X HIV/AIDS Prevention and Care in Resource-Constrained Settings

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Prevention activities in the state of Tamil Nadu inIndia began in 1996. By the end of 1998 the vulnerablegroups served by the program achieved significant,sustained change in sexual behavior and demonstratedsignificantly increased condom use among CSWs andtheir clients. Consistent condom use with non-regularsex partners increased from 56 percent to 80 percentamong CSWs, and by male factory workers from 17percent to 50 percent.Uganda has become a model for curbing a severeHIV epidemic in developing countries. Behavioralsurveillance has demonstrated significant increases incondom use, decreased casual partners and delayedsexual debut by one to two years. The proportion ofUgandan girls who have ever had sex declined byalmost half between 1989 and 1995, and more thanhalf of young sexually active Ugandans report usingcondoms in their last sexual contact. This rate wasclose to zero at the outset of the epidemic. As a result,HIV infection rates among 15- to 19-year-old girlsdeclined from 22 percent in the early 1990s to 8percent by 1998. National HIV adult prevalencedecreased from 14 percent in the early 1990s to 8.3percent at the end of 1999. Recent surveys in Zambiashow a 42 percent reduction in prevalence rates forthe 15- to 19-year-old age group in Lusaka and otherurban areas, from 28 percent to 15 percent between1994 and 1998.But there are no magic bullets. Implementing aneffective behavior change program is complicated,resource- and time-intensive and must be based onlocally collected information and careful strategicplanning. We have also learned that we must appropriatelytarget our behavior change interventions tothose most likely to transmit or contract HIV infection.The specific targeted groups may differ fromcountry to country, but across all regions of the worldthey invariably involve men, single women and youth.Knowledge alone is not enough. Behavior change iscomplex and painstaking for individuals, communitiesand societies as a whole. It requires far more thanhaving basic knowledge about AIDS, or even beingdisturbed or concerned about it. Knowledge surveyshave demonstrated that more than 95 percent of theadult population of Zimbabwe has learned aboutAIDS and more than 80 percent know two or moremodes of prevention. Yet the epidemic in Zimbabwe isstill out of control, with nearly one in every fouradults now infected with HIV and the number of newinfections continuing to rise.This gap between knowledge and practice has beenobserved all over the world. It has forced publichealth and development specialists to deal with individualhealth behavior—including sex—in its socialand cultural context. In much of the world, traditionsmake it unnecessary for individual men, and unthinkablefor women, to refuse sexual relations. We havelearned that promoting monogamy and condom use,and encouraging young people to wait, involves mobilizingwomen and men, individuals, communities andopinion-leaders to rethink policies and social normsand create environments where individuals who “getthe message” are supported, not derided, shunned orbeaten. We have learned that HIV/AIDS risk reductioninvolves positive social change that links health,gender and human rights in new and productive ways.This is why we should not be surprised that in theabsence of such social change—even in countries withraging, visible epidemics such as Botswana, SouthAfrica and Zimbabwe—people have continued todeny their own danger of becoming infected. This isone of the pernicious effects of the stigma associatedwith AIDS: AIDS is always someone else’s problem.We have seen this phenomenon in virtually everycountry in the world, including the United States.To counter this lack of perceived personal risk, we arenow using what we call a “second generation” ofbehavior change tools that include social mobilization,skills building, intensive interpersonal counseling and,increasingly, the addition of HIV testing. Having anHIV test often provokes a critical moment of personalawareness.HIV/AIDS Prevention and Care in Resource-Constrained Settings XXI
R EDUCING MOTHER-TO-CHILDTRANSMISSIONThe number of infants infected with HIV eachyear through mother-to-child transmission (MTCT) isgrowing with the increasing number of womeninfected with HIV. About 55 percent of all new HIVinfections in Africa occur among women, most ofwhom are in their childbearing years. Ten percent ofinfections—representing some half a million infants—are believed to be attributable to MTCT.The 1998 findings from the Thai Short CourseZidovudine (AZT) Regimen study in Thailand, and1999 findings from the Nevirapene Field Trial inUganda, demonstrated that even simple, relativelyinexpensive ARV regimens can substantially reduceMTCT. Recognizing that comprehensive interventionscan reduce MTCT rates by as much as half, we nowhave the tools to expand MTCT prevention programs,especially in those countries with high HIV prevalence.These programs must set standards; promotevoluntary counseling and testing (VCT); providetraining to health care workers; establish linkages tocommunity-based care services; and scale-up primaryprevention for all women.C ARE AND TREATMENTBasic HIV care services are minimal in manyresource-constrained countries. Few infected personsknow their HIV status; most health care workers lackthe training to treat HIV and its associated infections;and only a few settings have the capacity to use stateof-the-artARVs, which remain unavailable to themajority of those infected.Even without ARVs, much can be done to improvethe well-being of HIV-infected persons and theirfamilies. Foremost must be assuring access to a basicpackage of care that includes treatment of TB, treatmentand prevention of other opportunistic and AIDSrelatedillnesses and palliative care to reduce sufferingand enhance the quality of life. To achieve this goal,networks will have to be established to connect hospital,clinic, faith-based and community-based services.There must be an investment in expanding effectiveTB prevention and control programs in key countries.TB is a growing epidemic itself with two milliondeaths per year worldwide. Because it is the leadingcause of death for people with AIDS, efforts to preventand treat TB must receive special attention.There is increasing interest in the developing worldin the use of combination regimens of ARVs, whichcan prolong the lives of PLHA. It is inevitable thatthe cost of these drugs will decrease. Even now, localproduction of generic drug equivalents and recent pricereductions by the pharmaceutical companies havelowered the annual cost for a combination of ARVs toapproximately US$1500 per patient. But it is criticalto grasp the complexity of providing ARV therapy in adeveloping country setting. An effective ARV programrequires, at a minimum, four basic components:1. A sustainable supply of drugs: This is life-longtreatment and improper use will result in drugresistance.2. The capacity to use the drugs: Most Africancountries lack the necessary trained health careworkers, labs, drug management systems, etc. It isimportant to remember that the health infrastructurein many of the hardest hit countries is on theverge of collapse. Such basic services as childhoodimmunization rates are often less than 50 percent(Uganda), the number of attended births is only33 percent (Nigeria) and the number of trainedphysicians can amount to only one for every13,000 persons (Zambia).3. An equitable system to apportion treatment insettings where there is not enough to go around.4. Recognition that treatment of HIV does not preventnew infections and cannot replace soundprevention programs. As ARVs become less costlyand the regimens simpler, HIV/AIDS efforts mustincorporate ARVs as critical components of theirprograms.XXII HIV/AIDS Prevention and Care in Resource-Constrained Settings
Page 1 and 2: Edited byPeter R. Lamptey, MD, DrPH
Page 3 and 4: © 2001 Family Health International
Page 5 and 6: SECTION II:Chapter 6PAGE 137Chapter
Page 7 and 8: Chapter 21PAGE 501Chapter 22PAGE 51
Page 9 and 10: I N T R O D U C T I O NPAUL R. DE L
Page 11 and 12: F igure 1Factors That InfluenceThe
Page 13 and 14: F igure 3HIV Seroprevalence for Pre
Page 15 and 16: F igure 5HIV Seroprevalence for Com
Page 17 and 18: F igure 7HIV Seroprevalence for Pre
Page 19 and 20: F igure 9Life Expectancy With and W
Page 21 and 22: F igure 11Population of Zimbabwe,Wi
Page 23: invest; and feedback further amplif
Page 27 and 28: F igure 13HIV Seroprevalence in Adu
Page 29 and 30: ACKNOWLEDGEMENTSWe wish to express
Page 32 and 33: SOFIA GRUSKIN, JD, MIAAssistant Pro
Page 34 and 35: THOMAS M. PAINTER, PHDBehavioral Sc
Page 36 and 37: glossary of A C R O N Y M SACTG AID

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