex with men (MSM) in Asia do not identify themselves as gay because of cultural norms that discourage homosexuality; in some cases they may even be heads of families, with children.<sup>7</sup> This means that MSM can serve as a ‘bridge’ for HIV to spread into the broader population. HIV outbreaks are becoming evident among MSM in Cambodia, China, Nepal, Pakistan, Thailand and Vietnam.<sup>8</sup></li>
</ul>Mother-to-child transmission is also a significant HIV transmission route in Asia. At the end of 2007, it was estimated that 140,000 children in South and South-East Asia, and 7,800 children in East Asia, were living with HIV, most of whom became infected through mother-to-child transmission.<sup>9</sup><br />
<br />
<br />
<h2>Sources:</h2><ol><li>UNAIDS (2009) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2009) <a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=pub/Report/2009/intimate_partners_report_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d11631%26query%3d%2522hiv%2520transmission%2520in%2520intimate%2520partner%2522%26hiword%3dhiv%2520in%2520intimate%2520partner%2520transmission%2520%26PV%3d1" target="_blank">'HIV transmission in intimate partner relationships in Asia'</a></li>
<li>The Commission on AIDS in Asia (2008) <a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=pub/Report/2008/20080326_report_commission_aids_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d11433%26query%3d%2522redefining%2520aids%2520in%2520asia%2522%26PV%3d1" target="_blank">‘Redefining AIDS in Asia: Crafting an effective response’.</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2006) <a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=Publications/IRC-pub07/jc901-msm-asiapacific_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d3569%26query%3d%2522hiv%2520and%2520men%2520who%2520have%2520sex%2520with%2520men%2522%26hiword%3dand%2520have%2520hiv%2520men%2520sex%2520who%2520with%2520%26PV%3d1" target="_blank">'HIV and men who have sex with men in Asia and Pacific'</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
<li>UNAIDS (2008) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="_blank">‘Report on the global AIDS epidemic’</a></li>
</ol>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-12805373550111338482010-06-10T10:02:00.000-07:002010-06-10T10:02:51.984-07:00Am I ready for sex?<b>Almost everyone asks themselves "am I ready to have sex?" at some point in their lives, but unfortunately not many people will be able to answer it with a definite "yes" or "no".</b><br />
<br />
Having sex for the first time can be a very special experience, but it can also lead to all sorts of complications. Sex without a condom or other form of contraception can result in pregnancy, and if your partner has HIV or a sexually transmitted infection (and you might not always know they do), you can become infected too. There can also be emotional consequences to having sex with someone – it can really change a relationship, and not always for the better. Sex can be enjoyable with the right person, but it’s very easy to make mistakes and end up hurt, which is why people advise you: "don’t have sex until you’re ready!"<br />
Of course it's all very well saying this, but how do you know when you’re ready? Legally, you aren’t allowed to have sex with anyone until you’re over the <b>age of consent</b>. But it takes more than just being a legal age to make you ready for sex – you need to be emotionally ready too. Here are some questions to help you work out if you're ready to have sex.<br />
<a name='more'></a><br />
<div class="box bFull"><h2>1) Are you doing this because YOU want to?</h2>Or are you thinking about having sex because someone else wants you to? Maybe you’re not sure you’re ready, but your partner is keen? Or perhaps there's a bit of ‘peer pressure’ – all your friends seem to be having sex, so you feel you should be too?<br />
Do any of the following sound familiar? -<br />
<ul><li>“<q>You would if you loved me!</q>”</li>
<li>“<q>It’s only natural!</q>”</li>
<li>“<q>Everyone else is doing it!</q>”</li>
<li>“<q>Don’t you want to make our relationship stronger?</q>”</li>
<li>“<q>You’ll have to do it sometime – why not now, with me?</q>”</li>
<li>“<q>I'll be gentle, and it'll be really great, I promise!</q>”</li>
<li>“<q>I'll only put it in for a second...</q>”</li>
</ul>If you recognise any of these phrases, then you should think carefully! These are <b>not</b> the right reasons to have sex. A partner who says things like this is probably trying to put pressure on you and might not really care whether you’re ready or not – this person doesn’t respect your feelings, and they’re probably not the right person to have sex with.<br />
Nor should you have sex just because your friends are saying things like :<br />
<ul><li>“<q>You mean you’ve <b>never</b> done it?!?</q>”</li>
<li>“<q>I lost it when I was twelve. . .</q>”</li>
<li>“<q>Yeah, I’ve had sex loads of times. . .</q> ”</li>
<li>“<q>You’re a virgin, you wouldn’t understand. . .</q> ”</li>
<li>“<q>No-one’ll be interested in you if they hear you’re frigid.</q>”</li>
<li>“<q>It's amazing - you don't know what you're missing!</q>”</li>
</ul>It may feel like your friends are all more experienced and knowledgeable, but we guarantee they're probably not! Many of them will only be saying this sort of thing because they think everyone will laugh at them if they admit they’ve never really done anything! Besides, being sexually experienced at a young age doesn’t necessarily make someone mature or sensible - in fact, it usually indicates the opposite.<br />
<h2>2) Do I know my partner well enough?</h2>If you’ve only just met your partner, haven’t been going out with them very long, or perhaps don’t even really know them, then sex is never going to be a really good experience because there won't be much trust between you. If you've never even kissed the person you're with, then you're definitely not ready to have sex with them!<br />
Sex can leave you feeling very vulnerable afterwards in a way you might not be prepared for, so it’s better to be with someone that you know is likely to be sticking around. Usually, you’ll have better sex with someone you know really well, are comfortable with, and who you can talk to openly about relationships and feelings. Sex will be best with someone you love.<br />
<h2>3) Is it legal?</h2>The age of consent differs between countries. In most states of the U.S, for instance, it ranges between 16 and 18. In the UK and India it's 16. In Spain, it's 13 while in some Muslim countries, sex is illegal unless you're married. Have a look at our <b>age of consent</b> page to find out exactly what it is where you live.<br />
So why do countries have a legal age for having sex? Because this is the age when the government believes young people are mature enough to handle the responsibilities that come with having sex. All too often people think they are ready when they’re not. Age of consent laws are also designed to prevent older people from taking advantage of children and young teenagers who may not understand the consequences of having sex, or even what sex is.<br />
<h2>4) Do I feel comfortable enough with my partner to do this, and to do it sober?</h2>It’s natural to feel a little embarrassed and awkward the first time you have sex with someone because it’s not something you’ve ever done before. Your boyfriend or girlfriend will probably feel the same. But if you don’t trust your partner enough not to laugh at you or you don’t feel you can tell them you’ve never had sex before, then it’s far better to wait until you can.<br />
And if you think you’ll have to drink a lot of alcohol before you do it so you feel relaxed enough, or you only find yourself thinking about having sex when you’re drunk, then that suggests you’re not ready. A lot of people lose their virginity when they’re drunk or on drugs, and then regret it. So if you’re worried that you’re going to be in a situation where you might be tempted to do something you wouldn’t do normally, restrict your drinking, keep off the drugs, or make sure you stick with a sober friend who can look after you! Have a look at our drink, drugs and sex page for more information.<br />
<h2>5) Do I know enough about sex?</h2>Do you know what happens during sex? Do you know how it works, what it's for and how and why a woman can get <b style="font-weight: normal;">pregnant</b>? Do you know about <b>sexually transmitted infections</b>? Lots of people worry that they’re going to make a fool of themselves or do something wrong. Well, you shouldn’t have to worry if you’re with a partner who cares about you - (s)he won’t laugh. And if you’re not with a partner who cares, you probably shouldn’t be doing it! Physically, sex is actually quite simple, but the more you know, the more comfortable you’ll feel. Have a look at our <b>teens</b> pages for more information.<br />
<h2>6) Will I be glad when I’m older that I lost my virginity at the age I am now?</h2>Imagine that you’re looking back at yourself in ten years time. What do you think you’ll think then about how and when you lost your virginity? Is there any way in which you might regret it? The answer should be ‘no’ – if it’s not, you’re probably not yet ready for sex.<br />
<h2>7) Can I talk to my partner about this easily?</h2>If you can’t talk about sex, then you’re not ready to have sex. It’s as simple as that. Being honest about how you’re feeling will make it easier for both of you, and will make sex better in the future.<br />
<h2>8) Do I know how to have sex safely?</h2>It’s really important that you know how to protect against pregnancy, STIs and HIV. Again, this is something you need to talk to your boyfriend or girlfriend about before the event, so you’re both okay about what you’re going to use. Have a look on our teens’ <b>contraception options</b> page for more details.<br />
Especially with things like condoms, it’s good to have a bit of practise putting them on, and to feel okay about doing it – it’s not enough just to get a condom if you’re not confident enough to use it – they’re no good if they stay in your pocket the whole time!<br />
<h2>9) Do we both want to do this?</h2>You may decide that you are ready to have sex, but it might be that your partner isn’t, even if they have had sexual partners before. For sex to work, you both have to be willing to do it. Don’t ever pressure anyone to have sex if they’re not sure – this is very wrong, and it’ll cost you your partner’s respect and the respect of other people.<br />
Also - there’s a fine line between pressuring someone to have sex and forcing someone to have sex – if you put too much pressure on someone, it can become force – and if you force someone into sex, you can be prosecuted for rape.<br />
<h2>10) Does sex fit in with my/their personal beliefs?</h2>It may be that you, your partner or your family have beliefs that say sex at a young age (or before marriage) is wrong. Do you feel comfortable going against these views? Will it cause you unnecessary worry and guilt if you do (or frustration and heartbreak if you don’t!)? Some young people will have sex simply because their family has banned them from doing so, even if they don't realise that this is the reason. Having sex as an act of rebellion may feel great at the time, but if anything goes wrong, you face a very difficult situation, as you may not be able to rely on your family's support.<br />
Even if everything goes well, keeping sex (and all the emotions that go with it) a secret can be very hard – so, if possible, you should make sure you have someone else to talk to that you can trust to keep it to themselves. But remember, the decision to have sex should be an agreement between you and your partner, and while other people may help or influence your decision, they shouldn’t make it for you.<br />
<h2>So, are you ready for sex?</h2>If you answered “Yes!” to all ten of these questions, then you’re probably pretty much ready, as long as BOTH of you feel okay about it.<br />
If you didn’t, then there are probably some issues you need to work through first, because all of these questions are important.<br />
First time sex is always going to be scary whatever age you are when you have it. It can sometimes seem like losing your virginity is the most important thing in the world. But you can’t get your virginity back once it's gone, so what is really important is that you have enough respect for yourself to wait until you’re truly ready, and can truly trust the person you’re with.<br />
Good luck, have fun, and stay safe!</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-29924699019465573522010-06-10T08:58:00.000-07:002010-06-10T08:58:27.158-07:00The history of HIV and AIDS in America<div class="box bFull"> The history of AIDS in America began in 1981, when the United States became the first country to officially recognise a strange new illness among a small number of gay men. Today, it is generally accepted that the origin of AIDS probably lies in Africa. However, America was the first country to bring AIDS into the public consciousness and the American reaction undoubtedly contributed to the establishment of AIDS as one of the most politicised, feared and controversial diseases in the history of modern medicine - a reputation that stands today.<br />
</div><div class="box bFull"> <h2>The history of AIDS in America in the 1980s</h2><div class="photo_r"> <img alt="picture of the
National AIDS Memorial Grove in San Francisco" border="0" src="http://www.avert.org/media/photos/2264.jpg" width="250" /> <div style="width: 250px;">The Circle of Friends in the National </div><a name='more'></a><br />
<div style="width: 250px;">AIDS Memorial Grove in San Francisco</div></div>At the beginning of the 1980s various reports began to emerge in California and New York of a small number of men who had been diagnosed with rare forms of cancer and/or pneumonia. The cancer, Kaposi’s Sarcoma, normally only affected elderly men of Mediterranean or Jewish heritage and young adult African men. The pneumonia, Pneumocystis Pneumonia Carinii (PCP), is generally only found in individuals with seriously compromised immune systems. However, the men were young and had previously been in relatively good health. The only other characteristic that connected them was that they were all gay.<br />
The first official documentation of the condition was published by the US Centers for Disease Control and Prevention (CDC) on 5th June 1981.<sup>1</sup> Entitled “Pneumocystis Pneumonia – Los Angeles”, the report detailed the cases of five young gay men hospitalised with serious PCP, cytomegalovirus, and disseminated candida infections.<br />
<blockquote class="longquote">“I heard on UPI, it was like a paragraph or two, a very short report from the Centers for Disease Control that there was a new phenomenon of people dying of an unusual pneumonia, and they happen to be homosexual”.<cite> – Hank Wilson, living in San Francisco.<sup>2</sup></cite></blockquote>Almost a month after the CDC’s announcement, the New York Times reported that a total of 41 homosexual men had been diagnosed with Kaposi’s Sarcoma, eight of whom had died less than 24 months after the diagnosis was made.<sup>3</sup><br />
At the end of 1981, 5 to 6 new cases of the disease were being reported each week.<sup>4</sup><br />
By 1982 the condition had acquired a number of names - GRID<sup>5</sup> (gay-related immune deficiency), ‘gay cancer’, ‘community-acquired immune dysfunction’ and ‘gay compromise syndrome’<sup>6</sup>.<br />
By June, 355 cases of Kaposi’s Sarcoma and/or serious opportunistic infections in previously healthy young people had been reported to the CDC.<sup>7</sup> A total of 20 states had reported cases and the disease was no longer solely affecting gay men; there were a small number of cases among heterosexual men and women. Over half of those identified as heterosexual had used intravenous drugs at some point.<br />
<blockquote class="longquote">“By mid-1982 it was clearly different. People were starting to shake in their pants. It was clear that it was more than isolated incidents”<cite> – G’dali Braverman, AIDS activist living in San Francisco.<sup>8</sup></cite></blockquote>It was not until July at a meeting in Washington, D.C., that the acronym AIDS (Acquired Immune Deficiency Syndrome) was suggested<sup>9</sup>. The CDC used the term for the first time in September 1982, when it reported that an average of one to two cases of AIDS were being diagnosed in America every day.<sup>10</sup><br />
In December the CDC reported that three heterosexual haemophiliacs had died after developing PCP and other opportunistic infections.<sup>11</sup> There was nothing to suggest that the patients had acquired AIDS through homosexual contact, or intravenous drug use. What was significant was that all of the patients had received Factor VIII concentrates – a blood transfusion product made by pooling blood from hundreds of donors.<br />
The CDC also began to receive reports of AIDS amongst a small number of migrants from the Caribbean island of Haiti.<sup>12</sup> <sup>13</sup> In the popular press, AIDS had become a disease of the “four H club” – homosexuals, heroin addicts, haemophiliacs and Haitians – even though there had been cases among non-drug using non-Haitian women and children.<sup>14</sup><br />
The inclusion of Haitians as a risk group caused much controversy. Haitian Americans complained of stigmatisation, officials accused the CDC of racism, and Haiti suffered a serious blow to its tourism industry.<sup>15</sup> <sup>16</sup><br />
<h3>Stigma, discrimination and political inaction</h3>From the outset, AIDS was associated with a high level of stigma and discrimination. This prejudice arose in part because AIDS was linked to groups, such as gay men and intravenous drug users, that were already highly stigmatised, but also because evidence-based information about what was causing AIDS, and how it might be passed on, was in short supply.<br />
<blockquote class="longquote">“…as the ‘80s started going along, after ’82, say ’83, ’84, more and more people were getting sick. Fear was gripping the city and the nation. Gay people stopped going out. Nobody knew how it was transmitted and people were afraid… These were people my age. It was frightening”.<cite> – Peter Groubert, living in San Francisco.<sup>17</sup></cite></blockquote>While most of the scientists investigating AIDS already strongly suspected that it was related to sexual contact and the transfer of contaminated blood, there was no definitive evidence at the time to prove these were the only routes of transmission.<br />
<blockquote class="longquote">“The national authorities didn’t say nothing and people just kind of started developing their own theories. I knew a friend who thought it was blood. He thought it was when he went for an operation, don’t get a blood transfusion”<cite> – Robin Tichane, an artist living in San Francisco.<sup>18</sup></cite></blockquote>Some medical professionals were reluctant to investigate the causes of AIDS further because of their prejudicial beliefs. Dr Joel Weisman, one of the first physicians to identify AIDS as a distinct condition, summed up the attitude of one of his colleagues by describing one of their conversations:<br />
<blockquote class="longquote">"I remember calling a person [in infectious diseases] to describe what was occurring. He said - and this was a theme very early on - 'I don't know what you're making such a big deal of it for. If it kills a few of them off, it will make society a better place’.”<cite> <sup>19</sup></cite></blockquote>For a while the American government completely ignored the emerging AIDS epidemic. In a press briefing at the White House in 1982, a journalist asked a spokesperson for President Reagan <i>“…does the President have any reaction to the announcement – the Center for Disease Control in Atlanta, that AIDS is now an epidemic and have over 600 cases?”</i> The spokesperson responded - <i>“What’s AIDS?”</i><sup>20</sup> To a question about whether the President, or anybody in the White House knew about the epidemic, the spokesperson replied, <i>“I don’t think so”</i>.<br />
<blockquote class="longquote">"An entire political movement grew up around the silence of the Reagan administration. The AIDS activist movement took as its call to action 'silence equals death' because literally the silence of the Reagan administration was resulting in the deaths of thousands and thousands of gay men in our communities across the country."<cite> - Sue Hyde, National Gay and Lesbian Task Force<sup>21</sup></cite></blockquote>While the government failed to respond to the epidemic, a number of non-governmental organisations were founded in the most affected areas of America, such as The Kaposi’s Sarcoma Research and Education Foundation in San Francisco (later renamed the San Francisco AIDS Foundation) and, in New York, Gay Men’s Health Crisis (GMHC). In 1982 GMHC distributed 50,000 free copies of its first newsletter about the syndrome to hospitals, doctors, clinics and the Library of Congress.<sup>22</sup><br />
By the end of 1983 the number of AIDS diagnoses reported in America had risen to 3,064 and of these people 1,292 had died.<sup>23</sup><br />
On 22nd April 1984 The New York Times reported the head of the CDC - Dr. James Mason – as saying that he had reason to believe that French researchers had isolated the virus that causes AIDS.<sup>24</sup> The researchers had named the virus LAV, for lymphadenopathy-associated virus.<br />
<blockquote class="longquote">“We cannot know for sure now that the LAV virus is the agent that causes AIDS, but the pattern it follows in the human body makes us believe it is”.<cite> <sup>25</sup></cite></blockquote>Mason based his opinion on additional findings by the CDC and the National Institutes of Health in Bethesda, Maryland.<br />
<div class="photo_l"> <img alt="Margaret Heckler" border="0" src="http://www.avert.org/media/photos/384.jpg" width="135" /> <div style="width: 135px;">Margaret Heckler</div></div>The next day at a press conference in Washington, Margaret Heckler, Secretary of Health and Human Services under President Reagan, revealed that Dr. Robert Gallo and his colleagues at the National Cancer Institute had reason to believe that HTLV-III (LAV as named by the French researchers) was the virus that caused AIDS (HTLV-III was later renamed HIV). Heckler stated that there would soon be a commercial test available to identify the virus and a vaccine could be ready for testing within two years.<sup>26</sup><br />
By 1985 the US government had given five pharmaceutical companies licences to develop a test, and in March the first blood test for identifying antibodies to HIV was made commercially available. <sup>27</sup> The test was produced by Abbott Laboratories, and soon began to be used in a number of blood transfusion centres. <sup>28</sup> At this time 73 cases of haemophilia-associated AIDS had been reported.<sup>29</sup> Today it is estimated that by 1986 (when a heat treatment was introduced to kill HIV in blood products), more than half of all haemophiliacs in America had become infected with the virus.<sup>30</sup><br />
On 17th September 1985 President Reagan publicly mentioned AIDS for the first time, when he was asked about AIDS funding at a press conference.<br />
<blockquote class="longquote">“I have been supporting it for more than 4 years now. It's been one of the top priorities with us, and over the last 4 years, and including what we have in the budget for '86, it will amount to over a half a billion dollars that we have provided for research on AIDS in addition to what I'm sure other medical groups are doing”.</blockquote>Critics were quick to ask why, if AIDS had been a ‘top priority’ among the government, the president had not mentioned it in public before.<sup>31</sup><br />
President Reagan refused to advocate safer sex and condom use, choosing instead to press for a ban on HIV positive immigrants entering the country, then later sexual abstinence, as the keys to preventing the epidemic.<sup>32</sup><br />
On 3rd October 1985, the actor Rock Hudson died of AIDS. He was the first major public figure known to have died from an AIDS-related illness.<sup>33</sup><br />
In 1986 the Surgeon General's Report on AIDS was published. The report was the Government's first major statement on what the nation should do to prevent the spread of AIDS. The "unusually explicit" report urged parents and schools to start "frank, open discussions" about AIDS.<sup>34</sup><br />
<div class="photo_r"> <img alt="The cover of the
'Understanding AIDS' brochure from 1988" border="0" src="http://www.avert.org/media/photos/1823a.jpg" width="250" /> <div style="width: 250px;">The cover of the "Understanding AIDS" brochure from 1988</div></div>In 1987 playwright and novelist Larry Kramer co-founded ACT UP (the AIDS Coalition to Unleash Power). ACT UP’s slogan ‘Silence-Death’ reflected anger at the government’s slow response in dealing with the AIDS crisis.<br />
ACT UP’s first demonstration took place on 24th March on Wall Street in New York. The group demanded access to treatment for AIDS, public education to stop the spread of AIDS, an end to AIDS discrimination and the establishment of a national policy on AIDS.<sup>35</sup><br />
By 1988 the group had almost 3,000 members, many of whom were infuriated that little was being done while their friends and relatives were dying.<sup>36</sup><br />
The first national, coordinated AIDS education campaign was not finally launched until 1988, when 107 million brochures entitled “Understanding AIDS” were mailed to every household across the country. By this point, nearly 83,000 cases of AIDS had been identified in America, and over 45,000 people had died.<sup>37</sup> Six other nations had set up similar leaflet campaigns before America chose to do so.<sup>38</sup><br />
<h3 class="clearall">The introduction of antiretroviral treatment</h3>In September 1986, early results from clinical trials involving AZT (zidovudine) – a drug that was first investigated as a cancer treatment – showed that it might slow the attack of HIV. The AZT clinical trial divided patients into two groups: one received AZT and the other received a placebo. At the end of six months, only one patient in the AZT group had died, while there were 19 deaths among the placebo group. The clinical trial was stopped early, because it was thought to be unethical to deny the patients in the placebo group a better chance of survival.<sup>39</sup><br />
In March 1987 the U.S. Food and Drug Administration (FDA) approved AZT as the first antiretroviral drug to be used as a treatment for AIDS.<sup>40</sup><br />
By 1988 frustration was growing over the length of time it had taken to approve AZT and the FDA’s slow progress in improving access to other experimental AIDS drugs. On 11th October 1988 more than a thousand ACT UP demonstrators descended on the FDA headquarters in Rockville, Maryland, demanding quicker and more efficient drug approval. Eight days later the FDA announced regulations to cut the time it took for drugs to be approved.<sup>41</sup><br />
In 1989 results from a major drug trial know as ACTG019 were announced. The trial showed that AZT could slow progression to AIDS in HIV positive individuals with no symptoms.<sup>42</sup> These findings were thought to be extremely positive; on August 17th a press conference was held, at which the Health Secretary, Louis Sullivan said:<br />
<blockquote class="longquote">"Today we are witnessing a turning point in the battle to change AIDS from a fatal disease to a treatable one."<cite> <sup>43</sup></cite></blockquote>The initial optimism was short-lived when the price of the drug was revealed. A year’s supply for one person would cost around $7,000, and many Americans did not have adequate health insurance to cover the cost. Burroughs Wellcome, the makers of AZT, were accused of ‘price gouging and profiteering’.<sup>44</sup> <sup>45</sup> In September, the cost of the drug was cut by 20 percent.<br />
By August 1989, more than 100,000 people diagnosed with AIDS had been reported to the CDC.<sup>46</sup> The proportion of AIDS diagnoses among women had increased, and smaller cities and rural areas were increasingly affected.<br />
<h2>The history of AIDS in America in the 1990s</h2><div class="photo_r"> <img alt="Ryan White
(1971-1990), with his mother" border="0" src="http://www.avert.org/media/photos/177.jpg" width="220" /> <div style="width: 220px;">Ryan White (1971-1990), with his mother</div></div>On April 5th 1990, Ryan White died. Ryan was a schoolboy who had become infected with HIV via a blood transfusion for his haemophilia. He had become well known in the 1980s as a result of his fight to be allowed to attend public school, from which he had been banned due to fears that other children 'might pick up AIDS'. Eventually, after months of legal battles, Ryan was allowed to return, but then faced considerable hostility from students and parents. Ryan spent the next seven years of his life publicly speaking about HIV and how those with the infection should not be feared.<sup>47</sup><br />
Following Ryan’s death, the American government implemented a new programme named after him – the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Its aim was to improve the quality and availability of care for low-income, uninsured and underinsured individuals and families affected by HIV disease.<br />
Members of Gay Men’s Health Crisis organised the Sixth Annual AIDS Walk in New York, which took place on 19th May 1991.<sup>48</sup> The walk was estimated to raise $4.1 million, which would be put towards AIDS education and prevention programmes. Around 26,000 people turned up to walk the streets of the Upper West Side of Manhattan.<br />
In 1991, American basketball player Earvin ‘Magic’ Johnson, Jr. announced that he too had HIV. Taking advice from his doctors he retired from professional basketball and planned to use his celebrity status to help educate young people about the disease. He said:<br />
<blockquote class="longquote">“I think sometimes we think, well, only gay people can get it – ‘It’s not going to happen to me’. And here I am saying that it can happen to anybody, even me, Magic Johnson”.<cite> <sup>49</sup> </cite></blockquote>Johnson’s announcement had a massive impact on America’s public awareness of AIDS; in the month after he revealed his status, the number of people being tested for HIV in New York City increased by almost 60 percent.<sup>50</sup><br />
Around 45,500 cases of AIDS were reported to the CDC in 1991.<sup>51</sup> Ten years after the first cases of AIDS-related PCP were identified, AIDS had become the second leading cause of death among American men aged 25-44 years.<sup>52</sup><br />
In March 1993 the House of Representatives voted overwhelmingly to keep the ban of HIV infected people entering America,<sup>53</sup> which had been in place since 1987.<sup>54</sup> Thomas J. Bliley Jr., Republican of Virginia stated:<br />
<blockquote class="longquote">“Because HIV is always fatal, the public health consequences of allowing HIV individuals to immigrate is of the highest order… We have never before permitted immigration of those who were infected in the middle of an epidemic. We should not start now”.<cite> <sup>55</sup></cite></blockquote>As well as immigrants, all HIV positive visitors were banned from entering the country. Despite President Clinton’s opposition to the ban, the Clinton administration made no apparent efforts to lobby against the House vote, believing it to be a lost cause.<sup>56</sup><br />
Controversy surrounded a condom campaign launched by the CDC and the Health and Human Services Department in early 1994.<sup>57</sup> The campaign promoted condom use – a first in involving government agencies, state and local organisations – through a series of advertisements on national television networks, cable networks and radio stations. The advertisements were far more frank about sex and condoms than previous ones, which angered some who encouraged young people to abstain from sex. Lamar Smith, a Texas Republican called the advertisements:<br />
<blockquote class="longquote">“…an insult to the taxpayers who will be forced to pay for something they find personally and morally offensive”.<cite> <sup>58</sup></cite></blockquote><div class="photo_r"> <img alt="Pedro Zamora" border="0" src="http://www.avert.org/media/photos/393.jpg" width="120" /> <div style="width: 120px;">Pedro Zamora</div></div>On 11th November 1994, Pedro Zamora died from AIDS complications.<sup>59</sup> After testing positive for HIV at 17 and graduating from high school a year later, Pedro travelled the country educating about HIV/AIDS. He became famous for his activism, testimony before congress and for his appearance on MTV’s reality television show, The Real World: San Francisco. After Pedro’s death, a number of organisations were created in his name and President Clinton publicly praised his AIDS activism.<br />
<blockquote class="longquote">“Pedro was particularly instrumental in reaching out to his own generation, where AIDS is striking hard. Through his work with MTV, he taught young people that ‘the real world’ includes AIDS and that each of us has the responsibility to protect ourselves and our loved ones”<cite> – President Clinton<sup>60</sup></cite></blockquote>During the beginning of the 1990s, ACT-UP established two illegal underground needle exchanges for around 1,000 injecting drug users (IDUs).<sup>61</sup> By providing sterile needles for IDUs, it was thought that the transmission of HIV among this group could be reduced.<br />
By 1995 there were around 75 needle exchange programmes in 55 cities of America. Although an expert panel had concluded that providing sterile needles and bleach to IDUs was an effective way to reduce HIV transmission among IDUs,<sup>62</sup> none of the programmes were legally entitled to any federal funding.<br />
The non-governmental AIDS organisations continued to lobby the government on AIDS issues throughout the 1990s. They provided invaluable support to those living with and affected by HIV/AIDS. In 1995 Gay Men’s Health Crisis announced that a donation of $4 million would be used to open its own testing programme for HIV.<sup>63</sup> AIDS Project Los Angeles aimed to reduce the incidence of unprotected sex amongst gay men by running an advertising campaign targeted at this group.<sup>64</sup><br />
<h3>A breakthrough in HIV treatment</h3>Since the FDA approved AZT in 1987, thousands of HIV positive people had been prescribed the drug. However, results from a federal study in 1991 questioned its effectiveness. The study showed that those who took AZT before they had any AIDS-related symptoms lived no longer than those who delayed taking it until they showed symptoms.<sup>65</sup> Many doctors were unsure whether to prescribe their patients the drug and confusion over the effectiveness of AZT escalated.<br />
<blockquote class="longquote">“I will tell my patients that one study suggests there is little or no benefit to taking AZT early and then let them make their decision”<cite> – Dr. Wayne Greaves, infectious disease specialist, Howard University, Washington.<sup>66</sup></cite></blockquote>In 1991 the FDA approved a second nucleoside reverse transcriptase inhibitor (NRTI) - dideoxyinosine (ddI) - for treating patients who were intolerant or whose health had deteriorated while on AZT.<sup>67</sup> At around the same time, a third antiretroviral drug – dideoxycytidine (ddC) - was authorised by the FDA, but only for investigational use in patients with AIDS and advanced AIDS-related complex.<sup>68</sup><br />
In January 1992 a study comparing the effectiveness of ddC against AZT was stopped. Early results showed that the number of deaths was higher amongst those taking ddC than those taking AZT.<sup>69</sup><br />
Later that year ddC was used in combination with AZT – the first successful use of combination drug therapy for the treatment of AIDS in America. The FDA approved the use of this new therapy for adult patients with advanced HIV infection who were continuing to show signs of clinical or immunological deterioration.<sup>70</sup><br />
By 1993 AIDS was reported as the fourth leading cause of death among women aged 25-44 years in America.<sup>71</sup> In the same year it was reported that around 1,000-2,000 children were becoming infected with HIV every year through mother-to-child transmission.<sup>72</sup><br />
In November 1994 a study - ACTG 076 - showed that AZT reduced the risk of HIV transmission from infected mothers to their babies by two thirds.<sup>73</sup> According to Dr Harold Jaffe of the CDC:<br />
<blockquote class="longquote">“It is the first indication that mother-to-child transmission of HIV can be at least decreased, if not prevented. And it will provide a real impetus for identifying more HIV-infected women during pregnancies so that they could consider the benefit of AZT treatment for themselves and their children.”<cite> <sup>74</sup></cite></blockquote>This important discovery heightened the benefits of identifying HIV infected pregnant women. As a result, in 1995 the Public Health Service published guidelines recommending universal counselling and voluntary HIV testing of all pregnant women and treatment for those infected.<sup>75</sup> The recommendations were widely implemented by health-care providers, resulting in a steep decline in infant infections.<br />
During the first half of the 1990s, a number of studies had shown that HIV could quickly become resistant to AZT and that the drug had no benefit for those in the early stages of the disease. It was positive news therefore when the FDA announced on 20th November 1995 that the drug 3TC (lamivudine) had been approved for use in combination with AZT in treating AIDS and HIV.<sup>76</sup> Clinical trials had shown that taking a combination of 3TC and AZT was more effective than taking AZT and ddC or AZT on its own.<sup>77</sup> The trials had also shown that 3TC had less severe side effects than the others already on the market.<sup>78</sup><br />
Even though treatment had progressed in the past few years, the CDC announced that AIDS had become the leading cause of death amongst all Americans aged 25 to 44.<sup>79</sup> Half a million people with AIDS had been reported to the CDC, over half of whom had died.<sup>80</sup><br />
At the end of 1995 there was a dramatic breakthrough in HIV treatment. The FDA approved saquinavir, the first of a new class of drug called protease inhibitors.<sup>81</sup><br />
<blockquote class="longquote">“I strongly believe that as a class, these are the most active agents against HIV we have seen to date… This is about more than one drug. This represents the first of a set of drugs that will be coming along in the next 12 months that should really change how we treat AIDS and HIV infection”<cite> – Dr Kessler, Commissioner of Food and Drugs.<sup>82</sup></cite></blockquote>Protease inhibitors were used in combination with one or two of the other NRTIs, in what was known as Highly Active Antiretroviral Therapy (HAART). Protease inhibitors attack a different part of the virus’s replication process and when taken in combination with NRTIs, are extremely effective in suppressing HIV – in some cases reducing the amount of virus in the body by 99 percent.<sup>83</sup><br />
At the time there was a reluctance to show any excitement about HAART, as early hopes about AZT had been dashed when people quickly developed resistance to the drug. However, it soon became obvious that HAART was going to be revolutionary in HIV treatment. It proved to significantly delay the onset of AIDS, and the life expectancy of HIV positive people was greatly increased. HIV infection was no longer thought of as a death sentence, but a manageable condition.<sup>84</sup> In 1996 the FDA approved nevirapine, the first in another new class of drug known as non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs).<sup>85</sup> These could also be taken in combination with NRTIs and widened the range of treatment options.<br />
However, there were limitations to the drugs, such as side effects and the difficulties of taking a large number of pills each day,<sup>86</sup> and it was still uncertain how effective the new treatments would be over the long term.<br />
In 1997 it was reported that, for the first time since the start of the AIDS epidemic in 1981, the number of deaths from AIDS had dropped substantially across America.<sup>87</sup> This decline was largely attributed to the effect of antiretroviral therapies on survival rates of those living with HIV. However, Dr John Ward, an AIDS expert at the CDC stated:<br />
<blockquote class="longquote">"The decline in deaths leaves more people living with AIDS and HIV infection. We do not want to be a wet blanket here, but we still need programs that assure good access to treatment and care for infected people."<cite> <sup>88</sup></cite></blockquote><h2>The history of AIDS in America since 2000</h2>At the beginning of the new century, 774,467 persons with AIDS had been reported to the CDC - 448,060 of whom had died<sup>89</sup>. The HIV infection rate had failed to decline since the mid-nineties, highlighting the need for more effective prevention initiatives.<br />
<h3>Prevention strategies in the 2000s</h3>A report published by the Institute of Medicine (IOM) in September 2000 criticised the American government for its failure to implement appropriate HIV prevention services to decrease the number of new HIV infections. Harvery Fineberg, provost of Harvard University and co-chair of the committee that wrote the report, stated:<br />
<blockquote class="longquote">“Thousands of new HIV infections could be avoided each year if we gave greater emphasis to prevention, and were smarter in the way we spent our prevention dollars.”<cite> <sup>90</sup></cite></blockquote>The report called for more federal funding for the most cost-effective prevention strategies, such as needle exchange services. The IOM report also criticised government spending on abstinence-only education; there is no evidence that such programmes are effective in preventing the spread of HIV.<sup>91</sup><br />
Although some of the report’s key recommendations were ignored, in 2001 the CDC set a goal to halve the number of people infected with HIV each year in America to 20,000.<sup>92</sup> The target was set to be achieved by the end of 2005.<br />
By 2003 it was already clear that the CDC’S goal would be missed - the number of new infections had shown no sign of declining.<sup>93</sup> As a result, the CDC decided that a major change in HIV prevention strategies was needed. In April 2003 the CDC announced a new initiative called Advancing HIV Prevention: New Strategies for a Changing Epidemic – or AHP for short.<sup>94</sup> Previously, the CDC had aimed its prevention efforts at<i> “persons at risk of becoming infected with HIV by providing funding for…programs aimed at reducing sexual and drug-using risk behaviour”</i>.<sup>95</sup> In contrast, AHP would focus mainly on people who already had HIV but were unaware of their infection, in order to reduce onward transmission.<sup>96</sup><br />
In September 2006 the CDC published guidelines calling for routine HIV testing of all adults and adolescents attending healthcare services – a strategy that was mentioned in the AHP plan. The routine testing drive was an attempt to identify the estimated one-quarter of people living with HIV in America unaware of their infection.<sup>97</sup> The President’s 2007 budget also increased focus on testing by requesting $93 million to purchase and distribute rapid HIV test kits for communities with the highest rates of newly discovered HIV cases.<sup>98</sup><br />
In 2007 the CDC stepped up its response to HIV among African Americans, who had been disproportionately affected by the AIDS epidemic for some time. Between 2000 and 2003 more than half of the HIV/AIDS diagnoses reported to the CDC were among black Americans, even though blacks represented only 13 percent of the population.<sup>99</sup> In 2005 the rate of HIV/AIDS diagnoses among black females aged 13 years and older was 20 times the rate for white women.<sup>100</sup><br />
A report published by the CDC in June acknowledged that previous attempts at preventing HIV transmission among this group had been unsuccessful.<sup>101</sup> The report therefore stated,<br />
<blockquote class="longquote">“A heightened national response, one that ignites focused, collaborative action among public health partners and community leaders, is vital at this time to reduce the toll of HIV/AIDS on blacks”.<cite> <sup>102</sup></cite></blockquote>By October 2007 the CDC had published a new general prevention strategic plan that would guide prevention efforts through 2010.<sup>103</sup> The plan recognised how advances in treatment had improved the lives of many HIV positive individuals, but argued that America was not investing enough in prevention.<br />
<div class="photo_r"> <img alt="The 2007 San
Francisco AIDS Walk " border="0" src="http://www.avert.org/media/photos/1688.jpg" width="300" /> <div style="width: 300px;">The 2007 San Francisco AIDS Walk</div></div>In 2006 only 5 percent of the domestic HIV/AIDS budget was spent on prevention,<sup>104</sup> while there were still around 40,000 new HIV infections in America each year.<br />
On 15th July 2007 AIDS Walk San Francisco raised a record $4.5 million - the largest single-day AIDS fundraiser that had ever taken place in California.<sup>105</sup> Around 25,000 people walked for 6 miles through Golden Gate Park to raise money for local HIV/AIDS service organisations. Across the country, hundreds of non-governmental organisations continued their invaluable work supporting those affected by AIDS.<br />
<h3>Treatment access and development in the 2000s</h3>The new millennium saw important advances in HIV treatment. By 2003 a new drug had been developed that prevented HIV from entering human immune cells. Enfuvirtide - an ‘entry inhibitor’ - was approved by the FDA on 13th March - seven years since the last approval of a new drug class.<sup>106</sup> The drug could be used in combination with other anti-HIV medications to treat advanced HIV infection. As enfuvirtide worked in a different way to other antiretroviral drugs, there was more hope for those who had developed resistance to the existing medications.<br />
Yet although there was optimism about the advances in treatment options, a report published by the IOM in March 2002 highlighted the disparities in access to healthcare services for racial and ethnic minorities.<sup>107</sup> Of particular concern were the apparent inequalities in access to AIDS treatment for African Americans. The report found that even when money was not a factor, African Americans were less likely to be given the most advanced treatments for HIV than whites.<sup>108</sup><br />
<blockquote class="longquote">“The IOM report found that the discrepancy in HIV/AIDS care is particularly blatant. Many of the minorities affected by HIV/AIDS are members of the working poor, who lack health insurance and have limited access to health care, including HIV testing and prevention methods. Further, a lack of prevention programs targeting communities of color hampers African Americans’ ability to protect themselves”.<cite> <sup>109</sup></cite></blockquote>The racial divide in access to treatment added to the problems that the epidemic was posing for the black community. African Americans were not only at a greater risk of HIV infection, but also were facing barriers to testing, treatment, and HIV prevention education.<sup>110</sup><br />
By 2004 it was estimated that around 50 percent of Americans receiving antiretroviral therapy were infected with a strain of HIV that was resistant to at least one of the available drugs.<sup>111</sup> The treatment options for many patients were dwindling and the transmission of the drug-resistant virus was an increasing concern.<br />
On 19th December 2006, President Bush signed the reauthorisation of the Ryan White HIV/AIDS Program.<sup>112</sup> Since its creation in 1990 the program had provided federal funding for thousands of Americans living with HIV/AIDS unable to pay for their treatment themselves.<br />
<blockquote class="longquote">“This legislation focuses on life-saving and life-extending services and increased accountability, and will provide more flexibility to the Secretary of Health and Human Services to direct funding to areas of greatest need”<cite> – President Bush.<sup>113</sup></cite></blockquote>However, the 2006 reauthorisation caused much controversy, as five new cities were to receive funding, even though there was no increase in the overall financing of the programme.<sup>114</sup> There was also a shift of funding to rural areas and the South, taking money away from areas where the epidemic began, such as San Francisco and New York.<sup>115</sup><br />
On 12th July 2006 the first once-a-day single combination pill for the treatment of HIV was approved by the FDA.<sup>116</sup> Atripla tablets – a fixed-dose combination of efavirenz, emtricitabine and tenofovir – were designed to simplify treatment regimes.<br />
Maraviroc, a second entry inhibitor, was approved by the FDA on 6th August 2007.<sup>117</sup> As the drug worked in a novel way by blocking the CCR5 receptor – the most common route of entry for HIV into uninfected cells – it received priority review by the FDA.<br />
<blockquote class="longquote">“This is an important new product for many HIV-infected patients who have not responded to other treatments and have few options”<cite> – Steven Galson, M.D., M.P.H., director of FDA’s Center for Drug Evaluation and Research.<sup>118</sup></cite></blockquote>A few months later, another drug – raltegravir – was approved by the FDA.<sup>119</sup> Raltegravir was the first of a new class called integrase inhibitors.<sup>120</sup><br />
The significant progress in treatment proved to be particularly important to thousands of HIV positive Americans whose treatment had been failing due to drug resistance. The developments were described by some as comparable to the introduction of HAART in the mid-1990s and would <i>“provide extended years of meaningful survival to patients” – Dr. Hammer, chief of infectious disease at Columbia University.<sup>121</sup></i><br />
In July 2008 the Senate Appropriations Committee passed the Financial Services appropriations bill for 2009, which included an allocation of $1.4 million to develop a National AIDS Strategy.<sup>122</sup> In April 2010, the Office of National AIDS Policy released a report summarising feedback from community discussions held in 14 sites across the U.S intended to inform the the development of the strategy.<sup>123</sup> Since America has never had such a strategy, hundreds who had been campaigning for it welcomed the plan.<br />
<blockquote class="longquote">“We are incredibly encouraged to see bodies within both chambers of Congress support the development of a National AIDS Strategy which will facilitate continuity of the domestic governmental response to the epidemic, ensuring resources and efforts are maximised… We strongly believe the National AIDS Strategy will help reduce the number of new HIV infections in this country, improve support services and the quality of lives for people living with HIV/AIDS”<cite> – Dr. Marjorie Hill, Chief Executive Officer at Gay Men’s Health Crisis (GMHC).</cite></blockquote>President Obama signed the Ryan White HIV/AIDS Treatment Extension Act in October 2009.<sup>124</sup> The legislation authorized the Act until 2013.<sup>125</sup><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-81037760863518693642010-06-10T08:46:00.000-07:002010-06-10T08:46:10.575-07:00HIV and AIDS in the Caribbean<div class="box bFull"> In 2008 an estimated 20,000 people in the Caribbean became infected with HIV, and around 12,000 died of AIDS. After sub-Saharan Africa, the Caribbean has a higher HIV prevalence than any other area of the world, with 1.0% of the adult population infected.<sup>1</sup><br />
</div><div class="box bFull"> <h2>An overview of AIDS in the Caribbean </h2>Due largely to their close geographic locations, the Caribbean is usually grouped with Latin America in discussions about HIV and AIDS, but the epidemics in these regions are very different. Even within the Caribbean, each country faces a unique situation. The diversity of the region – which is apparent in terms of politics, languages spoken, geographic location and wealth – is reflected in the significantly different ways that countries are affected.<br />
At one extreme, the Bahamas has the highest HIV prevalence in the entire western hemisphere (3%); at the other, Cuba has one of the lowest (0.1%). Trinidad and Tobago (1.5%) and Jamaica (1.6%) are heavily affected, while Puerto Rico is the only Caribbean country apart from Cuba where it is thought that less than 1% of the population is living with HIV.<sup>2</sup> Other factors, such as AIDS mortality rates and transmission patterns, also vary across countries and areas. See our Caribbean statistics page for more data.<br />
Before Haiti's devastating earthquake in January 2010, an estimated 2.2 percent of the population were living with HIV. Haiti's AIDS epidemic is one of the most severe in the Caribbean. Before the earthquake an estimated 126,800 people under the age of 49 were living with the virus, which included 6,800 children; and an estimated 19,000 people were receiving antiretroviral drugs (ARVs). Since the earthquake, thousands of people will still be in need of ARVs, and the priority for AIDS organisations is to get the medication to those in need. It is also critical that HIV prevention, treatment, care and support services are resumed.<sup>3</sup><br />
<blockquote class="bigquoteright"> <div class="bigquotebody">“Haiti's AIDS epidemic is one of the most severe in the Caribbean”</div><a name='more'></a><br />
</blockquote>Prior to Haiti's earthquake there were signs of decreasing HIV infection levels, which were partly attributed to an increase in condom use and changes in sexual behaviour. Similarly, in the Dominican Republic prevalence fell from 1% in 2002 to 0.8% in 2007. However, HIV surveillance in the Caribbean is generally considered inadequate, so these reported trends are only vague indicators. Both HIV prevalence and AIDS cases are thought to be widely underestimated in the region.<sup>4</sup><br />
Reflecting global patterns, heterosexual sex is now the main route of transmission throughout the region, and it has been established that women and young people are particularly vulnerable.<sup>5</sup> Little is known about the role that sex between men plays in the region’s epidemics – it has been estimated that men who have sex with men account for 12% of infections, but it is thought that the actual proportion is higher than this, since the rampant homophobia that exists throughout the region has led to denial and under-reporting.<sup>6</sup><br />
Despite differences between countries, the spread of HIV in the Caribbean has taken place against a common background of poverty, gender inequalities and a high degree of HIV-related stigma. Migration between islands and countries is common, contributing to the spread of HIV and blurring the boundaries between different national epidemics.<sup>7</sup> Additionally, poor availability of HIV and AIDS data makes it difficult to gain a clear picture of each country’s situation.<br />
<h2>Responding to the crisis</h2><div class="photo_r"><img alt="AIDS activists in
Haiti " border="0" src="http://www.avert.org/media/photos/1590.jpg" width="260" /> AIDS activists in Haiti<br />
</div>Since countries in the Caribbean face common problems, and resources are limited, the need for a coordinated response to HIV and AIDS has long been recognised. The Pan Caribbean Partnership Against HIV/AIDS (PANCAP) was established in 2001, with the aim of preventing the spread of HIV and alleviating the suffering it causes across the Caribbean. PANCAP has brought together governments, non-governmental organisations, private sector groups, faith-based organisations and donor agencies to co-ordinate both prevention and treatment efforts.<sup>8</sup> It has also helped to establish a Caribbean Regional Strategic Framework for HIV/AIDS, under which PANCAP members have made significant progress in drawing attention to the crisis and establishing dialogue between separate groups. In 2004 PANCAP was named a ‘best practice’ response by the Joint United Nations Programme on HIV and AIDS (UNAIDS).<sup>9</sup><br />
Some strong responses have been formed on a local level, too: most nations have developed National AIDS Commissions, strategic plans, legislation and HIV-related programmes and services.<sup>10</sup> <sup>11</sup><br />
However, since most countries in the region are limited by poor public infrastructure and fragile economies, acting out these responses has been difficult. Political leadership has also been varied. Many Caribbean islands are heavily dependent on tourism, and in some areas officials are reluctant to draw attention to the problem of AIDS for fear that this might discourage visitors.<sup>12</sup> This is exactly what happened to Haiti in the early 1980s, when it was established that a number of early cases of HIV in the United States had occurred among Haitian immigrants. Since AIDS had only recently emerged, people were quick to associate this new problem with Haiti:<br />
<blockquote class="longquote">“It was a disaster, the tourism industry died. Nobody wanted to come here. Even the Haitians in the United States were afraid to come” <cite>Jean Pape, founder of GHESKIO AIDS clinic in Haiti<sup>13</sup></cite></blockquote>As well as concerns about tourists, fears about local opinions may also be obstructing political action. Many politicians have been vocal about the impact of the problem and the need to take action, but HIV and AIDS are heavily stigmatised in all Caribbean countries and this is limiting public demand for political initiatives.<sup>14</sup> Traditional, religious and cultural norms prevent people from talking openly about HIV and AIDS in most countries, and create a situation where misinformation and prejudice thrive. It is hard for officials to properly address the issue in this climate, and politicians are sometimes reluctant to publicise the true nature of their AIDS epidemics. This may be influencing the lack of HIV surveillance and monitoring in the area.<br />
<h2>HIV Prevention in the Caribbean </h2>Numerous different approaches have been taken to preventing HIV in the Caribbean. Some programmes have achieved significant success, but the barriers of poverty and insufficient resources continue to limit HIV prevention throughout the region.<sup>15</sup><br />
It is difficult to give an overall assessment of how successful HIV prevention has been in the Caribbean, but the examples below give an indication of the achievements that have been made in certain areas.<br />
<h3>Voluntary counselling and testing</h3>In general, experts recommend that testing for HIV should occur with the consent of individuals involved, and should be complemented by counselling. Most countries in the Caribbean have opened voluntary counselling and testing (VCT) centres, and international agencies such as USAID and the Global Fund to Fight AIDS, Tuberculosis and Malaria have provided grants to expand such services in a number of countries.<sup>16</sup><br />
In the past, <span class="highlight">Cuba</span> adopted the controversial approach of adopting mandatory testing among certain groups, such as pregnant women, hospital patients and inmates of prisons. If found HIV positive, individuals were taken to sanatoriums, where they were provided with care and support while their sexual partners were traced. The rules have relaxed in recent years: it is no longer compulsory for HIV positive people to stay at sanatoriums following an eight week probationary period, and testing is now generally voluntary, with the exceptions of blood donors and prisoners.<sup>17</sup><br />
Although Cuba’s approach has been questionable in terms of human rights, it has certainly worked – infection rates have remained exceptionally low. Additionally, reports suggest that the sanatoriums are far from the restrictive institutions that people have sometimes portrayed them to be. Even now that it is not compulsory, many HIV positive people choose to remain at the sanatoriums due to the quality of care and support that they receive.<sup>18</sup><br />
<h3>Providing condoms and information</h3>Before the earthquake in Haiti, the Foundation for Reproductive Health and Family Education (FOSREF, a non-profit organisation established in 1989) provided basic training on reproductive health, including HIV and AIDS, to 500 teachers, 6,500 young workers, and 30,000 young volunteers who disseminate information to their peers. As a result, a large number of people were using condoms, and there was evidence of sexual behaviour change and reductions in HIV prevalence where the programme had been carried out. In 2006, FOSREF was awarded a United Nations Population Award for its work.<sup>19</sup><br />
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</div>On the other side of the Hispaniola Island, HIV prevalence has receded in the <span class="highlight">Dominican Republic</span>. This decline is largely attributed to effective prevention campaigns, which have encouraged people to use condoms and reduce their number of sexual partners.<sup>20</sup> In the capital city of Santo Domingo, sustained efforts to promote consistent condom use and safer sexual behaviour among sex workers and their clients have been linked to decreasing HIV prevalence among pregnant women.<sup>21</sup><br />
There are still, however, major gaps in the Dominican Republic’s prevention programmes. In the <i>bateyes</i> - shanty towns, which are disproportionately affected by HIV – prevention tools such as condoms and information are not generally available. Researchers argue that the Dominican government’s response to HIV/AIDS has been weak and that investment in HIV/AIDS programmes is falling short.<sup>22</sup><br />
Condom use is still stigmatised in many parts of the Caribbean. Many people are often too embarrassed to buy condoms from shops, and even to use them with their partners:<br />
<blockquote class="longquote">“Women wonder what a guy’s been up to if he wants to use one... if you want to use a condom people assume something must be wrong.” <cite>Harry, St. Kitts<sup>23</sup></cite></blockquote><h3>Preventing mother-to-child-transmission</h3>Most countries in the Caribbean have taken steps to prevent mother-to-child-transmission of HIV. <span class="highlight">Cuba</span>’s mother-to-child-transmission programme is one of the most effective in the world; all pregnant women are tested for HIV, and those that test positive are provided with antiretroviral drugs to reduce the risk of transmission. This scheme has helped to keep the total number of HIV-positive babies below 100.<sup>24</sup><br />
In <span class="highlight">Barbados</span> and the <span class="highlight">Bahamas</span>, a combination of increased voluntary counselling and testing services and improved access to antiretroviral drugs has helped to significantly reduce the rate of mother-to-child-transmission.<sup>25</sup><br />
AVERT is currently calling for improvements in PMTCT services worldwide through our Stop AIDS in Children campaign.<br />
<h3>Media campaigns</h3>In 2005, television and radio broadcasters in the Caribbean united to form the Broadcast Media Partnership on HIV/AIDS. This was followed by the announcement in August 2006 that a group of international donors - the Henry J. Kaiser Family Foundation, the Ford Foundation and the Elton John AIDS Foundation – would provide US$1 million to initiate the project. Participating broadcasters have promised that 12 minutes of airtime every day will be dedicated HIV/AIDS related programming, and that this coverage will include news, documentaries, dramas and other formats.<br />
<blockquote class="longquote">"This is the first time broadcasters have come together to combat a social problem. We have a unique opportunity to leverage the communication power of our media platforms to raise awareness, fight stigma and intolerance, and support people already living with [HIV].” <cite>Allyson Leacock, general manager of the Caribbean Broadcasting Corporation (CBC)<sup>26</sup></cite></blockquote>Some programmes have already been aired, and a website has been established. It is expected that the partnership will become fully operational during 2007.<sup>27</sup><br />
<h3>HIV/AIDS education in schools</h3>In 2002, ministers from several Caribbean countries convened in Havana, Cuba, to agree upon a commitment to HIV/AIDS education:<br />
<blockquote class="longquote">"We, the Ministers of Education of the Caribbean… recognize that education is integral to the fight against AIDS, and that the disease will not be overcome without the full involvement of the education sector." <cite>Havana Commitment of Caribbean Ministers of Education, November 2002<sup>28</sup></cite></blockquote>But while political commitment is seemingly in place, poverty and a lack of resources have generally hindered progress. Many children have no access to school education, particularly in rural areas, which are often acutely affected by HIV.<sup>29</sup> Cuba is the only Caribbean country that has made sex education mandatory at all levels of teaching, from preschool to university.<sup>30</sup><br />
<h2>HIV prevention among risk groups in the Caribbean </h2><blockquote class="bigquoteright"> <div class="bigquotebody">“Gays and lesbians in Jamaica exist with the possibility that you might be chased, you might be run down, you might be killed because of your sexual orientation”</div><div class="bigquotecite">Gareth Williams, JFLAG</div></blockquote>There is a general lack of HIV prevention campaigns targeting sex workers and men who have sex with men in the Caribbean – two key risk groups in the region. These are hidden populations, which are highly stigmatised and not generally recognised as part of mainstream society.<br />
HIV prevalence amongst men who have sex with men (MSM) varies between Caribbean countries. In <b>Cuba</b> MSM account for 80% of all reported HIV cases. Dominica (70%), Trinidad and Tobago (20%) and the Dominican Republic (11%) report a high percentage of infection among this group.<sup>31</sup> Homophobia and cultural taboos about sex between men are major barriers to reaching this group with prevention campaigns. A good example is <span class="highlight">Jamaica</span>, where groups attempting to provide HIV-related services to men who have sex with men have faced harassment from both the public and the police. In November 2005, Steve Harvey, head of Jamaica AIDS Support - a group that works with gay and bisexual people affected by HIV – was kidnapped and killed when it was discovered that he was homosexual.<sup>32</sup><br />
<blockquote class="longquote">“Gays and lesbians in Jamaica exist with the possibility that you might be chased, you might be run down, you might be killed because of your sexual orientation, and when a day ends when that does not happen, we give thanks.” <cite>Gareth Williams, the Jamaica Forum for Lesbians, All-Sexuals and Gays (JFLAG)<sup>33</sup></cite></blockquote>This problem is not helped by Jamaica’s legal system, which bans sex between men. Such laws exist in most countries in the region. UNAIDS reports that, of the Caribbean countries that submitted data for its 2006 global report, over three-quarters had laws that may hinder the provision of prevention and treatment services to vulnerable and high-risk populations. This includes banning sex between men and not providing condoms to certain groups, such as prisoners.<sup>34</sup><br />
Prevention is also lacking among commercial sex workers. The Caribbean is a popular destination for sex tourists, and several countries, such as the Dominican Republic, Jamaica and <span class="highlight">Trinidad and Tobago</span>, have reported that sex tourism is linked to rising infection rates in certain areas.<sup>35</sup> Commercial sex work involving local clients also plays a significant role in some areas.<sup>36</sup><br />
Injecting drug use, although a prominent factor in the spread of HIV worldwide, plays a minimal role in the epidemics of most countries in the Caribbean. The exceptions are <span class="highlight">Bermuda</span> and <span class="highlight">Puerto Rico</span>. In Puerto Rico, experts argue that there is an urgent need for more needle exchanges and methadone treatment clinics, which have proved efficient in lowering transmission rates among injecting drug users in other countries around the world.<sup>37</sup><br />
<h2>Stigma and discrimination in the Caribbean</h2>HIV-related stigma and discrimination are extremely common in the Caribbean. In some cases, prejudice towards people living with HIV is linked with homophobia; sex between men carries a high risk of HIV transmission and, as elsewhere, people in the Caribbean often associate HIV with homosexuality, despite the fact that the majority of infections occur through heterosexual sex.<br />
<blockquote class="longquote">“With HIV, because it’s seen as a gay thing, there’s a lot of shame. If someone finds out they are positive, they’re afraid that everyone will assume they are gay, so it’s best to keep it to yourself.” <cite>HIV Positive man, Jamaica<sup>38</sup></cite></blockquote>In other cases, HIV is stigmatised because of general cultural taboos about sex, and unfounded fears that infection can be passed on through everyday contact.<br />
<blockquote class="longquote">“Why are my friends treating me this way? What could I have done to stop my mother dying of AIDS? I miss her so much and now nobody will talk to me.” <cite>Schoolgirl from the Caribbean<sup>39</sup></cite></blockquote>The effects of this prejudice are numerous. For one thing, it causes a great deal of stress and suffering to people who are living with HIV and their families, who often face social isolation and harassment. In another sense, stigma stops people who are at risk of infection from accessing information on prevention and testing, and reduces people’s willingness to buy condoms or alter their sexual behaviour. It also prevents people from accessing counselling services, support groups and treatment.<br />
<blockquote class="bigquoteleft"> <div class="bigquotebody">“Why are my friends treating me this way? What could I have done to stop my mother dying of AIDS? I miss her so much and now nobody will talk to me.”</div><div class="bigquotecite">Schoolgirl from the Caribbean</div></blockquote><blockquote class="longquote">“I don’t want them [my neighbours] to think I am one of those people.” <cite>HIV positive woman, Guyana<sup>40</sup></cite></blockquote>It is generally acknowledged that stigma and discrimination are helping to fuel the HIV epidemics of Caribbean countries. Some progress is being made in overcoming this problem, particularly through the work of organisations of people living with HIV and non-governmental organisations that work with vulnerable populations.<sup>41</sup> Many HIV prevention campaigns include anti-stigma messages.<br />
At the same time, there is still an urgent need for stronger and more co-ordinated efforts to fight this problem. Since HIV-related stigma is often linked with negative attitudes towards marginalised groups, there is a particular need for government officials to review legislation that may be fuelling discrimination against such groups, such as laws against sex between men.<sup>42</sup><br />
<h2>AIDS treatment in the Caribbean </h2>The provision of antiretroviral drugs (ARVs), which delay the progression from HIV to AIDS, has been a major challenge for countries in the Caribbean, primarily due to the high price of the treatment.<br />
In 2002, important progress was made when PANCAP signed a deal with six pharmaceutical companies that reduced the price of ARVs for all Caribbean countries.<sup>43</sup> Significant gains have been made in many countries since this agreement was signed; an estimated 51% of people needing antiretroviral treatment in the region are receiving it.<sup>44</sup><br />
<div class="photo_r"><img alt="An HIV positive
woman appealing for help to afford HIV treatment in Jamaica" border="0" src="http://www.avert.org/media/photos/1382.jpg" width="225" /> An HIV positive woman appealing for help<br />
to afford HIV treatment in Jamaica<br />
</div>Progress however, has been uneven. Cuba is the only country in the region with universal access to ARVs, an achievement made easier by a low national HIV prevalence. For years, however, Cubans had no access to the medication because of the U.S. embargo that prevents the government from trading with U.S. pharmaceutical companies and their foreign-based subsidiaries. To overcome this problem, Cuban scientists began to manufacture generic versions of ARVs in 2001.<sup>45</sup> Today, the supply of these generic drugs is plentiful enough to cover everyone who needs them. The Cuban government has also offered to provide other Caribbean countries with ARVs, and to send them doctors and nurses to help in their fight against AIDS.<sup>46</sup><br />
ARVs were first made available on a small scale in Haiti in 1998, when the U.S. organisation Partners in Health helped to launched a community-based scheme that trained and employed local Haitians to administer ARVs and provide support to those taking them.<sup>47</sup> As the poorest country in the Western Hemisphere, Haiti’s government could not afford to distribute treatment without help, and so from 2002, the Global Fund to Fight HIV, Tuberculosis and Malaria, along with other international organisations, provided funding for the programme. While only 41% of those needing ARVs in Haiti were receiving them by the end of 2007, this was double the amount that had access in 2005, and four times the figure for 2004.<sup>48</sup> <sup>49</sup> <sup>50</sup><br />
In the aftermath of Haiti's earthquake it emerged that stocks of HIV treatment and prevention supplies had been destroyed. In response, Michel Sidibé, Executive Director of UNAIDS stated:<br />
<blockquote class="longquote">"We are seeing real suffering. It is in moments like this where those most at risk are forgotten. We must ensure that the marginalized members of our communities have access to HIV prevention, treatment, care and support services" <cite><sup>51</sup></cite></blockquote>Unfortunately in the Dominican Republic the commitment to treatment provision has generally been lacking. Critics argue that the government’s treatment programme has been slow and inefficient, particularly in poorer areas:<br />
<blockquote class="longquote">“People with AIDS in the bateyes are dying without any kind of help.” <cite>Sister Concepcion Rivera, nurse, Dominican Republic<sup>52</sup></cite></blockquote><h2>The way forward</h2>There is still a long way to go before HIV and AIDS are under control in the Caribbean. Gaps exist in testing, treatment and prevention programmes, and stigma and discrimination are having a devastating effect. National responses to the crisis are generally lacking, though often as a result of weak public infrastructures and human capacity, rather than a lack of political will.<sup>53</sup> Additionally, monitoring and reporting of the epidemic is consistently poor, which makes it difficult to gain an understanding of the crisis and consequently holds back HIV prevention campaigns.<br />
Nonetheless, there is some cause for optimism. Through PANCAP, countries in the region have proved that they can work together to make important headway, in terms of both treatment and prevention, and it is likely that the full potential of this collaboration has yet to be realised.<sup>54</sup> There are several success stories in the region: take Cuba’s 100% treatment coverage, or the progress made in preventing mother-to-child-transmission in Barbados. On top of this, continued support from international agencies such as USAID and the Global Fund to Fight HIV, Tuberculosis and Malaria will make a big difference in coming years. The involvement of such groups has encouraged political leaders to speak out more about HIV and AIDS.<br />
These successes should be celebrated, but it is important that the severity of the Caribbean’s epidemics is not overlooked. Both within the Caribbean and amongst the international community, a greater level of discussion and decision-making is needed to fight the spread of HIV in the region.<br />
<br />
<br />
<div class="box bFull" id="footnote"> <h2>References</h2><ol><li><span class="externallink">UNAIDS (2009), '<a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp" target="_blank">2009 AIDS epidemic update</a>'.</span></li>
<li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li>UNAIDS (2010, 29th January) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2010/20100128_Haiti.asp" target="_blank">'Building Haiti's AIDS response better'</a></li>
<li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li><span class="externallink">UNAIDS (2009), '<a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp" target="_blank">2009 AIDS epidemic update</a>'.</span></li>
<li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li>The World Bank (2005), HIV/AIDS in the Caribbean region: a multi-organization review</li>
<li><a ,="" href="http://www.pancap.org/" target="_blank">PANCAP</a>, press release (April 20th 2006)</li>
<li>UNAIDS press release (December 12th 2004), ‘Pan Caribbean Partnership Against AIDS Selected As International Best Practice’</li>
<li>CARICOM/PANCAP (March 2002), ‘The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006’</li>
<li>UNAIDS (2004), UNAIDS at Country-level: Progress Report 2004’</li>
<li>Frasca T. (2005), ‘AIDS in Latin America’, Palgrave/Macmillan, p.144</li>
<li>Cohen, J. (2006), ‘Haiti: Making Headway Under Hellacious Circumstances’, Science Vol. 313 Issue 5786, 28th July 2006</li>
<li>Yorke L. (March 2002), ‘Losing Paradise?’, Focus, magazine of the Joint Center for Political and Economic Studies</li>
<li>Fraser H. (2004), ‘Health and Wealth in Paradise’, Perspectives in Health – The magazine of the Pan American Health Organisation, Volume 9, Number 2</li>
<li><a ,="" href="http://www.theglobalfund.org/en/" target="_blank">The Global Fund to Fight AIDS, Tuberculosis and Malaria</a>, Scaling up the Regional Response to HIV/AIDS Through the Pan Caribbean Partnership Against HIV/AIDS, round 3, proposal summary</li>
<li>Fink S. (May 2003), ‘Cuba’s Energetic AIDS Doctor’, American Journal of Public Health, 93(5):712-716</li>
<li>Zipperer M. (July 2005), ‘HIV/AIDS Prevention and Control: the Cuban Response’, The Lancet Infectious Diseases, Volume 5, Issue 7</li>
<li><a ,="" href="http://www.unfpa.org/" target="blank">UNFPA</a> press release (13th April 2006), Bangladeshi Doctor, Haitian Family Planning Provider, Win 2006 United Nations Population Award</li>
<li>UNAIDS/WHO 2004 Report on the Global AIDS Epidemic</li>
<li>UNAIDS/WHO 2006 Report on the Global AIDS Epidemic</li>
<li>Cohen, J. (2006), ‘Dominican Republic: A Sour Taste on the Sugar Plantations’, Science Vol. 313 Issue 5786, 28th July 2006</li>
<li>Cole S. (April 2006), 'Closet of the Caribbean', Positive Nation, Issue 121</li>
<li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li>Inter Press News Service (August 18th 2006), <a ,="" href="http://www.aegis.org/news/ips/2006/IP060811.html" target="_blank">'Caribbean: HIV/AIDS goes primetime'</a></li>
<li>Inter Press News Service (August 18th 2006), <a ,="" href="http://www.aegis.org/news/ips/2006/IP060811.html" target="_blank">'Caribbean: HIV/AIDS goes primetime'</a></li>
<li>UNESCO (2003), ‘Education & HIV/AIDS: Quarterly Report to United Nations HIV/AIDS Theme Groups in the Caribbean on UNESCO’s programme and activities in the Caribbean’</li>
<li>United Press International (18th May 2006), <a ,="" href="http://www.aegis.com/news/upi/2006/UP060527.html" target="_blank">'U.N. Opens Caribbean Education Forums'</a></li>
<li>U.S. Centers for Disease Control and Prevention, International News, (April 19th 2006), <a ,="" href="http://www.thebody.com/cdc/news_updates_archive/2006/apr19_06/lamerica_sex_ed.html" target="blank">‘Latin America: Let's (Not) Talk About Sex’</a></li>
<li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li>Inter Press Service News Agency (September 26th 2006), ‘Rights-Jamaica: Hauling HIV/AIDS out of the closet’</li>
<li>Inter Press Service News Agency (September 26th 2006), 'Rights-Jamaica: Hauling HIV/AIDS out of the closet'</li>
<li>UNAIDS/WHO 2006 Report on the Global AIDS Epidemic</li>
<li>Sullivan M.P. (January 2005), ‘AIDS in the Caribbean and Central America’, CRS report for Congress</li>
<li>Cohen, J. (2006), ‘Dominican Republic: The Sun. The Sand. The Sex’, Science Vol. 313 Issue 5786, 28th July 2006</li>
<li>Cohen, J. (2006), ‘Puerto Rico: Rich Port, Poor Port’, Science Vol. 313 Issue 5786, 28th July 2006</li>
<li>Cole S. (April 2006), 'Closet of the Caribbean', Positive Nation, Issue 121</li>
<li>Department for International Development [DIFID] webpage (2006), Case Studies, 'Tackling HIV and AIDS stigma and discrimination in the Caribbean'</li>
<li><a ,="" href="http://www.amnesty.org/" target="blank">Amnesty International</a> (2006, May), 'I am not ashamed!': HIV/AIDS and human rights in the Dominican Republic and Guyana'</li>
<li>UNAIDS (December 2004), ‘A Study of the Pan Caribbean Partnership against HIV/AIDS (PANCAP) Common goals, shared responses’</li>
<li>The World Bank (2005), HIV/AIDS in the Caribbean region: a multi-organization review</li>
<li>UNAIDS (December 2004), ‘A Study of the Pan Caribbean Partnership against HIV/AIDS (PANCAP) Common goals, shared responses’</li>
<li>WHO/UNAIDS/UNICEF (2009) <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector'</a></li>
<li>Fawthrop T. (December 2003), 'Cuba: Is It a Model in HIV-AIDS Battle?', <a ,="" href="http://www.panos.org.uk/" target="_blank">Panos London</a></li>
<li>BBC News (16th July 2004), '<a ,="" href="http://news.bbc.co.uk/1/hi/world/americas/3899657.stm" target="_blank">Cuba to help Caribbean fight AIDS</a>'</li>
<li>Partners in Health website, <a ,="" href="http://pih.org/where/Haiti/Haiti.html" target="_blank">Haiti: Partner Overview</a> (accessed 5/10/06)</li>
<li>WHO (2008), '<a ,="" href="http://www.who.int/hiv/mediacentre/2008progressreport/en/index.html" target="blank">Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector</a>'</li>
<li>World Health Organisation, 3 by 5 Progress Report December 2004</li>
<li>World Health Organisation (2006), "Progress on Global Access to HIV Antiretroviral Therapy"</li>
<li>UNAIDS (2010, 29th January) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2010/20100128_Haiti.asp" target="_blank">'Building Haiti's AIDS response better'</a></li>
<li>Cohen, J. (2006), ‘Dominican Republic: The Sun. The Sand. The Sex’, Science Vol. 313 Issue 5786, 28th July 2006</li>
<li>Cohen, J. (2006), 'Dominican Republic: The Sun. The Sand. The Sex', Science Vol. 313 Issue 5786, 28th July 2006</li>
<li>The World Bank (2005), HIV/AIDS in the Caribbean region: a multi-organization review</li>
</ol></div></div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-29800436294607418312010-06-10T08:31:00.000-07:002010-06-10T08:32:24.104-07:00HIV & AIDS in Latin America<div class="box bFull"><b>At the end of 2008 there were around 2 million people living with HIV in Latin America - more than in the U.S., Canada, Japan and the UK combined.<sup>1</sup> While this region has often been overlooked in the past, there is now growing recognition amongst the international community that the HIV epidemics of Latin American countries demand more attention than they have received so far. </b><br />
Latin American countries have been affected by HIV and AIDS in different ways, and to different extents. Responses have varied, with some countries displaying weak political leadership and others – most notably Brazil – forming strong and positive responses. Despite many differences between the epidemics of individual countries, high levels of poverty, migration, homophobia and HIV-related discrimination are apparent throughout the region, and these factors present common barriers to overcoming the crisis.<sup>2</sup><br />
In this page, we use the term Latin America to refer to the countries of South and Central America, excluding Suriname, Guyana, French Guyana and the Caribbean islands, which we discuss in our HIV & AIDS in the Caribbean page. AVERT.org also has an individual country page about AIDS in Brazil.<br />
<a name='more'></a></div><div class="box bFull"><h2>The scale of Latin America’s AIDS epidemics</h2><div class="photo_r"><img alt="Condom obelisk in
Buenos Aires" border="0" src="http://www.avert.org/media/photos/1465.jpg" width="250" /> <br />
<div style="width: 250px;">Condom obelisk in Buenos Aires</div></div>Although HIV prevalence (the percentage of a population living with HIV) in Latin American countries is relatively low compared to the rates found in many parts of Africa, the number of people affected is still substantial. What is more, the situation is likely to get worse in many Latin American countries. No country in the region has experienced a significant drop in HIV prevalence, and it is projected that the total number of people living with HIV in Latin America will increase in coming years.<sup>3</sup> As well as affecting millions of people’s lives, HIV and AIDS have had widespread social and economic implications for Latin American countries, and these effects will become more severe as epidemics worsen.<sup>4</sup><br />
More than half of Latin Americans living with HIV reside in the region’s four largest countries: Brazil, Columbia, Mexico and Argentina. Brazil is home to 730,000 people living with HIV – more than any other Latin American country – but due to the large size of its population, this equates to a relatively low HIV prevalence of 0.6%. The most severe epidemics are found in smaller countries such as Belize, Guyana and Suriname, which have HIV prevalence rates of 2.1%, 2.5% and 2.4% respectively. The majority of countries in the region have prevalence rates of less than 1%, but the prevalence among specific groups, such as men who have sex with men and sex workers, is often very high. For more figures, see our Latin America Statistics Page.<br />
<h2>Key affected groups</h2><h3>Men who have sex with men</h3>Men who have sex with men (MSM) account for the largest share of infections in Latin America.<sup>5</sup> This problem is largely hidden, since homophobia and ‘machismo’ culture are common throughout the region and sex between men is highly stigmatised. The extent of HIV infection among MSM is downplayed in many countries, and prevention campaigns often neglect this group.<br />
An example is Guatemala, where critics have disputed the government’s claim that the country’s AIDS epidemic is primarily heterosexual. Activists within the country argue that the official statistics, which attribute around 15% of HIV infections to MSM, do not reflect the reality of Guatemala’s epidemic. Some claim that the real figure is closer to 40%.<sup>6</sup> As one civil society worker explained, MSM are often hesitant to reveal how they became infected and many are mistakenly classed as heterosexual:<br />
<blockquote class="bigquoteleft"><div class="bigquotebody">“Annual spending estimates… confirm that many Latin American countries make little effort to provide AIDS-related services that address the needs of men who have sex with men.”</div></blockquote><blockquote class="longquote">“Unless he’s a total queen, a man will always be [counted as] heterosexual. Plus, people don’t want to be recognised [as homosexual]”.<cite>Ruben Mayorga, civil society worker, Guatemala City<sup>7</sup></cite></blockquote>On the other hand, other Latin American countries – such as Mexico and Peru - openly acknowledge that their epidemics are primarily driven by MSM. In Mexico, the government has appointed Jorge Saavedra, an openly gay, HIV positive man, as head of its leading AIDS agency, which has helped the country to make significant progress in addressing the problem. Among other initiatives, Saavedra has helped to launch a provocative anti-homophobia campaign.<sup>8</sup> In Peru, a large amount of research is being conducted relating to HIV and MSM. The country is now recognised by researchers around the world as an important base for studies of HIV infection among this group.<br />
<blockquote class="longquote">“It’s a very concentrated epidemic, and we have a very good relationship with the community.”<cite>Jorge Sanchez, Peruvian epidemiologist <sup>9</sup></cite></blockquote>Overall 0.5% of Peruvian adults are living with HIV, but studies have suggested much higher rates of infection among MSM. Research has shown that men who have sex with men account for 55 percent of HIV incidence in Peru.<sup>10</sup><br />
For the most part, the epidemic among MSM in Peru has not spread to other segments of the population, but there is a risk that this will soon occur. As is the case in other Latin American countries, large numbers of MSM in Peru do not identify themselves as homosexuals, and have sex with women as well as men. MSM therefore form a ‘bridge’ population - rising rates of infection among this group are likely to aggravate the spread of HIV among the heterosexual population.<sup>11</sup> In both Columbia and Ecuador, it has been reported that a large number of women with HIV have been infected by their husbands or regular partners who have acquired infection through sex with another man.<sup>12</sup><br />
While Brazil, Mexico and Peru have made progress in addressing high infection rates among MSM, most other countries are still neglecting this group. According to the 2006 UNAIDS global report:<br />
<blockquote class="longquote">“Annual spending estimates… confirm that many Latin American countries make little effort to provide AIDS-related services that address the needs of men who have sex with men… Often, health professionals are too embarrassed to ask the right questions and, even if asked, men are afraid to provide the right answers.”<sup>13</sup></blockquote><h3>Sex workers</h3>HIV transmission between sex workers and their clients is recognised as a major factor in the spread of HIV in several Latin American countries. The extent to which sex workers are affected varies between areas – one study of different countries, which looked at brothel-based sex workers, found HIV prevalence rates ranging from 0% to 6.3%.<sup>14</sup> However, higher rates are found among street-based sex workers, who are harder to reach with HIV prevention services. In Guatemala, for instance, surveillance suggests that 15% of street-based sex workers are living with HIV.<sup>15</sup> Similarly, studies of cities in El Salvador found infection rates of around 16%.<sup>16</sup> Since condom use is often low among regular sexual partners, male clients of sex workers may pass on HIV to their wives and girlfriends once infected.<br />
In some countries, such as Ecuador and Bolivia, relatively low rates of infection have been found among sex workers. In La Paz, one of Bolivia’s capital cities, prevalence was 0.4% in 2007 – a figure that can partly be explained by the fact that an estimated 70% of sex workers in the city use condoms, according to health authorities.<sup>17</sup> <sup>18</sup> Again, though, these figures are largely based on brothel-based sex workers who regularly visit sexually transmitted infection clinics for check-ups, rather than street-based workers. In other countries, such as Honduras and Guatemala, commercial sex work has been noted as a major driving factor behind the spread of HIV.<sup>19</sup><br />
<h3>Injecting drug users</h3>Drug use is common in many Latin America countries. A number of Southern Cone countries (those found in the southernmost area of South America,) have shifted from dictatorships to democracies in recent history, and this goes some way towards explaining the rise in drug use - for some people, liberation led to experimentation and excess, as one Argentinian explained to reporters:<br />
<blockquote class="longquote">“Around 1986 there was a tremendous fascination, especially among intellectual circles, with intravenous drugs. People wanted to try everything, and I think it was in some way a result, a legacy, of the military dictatorship because during the dictatorship you couldn’t do anything”<sup>20</sup></blockquote>In Argentina, injecting drug use has been a major driving factor behind the spread of HIV, as infected needles are shared between users. The same is true in Brazil, Uruguay and Paraguay.<sup>21</sup> Cocaine and heroin are the most commonly injected drugs, with cocaine users facing the greatest risk of HIV infection because they inject more frequently than heroin users.<sup>22</sup><br />
Harm reduction programmes, including needle exchanges, have been implemented in Brazil and are thought to have contributed to declining HIV prevalence rates among injecting drug users in several Brazilian cities.<sup>23</sup> <sup>24</sup> Some harm reduction activities have also been carried out in Argentinean cities. In general, though, Argentina lacks harm reduction programmes at national, state and local level.<sup>25</sup> This is despite a severe HIV epidemic among injecting drug users – one study carried out in Buenos Aires, for instance, found an HIV prevalence rate of 44% among this group.<sup>26</sup> Other Latin American countries face severe restrictions in carrying out programmes of this kind, due to restrictive laws and a lack of political support.<sup>27</sup><br />
In several Southern Cone countries, <span class="techterm">‘pasta base’</span> or <span class="techterm">‘paco’</span> – a form of cocaine, which is smoked – has become extremely popular in recent years, both among poorer populations and the middle-classes.<sup>28</sup> Although the rise in popularity of pasta base has generally had negative health implications, there is evidence to suggest that some drug users have started smoking cocaine in this form instead of injecting it. While there is currently little solid evidence, this may be reducing the level of needle-sharing in the region, thereby reducing the number of people becoming infected with HIV through injecting drug use.<sup>29</sup> <sup>30</sup><br />
In other countries, such as Bolivia, Peru and Ecuador, the spread of HIV through injecting drug use has been limited in scope. In Chile, data are scarce, and in Venezuela the role of injecting drug use in the HIV epidemic is negligible. However, the availability of heroin is increasing in these countries, which may lead to a change in the situation in coming years.<sup>31</sup><br />
<h3>Migrants</h3>Migration occurs on a large scale throughout Latin America. Patterns of migration have been particularly well documented in Central America, where civil conflicts and political conditions in the past created a high degree of movement between countries that continues today. International migration, particularly between Mexico and the United States, is also increasingly common.<sup>32</sup> Although it was not well documented in previous years, studies have now established that the movement of people is linked with the spread of HIV in Latin America.<br />
Several factors may put migrants in this region at a high risk of HIV infection: poverty, violence, few available health services, increased risk-taking, rape, loneliness, and contact with large numbers of sex workers. In some cases, migrants themselves are sex workers, or resort to sex work while travelling in order to survive.<sup>33</sup> In one Mexican study, less than 20% of male migrants reported having used condoms, and 8% of the women surveyed said they had been raped.<sup>34</sup><br />
As migration increases, the epidemics of individual countries are becoming less well defined, and the problems surrounding the crisis in each country are merging.<br />
<h2>Different countries, different problems</h2>Latin America is a vast region – in some ways it is misleading to talk about the ‘Latin American epidemic’, because of the scale of the lands, cultures and populations involved. Although there are many close links and similarities between countries, it should be recognised that AIDS in Latin America is not a homogeneous problem, and that each country faces an unique situation. Below are some examples of the problems faced in particular countries.<br />
<h3>Colombia</h3>A violent civil conflict between left-wing guerilla groups and right-wing paramilitaries has raged for decades in Colombia, causing suffering on a huge scale. Economic decline, violence, murder and drug trafficking are just some of the results of the fighting.<br />
Gay men, who are more heavily affected by Colombia’s HIV/AIDS epidemic than any other group, have faced violent oppression from both sides of the conflict. Armed groups have also capitalised on the social fears that surround HIV and have victimised HIV positive people; in one incident, the AUC (the United Self-Defence Forces of Colombia, the country’s most powerful paramilitary force) demanded that all HIV positive people in Barrancabermeja abandon the city within twenty-four hours.<sup>35</sup> The AUC has also been responsible for oppressing gay men. In one reported example, a young gay man was forced to walk around his neighbourhood naked with a sign reading <i>“I am gay”</i> tied to his neck.<sup>36</sup><br />
On the other side of the political divide, FARC (the Revolutionary Armed Forces of Colombia) is known to have forced residents of areas they control to take HIV tests. At least one activist who spoke out about this policy was forced to flee the country following death threats.<sup>37</sup><br />
The stigma and discrimination created by these groups is stopping people from talking about HIV, reducing awareness and therefore putting more people at risk. It is also hindering HIV prevention programmes, and campaigns to support and provide treatment for those who are already living with HIV.<br />
As well as fuelling stigma, the civil conflict has also displaced an extremely large number of people within Colombia, and caused many to migrate to neighbouring countries.<sup>38</sup> Since migrants may face a higher risk of HIV infection, this high level of movement could be having an effect on the epidemic.<br />
<h3>Honduras</h3>In Honduras, where HIV is mainly spread through heterosexual sex, a severe epidemic has developed among communities of Garifuna – descendents of Nigerian slaves, who have maintained their culture in the country for over two hundred years. Widespread poverty, poor access to health care and the popularity of traditional myths about HIV are some of the factors putting Garifuna communities at risk of HIV infection.<br />
Already highly stigmatised as a minority group, Garifuna now face added prejudice as a result of HIV.<br />
<blockquote class="longquote">“If you go to the street and ask the people about AIDS, many of them think ‘AIDS, it’s not in my house – it’s in the house of the Garifuna” <cite>Sergio Flores, doctor, La Ceiba <sup>39</sup></cite></blockquote>Honduras has a large population of people living with HIV and the high prevalence among the Garifuna community is only part of the problem. But there is a risk that the stigma surrounding this group will create a ‘somebody else’s problem’ attitude, where members of the general population falsely believe that they are not at risk of becoming infected with HIV.<br />
<h3>Guatemala</h3>In Guatemala, the sizeable Mayan population is another example of a stigmatised group that may face increased risk of HIV infection. Mayans generally have a lower socio-economic status than other Guatemalans, meaning that they have less access to health care services. Many Mayan communities have trouble speaking Spanish (the most commonly used language in the country), which also makes it hard for HIV prevention campaigns to get through to them.<br />
Although the spread of HIV among Mayans has not been fully evaluated, the results of a small-scale study carried out in one clinic suggest that Mayans may be three times more vulnerable to HIV than other members of the population. <sup>40</sup><br />
Indigenous communities in Guatemala have particularly been overlooked by HIV prevention programmes which need to be more accessible, culturally appropriate and tailored to their specific health beliefs. Rising HIV and AIDS rates have been reported amongst such communities. If their vulnerability to HIV is not seriously addressed, misinformation and cultural taboos will continue to increase the risk of contagion. <sup>41</sup><br />
<h3>Nicaragua</h3>Nicaragua is proportionally less affected by HIV/AIDS than any other country in Central America, with 0.2% of the adult population living with HIV.<sup>42</sup> However, there is currently potential for a more severe epidemic. One major issue is the stigma surrounding condom use.<sup>43</sup> Negative attitudes towards condoms may discourage young people from using them, even though many are aware of the protection that condoms can provide. One study of adolescents that had been sexually active in the previous three months suggested that only 21% had used a condom, despite the fact that most knew that condoms could prevent HIV.<sup>44</sup><br />
HIV testing in Nicaragua is also a concern, as there are currently insufficient voluntary counselling and testing services. <sup>45</sup> There is only one central laboratory with government authorisation, and this laboratory therefore carries out all HIV tests. Because of the cost of testing materials, stock is sometimes depleted, and HIV test results can be delayed by up to six months. <sup>46</sup> Such a long wait for results causes a lot of anxiety for the individuals concerned, and may dissuade people from accessing testing in the first place.<br />
<h2>HIV prevention in Latin America</h2>Overall, HIV prevention efforts in Latin America have been small-scale, slow, and largely dependent upon non-governmental organisations and international programmes.<sup>47</sup> This is partly due to poverty and a shortage of resources throughout the region, but lack of political leadership and will has also played a role.<br />
At the same time, several countries have put a lot of time and effort into raising awareness about HIV, promoting condom use and encouraging testing, among other schemes. Some of these interventions have been enormously successful, and have helped to reduce HIV incidence among certain groups in particular areas. Despite the overall picture, in terms of individual prevention campaigns Latin America has some of the strongest and most creative programmes found anywhere in the world.<br />
<div class="photo_r"><img alt="Teacher showing a
condom in Mexico" border="0" src="http://www.avert.org/media/photos/223.jpg" width="300" /> HIV/AIDS education in a school in Mexico</div>Many of the most effective prevention efforts have taken place in Brazil, where civil society groups and non-governmental organisations have helped to fight the stigma surrounding AIDS and to raise awareness about the subject. The government itself has vigorously promoted condom use, through media campaigns and advertisements. They have also given away large numbers of free condoms, distributing 25 million at the 2006 pre-Lenten festival (held annually in Rio de Janeiro) alone.<sup>48</sup> HIV prevention efforts have focused on high-risk groups such as sex workers and men who have sex with men, and attempts have been made to reduce the stigma that these groups face. Needle exchanges have also been opened in many areas, which has helped to reduce the HIV prevalence among injecting drug users.<sup>49</sup><br />
Across Latin America, governments have used television, radio, billboards and posters as means of raising awareness about AIDS. Various messages have been promoted by these campaigns, including condom promotion and anti-discrimination messages. In many cases, though, these messages are not getting through. Young people in particular are often more likely to respond to folk wisdom and inaccurate information circulated by their peers than to these adverts. Sex education in schools can help young people to protect themselves, but recent reports suggest that the subject is absent in many Latin American schools, and inadequate where it is available. <sup>50</sup><br />
<div class="photo_l"><img alt="Picture of an
animated HIV & AIDS prevention advertisement in Peru. The text reads
as 'AIDS is incurable and fatal. You must prevent it.'" border="0" src="http://www.avert.org/media/photos/227.jpg" width="300" /> HIV/AIDS prevention advertisement in Peru</div>Some of the most impressive prevention campaigns in the region have been carried out through outreach work, which takes anti-HIV messages directly to the people at risk. In Tijuana, Mexico, a mobile health clinic travels to areas of the city that health workers usually avoid, providing HIV testing and clean syringes to injecting drug users.<sup>51</sup> In Mexico City, a former sex worker runs an initiative that provides counselling and HIV testing services to sex workers. Along with her son, she also sits in her car overseeing sex worker’s transactions and transporting them to ensure that they have security at work.<sup>52</sup> In Belize, a government program called Youth for the Future works with gang members in an attempt to link violence reduction with HIV/AIDS education. Gang members are provided with information and free condoms, both on the street and at the organisation’s resource centre.<sup>53</sup><br />
Although they are no doubt making a large impact in the areas in which they are carried out, these outreach schemes are only small-scale. On a wider scale, most countries still need to expand harm-reduction programmes for injecting drug users, raise a greater level of awareness about HIV, tackle the stigma surrounding AIDS, improve testing facilities and encourage more people to use condoms, among other things. For the most part, governments have neglected high infection rates among vulnerable groups, and rising rates among the general population.<br />
<blockquote class="longquote">“[Latin American countries] are far behind when it comes to prevention for highly vulnerable populations like men who have sex with men and injecting drug users. My conclusion is it looks easier for a government to deal with treatment than prevention.” <cite>Luiz Loures, Brazilian epidemiologist<sup>54</sup> </cite></blockquote><h2>AIDS treatment in Latin America</h2>Since highly active antiretroviral therapy (HAART) became available to treat HIV in the late 1990s, the distribution of this treatment across the Latin American region has been impressive. By the end of 2008 an estimated 55% of those needing antiretroviral therapy in Latin America were receiving it.<sup>55</sup> Considering the poverty that exists throughout the area, this is quite an achievement - on average just 42% of those in need of treatment in low- and middle-income countries are receiving it.<sup>56</sup> It is estimated that, as a result of combination antiretroviral therapy, people living with HIV in the Latin American region have gained some 834,000 years of life between 2002 and 2006.<sup>57</sup><br />
Brazil has led the way in terms of ARV provision, with an internationally renowned treatment campaign. Since 1996, the government has made treatment provision a priority, and has made aggressive efforts to drive down drug prices. Under Brazil’s policy, all people with advanced HIV infection are eligible for ARVs through the public health system. This has improved the health of thousands of people living with HIV, and allowed them to live relatively normal, healthy lives. It has been reported that deaths from AIDS and HIV-related hospitalisations in Brazil have fallen by 50% and 70-80% respectively since 1997.<sup>58</sup><br />
Treatment coverage is also high in Argentina, Chile, Costa Rica, Mexico, Panama and Venezuela.<br />
Elsewhere, ARVs are less widely available. Countries such as Honduras, Ecuador, El Salvador and Nicaragua have yet to reach half of those in need. It is generally difficult to find ARVs outside major cities in these countries, meaning that HIV positive people in rural areas find it particularly difficult to access treatment.<br />
<h2>Stigma and discrimination in Latin America </h2><blockquote class="bigquoteright"><div class="bigquotebody">“Is AIDS a big problem in Chile?” people often ask me, to which the only possible response is yes: If you get AIDS in Chile, it is a big problem.”</div><div class="bigquotecite">Tim Frasca</div></blockquote>HIV/AIDS is not confined to groups such as gay men, injecting drug users or sex workers - in Latin America or elsewhere. Yet people continue to associate the epidemic with these groups, which are already highly stigmatised by people who have moral objections to their lifestyles.<br />
Additionally, HIV carries its own stigma. Since HIV and AIDS directly affect less than 1% of the population in most Latin American countries, the epidemic has a low visibility and many people are ignorant or fearful of HIV and AIDS. Many people are unclear about the ways in which HIV can be transmitted, and mistakenly believe that everyday contact with an HIV positive person will put them at risk.<br />
<blockquote class="longquote">“[His family] fed him in the same plate ever, and like that, he had his own cup, glass, fork, knife, spoon, you get the idea, he was isolated by his own family. His razors where always trashed, and his tooth brush too, also, no one was ever taking care of his pills... One week before he died, in the middle of a discussion because of he having AIDS he was thrown out of his house by his older sister... he died alone.” <cite>Lover of an HIV positive man in Honduras<sup>59</sup></cite></blockquote>The following examples further illustrate how prejudice has caused immense suffering for people living with HIV in Latin America:<br />
<ul><li>In Peru, soccer player Eduardo Esidio was removed from the University Sports Club professional team when it was discovered that he was HIV positive. The club’s directors argued that if he was allowed to stay, he might be a health risk to other players.<sup>60</sup></li>
<li>In Costa Rica, officials tried to transfer a teacher from a small-town school when it was found that he was HIV positive. The transfer was eventually stopped, but only after protests from citizen groups forced the Ministry of Education to intervene.<sup>61</sup></li>
<li>In Mexico, there have been numerous cases of HIV-related discrimination involving health-care workers. HIV tests are sometimes applied to those who are perceived to be at risk of infection without their consent, and patients who test positive are often isolated from other patients in a hospital.<sup>62</sup></li>
<li>In Brazil, the results of a study published in 2006 indicate that children living with HIV in São Paulo face a high level of stigma as they grow up.<sup>63</sup></li>
</ul>These are just a few examples of HIV-related discrimination, but situations such as these occur on a regular basis in Latin America. This is a major barrier to the fight against AIDS, partly because fear of stigma often prevents people from accessing testing and treatment. Discrimination also stops people from talking openly about HIV and AIDS, which leads to a climate of silence in which people are unaware that they may be at risk. On top of these factors, the prejudice that HIV positive people face also causes them a great deal of suffering on a personal level, at a time when they are already dealing with the burden of being infected.<br />
<blockquote class="longquote">“Although there is a law against it, my husband, who is dead now, was fired when they found out he was sick. My relatives refused to take us in, my daughter and I, because we are [HIV] carriers”<cite>Peruvian woman marching on World AIDS Day<sup>64</sup></cite></blockquote>Some Latin American countries have taken steps to address the problem of stigma and discrimination, mainly through media campaigns to raise awareness about HIV and AIDS. HIV positive people themselves have done a great deal to fight this problem, forming citizen groups and standing up to discrimination through protests and campaigns. Governments must continue to support these groups, and expand their own anti-stigma efforts.<br />
<h2>The future of HIV and AIDS in Latin America</h2><div class="photo_l"><img alt="Picture of an HIV
positive young girl who lives under the care of 'Hogar Amor Y Vida' in
Honduras" border="0" src="http://www.avert.org/media/photos/172.jpg" width="300" /> HIV-positive young girl, Honduras</div>HIV/AIDS in Latin America is sometimes referred to as a <i>‘hidden’</i> crisis: awareness is low, governments have been relatively inactive, surveillance of those affected is sometimes unreliable and stigma has stopped people from conducting open and frank debate about the problem. This is not just an issue within Latin America though – the international community has also overlooked the region. In the face of a more severe situation in Africa, rapidly rising infection rates in Asia and higher profile epidemics in richer parts of the world, Latin America has often been neglected.<br />
While it is understandable that more attention has been devoted to other areas that have been worse affected, many have been frustrated by the lack of notice given to Latin America’s epidemics. The tendency of some people to compare Latin America’s AIDS problem with those of other regions is also a point of contention for AIDS activists in the region:<br />
<blockquote class="longquote">“The suggestion that the region has somehow been ‘luckier’ than others is reprehensible. “Is AIDS a big problem in Chile?” people often ask me, to which the only possible response is yes: If you get AIDS in Chile, it is a big problem… Examining successes and obstacles to future progress is far more useful than ranking human tragedy on a scale”<cite>Tim Frasca, author and AIDS activist in Chile<sup>65</sup></cite></blockquote>The region is gradually gaining more notice from the international community though, largely due to the success that has been achieved in providing treatment. As well as continuing to provide ARVs and care for people living with HIV, prevention schemes now need to be improved. Efforts to tackle stigma and discrimination must run parallel to these programmes, because prevention is likely to be ineffective while the fear and ignorance surrounding AIDS is so widespread.<br />
<br />
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<li>Inter Press Service (December 13th 2000), ‘Peru: Fighting AIDS discrimination’ (<a ,="" href="http://www.aegis.com/" target="blank">AEGIS</a>)</li>
<li>Frasca T. (2005), “AIDS in Latin America”, Palgrave/Macmillan, p.253</li>
</ol></div></div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-42048669266057637242010-06-10T08:25:00.000-07:002010-06-10T08:27:54.215-07:00HIV & AIDS in Brazil<div class="box bFull">The first case of AIDS was recorded in Brazil in 1982, and whilst many countries have struggled to curb the spread of HIV and to care for those with AIDS, Brazil’s response has been seen as a success story. Working alongside civil society groups, the Brazilian government has made aggressive efforts to minimise the impact of the AIDS epidemic. By the end of 2007, 730,000 Brazilians were living with HIV<sup>1</sup> – just over half the number that estimates in the previous decade had predicted.<sup>2</sup> The AIDS mortality rate has fallen and the number of people who avoided hospital due to to effective treatment saved over US$2 billion in medical costs between 1996 and 2004.<sup>3</sup><br />
To understand Brazil’s achievements, the historical context in which they took place must first be acknowledged.</div><div class="box bFull"><h2>The history of AIDS in Brazil</h2>Although it was first declared a republic in 1889, Brazil spent most of the following century under a series of military dictatorships. It was under the last of these dictatorships, at a time when citizen groups and non-governmental organisations (NGOs) were expanding and becoming more outspoken in their calls for change, that the country’s first AIDS case was recorded in 1982. <sup>4</sup> Although relatively few cases of HIV were recorded over the next few years, these civil society groups made sure that the government was quick to act and did not ignore the problem. As the country moved closer to democracy, they encouraged a climate of social solidarity, allowing open and frank debate about HIV and AIDS.<br />
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<div class="photo_r"><img alt="Sao Paulo, Brazil" border="0" src="http://www.avert.org/media/photos/3048.jpg" width="325" /> <br />
<div style="width: 325px;">Brazil's AIDS epidemic was initially concentrated in large cities such as Sao Paulo.</div></div><blockquote class="longquote">“We were living under the dictatorship, so little groups formed but not just political ones. They were responding to larger, deeper issues of repression, with worldwide implications. We were trapped in a symbolic prison; homosexuals had to hide, to live in very closed circles. The right to the body was bound up with the issue of democracy.” <cite>Wildenay Contrera, AIDS Prevention and Support Group<sup>5</sup></cite></blockquote>In 1985, the same year that democracy was restored to Brazil, the government set up the National AIDS Program (NAP) in partnership with civil society groups. This program initially focused on distributing information about HIV and AIDS, especially to high-risk groups such as men who have sex with men (MSM), who accounted for many of the country’s first HIV infections. <sup>6</sup> In the same year, the AIDS Prevention and Support Group (known as GAPA in Brazil) was set up as the first Brazilian HIV and AIDS NGO. By this time, the rate of new HIV infections was rapidly increasing.<br />
Several similar groups were set up in the following years, including Grupo Pela Vidda (‘Group for Life’), the country’s first self-identified group for people living with HIV. Groups such as this put pressure on politicians to improve treatment and care for people living with HIV.<br />
<blockquote class="longquote">“The important thing was solidarity, full participation by everyone based on respect for differences, fighting for full citizenship, not just for HIV-positive people, but for everyone facing a situation of vulnerability.” <cite>Veriano Terto, Brazilian Interdisciplinary AIDS Association (ABIA)<sup>7</sup></cite></blockquote>In 1988, a new Constitution of Brazil was established, with a heavy focus on human rights. The Constitution was very significant to people living with HIV, since it included articles that gave them legal protection against discrimination and defended their right to free healthcare. Legal guidelines on how these articles could be applied to people living with HIV were subsequently established, including Legal Opinion CFM No.14/88, which set out ethical guidelines for the management of HIV/AIDS in relation to professionals such as doctors, physicians and researchers. <sup>8</sup><br />
Despite such advances, not everyone was happy with the way that the government was handling the epidemic. In a book published in 1993, Herbert Daniel, an HIV positive activist, wrote:<br />
<div class="photo_l" style="width: 243px;"><img alt="Dinner at centre
for People Living with HIV and AIDS, Brazil" border="0" height="159" src="http://www.avert.org/media/photos/1144.jpg" width="233" /> Dinner at centre for People Living with HIV and AIDS.</div><blockquote class="longquote">“To this day the government has taken no significant action in response to the epidemic, continuing the five-year record of inaction and indifference of the previous administration. There is today no adequate national programme for controlling the epidemic.”<sup>9</sup></blockquote>By the second half of the 1990s, though, the Brazlilian government was being widely commended for its HIV/AIDS policies, largely due to its treatment programme. An important element of the 1988 Constitution had been the declaration that healthcare was “<q>a right of all and a duty of the state".<sup>10</sup></q> When trials in 1996 showed that HAART - a form of treatment involving combinations of antiretroviral drugs (ARVs) - had significant benefits to the health of people living with HIV, activist groups in Brazil put pressure on the government to act upon this pledge. In July 1996, the Brazilian Minister of Health announced that ARVs would be provided for free to all people living with HIV that required them. <sup>11</sup><br />
Campaigns to prevent new people becoming infected with HIV were also expanded throughout the 1990s. In the early 1990s, the World Bank had predicted that 1.2 million people in Brazil would be living with HIV by the year 2000. Due to the effectiveness of prevention campaigns, though, the actual figure was around 600,000. <sup>12</sup><br />
While the government’s reaction to AIDS has been impressive, the involvement of civil society groups and people living with HIV has been the most outstanding feature of Brazil’s response. These groups have ensured that stigma and discrimination have been reduced; human rights have been taken into account; moral and religious views have not impeded prevention campaigns; and the government has acted swiftly.<br />
<h2>Trends in Brazil's AIDS epidemic</h2>At the beginning of the Brazilian AIDS epidemic, most of the people becoming infected with HIV were men who have sex with men. The majority lived in Brazil’s biggest cities, Rio de Janeiro and São Paulo. However, the epidemic soon affected more than just MSM, and by 1993 more cases of AIDS were attributed to heterosexual transmission than homosexual transmission.<sup>13</sup> <sup>14</sup> Among adult males (13 years and over), 17% of AIDS cases were due to heterosexual sex from 1980 to 1995, compared to 35% in 2000 and over 46% in 2007. (The exposure category among 15-20% of male AIDS cases each year is unknown.) Similarly, among adult women, heterosexual sex accounted for nearly 95% of all AIDS cases in 2007 compared with 75% before 1995.<sup>15</sup><br />
From before 1995 until 2007, the share of injecting drug use as the exposure category in new AIDS cases declined from 27.5% to around 10% among adult males, and 21.9% to just over 4% among adult females.<sup>16</sup><br />
At the start of the epidemic, HIV transmission through blood transfusion and blood products was also common. In 1986 HIV blood-screening tests were made compulsory at blood banks in São Paulo, and by 1988 this policy was implemented nationwide, signalling the start of a decline in HIV-transmissions occurring through these routes. <sup>17</sup><br />
Between 1996 and the turn of the century, the introduction of antiretroviral therapy led to a significant drop in the level of AIDS-related mortality.<sup>18</sup> The number of cases where HIV was transmitted from pregnant mothers to their children also declined in this period, due to the availability of ARVs, which significantly reduce the chances of transmission occurring through this route. <sup>19</sup><br />
Since 2000, the number of Brazilians living with HIV has stabilised around 600,000. However, the overall AIDS incidence rate has increased, possibly due to the delayed effect of HIV infections in previous years. The rise in AIDS incidence has not led to an increase in the AIDS mortality rate, which significantly declined since the introduction of treatment in 1996 from 9.6 annual deaths per 100,000 people, to 5.1 in 2006.<sup>20</sup> It should be noted, however, that the North and North-East regions of Brazil have seen increases in AIDS mortality over the course of the decade.<sup>21</sup><br />
Although men still account for the majority of infections, women represent an increasing share of the epidemic with the ratio of male-to-female AIDS cases shrinking from 15-to-1 in 1986 to 1.4 in 2006.<sup>22</sup> It has become increasingly clear that young people are bearing the brunt of the epidemic, and that poor people and those with a low level of education are at a higher risk of becoming infected. <sup>23</sup> HIV transmission resulting from contaminated blood products and blood transfusions is now thought to be practically non-existent, <sup>24</sup> and studies in major cities have pointed to a decline in HIV prevalence among IDUs. <sup>25</sup> <sup>26</sup><br />
<h2>HIV testing in Brazil </h2><div class="photo_r" style="width: 250px;"><a href="http://www.avert.org/aids-picture.php?photo_id=1413"><img alt="A social worker
counsels an HIV-positive woman, Brazil" border="0" height="172" src="http://www.avert.org/media/photos/1171.jpg" width="250" /></a> TA social worker counsels an HIV-positive woman.</div>Encouraging people to access testing is an important part of worldwide HIV prevention, as HIV-positive people who are aware of their status are less likely to pass infection on to other people. People who test positive can also be directed towards support and treatment, and be given advice for the future. HIV testing in Brazil either takes place through public health facilities such as hospitals or through centres that provide voluntary counselling and testing (VCT, a process that combines HIV testing with counselling, advice and support). Since the mid-1990s, the availability of ARVs has given people more incentive to get tested and has led to testing becoming more popular and more widely available. Between 1997 and 2002, both the number of VCT centres and the number of HIV tests carried out through the public sector doubled.<sup>27</sup><br />
The Brazilian government has used media campaigns to promote universal HIV testing. The central message of these campaigns is that everyone in the country should know their status. One major initiative, known by its slogan ‘Fique Sabendo’ (‘Be in the Know’), enlisted the help of models and other celebrities to promote testing. Before this campaign was unveiled through TV and newspaper adverts in 2003, it was promoted at one of the country’s biggest fashion shows in São Paulo. Models wore t-shirts decorated with the campaign’s logo – a smiling face with ‘plus’ and ‘minus’ signs for its eyes, representing the two possible results of a HIV test. <sup>28</sup> In many countries, such an event would be unimaginable given the stigma and taboo surrounding HIV.<br />
Despite the success of such initiatives, there is still a need for many more people to access testing facilities. It is estimated that only one third of HIV-positive Brazilians are aware of their status, and that just 20% of Brazil’s sexually active population has been tested for HIV.<sup>29</sup><br />
<h2>AIDS treatment in Brazil</h2>When AZT (one of the first antiretroviral drugs available to treat HIV) was first developed in the late 1980s, small quantities were made available for free in São Paulo state. In 1991 the government announced that it would make the drug available for free to all Brazilians that required it. <sup>30</sup> Although there were a number of problems with AZT, the government’s decision to distribute it universally set the precedent that people living with HIV had a right to receive treatment.<br />
In 1996 HAART was developed, revolutionising HIV treatment. Once again, the drugs were made available for free throughout the public sector. In following years the national AIDS mortality rate began to decline due to the effectiveness of the treatment.<sup>31</sup> By 2002 the Ministry of Health estimated that the availability of ARVs had prevented around 358,000 HIV-related hospitalisations, resulting in a saving of more than US$1.1 billion. <sup>32</sup><br />
By the end of 2007, it was estimated that 181,000 people living with HIV in Brazil were receiving ARVs – 80% of those requiring the drugs. <sup>33</sup> This level of treatment coverage is more typical of a developed nation than a middle-income country such as Brazil.<br />
A major factor in Brazil’s success has been its ability to produce several AIDS drugs locally. Brazil has a large pharmaceutical industry and around 40% of ARVs currently purchased by the government are manufactured domestically.<sup>34</sup> Since 1996 Brazil has complied with the international Agreement on Trade Related Aspects of Intellectual Property (TRIPS), which was established to protect the patent rights of pharmaceutical companies. This agreement limits the production of generic drugs that have already been patented in another country. Several ARVs that are produced generically in Brazil were patented before the TRIPS agreement, which means that they can legally be copied. <sup>35</sup><br />
<div class="photo_r"><img alt="Transport union
members educate a truck driver about HIV and AIDS, Sao Paulo, Brazil" border="0" src="http://www.avert.org/media/photos/3043.jpg" width="325" /> <br />
<div style="width: 325px;">Transport union members educate a truck driver about HIV and AIDS, Sao Paulo, Brazil</div></div>However, some of the ARVs required for the Brazilian treatment program have to be obtained internationally. To ensure that these drugs are not too expensive, the government has continually put pressure on international pharmaceutical companies to lower their prices. A major tool in these negotiations has been a clause in the TRIPS agreement that allows developing countries to issue 'compulsory licenses' for drugs. Compulsory licenses allow countries to override patent laws and produce their own generic (copied) versions of company-owned drugs, and can be issued when the government of a developing country deems it to be a public health emergency. Many developing countries are hesitant to actually issue compulsory licenses, because of fears about damaging trade relations with drug companies and governments such as the U.S. who are keen to protect pharmaceutical patents. For years the Brazilian government frequently threatened to invoke compulsory licenses for AIDS drugs, without actually going ahead, and this led to significant price reductions.<sup>36</sup><br />
<blockquote class="bigquoteleft"><div class="bigquotebody">“Brazil’s unprecedented accomplishments in AIDS treatment have profoundly influenced global AIDS and health policy.”</div></blockquote>In May 2007 however, the Brazilian President Luiz Inacio Lula da Silva announced that Brazil would be issuing a compulsory license to import a lower cost version of the ARV efavirenz, patented by the company Merck. This followed Thailand's decision five months earlier to break patent for the same drug, along with others. The Brazilian government had previously been in talks with Merck on lowering the price of efavirenz, and although the company had offered to sell the drug at a lowered price, the government argued that these reductions did not go far enough. The Brazilian government estimated that their decision would save them $240 million by 2012, when Merck's patent on the drug expires, and would help them to improve the provision of ARVS.<sup>37</sup><br />
As expected, the government's decision to break the patent on efavirenz received a mixed reaction. AIDS activists and many officials involved in the global fight against AIDS applauded the move. Michael Weinstein, president of AIDS Healthcare Foundation, which operates clinics in Latin America, called it:<br />
<blockquote class="longquote">“A victory for Aids activists and patients everywhere, and proof that drug companies will go down in defeat every time they place themselves in the way of justice for Aids patients.”<sup>38</sup></blockquote>On the other hand, Merck, along with other pharmaceutical companies and business experts, argued that the government's decision was unfair on the patent holder and was likely to discourage investment in AIDS drug research and production. The U.S.-Brazil Business Council called the move:<br />
<blockquote class="longquote">“A major step backward for the country's development. Brazil is working to attract investment in innovative industries that rely on intellectual property, and this move will likely cause investments to go elsewhere.”<sup>39</sup></blockquote>Brazil has now also begun producing a generic version of efavirenz, and is expected to import a generic version of tenofovir following the 2008 rejection of its patent.<sup>40</sup><br />
While some criticise the tactics that the Brazilian government has used to get cheaper AIDS drugs, their strategy seems to have worked well so far, and has undoubtedly saved many lives.<br />
<blockquote class="longquote">"Local manufacturing of many of the drugs used in the anti-AIDS cocktail permits Brazil to continue to control the spread of AIDS. The drugs industry sees this as an act of war. We see it as an act of life." <cite>Publicity poster released by the Ministry of Health and civil society groups<sup>41</sup></cite></blockquote>It has also been suggested that Brazil's strong stance against pharmaceutical companies in its bid to promote access to HIV treatment has greatly influenced treatment provision globally. Thanks to Brazil's public debate about the cost of AIDS treatment, transparency about drug prices has been promoted in other developing countries. The economies of scale that Brazil offered to the generic ARV market encouraged more firms to enter it, thereby increasing competition and driving costs down.<sup>42</sup> One paper concluded that Brazil's achievements have "profoundly inf luenced global AIDS and health policy".<sup>43</sup><br />
<h2>Tensions between Brazil and the United States</h2>Among those who criticised Brazil’s treatment campaign for the pressure it put on pharmaceutical companies was the United States government. In February 2001 the U.S. issued a complaint to the World Trade Organisation, claiming that Brazil’s threats to manufacture generic ARVs undermined the intellectual property rights of drug companies. By forcing companies to lower their prices, the U.S. argued, Brazil was discouraging the drug industry from researching and producing new ARVs. In response, the Brazilian government argued that western drug firms could easily afford to reduce their prices. They also pointed out that the vast profits such companies make in richer countries (where patenting laws are more restrictive) provide enough incentive for them to continue ARV production regardless of what happens in poorer countries. The U.S. eventually dropped their complaint, perhaps due to pressure from the United Nations.<sup>44</sup> <sup>45</sup><br />
Brazil’s HIV prevention policies, such as its focus on condom promotion, have also been a point of dispute. When working with developing countries, the U.S. government generally encourages them to adopt an ‘ABC’ approach to HIV prevention, which promotes abstinence and being faithful to one partner as well as condom use. Although Brazil does incorporate these other messages into its prevention schemes, it has placed a heavy emphasis on condom use and refused to stick to an ABC approach. This has been a source of conflict with U.S. officials. <sup>46</sup><br />
On top of this, the Brazilian government's focus on preventing HIV amongst sex workers has clashed with the U.S. policy of refusing aid to any HIV and AIDS prevention schemes that do not explicitly oppose the sex trade. In 2005, the Brazilian government refused the US government’s offer of $40 million funding for HIV and AIDS programs, as it would have required them to state that they are against the practice of commercial sex work.<sup>47</sup> As Katia Guimaraes from the National AIDS program stated, this was not viable in Brazil:<br />
<blockquote class="longquote">“Prostitutes are very major partners in this program. They work along with us. We could never say that we are against prostitution, because it is not illegal in Brazil. It’s a tolerated, regulated profession.”<sup>48</sup></blockquote><h2>HIV prevention in Brazil</h2>Sexuality and sexual expression are integral to Brazilian culture and are discussed openly. While some cultures associate sex with shame and corruption, many Brazilians see it as something that should be celebrated, and this social climate has made it much easier to carry out HIV prevention work.<br />
<blockquote class="longquote">“Brazil’s sexual culture is very different from the puritanical tradition in [countries such as] the United States. Our AIDS programs have also been radically different. The denial and the stigma that you find attached to sexual health issues in so many places isn’t found in Brazil” <cite>Sonia Correa, Brazilian AIDS activist<sup>49</sup></cite></blockquote><h3>Condom use</h3>In 1986 it was estimated that only 4% of the Brazilian population used condoms during their first sexual encounter. By 1999, the level had increased to 48%.<sup>50</sup> Both female and male condoms have been widely distributed and promoted by the government, and there has been a dramatic increase in condom sales. In 2005, a study of Brazilian adults revealed that 35% used a condom during the previous year, compared with 24% in 1998. <sup>51</sup> The increase in condom use has not only occurred among the general population, but also among HIV-positive people.<sup>52</sup><br />
<div class="photo_l"><img alt="Condom
distribution at the Carnaval de Olinda, Brazil." border="0" src="http://www.avert.org/media/photos/3047.jpg" width="325" /> <br />
<div style="width: 325px;">Condom distribution at the Carnaval de Olinda, Brazil.</div></div>The Brazilian government has vigorously promoted the use of condoms through media campaigns, adverts and other prevention initiatives. Around 45 million are handed out a month with more handed out at big events such as carnivals, which are linked with increased sexual activity. During the 2009 carnival season, for example, a further 20 million condoms were distributed.<sup>53</sup> Condom use has also been promoted by NGOs working in the favelas (shanty towns), where young people have been educated about AIDS and encouraged to act as ‘information spreaders’, passing information on to their peers. <sup>54</sup><br />
Brazil’s aggressive efforts to promote condom use, as part of its fight against AIDS make it the world’s largest importer buying 1.2 billion in 2009.<sup>55</sup> Furthermore, a state-run factory began producing 100 million condoms a year from Amazon rainforest rubber in 2008. The move was designed to reduce the reliance on foreign imports and to preserve a large area of tropical rainforest.<sup>56</sup><br />
<h3>Media campaigns</h3>HIV prevention messages have been promoted through a variety of media, including television, newspapers and public spaces such as billboards and bus shelters. The messages conveyed by these campaigns are among the most explicit that any government has put forward, causing controversy among some groups. They address issues such as homosexuality, the rights of HIV-positive people, the stigma surrounding HIV and AIDS, and condom promotion. A number of Brazilian celebrities have helped to get these messages across, such as athletes, entertainers and models. For example, in one media campaign, the famous pop-singer Kelly Key tells her teenage audience “<q>Show how you’ve grown up. This carnival, use condoms.</q>” <sup>57</sup><br />
Telenovelas (television soap operas) are very popular in Brazil, and have also been used to educate people about HIV/AIDS. The program ‘Malhaçã’, for instance, has featured characters living with HIV and has demonstrated how ARVs should be taken. <sup>58</sup><br />
<h3>Preventing mother-to-child transmission (PMTCT)</h3>The first recorded case of HIV being transmitted from a pregnant mother to her child in Brazil occurred in 1987. Since then a number of measures have been taken to reduce the rate of mother-to-child transmission (MTCT).<br />
<div class="photo_r" style="width: 190px;"><img alt="An AIDS reception
center for patients in Brazil" border="0" height="161" src="http://www.avert.org/media/photos/1167.jpg" width="190" /> An AIDS reception center for patients.</div>These include the routine recommendation that HIV-positive mothers do not breastfeed (which can result in HIV being transmitted), the provision of infant formula (a replacement for breast milk) to all children with HIV-positive mothers, the introduction of rapid HIV tests in maternity units, and the routine recommendation to all pregnant women that they should be tested.<sup>59</sup><br />
The introduction of ARVs in 1996 had a significant impact on the situation, as women who take ARVs during pregnancy are much less likely to pass HIV on to their baby. At the end of 2005, more than half of HIV-positive pregnant women in Brazil were receiving ARVs.<sup>60</sup> While this means that large numbers of pregnant women are still not accessing treatment, particularly in poorer areas, the availability of ARVs has made a big impact. In São Paulo state, the area of Brazil hit hardest by AIDS, the rate of MTCT fell from 16% in 1995 to 2.4% in 2002.<sup>61</sup> The national rate fell from 8.6% in 2000 to 6.8% in 2004 - a 20% decline - and in 2007 the Operational Plan to Reduce Mother-to-Child Transmission of HIV and Syphilis was launched aiming to reduce the rate even further by 2011 through coordination between the different levels of government.<sup>62</sup><br />
For more information on this issue, visit our page on preventing mother-to-child transmission.<br />
<h2>HIV prevention with high-risk groups in Brazil </h2>The idea that HIV and AIDS are confined only to certain risk groups - sometimes referred to as the ‘someone else’s problem’ attitude - is misguided and can make people less likely to take precautions against HIV, increasing the risk of infection. In Brazil, as elsewhere, the epidemic affects people from all parts of society. Nonetheless, there are certain groups that run a greater risk of becoming infected than others. HIV prevention campaigns in Brazil have attempted to target these specific groups with information, advice and support.<br />
<h3>Men who have sex with men</h3>Civil society groups representing gay men played an important role in Brazil’s initial response to AIDS, and have continued to do so as the epidemic has progressed. Although there is still a lot of stigma surrounding homosexuality, the openness of Brazilian culture has led to a greater tolerance of gay people than is seen in many other countries. The government has supported this tolerance, and has worked to reduce discrimination by carrying out media campaigns and working with NGOs. An example of this is SOMOS, an HIV prevention and care project run jointly by the government and the Brazilian Gay, Lesbian and Transgender Association. SOMOS promotes gay rights and HIV prevention messages. It also provides support to gay men living with HIV. <sup>63</sup><br />
Although the majority of HIV-positive Brazilians become infected through heterosexual sex, men who have sex with men (MSM) still face a proportionately higher risk. The government has estimated that MSM are around 11 times more likely to become infected with HIV than heterosexual people. <sup>64</sup><br />
<h3>Sex workers</h3>Sex work is not illegal in Brazil and the government has taken an unprejudiced approach to preventing HIV infection among this group. A number of schemes have been carried out, including a high profile campaign based around a cartoon character called ‘Maria without Shame’. Advertised on posters, leaflets and stickers placed in women’s toilets, this character was shown with the message “<span class="shortquote">You need have no shame, girl. You have a profession</span>”. A radio advert featuring a famous Brazilian singer was also broadcast. The aim of this campaign was to improve the self-esteem of sex workers and to encourage them to take care of their health, with an emphasis on using condoms.<sup>65</sup><br />
Sex workers in Brazil still face many barriers to condom use though, such as fear of violence, increased payment for unprotected sex and competition for clients.<sup>66</sup><br />
<h3>Injecting drug users</h3>Injecting drug users (IDUs) accounted for a large proportion of HIV cases in the early stages of Brazil’s epidemic. This problem escalated during the early 1990s, leading the government to implement widespread harm reduction strategies including needle exchange programmes. Needle exchanges reduce the risk that HIV will be spread through needle sharing by providing IDUs with clean needles. They also offer counselling and information, which can encourage people to stop taking drugs. Such schemes have proved effective around the world and Brazil has been no exception, with studies in major cities indicating a significant decline in HIV prevalence among IDUs since needle exchanges were implemented. For example, the city of Santos saw a 20% decline in HIV prevalence among IDUs between 1998 and 2000. The total number of needle exchanges in Brazil increased from 12 in 1998 to 40 by the end of 2000, with around 150,000 syringes exchanged between 1999 and 2000.<sup>67</sup> The number of AIDS cases attributable to IDUs dropped dramatically between 1996 (4,814 cases) and 2006 (1,319 cases).<sup>68</sup><br />
Brazil has also led the way in providing IDUs with access to treatment. Of the 34,000 former and current injecting drug users on antiretroviral therapy in 2004 in 50 developing and transitional countries, 30,000 were in Brazil.<sup>69</sup><br />
<h2>Combating stigma and discrimination</h2>Globally, stigma has widely been recognised as a contributing factor to the spread of HIV. Fear of discrimination stops people going for HIV tests, causes denial in communities (which can lead to prevention messages being ignored) and can prevent HIV-positive people from admitting their status or from accessing medication. The prejudice that people living with HIV face also adds to the emotional strain and suffering that they must deal with.<br />
Brazil is a rare example of a country that has managed to minimise this problem. The human rights movement that emerged in Brazil during the 1980s was active in fighting AIDS-related discrimination, and encouraged the government to protect the rights of people living with HIV. The government has since shown commitment to protecting the rights of marginalised groups who may be affected by HIV and AIDS, such as sex workers, gay men and drug users. It has also been generous with funding to groups of people living with HIV and AIDS, as well as events such as gay pride marches, which encourage people to respect sexual diversity. The fight against stigma has been understood as a central part of responding to the epidemic.<sup>70</sup><br />
To learn more about the stigma surrounding HIV globally, visit our stigma and discrimination page.<br />
<h2>What can other countries learn from Brazil's response to AIDS?</h2><blockquote class="bigquoteright"><div class="bigquotebody">No developing country has had more success in tackling AIDS than Brazil.<sup>71</sup></div><div class="bigquotecite">- The Economist</div></blockquote>Brazil has faced (and continues to face) a significant number of social, economic and political problems. Its population is divided by vast inequalities, and in many areas people live in great poverty. In the struggle to overcome HIV and AIDS, though, Brazil has made impressive progress. Close ties between civil society groups and the government, which largely resulted from the struggle for democracy in the 1980s, have ensured that fast, effective action has been taken to stem the spread of HIV. Efforts to treat and care for people living with HIV have also been extensive, and the level of stigma and discrimination facing such people has been minimised. Brazil’s ARV program is comparable to those of more wealthy, developed countries.<br />
It has often been said that Brazil’s mobilisation against AIDS should act as a model for other developing countries to follow. A number of countries have already attempted to follow its example; by 2003 Brazil’s guidelines for treatment and prevention had been adopted by 31 developing countries. <sup>72</sup> In the same year, the late Lee Jong-Wook (then head of the World Health Organization) asked the chief of Brazil’s National AIDS Program to visit Geneva to help formulate new policies for fighting AIDS around the world. <sup>73</sup><br />
While Brazil’s response to AIDS must be understood within the context of the social and political changes that have occurred within the country, there are many elements of its success that other countries – both developing and developed – can learn from.<br />
Some major elements of Brazil’s success that could possibly be encouraged in other countries are:<br />
<ul><li>A strong relationship between the government, civil society groups and NGOs.</li>
<li>Strong political leadership and will to fight the epidemic.</li>
<li>A tolerant, non-judgemental approach to HIV prevention.</li>
<li>A strong focus on condom promotion.</li>
<li>The provision of free treatment to all, and aggressive efforts to minimise the cost of ARVs.</li>
<li>A commitment to fighting stigma and discrimination, and encouraging a culture where people living with HIV are not looked down upon, but are actively involved in helping the government respond to the epidemic.</li>
</ul><h2 style="font-weight: normal;"><b>The future of Brazil’s AIDS epidemic</b></h2>The pattern of Brazil’s AIDS epidemic has changed in recent years. The epidemic is evolving more slowly among men who have sex with men and injecting drug users than before, but its impact on the heterosexual population has increased dramatically. This increase has brought with it an alarming rise in the percentage of women affected by HIV. There is evidence that women are less likely to use condoms when having sex with casual partners than men, adding to concerns that many women do not see themselves as being at risk of becoming infected with HIV. <sup>74</sup> Men and women are still divided by gender inequalities in many parts of Brazil, and the subordinate social position of women may be fuelling the large numbers of heterosexually acquired infections that are being seen, by giving women less control over their sexual relationships and allowing men to have multiple partners. The epidemic has also had an increasing effect on poorer members of Brazilian society, and those with lower levels of education. <sup>75</sup><br />
Prevention campaigns that target these risk groups need to be maintained and strengthened. It is also important that prevention campaigns continue to target the general population, as the optimism surrounding Brazil’s successes in regards to HIV and AIDS may lead to an increase in unsafe sexual practices in coming years. <sup>76</sup><br />
Though Brazil has been very successful in providing HIV treatment to those who need it, particularly through its promotion of cheaper imported and locally-produced generic ARVs, it is facing some challenges in this area. Providing a high level of access to treatment means the overall cost of treatment is rising. In this way, Brazil could be said to be a victim of its own success: more and more people are receiving treatment and living longer thanks to ARVs, and more drugs are being added to its treatment guidelines.<sup>77</sup> Brazil relies more on locally-produced generic drugs than do other developing countries, when imported drugs are often cheaper, and the cost of manufacturing drugs locally rose in the late 2000s.<sup>78</sup> However, the challenges faced by Brazil's approach to treatment approach are likely far outweighed by its positive results.<br />
Brazil should take pride in its success, but it is important that complacency does not take hold and that both prevention and treatment programs are sustained and improved.<br />
<br />
<div class="box bFull" id="footnote"><h2>Sources:</h2><ul><li> <a href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li>Berkman A. et al. (July 2005), <a class="externallink" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15933232&dopt=Abstract" target="_blank">'A critical analysis of the Brazilian response to HIV/AIDS: Lessons learned for controlling and mitigating the epidemic in developing countries'</a>, American Journal of Public Health, Volume 95, No. 7</li>
<li>Okie S. (May 2006), <a class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
</ul><h2>References:</h2><ol><li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li>Ministry of Health, Brazil (2001), <a ,="" class="externallink" href="http://www.unodc.org/brazil/en/publications.html" target="_blank">'AIDS: the Brazilian experience'</a></li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>Ministry of Health, Brazil (2001), <a ,="" class="externallink" href="http://www.unodc.org/brazil/en/publications.html" target="_blank">'AIDS: the Brazilian experience'</a></li>
<li>Frasca T. (2005), AIDS in Latin America, Palgrave/Macmillan, p.195</li>
<li>USAID (2004), <a ,="" class="externallink" href="http://www.usaid.gov/our_work/global_health/aids/Countries/lac/brazil.html" target="_blank">USAID Country Profile: Brazil</a></li>
<li>Frasca T. (2005), "AIDS in Latin America", Palgrave/Macmillan, p.196</li>
<li>UNAIDS (2003), '<a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=Topics/UNGASS2003/Americas/brazil_ungassreport_2003-2_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d6583%26query%3dcty%24bra%26PV%3d1" target="_blank">Brazil UNGASS report 2003, annex 2 - National composite policy index questionnaire</a>'</li>
<li>Daniel H. and Parker R. (1993), "Sexuality, politics and AIDS in Brazil", RouteledgeFalmer/London, p.36</li>
<li><a ,="" class="externallink" href="http://www.v-brazil.com/government/laws/constitution.html" target="_blank">1988 Constitution of Brazil</a></li>
<li>PANOS London (1996), <a ,="" class="externallink" href="http://www.aegis.com/news/panos/1996/PS960901.html" target="_blank">'Brazilian activists win AIDS-treatment battle'</a></li>
<li>Ministry of Health, Brazil (2001), <a ,="" class="externallink" href="http://www.unodc.org/brazil/en/publications.html" target="_blank">'AIDS: the Brazilian experience'</a></li>
<li>Frasca T (2005), 'AIDS in Latin America', Palgrave Macmillan'</li>
<li>AIDS Policy Research Center, University of California San Francisco (2004), <a ,="" href="http://ari.ucsf.edu/programs/policy_country.aspx" target="_blank">'HIV/AIDS in Brazil'</a></li>
<li>Ministry of Health Brazil (2007), 'Bulletin Epidemiological STD/AIDS'</li>
<li>Ministry of Health Brazil (2007), Bulletin Epidemiological STD/AIDS</li>
<li>Levi, Guido Carlos, and Vitoria, Marco Antonio A. (December 6th 2002), <a ,="" class="externallink" href="http://www.aidsonline.com/pt/re/aids/fulltext.00002030-200212060-00001.htm;jsessionid=GzxJrwJtLS6sQMzrcgy92c68mdM8RZMytBTWkNRgJsDQQhqrPFb2%21-1734750035%21-949856144%218091%21-1" target="_blank">'Fighting against AIDS: the Brazilian experience'</a>, AIDS 16: pp. 2373-2383.</li>
<li>Ministry of Health Brazil (2007), 'Bulletin Epidemiological STD/AIDS'</li>
<li>Levi, Guido Carlos, and Vitoria, Marco Antonio A. (December 6th 2002), <a ,="" class="externallink" href="http://www.aidsonline.com/pt/re/aids/fulltext.00002030-200212060-00001.htm;jsessionid=GzxJrwJtLS6sQMzrcgy92c68mdM8RZMytBTWkNRgJsDQQhqrPFb2%21-1734750035%21-949856144%218091%21-1" target="_blank">'Fighting against AIDS: the Brazilian experience'</a>, AIDS 16: pp. 2373-2383.</li>
<li>Dourado I, S. M. Veras M.A. et al. (2006), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16729154" target="_blank">'AIDS epidemic trends after the introduction of antiretroviral therapy in Brazil'</a>, Rev Saude Publica 2006;40(Supl.)</li>
<li>Ministry of Health Brazil (2007) 'Bulletin Epidemiological STD/AIDS'</li>
<li>Ministry of Health (2007),<a ,="" href="http://www.aids.gov.br/data/Pages/LUMIS9DAF1EC6ENIE.htm" target="_blank"> ‘Integrated plan to combat the feminization of the AIDS epidemic and other STDs’</a></li>
<li>Berkman A. et al. (July 2005), <a ,="" class="externallink" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15933232&dopt=Abstract" target="_blank">'A critical analysis of the Brazilian response to HIV/AIDS: Lessons learned for controlling and mitigating the epidemic in developing countries'</a>, American Journal of Public Health, Volume 95, No. 7</li>
<li>Levi, Guido Carlos, and Vitoria, Marco Antonio A. (December 6th 2002), <a ,="" class="externallink" href="http://www.aidsonline.com/pt/re/aids/fulltext.00002030-200212060-00001.htm;jsessionid=GzxJrwJtLS6sQMzrcgy92c68mdM8RZMytBTWkNRgJsDQQhqrPFb2%21-1734750035%21-949856144%218091%21-1" target="_blank">'Fighting against AIDS: the Brazilian experience'</a>, AIDS 16: pp. 2373-2383.</li>
<li>Hacker MA, Friedman SR (2005), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15702651" target="_blank">'The role of "long-term" and "new" injectors in a declining HIV/AIDS epidemic in Rio de Janeiro, Brazil'</a>, Substance Use & Misuse. 2005;40(1):99-123.</li>
<li>Bastos F. I., Bongertz V. (2005), <a ,="" href="http://www.scielo.br/scielo.php?pid=S0074-02762005000100017&script=sci_arttext" target="_blank">'Is human immunodeficiency virus/acquired immunodeficiency syndrome decreasing among Brazilian injection drug users? Recent findings and how to interpret them'</a>, Memorias do Instituto Oswaldo Cruz, vol.100 no.1 Rio de Janeiro, February 2005</li>
<li>AIDS Policy Research Center, University of California San Francisco (2004), <a ,="" href="http://ari.ucsf.edu/programs/policy_country.aspx" target="_blank">'HIV/AIDS in Brazil'</a></li>
<li>Pacific News Service (June 2003), <a ,="" class="externallink" href="http://news.pacificnews.org/news/view_article.html?article_id=28438752d2b16287129a77963400e569" target="_blank">'Brazil, not U.S, may lead world's fight against HIV'</a></li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>Mattos HR; Hanan JL et al. (2002), <a ,="" class="externallink" href="http://www.aegis.com/aidsline/1992/dec/M92C2145.html" target="_blank">'Who gets AZT and who doesn't: analysis of the impact of the Brazilian Health Ministy's criteria for distribution of free AZT'</a>, International Conference of AIDS 1992, Jul 19-24;8(2):D511</li>
<li>Ministry of Health Brazil (2007), 'Bulletin Epidemiological STD/AIDS'</li>
<li>Ministry of Health of Brazil (2002), "Resposta positiva: a experiencia do programa brasileiro de AIDS"</li>
<li>World Health Organisation (2008) <span class="externallink">'<a ,="" href="http://www.who.int/hiv/pub/2008progressreport/en/" target="_blank">Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector</a></span>'</li>
<li>Wise J. (2006), <a ,="" class="externallink" href="http://www.who.int/bulletin/volumes/84/5/news10506/en/index.html" target="_blank">'Access to AIDS medicines stumbles on trade rules'</a>, Bulletin of the World Health Organization, Volume 84, Number 5, May 2006, 337-424</li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>Agence France-Presse (May 2006), <a ,="" class="externallink" href="http://www.aegis.com/news/afp/2006/AF060519.html" target="_blank">'Brazil, Gilead agree AIDS drug price cut'</a></li>
<li>Associated press (2007, 4th May), <a ,="" href="http://www.usatoday.com/news/health/2007-05-04-4260160309_x.htm" target="blank">'Brazil Bypasses Patent on U.S. AIDS Drug'</a></li>
<li>Financial Times (2007, May 4th), <a ,="" href="http://www.ft.com/cms/s/c7d3f1f4-fa78-11db-8bd0-000b5df10621.html" target="blank">'Brazil overrides Merck patent on HIV drug'</a></li>
<li>Financial Times (2007, May 4th), <a ,="" href="http://www.ft.com/cms/s/c7d3f1f4-fa78-11db-8bd0-000b5df10621.html" target="blank">'Brazil overrides Merck patent on HIV drug'</a></li>
<li>Nunn A, (2009), <a ,="" href="http://content.healthaffairs.org/cgi/content/abstract/28/4/1103" target="_blank">'AIDS Treatment in Brazil: Impacts and Challenges'</a>, Health Affairs 28(4)</li>
<li>Ministry of Health of Brazil (2002), "Resposta positiva: a experiencia do programa brasileiro de AIDS"</li>
<li>Nunn A, (2009), <a ,="" href="http://content.healthaffairs.org/cgi/content/abstract/28/4/1103" target="_blank">'AIDS Treatment in Brazil: Impacts and Challenges'</a>, Health Affairs 28(4)</li>
<li>Nunn A, (2009), <a ,="" href="http://content.healthaffairs.org/cgi/content/abstract/28/4/1103" target="_blank">'AIDS Treatment in Brazil: Impacts and Challenges'</a>, Health Affairs 28(4)</li>
<li>BBC News online (3 February 2001), <a ,="" class="externallink" href="http://news.bbc.co.uk/1/hi/world/americas/1151437.stm" target="_blank">Brazil in US Aids drugs row</a></li>
<li>BBC News online (25th June 2001), <a ,="" class="externallink" href="http://news.bbc.co.uk/1/hi/business/1407472.stm" target="_blank">'US drops Brazil AIDS drug case'</a></li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>BBC News online (May 2005), <a ,="" class="externallink" href="http://news.bbc.co.uk/1/hi/world/americas/4513805.stm" target="_blank">'Brazil turns down US AIDS funds'</a></li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>Washington Post Foreign Service (March 2nd 2006), <a ,="" class="externallink" href="http://www.washingtonpost.com/wp-dyn/content/article/2006/03/01/AR2006030102316.html" target="_blank">'Where prostitutes also fight AIDS'</a></li>
<li>Ministry of Health of Brazil (2002), "Resposta positiva: a experiencia do programa brasileiro de AIDS"</li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>Associated Press (2009, 13th February), <a ,="" href="http://www.aegis.org/news/ap/2009/AP090221.html" target="_blank">‘Brazil boosts condom handouts by 20M for Carnival’</a></li>
<li>BBC News online (2003), <a ,="" class="externallink" href="http://news.bbc.co.uk/1/hi/world/americas/3065397.stm" target="_blank">'Brazil's pioneering AIDS programme'</a></li>
<li>New York Daily News (2009, 13th February), <a ,="" href="http://www.nydailynews.com/latino/2009/02/13/2009-02-13_brazil_boosts_condom_handouts_by_20m_for.html" target="_blank">‘Brazil boosts condom handouts by 20M for Carnival’</a></li>
<li>BBC News online (2008, 8th April), <a ,="" href="http://news.bbc.co.uk/1/hi/world/americas/7335925.stm" target="_blank">‘Brazil makes “rainforest” condoms’ </a></li>
<li>BBC News online (2003), <a ,="" class="externallink" href="http://news.bbc.co.uk/1/hi/world/americas/3065397.stm" target="_blank">'Brazil's pioneering AIDS programme'</a></li>
<li>Singhal A. and Rogers E.M. (2003), "Combating AIDS: communication strategies in action" Sage Publications, p.113</li>
<li>L. H. Matida, M. H. da Silva et al. (2005), <a ,="" class="externallink" href="http://www.aidsonline.com/" target="_blank">'Prevention of mother-to-child transmission of HIV in São Paulo State, Brazil: an update'</a>, AIDS 19 (suppl 4):S37-S41</li>
<li><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">UNAIDS 2008 Report on the global AIDS epidemic</span></a></li>
<li>L. H. Matida, M. H. da Silva et al. (2005), <a ,="" class="externallink" href="http://www.aidsonline.com/" target="_blank">'Prevention of mother-to-child transmission of HIV in Sao Paulo State, Brazil: an update'</a>, AIDS 19 (suppl 4):S37-S41</li>
<li>Ministry of Health (2008), <a ,="" href="http://www.unaids.org/en/CountryResponses/Countries/brazil.asp" target="_blank">'UNGASS Brazilian Response 2005-2007 Country Progress Report'</a></li>
<li>Ministry of Health of Brazil (2002), 'Resposta positiva: a experiencia do programa brasileiro de AIDS'</li>
<li>Ministry of Health of Brazil (2002), "Resposta positiva: a experiencia do programa brasileiro de AIDS"</li>
<li>Ministry of Health of Brazil (2002), "Resposta positiva: a experiencia do programa brasileiro de AIDS"</li>
<li>AIDS Policy Research Center, University of California San Francisco (2004), <a ,="" href="http://ari.ucsf.edu/programs/policy_country.aspx" target="_blank">'HIV/AIDS in Brazil'</a></li>
<li>Okie S. (May 2006), <a ,="" class="externallink" href="http://content.nejm.org/cgi/content/short/354/19/1977" target="_blank">'Fighting HIV - lessons from Brazil'</a>, The New England Journal of Medicine 354;19</li>
<li>Ministry of Health (2008), <a ,="" href="http://www.aids.gov.br/Main.asp?View=%7B29D2BB4D-5BE0-4A64-AF35-B37B99C629F8%7D&UIPartUID=%7B0B5F05BA-8CC2-4048-A2B2-224C2BCB03F0%7D&params=_EZTStartAt_=0" target="_blank">'<span class="txt_azul2">RESPONSE + 2008 Magazine: Experiences of the Brazilian STD & AIDS Programme'</span></a></li>
<li>Aceijas C et al (2006), '<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/16911723" target="_blank">Antiretroviral treatment for injecting drug users in <br />
developing and transitional countries 1 year before the end of the ‘Treating 3 million by 2005. Making it happen. The WHO strategy’ (‘3by5’)'</a>, Addiction. 101 (9).'</li>
<li>Berkman A. et al. (July 2005), <a ,="" class="externallink" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15933232&dopt=Abstract" target="_blank">'A critical analysis of the Brazilian response to HIV/AIDS: Lessons learned for controlling and mitigating the epidemic in developing countries'</a>, American Journal of Public Health, Volume 95, No. 7</li>
<li>The Economist (2007, 10th May), <a ,="" href="http://www.economist.com/world/americas/displaystory.cfm?story_id=9154222" target="_blank">'Brazil's AIDS programme: A conflict of goals'</a></li>
<li>Chicago Tribune (June 8th 2003), <a ,="" class="externallink" href="http://www.aegis.com/news/ct/2003/CT030601.html" target="_blank">'Brazil AIDS program touted as model for world'</a></li>
<li>Chicago Tribune (June 8th 2003), <a ,="" class="externallink" href="http://www.aegis.com/news/ct/2003/CT030601.html" target="_blank">'Brazil AIDS program touted as model for world'</a></li>
<li>C. L. Szwarcwald, Barbosa-Junior A. et al. (2004), "Knowledge, practices and behaviours related to HIV transmission among the Brazilian population in the 15-54 years age grouyp, 2004", AIDS 19 (suppl. 4):S51-S58</li>
<li>C. L. Szwarcwald, Barbosa-Junior A. et al. (2004), "Knowledge, practices and behaviours related to HIV transmission among the Brazilian population in the 15-54 years age grouyp, 2004", AIDS 19 (suppl. 4):S51-S58</li>
<li>C. G. M. da Silva, D. A. Goncalves et al. (2005), "Optimistic perceptions of HIV/AIDS, unprotected sex and implications for prevention among men who have sex with men, Sao Paulo, Brazil", AIDS 19 (suppl 4):S31-36</li>
<li>Nunn A, (2009), <a ,="" href="http://content.healthaffairs.org/cgi/content/abstract/28/4/1103" target="_blank">'AIDS Treatment in Brazil: Impacts and Challenges'</a>, Health Affairs 28(4)</li>
<li>Nunn A, (2009), <a ,="" href="http://content.healthaffairs.org/cgi/content/abstract/28/4/1103" target="_blank">'AIDS Treatment in Brazil: Impacts and Challenges'</a>, Health Affairs 28(4)</li>
</ol></div><br />
</div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-89567127291891515202010-06-08T13:22:00.000-07:002010-06-08T13:22:56.354-07:00HIV and AIDS in America<div class="box bFull"> <b>Since the beginning of the HIV and AIDS epidemic well over half a million people have died of AIDS in America<sup>1</sup> </b> – the equivalent of the entire population of Las Vegas. There are currently more than one million people living with HIV and AIDS in America and around a fifth of these are unaware of their infection,<sup>2</sup> posing a high risk of onward transmission.<br />
America’s response to the AIDS epidemic has produced mixed results. HIV prevention efforts have not always been successful and every year approximately 56,000 Americans are infected with HIV.<sup>3</sup> In March 2009 Washington DC reported an HIV prevalence of at least 3% among people over 12 years - similar to rates in some parts of sub-Saharan Africa.<sup>4</sup><br />
Stigma and discrimination towards HIV positive people still persist and thousands of uninsured Americans struggle to access good HIV care and antiretroviral therapy. The world’s biggest donor of AIDS-related funding is itself facing a major, ongoing AIDS epidemic, which shows little sign of abating.<br />
</div><h2>Who is affected by AIDS in America?</h2>Although HIV and AIDS can and do affect all sectors of American society, the impact has been more serious among some groups than others. In the early years of the epidemic, the most commonly identified ‘vulnerable groups’ in America were men who have sex with men, injecting drug users, haemophiliacs and Haitians. Today, AIDS continues to directly affect thousands of gay and bisexual men and injecting drug users every year, but it has also become a serious problem among Black Americans and, more recently, among the Hispanic/Latino population.<br />
<a name='more'></a><br />
The table below shows how the burden of AIDS among various ethnic groups compares to the percentage of the population that each ethnic group represents.<br />
<table><tbody>
<tr> <th>Race</th> <th>% of AIDS diagnoses in 2007<sup>5</sup></th> <th>% of population in 2007<sup>6</sup></th> </tr>
<tr> <td class="row_title">White</td> <td>30%</td> <td>66%</td> </tr>
<tr> <td class="row_title">Black/African American</td> <td>49%</td> <td>12%</td> </tr>
<tr> <td class="row_title">Hispanic/Latino</td> <td>19%</td> <td>15%</td> </tr>
<tr> <td class="row_title">Asian</td> <td>1%</td> <td>4%</td> </tr>
<tr> <td class="row_title">American Indian/Alaska Native</td> <td><1%</td> <td><1%</td> </tr>
<tr> <td class="row_title">Native Hawaiian/Other Pacific Islander</td> <td><1%</td> <td><1%</td> </tr>
</tbody> </table><b>African Americans: </b>As the table above shows, African Americans are disproportionately affected by the AIDS epidemic. To date, black Americans account for 40% of AIDS related deaths. <sup>7</sup> The AIDS related deaths of well-known African Americans - such as anchorman Max Robinson, tennis player Arthur Ashe, and rapper Eazy-E - during the 1980s and 90s, increased awareness of the AIDS epidemic among the black community, though there are signs that this level is decreasing. Both African American men and women are most likely to have become infected through sex with a man, with injecting drug use being the second most likely infection route. Factors such as heightened levels of poverty, lack of access to adequate healthcare, and stigma surrounding men who have sex with men shape the epidemic among African Americans.<br />
Visit our HIV & AIDS among African Americans page for more information.<br />
<b>Hispanics/Latinos: </b>Hispanics/Latinos are also disproportionately affected by the AIDS epidemic in America. The number of deaths from AIDS among Hispanics/Latinos has remained relatively stable since the beginning of the new millennium, even though there has been a decline in overall AIDS mortality in America.<sup>8</sup> Language barriers, cultural factors, migration patterns and lack of regular health care have been identified as barriers to HIV treatment and prevention among the Hispanic/Latino community.<sup>9</sup> In New York City, where 40% of all households are made up of of Latinos born outside the U.S, the majority of health and civil society organisations cite a lack of bilingual and culturally sensitive HIV and AIDS services for the large Hispanic/Latino community as a key obstacle to dealing with the city's epidemic.<sup>10</sup><br />
<div class="photo_r"> <img alt="Pedro Zamora" border="0" src="http://www.avert.org/media/photos/393.jpg" width="120" /> <div style="width: 120px;">Pedro Zamora, who died of AIDS in 1994</div></div><b>Men who have sex with men:</b> At the beginning of America’s epidemic, AIDS primarily affected men who have sex with men (MSM). Today, MSM still account for around two-thirds of HIV diagnoses among male adults and adolescents.<sup>11</sup> There have been concerns that an increasing number of MSM are having unprotected sex, leading to a rise in the number of new HIV infections among this group.<sup>12</sup> The CDC has reported that between 2001 and 2006, HIV and AIDS diagnoses among MSM increased by 8.6 percent.<sup>13</sup> It is thought that the availability of antiretroviral treatment may have lessened the fear surrounding AIDS, leading to complacency about using condoms.<sup>14</sup> This complacency is evident in Washington D.C, where a study by the city's HIV/AIDS Administration revealed 40% of gay men had not used a condom with their last sexual partner. The study also found that, contrary to popular belief, men older than 30 had more sexual partners and were less likely to use condoms or get tested than their younger counterparts.<sup>15</sup><br />
<b>Injecting drug users:</b> Injecting drug users (IDUs) have accounted for around a quarter of all AIDS diagnoses in America.<sup>16</sup> Throughout the epidemic, prevention efforts amongst IDUs have been controversial. For 21 years, needle exchange services – where users exchange their used needles for clean ones – were not permitted any federal funding, even though in some areas of America these programmes have proved to be successful in reducing the rate of HIV transmission.<sup>17</sup> <sup>18</sup> HIV transmission decreased by 9.5 % between 2001 and 2006.<sup>19</sup> The ban on federal funding for needle exchanges was lifted in 2009.<br />
<h2>Geographical variations</h2><div class="photo_r"><img alt="Concentration
of AIDS cases in America" border="0" src="http://www.avert.org/media/photos/usa-map.jpg" width="300" /></div>The HIV/AIDS epidemic in America was once concentrated mainly in the gay populations on the East and West coasts. However, in recent years AIDS has become increasingly prevalent within black and Latino communities in many Southern states. The map on the right shows which states had the highest number of people living with AIDS in 2007, relative to the population of each state.<sup>20</sup><br />
<ul class="map_key"><li>highest</li>
<li><img src="http://www.avert.org/media/template/layout/Legend-brown.gif" /></li>
<li><img src="http://www.avert.org/media/template/layout/Legend-light-brown.gif" /></li>
<li><img src="http://www.avert.org/media/template/layout/Legend-orange.gif" /></li>
<li><img src="http://www.avert.org/media/template/layout/Legend-light-orange.gif" /></li>
<li>lowest</li>
</ul><h2 class="clear-all">HIV and AIDS prevention in America</h2>During the early years of the epidemic, America’s prevention efforts primarily targeted people most at risk of acquiring HIV. In the new millennium more focus has been placed upon people living with HIV. One particular programme, Advancing HIV Prevention (AHP), established by the CDC in 2003, has the aim of identifying undiagnosed HIV infections in order to prevent onward transmission.<sup>21</sup> Although AHP is rarely referred to by name today, its principles persist in America’s prevention strategy.<br />
The success of prevention efforts in America has been variable. One area where efforts have been particularly successful is the prevention of mother to child transmission.<sup>22</sup> Routine HIV testing for pregnant women in many states, and good preventive interventions, mean that diagnoses of HIV in babies have dropped dramatically.<br />
In other areas, prevention efforts have had less of an effect and while combination antiretroviral treatment has helped to dramatically reduce the number of people developing and dying of AIDS in America, there are still around 56,000 new HIV infections every year.<sup>23</sup> Some blame America's worsening AIDS epidemic on the CDC and ineffective leadership in Washington.<br />
<blockquote class="longquote">"The fact that Washington DC's HIV prevalence rate is now higher than some hard-hit African countries is an indictment of how the CDC has failed to lead in HIV prevention efforts". - <cite>Michael Weinstein, President of AIDS Healthcare Foundation<sup>24</sup></cite></blockquote>There was renewed hope when Barack Obama became President of the United States in early 2009. However, only a few months after his inauguration, the AIDS Healthcare Foundation launched a campaign highlighting Obama's silent response to the Washington HIV statistics and prompting him into taking more action on AIDS.<sup>25</sup><br />
For more information about prevention in America visit the HIV and AIDS prevention in America page.<br />
<h2>HIV testing in America</h2><div class="photo_r"> <img alt="somebody being
tested for HIV, blood being taken" border="0" src="http://www.avert.org/media/photos/1819a.jpg" width="300" /> <div style="width: 300px;">HIV testing at a community outreach day in America</div></div>There is a clear need for improved HIV testing initiatives in America. Estimates suggest that around 20 percent of those infected with HIV are unaware of their status and around 38 percent of people diagnosed with HIV are diagnosed with AIDS within a year.<sup>26</sup><br />
In September 2006 the CDC published a new set of guidelines on HIV testing which aimed to reduce the high number of people who do not know their HIV status.<sup>27</sup> The guidelines call for automatic, routine HIV testing of all adults and adolescents attending a healthcare setting. The policy allows patients to opt out if they do not wish to take a test, but removes the need for written consent and lengthy pre-test prevention counselling, which were viewed as barriers to HIV testing. It is too early to tell whether this policy will be successful; early reports have revealed reluctance by some healthcare workers to implement the strategy.<sup>28</sup><br />
The CDC has estimated that 31 percent of people fail to go back to public testing sites to obtain their results,<sup>29</sup> either because they forget, or because they lose the courage to return. In an effort to overcome this problem, the American government has invested large sums of money in the distribution of ‘rapid tests’. With a rapid test, the individual can be given their results on the same day, sometimes in as little as 20 minutes. This makes these tests particularly well suited for use in busy hospitals, or non-healthcare settings.<br />
Rapid testing now plays a major role in the USA’s annual HIV testing day, which takes place on 27th June and is sponsored by the National Association of People with AIDS (NAPWA). In recent years, centres throughout the country have offered free rapid tests on this day. More about National HIV Testing Day can be found on NAPWA’s website.<br />
There are certain sectors of society who are required by law to be tested for HIV, such as immigrants and military personnel. In some American states mandatory testing policies also apply to prison inmates. This has been criticised by the World Health Organisation, human rights groups and AIDS organisations, as it removes the basic human right of choice and can lead to the discrimination and segregation of HIV positive prison inmates.<sup>30</sup> There is currently very little evidence showing that mandatory testing in prisons is effective as a public health measure, so most AIDS organisations advocate a voluntary opt-out policy similar to that offered to pregnant women.<br />
In 2010 the CDC announced an increase in funding for the country's HIV testing programme, bringing the total budget for three years to $142.5 million.<sup>31</sup> Dr. Kevin Fenton, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases and Tuberculosis Prevention, said:<br />
<blockquote class="longquote">"This expansion will help ensure that more Americans have access to what could be life-saving information about their HIV status." <cite><sup>32</sup></cite></blockquote><h2>AIDS and sex education in America</h2>Education is an important part of HIV prevention. It is vital not only for teaching people affected by HIV/AIDS about treatment and care, but also for educating people about the ways in which HIV is transmitted and how to minimise the risk of infection. This can help to reduce the number of new infections and can assist in combating stigma.<br />
The level and type of HIV/AIDS education received by school children and students in America tend to vary depending on state regulations and the type of school or college. In some areas, sex education that incorporates information about HIV is comprehensive and compulsory. In others, it is not, and children may leave school knowing virtually nothing about HIV and AIDS.<br />
Since the Welfare Reform Law earmarked $100 million for abstinence only education in 1996, increased amounts of federal funding became available for this type of education, particularly under the presidency of George W. Bush. Abstinence only education encourages people to abstain from sex until after they are married, and unlike comprehensive sex education, it does not teach people how to protect themselves during sex from disease and unwanted pregnancy. A number of studies have shown that abstinence only education is largely ineffective,<sup>33</sup> and as a result, this form of sex education has proved controversial. Many AIDS and sexual health organisations advocate a more comprehensive approach that includes information about condoms and general discussion of teenage sexual relationships.<br />
AIDS education amongst adults is used as a prevention tool in America, particularly in communities where HIV levels are high. Discussion of AIDS in the workplace, or at community meetings and religious gatherings, can provide essential information to adults who might otherwise be unaware that they are at risk. Due to the increasing number of new HIV infections among people over 50 years old, some communities have started to provide AIDS education for the older generation.<sup>34</sup><br />
<h2>HIV and AIDS treatment and care in America</h2>Antiretroviral treatment is available to anyone with good medical insurance in America. For those who are without insurance, or are underinsured for their condition, there are a number of options available to help fund treatment, including Medicaid, Medicare, and funding provided by the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act.<sup>35</sup><br />
Unfortunately for those underinsured, levels of funding have not always been sufficient to provide adequate treatment and care services for an ever-growing HIV positive population. The US AIDS Drug Assistance Program (ADAP), which aims to provide treatment for the very poorest through Ryan White CARE Act funding, was critically underfunded for many years. By June 2004 there were 1,629 people waiting for AIDS drugs in 11 states.<sup>36</sup> These waiting lists were not fully cleared until September 2007 and soon reappeared. As of May 2010, there were more than 1,100 people on waiting lists in a total of 10 states.<sup>37</sup><br />
Those with advanced HIV infection who need newer, more expensive AIDS drugs to keep their condition under control may also face problems with obtaining funding from their insurance company. This said, ‘expanded access’ trials of new antiretroviral drugs for people who have exhausted their treatment options are regularly conducted across America, extending the lives of many who might otherwise die of AIDS.<sup>38</sup> This is a legacy of strong activism in the early days of the epidemic that encouraged better and more rapid access to new drugs.<br />
AVERT.org has more about AIDS treatment and care in America.<br />
<h2>Stigma and discrimination</h2><div class="photo_l"> <img alt="an AIDS poster
reading 'I HAVE AIDS please hug me, I can't make you sick'" border="0" src="http://www.avert.org/media/photos/337.jpg" width="250" /> <div style="width: 250px;">'I have AIDS please hug me' poster</div></div>While HIV and AIDS today affect more people than ever before, the general attitude towards AIDS has relaxed somewhat. Once a subject that caused considerable panic and hysteria in the media, AIDS in America is now comparatively overlooked by the press. This is in part due to the fact that AIDS never became the generalised epidemic once feared, and also because the introduction of antiretroviral therapy in the mid-1990s signalled the end of AIDS as a condition always considered fatal. Better knowledge of transmission routes and risk factors has also helped to calm fears.<br />
Legislation has contributed to the improvement of the lives of those living with HIV and AIDS in America. In 1986, the government made clear to employers that they would be prosecuted if they discriminated against HIV positive people. The ‘Americans with Disabilities Act’ now makes it illegal to discriminate against someone on the basis of their HIV status.<sup>39</sup><br />
However, stigma and discrimination in America does persist and many HIV positive people find that they are discriminated against on a day-to-day basis. In 2007, a woman from New York State filed a lawsuit against a summer holiday camp after her 10-year-old son was turned away for having HIV.<sup>40</sup><br />
In October 2009, President Obama announced that America's ban on entry into the country for HIV positive people, would be lifted.<sup>41</sup> The ban, which was instituted in 1987, restricted all HIV positive people from entering the country, whether they were on holiday or visiting on a longer-term basis. Those who did not hold an approved medical waiver form (which was often difficult to acquire) risked being barred entry or deported if they test HIV positive or were found to be carrying antiretroviral medication. In his speech, the President said:<br />
<blockquote class="longquote">"Twenty-two years ago, in a decision rooted in fear rather than fact, the United States instituted a travel ban on entry into the country for people living with HIV/AIDS. Now, we talk about reducing the stigma of this disease - yet we've treated a visitor living with it as a threat. We lead the world when it comes to helping stem the AIDS pandemic - yet we are one of only a dozen countries that still bar people from HIV from entering our own country". - <cite>President Barack Obama<sup>42</sup></cite></blockquote>The full removal of the ban took effect on 4th January 2010.<sup>43</sup><br />
<h2>Spending on AIDS in America</h2>The federal budget request for fiscal year (FY) 2011 includes a total of $20.5 billion for domestic HIV and AIDS, a 5% increase from the FY 2010 funding, which totaled $19.4 billion. Of this, 69 percent is for care, 11 percent for research, 10 percent for cash and housing assistance, and 3 percent for prevention.<sup>44</sup><br />
Although spending on the domestic HIV epidemic has risen in recent years, many AIDS organisations say it remains inadequate. Cash shortages are particularly severe in Southern states, where the epidemic is newer, and funding has not yet been allocated to reflect the increase in cases. Recent changes to the Ryan White CARE Act were designed to address this problem, but have met with strong opposition from those in higher prevalence areas, who have suffered cuts in federal funding to pay for improved services in the South.<sup>45</sup><br />
<h2>Conclusion</h2><div class="photo_r"> <img alt="The NAMES Project
AIDS quilt" border="0" src="http://www.avert.org/media/photos/1195.jpg" width="300" /> <div style="width: 300px;">The NAMES Project AIDS quilt</div></div>Of all the industrialised countries in the world, America is home to the largest number of people living with HIV. Tens of thousands of people are newly infected with HIV in America every year and although infection rates have declined among injecting drug users, there has been an alarming increase among men who have sex with men.<sup>46</sup><br />
Over 14,500 people died of AIDS in 2007 alone, yet increasingly AIDS is seen as an ‘overseas’ or an ‘African’ problem, rather than something that directly affects American citizens. The President’s Emergency Plan for AIDS Relief (PEPFAR) tends to receive greater attention and attract considerably more comment in the press than the work taking place within America.<br />
When AIDS is mentioned on a national level, it is often in relation to the chronic funding shortages for AIDS services, or the epidemic among African Americans. With the exception of the reduction in mother-to-child transmission in recent years, the news is rarely good. AIDS continues to affect marginalised groups, and continues to receive nowhere near the attention or funding that is required to effectively tackle the problem<br />
<br />
<div class="box bFull" id="footnote"> <h2>References:</h2><ol><li>Centers for Disease Control and Prevention (2009), <a ,="" href="http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/default.htm" target="_blank">HIV/AIDS Surveillance Report 2007, (Vol. 19)</a></li>
<li>CDC '<a ,="" href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5739a2.htm" target="_blank">HIV Prevalence Estimates -- United States, 2006</a>' MMWR 57(39), 3 October 2008</li>
<li>Hall, H.I. et al (2008, 6th August) '<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18677024" target="_blank">Estimation of HIV incidence in the United States</a>' JAMA 300(5)</li>
<li>The Washington Post (2009, 15th March) <a ,="" href="http://www.washingtonpost.com/wp-dyn/content/article/2009/03/14/AR2009031402176_pf.html" target="_blank">'HIV/AIDS rate in D.C. hits 3%'</a></li>
<li>Centers for Disease Control and Prevention (2009), <a ,="" href="http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/default.htm" target="_blank">HIV/AIDS Surveillance Report 2007, (Vol. 19)</a></li>
<li>United States Census Bureau <a ,="" href="http://factfinder.census.gov/servlet/DTTable?_bm=y&-context=dt&-ds_name=PEP_2007_EST&-mt_name=PEP_2007_EST_G2007_T003_2007&-mt_name=PEP_2007_EST_G2007_T004_2007&-CONTEXT=dt&-tree_id=306&-redoLog=true&-all_geo_types=N&-currentselections=ACS_2006_EST_G2000_B02001&-geo_id=01000US&-search_results=01000US&-format=&-_lang=en" target="_blank">‘2007 American Community Survey’</a>.</li>
<li>Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 2007, (Vol. 19)</li>
<li>The Henry J. Kaiser Family Foundation (2008, May) <a ,="" href="http://www.kff.org/hivaids/6007.cfm" target="blank">‘HIV/AIDS policy fact sheet: Latinos and HIV/AIDS’</a>.</li>
<li>CDC (2008, April) <a ,="" href="http://www.cdc.gov/hiv/hispanics/resources/factsheets/hispanic.htm" target="blank">‘HIV/AIDS among Hispanics/Latinos’</a>.</li>
<li>Latino Commission on AIDS (2009) '<a ,="" href="http://www.latinoaids.org/news_detail.php?cat=pr&id=155" target="_blank">New York State Responds to the Latino HIV/AIDS Crisis and Plans for Action</a>'</li>
<li>Centers for Disease Control and Prevention (2009), <a ,="" href="http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/default.htm" target="_blank">HIV/AIDS Surveillance Report 2007, (Vol. 19)</a></li>
<li>CDC (2007, June) <a ,="" href="http://www.cdc.gov/hiv/topics/msm/resources/factsheets/msm.htm" target="blank">‘HIV/AIDS among men who have sex with men’</a>.</li>
<li>MMWR (2008, 27th June) <a ,="" href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a2.htm" target="blank">‘Trends in HIV/AIDS diagnoses among men who have sex with men – 33 states, 2001-2006’</a>.</li>
<li>CDC (2007, June) <a ,="" href="http://www.cdc.gov/hiv/topics/msm/resources/factsheets/msm.htm" target="blank">‘HIV/AIDS among men who have sex with men’</a>.</li>
<li>The Washington Post (2010, March 26th) '<a ,="" href="http://www.washingtonpost.com/wp-dyn/content/article/2010/03/25/AR2010032503730.html" target="_blank">Study of gay men in the District finds 14% are HIV positive</a>'</li>
<li>Centers for Disease Control and Prevention (2009), <a ,="" href="http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/default.htm" target="_blank">HIV/AIDS Surveillance Report 2007, (Vol. 19)</a></li>
<li>Monterroso, E.R et al (2000, 1st September) <a ,="" href="http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=11064506&cmd=showdetailview&indexed=google" target="blank">‘Prevention of HIV infection in street-recruited injection drug users’</a>. The Collaborative Injection Drug User Study (CIDUS).</li>
<li>Don, C et al (2005, August) <a ,="" href="http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1449378" target="blank">‘HIV incidence among injection drug users in New York City, 1990 to 2002: Use of serologic test algorithm to assess expansion of HIV prevention’</a>. American Journal of Public Health, Vol. 9, No. 8.</li>
<li>MMWR (2008, 27th June) <a ,="" href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a2.htm#fig1" target="blank">‘Trends in HIV/AIDS diagnoses among men who have sex with men – 33 states, 2001-2006’</a>.</li>
<li>Statehealthfacts.org <a ,="" href="http://www.statehealthfacts.org/comparemaptable.jsp?ind=508&cat=11" target="blank">‘New AIDS cases, reported in 2007’</a>. The Henry J. Kaiser Family Foundation.</li>
<li>MMWR (2003, 18th April) <a ,="" href="http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5215a1.htm" target="blank">‘Advancing HIV prevention: New Strategies for a Changing Epidemic – United States, 2003’</a>.</li>
<li>MMWR (2006, 2nd June) <a ,="" href="http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5521a4.htm" target="blank">‘Evolution of HIV/AIDS prevention programs – United States, 1981-2006’</a>.</li>
<li>Hall, H.I. et al (2008, 6th August) '<a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18677024" target="_blank">Estimation of HIV incidence in the United States</a>' JAMA 300(5)</li>
<li>AIDS Healthcare Foundation (2009, 2nd June) <a ,="" href="http://www.aidshealth.org/news/press-releases/aids-is-dcs-katrina-ad.html" target="_blank">'"AIDS is DC's Katrina" ad challenges Obama to act on U.S. epidemic'</a></li>
<li>Campaign website: <a ,="" href="http://www.changeaidsobama.com/" target="_blank">www.changeaidsobama.com</a></li>
<li>CDC (2009, 26th June) <a ,="" href="http://www.cdc.gov/mmWR/preview/mmwrhtml/mm5824a2.htm" target="_blank">'Late HIV Testing - 34 States, 1996-2005'</a>, MMWR Weekly, 58(24); 661-665.</li>
<li>CDC (2006, 22nd September) <a ,="" href="http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm" target="blank">‘Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings’</a>. MMWR Weekly Report, Vol. 55.</li>
<li>Amednews.com (2007, 8th October) <a ,="" href="http://www.ama-assn.org/amednews/2007/10/08/hlsa1008.htm" target="blank">‘Routine HIV testing making slow inroads’</a>.</li>
<li>CDC (2004) <a ,="" href="http://www.cdc.gov/hiv/topics/prev_prog/AHP/resources/factsheets/QuickFacts_April2004.htm" target="blank">‘Quick facts: Rapid testing April 2003 – April 2004’</a>.</li>
<li>Weinstein, C & Greenspan, J (2003) <a ,="" href="http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1448017" target="blank">‘Mandatory HIV testing in prisons’</a>. American Journal of Public Health, 2003 October; 93(10): 1617.</li>
<li>United Press International (2010, 2nd April) <a ,="" href="http://www.upi.com/Health_News/2010/04/02/CDC-increases-HIV-testing-program/UPI-68031270183397/" target="_blank">'CDC increases HIV testing program'</a></li>
<li>United Press International (2010, 2nd April) <a ,="" href="http://www.upi.com/Health_News/2010/04/02/CDC-increases-HIV-testing-program/UPI-68031270183397/" target="_blank">'CDC increases HIV testing program'</a></li>
<li>Mathematica Policy Reseach Inc. (2007, April) <a ,="" href="http://www.mathematica-mpr.com/press%20releases/abstinencereport0407.asp" target="blank">‘</a><a ,="" href="http://aspe.hhs.gov/hsp/abstinence07/" target="_blank">Impacts of four abstinence education programs</a>’.</li>
<li>CDC (2008, February) <a ,="" href="http://www.cdc.gov/hiv/topics/over50/resources/factsheets/over50.htm" target="blank">‘HIV/AIDS among persons aged 50 and older’</a>.</li>
<li>The Henry J. Kaiser Family Foundation (2007, March) <a ,="" href="http://www.kff.org/hivaids/7582.cfm" target="blank">‘Fact sheet: Ryan White Program’</a>.</li>
<li>The Body (2004, June 8th) ‘<a ,="" href="http://www.thebody.com/content/money/art10332.html" target="_blank">More Than 1,600 People on 11 State ADAP Waiting Lists, NASTAD Report Says’</a>.</li>
<li>The National Alliance of State and Territorial AIDS Directors (NASTAD) (2010, May) '<a ,="" href="http://www.nastad.org/Programs/ADAP/" target="_blank">National ADAP Monitoring Report</a>'</li>
<li>Huff, B (2006, January – March) <a ,="" href="http://www.aegis.com/pubs/gmhc/2006/GM200101.html" target="blank">‘Uncertain future for early access?’</a> Treatment Issues: Newsletter of current issues in HIV/AIDS. Vol. 20 No. 1,2 & 3. Gay Men’s Health Crisis.</li>
<li>The U.S. Equal Employment Opportunity Commission (2005, 17th October) <a ,="" href="http://www.eeoc.gov/facts/association_ada.html" target="blank">‘Questions and answers about the association provision of the Americans with Disabilities act’</a>.</li>
<li>POZ.com (2007, 26th July) <a ,="" href="http://www.poz.com/articles/summer_hiv_camp_1_12651.shtml" target="blank">‘Summer camp sued for barring positive 10-year-old’</a>.</li>
<li>President Obama's speech (2009, 30th October) <a ,="" href="http://www.whitehouse.gov/the-press-office/remarks-president-signing-ryan-white-hivaids-treatment-extension-act-2009" target="_blank">'Remarks by the President at signing of the Ryan White HIVAIDS Treatment Extension Act of 2009'</a></li>
<li>President Obama's speech (2009, 30th October) <a ,="" href="http://www.whitehouse.gov/the-press-office/remarks-president-signing-ryan-white-hivaids-treatment-extension-act-2009" target="_blank">'Remarks by the President at signing of the Ryan White HIVAIDS Treatment Extension Act of 2009'</a></li>
<li>Office of the Federal Register (2009, 2nd November) <a ,="" href="http://www.gpo.gov/fdsys/search/pagedetails.action?granuleId=E9-26337&packageId=FR-2009-11-02&acCode=FR" target="_blank">'74 FR 56547 - Medical examination of aliens-removal of Human Immunodeficiency Virus (HIV) from definition of communicable disease of public health significance'</a>, Federal Register Vol. 74, Issue 210</li>
<li>The Henry J. Kaiser Family Foundation (2008, April) <a ,="" href="http://www.kff.org/hivaids/7029.cfm" target="_blank">'U.S. federal funding for HIV/AIDS: The FY 2011 budget request'</a>.</li>
<li>The New York Times (2007, 1st August) <a ,="" href="http://www.nytimes.com/2007/08/01/washington/01aids.html" target="blank">‘HIV patients anxious as support programs cut’</a>.</li>
<li>MMWR (2008, 27th June) <a ,="" href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a2.htm#fig1" target="blank">‘Trends in HIV/AIDS diagnoses among men who have sex with men – 33 states, 2001-2006’</a>.</li>
</ol></div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0tag:blogger.com,1999:blog-5202886745511094780.post-33626178226106834512010-06-08T12:18:00.000-07:002010-06-08T12:18:46.853-07:00The impact of HIV & AIDS in Africa<div class="box bFull"> Two-thirds of all people infected with HIV live in sub-Saharan Africa, although this region contains little more than 10% of the world’s population.<sup>1</sup> AIDS has caused immense human suffering in the continent. The most obvious effect of this crisis has been illness and death, but the impact of the epidemic has certainly not been confined to the health sector; households, schools, workplaces and economies have also been badly affected.<br />
During 2008 alone, an estimated 1.4 million adults and children died as a result of AIDS in sub-Saharan Africa.<sup>2</sup> Since the beginning of the epidemic more than 15 million Africans have died from AIDS.<sup>3</sup><br />
Although access to antiretroviral treatment is starting to lessen the toll of AIDS, fewer than half of Africans who need treatment are receiving it.<sup>4</sup> The impact of AIDS will remain severe for many years to come.<br />
</div><h2>The impact on the health sector</h2>In all heavily affected countries the AIDS epidemic is adding additional pressure on the health sector. As the epidemic matures, the demand for care for those living with HIV rises, as does the toll of AIDS on health workers. In sub-Saharan Africa, the direct medical costs of AIDS (excluding antiretroviral therapy) have been estimated at about US$30 per year for every person infected, at a time when overall public health spending is less than US$10 per year for most African countries.<sup>5</sup><br />
<h3>The effect on hospitals</h3><div class="photo_r"><img alt="Kisiizi Hospital's
bedroom" border="0" height="225" src="http://www.avert.org/media/photos/1419.jpg" width="300" /> <div style="width: 300px;">Nurses working on the HIV ward at Kisiizi Hospital in Uganda</div><a name='more'></a><br />
</div>As the HIV prevalence of a country rises, the strain placed on its hospitals is likely to increase. In sub-Saharan Africa, people with HIV-related diseases occupy more than half of all hospital beds.<sup>6</sup> Government-funded research in South Africa has suggested that, on average, HIV-positive patients stay in hospital four times longer than other patients.<sup>7</sup><br />
Hospitals are struggling to cope, especially in poorer African countries where there are often too few beds available. This shortage results in people being admitted only in the later stages of illness, reducing their chances of recovery.<br />
<h3>Health care workers</h3>While AIDS is causing an increased demand for health services, large numbers of healthcare professionals are being directly affected by the epidemic. Botswana, for example, lost 17% of its healthcare workforce due to AIDS between 1999 and 2005. A study in one region of Zambia found that 40% of midwives were HIV-positive.<sup>8</sup> Healthcare workers are already scarce in most African countries. Excessive workloads, poor pay and migration to richer countries are among the factors contributing to this shortage.<br />
Although the recent increase in the provision of antiretroviral drugs (which significantly delay the progression from HIV to AIDS) has brought hope to many in Africa, it has also put increased strain on healthcare workers. Providing antiretroviral treatment to everyone who needs it requires more time and training than is currently available in most countries.<br />
<h2>The impact on households</h2>The toll of HIV and AIDS on households can be very severe. Although no part of the population is unaffected by HIV, it is often the poorest sectors of society that are most vulnerable to the epidemic and for whom the consequences are most severe. In many cases, the presence of AIDS causes the household to dissolve, as parents die and children are sent to relatives for care and upbringing. A study in rural South Africa suggested that households in which an adult had died from AIDS were four times more likely to dissolve than those in which no deaths had occurred.<sup>9</sup> Much happens before this dissolution takes place: AIDS strips families of their assets and income earners, further impoverishing the poor.<br />
<h3>Household income</h3>In Botswana it is estimated that, on average, every income earner is likely to acquire one additional dependent over the next ten years due to the AIDS epidemic. A dramatic increase in destitute households – those with no income earners – is also expected.<sup>10</sup><br />
Other countries in the region are experiencing the same problem, as individuals who would otherwise provide a household with income are prevented from working – either because they are ill with AIDS themselves or because they are caring for another sick family member.<br />
Such a situation is likely to have repercussions for every member of the family. Children may be forced to abandon their education and in some cases women may be forced to turn to sex work ('prostitution'). This can lead to a higher risk of HIV transmission, which further exacerbates the situation.<br />
<h3>Basic necessities</h3>A study in South Africa found that poor households coping with members who are sick from HIV or AIDS were reducing spending on necessities even further. The most likely expenses to be cut were clothing (21%), electricity (16%) and other services (9%). Falling incomes forced about 6% of households to reduce the amount they spent on food and almost half of households reported having insufficient food at times.<sup>11</sup><br />
<blockquote class="longquote">"She then led me to the kitchen and showed me empty buckets of food and said they had nothing to eat that day just like other days."<sup>12</sup></blockquote><h3>Food production</h3>The AIDS epidemic adds to food insecurity in many areas, as agricultural work is neglected or abandoned due to household illness. In Malawi, where food shortages have had a devastating effect, it has been recognised that HIV and AIDS are diminishing the country’s agricultural output.<sup>13</sup> It is thought that by 2020, Malawi’s agricultural workforce will be 14% smaller than it would have been without HIV and AIDS. In other countries, such as Mozambique, Botswana, Namibia and Zimbabwe, the reduction is likely to be over 20%.<sup>14</sup><br />
A study in Kenya demonstrated that food production in households in which the head of the family died of AIDS were affected in different ways depending on the sex of the deceased. As in other sub-Saharan African countries, it was generally found that the death of a male reduced the production of ‘cash crops’ (such as coffee, tea and sugar), while the death of a female reduced the production of grain and other crops necessary for household survival.<sup>15</sup><br />
<h3>Healthcare expenses and funeral costs</h3>Taking care of a person sick with AIDS is not only an emotional strain for household members, but also a major strain on household resources. Loss of income, additional care-related expenses, the reduced ability of caregivers to work, and mounting medical fees push affected households deeper into poverty. It is estimated that, on average, HIV-related care can absorb one-third of a household’s monthly income.<sup>16</sup><br />
The financial burden of death can also be considerable, with some families in South Africa easily spending seven times their total household monthly income on a funeral. Furthermore, although many South Africans contribute to some sort of funeral insurance plan, many of these are inadequately funded, and it is arguable that such financial arrangements detract from other savings plans or health insurance.<sup>17</sup><br />
Aside from the financial burden, providing home based care can impose demands on the physical, mental and general health of carers – usually family and friends of the sick person. Such risks are amplified if carers are untrained or unsupported by a home-based care organisation.<br />
<h3>How do HIV/AIDS-affected households cope in Africa?</h3>Three main coping strategies appear to be adopted among affected households. Savings are used up or assets sold; assistance is received from other households; and the composition of households tends to change, with fewer adults of prime working age in the households.<br />
Almost invariably, the burden of coping rests with women. Upon a family member becoming ill, the role of women as carers, income-earners and housekeepers is stepped up. They are often forced to step into roles outside their homes as well. In parts of Zimbabwe, for example, women are moving into the traditionally male-dominated carpentry industry. This often results in women having less time to prepare food and for other tasks at home.<br />
<blockquote class="longquote">"I used to stay with the children, but now it is a problem. I have to work in the fields. Last year I had more money to hire labour so the crops got weeded more often. This year I had to do it myself.” <cite>Angelina, Zimbabwe<sup>18</sup></cite></blockquote>Older people are also heavily affected by the epidemic; many have to care for their sick children and are often left to look after orphaned grandchildren. Older people left caring for the sick face the burden of providing financial, emotional and psychological support at a time when they would usually be expecting to receive more support as their energy levels drop with older age. Due to the amount of time spent caring for dependents, older people may become isolated from their peers as they no longer have the time to dedicate to their social networks that need to be fostered to prevent isolation and loneliness.<br />
Tapping into savings if available and taking on more debt are usually the first options chosen by households struggling to pay for medical treatment or funerals. Then as debts mount, precious assets such as bicycles, livestock and even land are sold. Once households are stripped of their productive assets, the chances of them recovering and rebuilding their livelihoods become even slimmer.<br />
The number of working adults in a family will often decrease.<br />
<blockquote class="longquote">“Our fields are idle because there is nobody to work them. We don't have machinery for farming, we only have manpower - if we are sick, or spend our time looking after family members who are sick, we have no time to spend working in the fields." <cite>Toby Solomon, commissioner for the Nsanje district, Malawi<sup>19</sup></cite></blockquote>One of the more unfortunate responses to a death in poorer households is removing the children (especially girls) from school. Often the school uniforms and fees become unaffordable for the families and the child's labour and income-generating potential are required in the household.<br />
<blockquote class="longquote">“Because I’m a poor African woman, I can’t raise enough money for three orphans. The one in secondary school, sometimes she misses first term because I’m looking for tuition. The others miss schools for two or three days at a time. I had a cow I used to milk, but as time went on the cow died, so I can’t find any other income…” <cite>Barbara, Uganda <sup>20</sup></cite></blockquote><h2>The impact on children</h2>It is hard to overemphasise the trauma and hardship that children affected by HIV and AIDS are forced to bear. The epidemic not only causes children to lose their parents or guardians, but sometimes their childhood as well.<br />
As parents and family members become ill, children take on more responsibility to earn an income, produce food, and care for family members. It is harder for these children to access adequate nutrition, basic health care, housing and clothing. Fewer families have the money to send their children to school.<br />
Often both of the parents are HIV positive in Africa. Consequently, more children have been orphaned by AIDS in Africa than anywhere else. Many children are now raised by their grandparents or left on their own in child-headed households.<br />
As projections of the number of AIDS orphans rise, some have called for an increase in institutional care for children. However this solution is not only expensive but also detrimental to the children. Institutionalisation stores up problems for society, which is ill equipped to cope with an influx of young adults who have not been socialised in the community in which they have to live. There are other alternatives available. One example is the approach developed by church groups in Zimbabwe, in which community members are recruited to visit orphans in their homes, where they live either with foster parents, grandparents or other relatives, or in child-headed households.<br />
The way forward is prevention. Firstly, it is crucial to prevent children from becoming infected with HIV at birth as well as later in life. Secondly, if efforts are made to prevent adults becoming infected with HIV, and to care for those already infected, then fewer children will be orphaned by AIDS in the future.<br />
To learn more, see our children HIV & AIDS page.<br />
<h2>The impact on the education sector</h2>The relationship between AIDS and the education sector is circular – as the epidemic worsens, the education sector is damaged, which in turn is likely to increase the incidence of HIV transmission. There are numerous ways in which AIDS can affect education, but equally there are many ways in which education can help the fight against AIDS. The extent to which schools and other education institutions are able to continue functioning will influence how well societies eventually recover from the epidemic.<br />
<blockquote class="longquote">"Without education, AIDS will continue its rampant spread. With AIDS out of control, education will be out of reach." <cite>Peter Piot, Director of UNAIDS<sup>21</sup></cite></blockquote><h3>Fewer children receiving a basic education</h3><div class="photo_r"><img alt="Children at a
school in Illinge, South Africa, many of which are affected by HIV and
AIDS" border="0" src="http://www.avert.org/media/photos/681.jpg" width="300" /> <div style="width: 300px;">Children at a school in Illinge, South Africa. Many are affected by HIV and AIDS.</div></div>A decline in school enrolment is one of the most visible effects of the epidemic. This in itself will have an effect on HIV prevention, as a good, basic education ranks among the most effective and cost-effective means of preventing HIV.<sup>22</sup><br />
There are numerous barriers to school attendance in Africa. Children may be removed from school to care for parents or family members, or they may themselves be living with HIV. Many are unable to afford school fees and other such expenses – this is particularly a problem among children who have lost their parents to AIDS, who often struggle to generate income.<br />
Studies have suggested that young people with little or no education may be around twice as likely to contract HIV as those who have completed primary education.<sup>23</sup> In this context, the devastating effect that AIDS is having on school enrolment is a big concern. In Swaziland and the Central African Republic, it has been reported that school enrolment has fallen by 25-30% due to AIDS.<sup>24</sup><br />
<h3>The impact on teachers</h3>HIV and AIDS are having a devastating affect on the already inadequate supply of teachers in African countries; for example, a study in South Africa found that 21% of teachers aged 25-34 are living with HIV.<sup>25</sup><br />
Teachers who are affected by HIV and AIDS are likely to take periods of time off work. Those with sick families may also take time off to attend funerals or to care for sick or dying relatives, and further absenteeism may result from the psychological effects of the epidemic.<sup>26</sup><br />
When a teacher falls ill, the class may be taken on by another teacher, may be combined with another class, or may be left untaught. Even when there is a sufficient supply of teachers to replace losses, there can be a significant impact on the students. This is particularly concerning given the important role that teachers can play in the fight against AIDS.<br />
The illness or death of teachers is especially devastating in rural areas where schools depend heavily on one or two teachers. Moreover, skilled teachers are not easily replaced. Tanzania has estimated that it needs around 45,000 additional teachers to make up for those who have died or left work because of HIV and AIDS. The greatest proportion of staff that have been lost, according to the Tanzania Teacher’s Union, were experienced staff between the ages of 41 and 50.<sup>27</sup><br />
<h2>The impact on enterprises and workplaces</h2>HIV and AIDS dramatically affect labour, setting back economic and social progress. The vast majority of people living with HIV in Africa are between the ages of 15 and 49 - in the prime of their working lives.<br />
AIDS damages businesses by squeezing productivity, adding costs, diverting productive resources, and depleting skills. Company costs for health-care, funeral benefits and pension fund commitments are likely to rise as the number of people taking early retirement or dying increases. Also, as the impact of the epidemic on households grows more severe, market demand for products and services can fall. The epidemic hits productivity through increased absenteeism. Comparative studies of East African businesses have shown that absenteeism can account for as much as 25-54% of company costs.<sup>28</sup><br />
A study in several Southern African countries has estimated that the combined impact of AIDS-related absenteeism, productivity declines, health-care expenditures, and recruitment and training expenses could cut profits by at least 6-8%.<sup>29</sup> Another study of a thousand companies in Southern Africa found that 9% had suffered a significant negative impact due to AIDS. In areas that have been hit hardest by the epidemic, it found that up to 40% of companies reported that HIV and AIDS were having a negative effect on profits.<br />
Some companies, though, have implemented successful programmes to deal with the epidemic. An example is the gold-mining industry in South Africa. The gold mines attract thousands of workers, often from poor and remote regions. Most live in hostels, separated from their families. As a result a thriving sex industry operates around many mines and HIV is common. In recent years, mining companies have been working with a number of organisations to implement prevention programmes for the miners. These have included mass distribution of condoms, medical care and treatment for sexually transmitted diseases, and awareness campaigns. Some mining companies have started to replace all-male hostels with accommodation for families, in order to reduce the transmission of HIV and other sexually transmitted diseases.<sup>30</sup><br />
In Swaziland, an employers' anti-AIDS coalition has been set up to promote voluntary counselling and testing. The coalition not only includes larger companies but also small and medium sized enterprises.<sup>31</sup> In Botswana, the Debswana diamond company offers all employees HIV testing, and provides antiretroviral drugs to HIV positive workers and their spouses.<sup>32</sup> This policy was introduced in 1999 when the company found that many of their workforce were HIV positive. With a skilled workforce, it is financially worth their while to protect the health and therefore the productivity of their workers. Nevertheless, workplace programmes for HIV treatment and prevention remain scarce in Africa.<sup>33</sup><br />
<h2>The impact on life expectancy</h2><div class="photo_l"><img alt="man standing in
front of his workshop" border="0" height="225" src="http://www.avert.org/media/photos/1646.jpg" width="300" /> <div style="width: 300px;">A coffin maker and his workshop in Nkhata Bay, Malawi</div></div>In many countries of sub-Saharan Africa, AIDS is erasing decades of progress in extending life expectancy. In the worst affected countries, average life expectancy has fallen by twenty years because of the epidemic.<sup>34</sup> Life expectancy at birth in Swaziland is just 31 years - less than half of what it would be without AIDS.<sup>35</sup><br />
The impact that AIDS has had on average life expectancy is partly attributed to child mortality, as increasing numbers of babies are born with HIV infections acquired from their mothers. The biggest increase in deaths, however, has been among adults aged between 20 and 49 years. This group now accounts for 60% of all deaths in sub-Saharan Africa, compared to 20% between 1985 and 1990, when the epidemic was in its early stages.<sup>36</sup> By affecting this age group so heavily, AIDS is hitting adults in their most economically productive years and removing the very people who could be responding to the crisis.<br />
<h2>The economic impact</h2>Through its impacts on the labour force, households and enterprises, AIDS has played a more significant role in the reversal of human development than any other single factor.<sup>37</sup> One aspect of this development reversal has been the damage that the epidemic has done to the economy, which, in turn, has made it more difficult for countries to respond to the crisis.<br />
One way in which AIDS affects the economy is by reducing the labour supply through increased mortality and illness. Amongst those who are able to work, productivity is likely to decline as a result of HIV-related illness. Government income also declines, as tax revenues fall and governments are pressured to increase their spending to deal with the expanding HIV epidemic.<br />
The abilities of African countries to diversify their industrial base, expand exports and attract foreign investment are integral to economic progress in the region. By making labour more expensive and reducing profits, AIDS limits the ability of African countries to attract industries that depend on low-cost labour and makes investments in African businesses less desirable. HIV and AIDS therefore threaten the foundations of economic development in Africa.<sup>38</sup><br />
The impact that AIDS has had on the economies of African countries is difficult to measure. The economies of the worst affected countries were already struggling with development challenges, debt and declining trade before the epidemic started to affect the continent. AIDS has combined with these factors to further aggravate the situation. It is thought that the impact of AIDS on the gross domestic product (GDP) of the worst affected countries is a loss of around 1.5% per year; this means that after 25 years the economy would be 31% smaller than it would otherwise have been.<sup>39</sup><br />
<h2>The future impact of HIV/AIDS</h2>This page has outlined just some of the ways in which the AIDS epidemic has had a significant impact on countries in sub-Saharan Africa. Although both international and domestic efforts to overcome the crisis have been strengthened in recent years, there is little sign of the epidemic diminishing. The people of sub-Saharan Africa will continue to feel the effects of HIV and AIDS for many years to come. It is clear that as much as possible needs to be done to minimise this impact.<br />
As access to treatment is slowly expanded throughout the continent, millions of lives are being extended and hope is being given to people who previously had none. Unfortunately though, the majority of people in need of treatment are still not receiving it, and campaigns to prevent new infections (which must remain the central focus of the fight against AIDS) are lacking in many areas.<br />
AIDS in Africa is linked to many other problems, such as poverty and poor public infrastructures. Efforts to fight the epidemic must take these realities into account, and look at ways in which the general development of Africa can progress. As the evidence discussed in this page makes clear, however, AIDS is acting as the single greatest barrier to Africa’s development. Much wider access to HIV prevention, treatment and care services is urgently needed.<br />
<div class="box bFull" id="footnote"> <h2>References</h2><ol><li><span class="externallink">UNAIDS (2008) </span><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">'Report on the global AIDS epidemic'</span></a></li>
<li>UNAIDS (2009) 'Report on the global AIDS epidemic'</li>
<li><span class="externallink">UNAIDS (2008) </span><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">'Report on the global AIDS epidemic'</span></a></li>
<li>WHO/UNAIDS/UNICEF (2009) <a ,="" href="http://www.who.int/hiv/pub/2009progressreport/en/index.html" target="_blank">'Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector'</a></li>
<li>UNAIDS (2002) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/Archive.asp" target="_blank">'Report on the global AIDS epidemic'</a></li>
<li>UNAIDS <span class="externallink">(2006) </span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">'Report on the global AIDS epidemic</a>', chapter 4: The impact of AIDS on people and societies</li>
<li>Inter Press Service News Agency (May 2006) <a ,="" class="externallink" href="http://www.ipsnews.net/africa/nota.asp?idnews=33396" target="_blank">'Health South Africa: a burden that will only become heavier'</a></li>
<li>UNAIDS (<span class="externallink">2006) </span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">'Report on the global AIDS epidemic</a>', chapter 4: The impact of AIDS on people and societies</li>
<li>Hosegood V., McGrath N et al. (2004), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/15238777?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum" target="_blank">‘The impact of adult mortality on household dissolution and migration in rural South Africa’,</a> AIDS, July 23rd, Vol. 18, issue 11</li>
<li>UNAIDS (<span class="externallink">2006) </span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">'Report on the global AIDS epidemic'</a>, chapter 4: The impact of AIDS on people and societies</li>
<li>The Henry J. Kaiser Family Foundation (October 2002), <a ,="" class="externallink" href="http://www.kff.org/southafrica/20021125a-index.cfm" target="_blank">'Hitting Home: How Households Cope with the Impact of the HIV/AIDS Epidemic'</a></li>
<li>The Henry J. Kaiser Family Foundation (October 2002), <a ,="" class="externallink" href="http://www.kff.org/southafrica/20021125a-index.cfm" target="_blank">'Hitting Home: How Households Cope with the Impact of the HIV/AIDS Epidemic'</a></li>
<li>bbc.co.uk (October 2005), <a ,="" class="externallink" href="http://news.bbc.co.uk/1/hi/world/africa/4345246.stm" target="_blank">'Malawi issues food crisis appeal'</a></li>
<li>UNAIDS (<span class="externallink">2006) </span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">'Report on the global AIDS epidemic'</a>, chapter 4: The impact of AIDS on people and societies</li>
<li>UNAIDS, <span class="externallink">(2006) '</span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">Report on the global AIDS epidemic</a>', chapter 4: The impact of AIDS on people and societies</li>
<li>Steinberg M. et al. (October 2002), <a ,="" class="externallink" href="http://www.kff.org/southafrica/20021125a-index.cfm" target="_blank">'Hitting Home: How Households Cope with the Impact of the HIV/AIDS Epidemic'</a>, The Henry J Kaiser Foundation</li>
<li>Collins, D.L., and Leibbrandt, M., (2007, November), <a ,="" href="http://www.ncbi.nlm.nih.gov/pubmed/18040168" target="_blank">'The financial impact of HIV/AIDS on poor households in South Africa'</a>, AIDS 21: Supplement 7</li>
<li>Food and Agriculture Organization of the United Nations (2001) <a ,="" class="externallink" href="http://www.fao.org/FOCUS/E/aids/aids3-e.htm" target="_blank">Rural Women Carry Family Burdens. Focus, AIDS - A Threat to Rural Africa.</a></li>
<li>Claire Nullis, Associated Press (2005), <a ,="" href="http://www.usatoday.com/news/world/2005-10-18-malawivillage_x.htm" target="_blank">'Malawi Village Underscores Impact of AIDS'</a>, 18th October 2005</li>
<li>Human Rights Watch (2005), <a ,="" href="http://www.aidsportal.org/Article_Details.aspx?ID=879" target="_blank">‘Letting them fail: government neglect and the right to education for children affected by AIDS’</a>, Report vol. 17, No. 13 (A)</li>
<li>World Bank/UNESCO/UNAIDS Press release (2002) <a ,="" href="http://portal.unesco.org/es/ev.php-URL_ID=7195&URL_DO=DO_TOPIC&URL_SECTION=201.html" target="_blank">'In turning the tide against HIV/AIDS, education is key',</a> October 18.</li>
<li>The World Bank (2002) <a ,="" href="http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTEDUCATION/0,,contentMDK:22032449%7EmenuPK:1342884%7EpagePK:210058%7EpiPK:210062%7EtheSitePK:282386%7EisCURL:Y,00.html" target="_blank">'Education and HIV/AIDS: A window of Hope'</a></li>
<li>Global Campaign for Education (2004), <a ,="" href="http://publications.oxfam.org.uk/oxfam/display.asp?K=002P0142&sf1=series&st1=Joint%20Agency%20Briefing%20Papers&sort=sort_date/d&m=29&dc=37" target="_blank"><span class="externallink">'Learning to Survive: </span>How education for all would save millions of young people from HIV/AIDS'</a></li>
<li>UNAIDS (2002) <a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/Archive.asp" target="_blank">'Report on the Global AIDS epidemic'</a></li>
<li>UNAIDS (<span class="externallink">2006) '</span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">Report on the global AIDS epidemic'</a>, chapter 4: The impact of AIDS on people and societies</li>
<li>The World Bank (2002) <a ,="" href="http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTEDUCATION/0,,contentMDK:22032449%7EmenuPK:1342884%7EpagePK:210058%7EpiPK:210062%7EtheSitePK:282386%7EisCURL:Y,00.html" target="_blank"><span class="externallink">'Education and HIV/AIDS: A window of hope</span>'</a></li>
<li>UNAIDS <span class="externallink">(2006) </span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">'Report on the global AIDS epidemic</a>', chapter 4: The impact of AIDS on people and societies</li>
<li>UNAIDS (2003), <a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=Publications/IRC-pub06/jc1008-business_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d3434%26query%3d%2522hiv%2520aids%2520it%2520s%2520your%2520business%2522%26hiword%3daids%2520business%2520hiv%2520it%2520s%2520your%2520%26PV%3d1" target="_blank"><span class="externallink">'HIV/AIDS: It's your business'</span></a></li>
<li>UNAIDS (2003), <a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=Publications/IRC-pub06/jc1008-business_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d3434%26query%3d%2522hiv%2520aids%2520it%2520s%2520your%2520business%2522%26hiword%3daids%2520business%2520hiv%2520it%2520s%2520your%2520%26PV%3d1" target="_blank"><span class="externallink">'HIV/AIDS: It's your business'</span></a></li>
<li>UNAIDS (2003), <a ,="" href="http://search.unaids.org/Preview.aspx?d=en&u=Publications/IRC-pub06/jc1008-business_en.pdf&p=%2fcgi-bin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d3434%26query%3d%2522hiv%2520aids%2520it%2520s%2520your%2520business%2522%26hiword%3daids%2520business%2520hiv%2520it%2520s%2520your%2520%26PV%3d1" target="_blank"><span class="externallink">'HIV/AIDS: It's your business'</span></a></li>
<li>IRINnews.org (April 2005), <a ,="" class="externallink" href="http://www.irinnews.org/report.asp?ReportID=46839&SelectRegion=Southern_Africa" target="_blank">'Business Coalition Launches HIV/AIDS Mitigation Plan'</a></li>
<li>News From Africa (2003), <a ,="" class="externallink" href="http://www.newsfromafrica.org/newsfromafrica/articles/art_1252.html" target="_blank">'Mining giant fights workplace HIV/AIDS'</a></li>
<li><span class="externallink">UNAIDS (2008) </span><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">'Report on the global AIDS epidemic'</span></a>, Chapter 6</li>
<li><span class="externallink">UNAIDS (2008) '</span><a ,="" href="http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/" target="blank"><span class="externallink">Report on the global AIDS epidemic</span></a>', Chapter 1</li>
<li>CIA (accessed September 2009), '<a ,="" href="https://www.cia.gov/library/publications/the-world-factbook/geos/wz.html" target="_blank">The World Factbook - Swaziland</a>'</li>
<li>UNAIDS (<span class="externallink">2006) '</span><a ,="" class="externallink" href="http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp" target="_blank">Report on the global AIDS epidemic'</a>, chapter 4: The impact of AIDS on people and societies</li>
<li>United Nations Development Programme, <span class="externallink"><a ,="" href="http://hdr.undp.org/en/reports/global/hdr2005/" target="_blank">Human Development Report 2005</a>,</span> overview</li>
<li>Rosen S. et al (2004) <a ,="" href="http://journals.lww.com/aidsonline/toc/2004/01230" target="_blank">'The cost of HIV/AIDS to businesses in southern Africa'</a>, AIDS 18:317-324.</li>
<li>Greener R. et al (November 2004), 'The Impact of HIV/AIDS on Poverty and Inequality' in '<a ,="" href="http://www.imf.org/external/pubs/ft/AIDS/eng/index.htm" target="_blank">The Macroeconomics of AIDS</a>'</li>
</ol></div>Childrenhttp://www.blogger.com/profile/08144921172375335873noreply@blogger.com0