AIDS and COVID-19 in southern Africa

By the end of the first year of the COVID-19 pandemic, in February 2021, the numbers of cases and deaths in southern Africa were low in absolute and relative numbers. The BBC ran a story (which was later retracted) headlined "Coronavirus in Africa: Could poverty explain mystery of low death rate?". A heading in the New York Post said: "Scientists can't explain puzzling lack of coronavirus outbreaks in Africa". Journalist Karen Attiah concluded: "It's almost as if they are disappointed that Africans aren't dying en masse and countries are not collapsing". We wondered if the knowledge that southern African countries have acquired in their struggle against AIDS has contributed to a more effective approach against COVID-19. The viral origins of the diseases through zoonotic events are similar; neither has a cure, yet. In both diseases, behaviour change is an important prevention tool, and there are specific groups that are more vulnerable to infection. Equally, there are important differences: most people with COVID-19 will recover relatively quickly, while people living with HIV will need lifelong treatment. COVID-19 is extremely infectious, while HIV is less easily transmitted.

Mixed results: the protective role of schooling in the HIV epidemic in Swaziland

Swaziland has the highest HIV prevalence in the world. It is recognised that young women, especially adolescents, are particularly vulnerable to HIV infection and bear a disproportionate burden of HIV incidence. The HIV data from Swaziland show the location of the epidemic, which is particularly high among adolescent girls and young women. This paper is based on research in Swaziland, commissioned because of the perception that large numbers of children were dropping out of the school. It was assumed that these "dropouts" had increased risk of HIV exposure. This study carried out a detailed analysis using the Annual Education Census Reports from 2012 to 2014 produced by the Ministry of Education. In addition, this topic was explored, during fieldwork with key informants in the country. While HIV prevalence rises rapidly among young women in Swaziland, as is the case across most of Southern Africa, the data showed there were few dropouts. This was the case at all levels of education ­ primary, junior secondary and senior secondary. The major reason for dropping out of primary school was family reasons; and in junior and senior secondary, pregnancy was the leading cause. Swaziland is doing well in terms of getting its children into school, and, for the most part, keeping them there. This paper identifies the students who face increased vulnerability: the limited number of dropouts; repeaters who consequently were "out-of-age for grade"; and orphans and vulnerable children (OVC). The learners who were classified as repeaters and OVC greatly outnumbered the dropouts. We argue, on the basis of these data, for re-focussed attention and the need to develop a method for tracking children as they move across the vulnerable groups. We acknowledge schooling is protective in reducing children's vulnerability to HIV, and Swaziland is on the right track in education, although there are challenges

Reckoning HIV/AIDS care: A longitudinal study of community home-based caregivers and clients in Swaziland

The article is a descriptive case study of a community home-based care (CHBC) organisation in Swaziland that depicts the convergence of CHBC expansion with substantially improved health outcomes. Comprised of 993 care supporters who tend to 3 839 clients in 37 communities across southern Swaziland; Shiselweni Home-based Care (SHBC) is illustrative of many resource-limited communities throughout Africa that have mobilised; at varying degrees of formality; to address the individual and household suffering associated with HIV/AIDS. To better understand the potential significance of global and national health policy/programming reliance on community health workers (task shifting); we analysed longitudinal data on both care supporter and client cohorts from 2008 to 2013. Most CHBC studies report data from only one cohort. Foremost; our analysis demonstrated a dramatic decline (71.4%) among SHBC clients in overall mortality from 32.2% to 9.2% between 2008 and 2013. Although the study was not designed to establish statistical significance or causality between SHBC expansion and health impact; our findings detail a compelling convergence among CHBC; improved HIV health practices; and declines in client mortality. Our analysis indicated (1) the potential contributions of community health workers to individual and community wellbeing; (2) the challenges of task-shifting agendas; above all comprehensive support of community health workers/care supporters; and (3) the importance of data collection to monitor and strengthen the critical health services assigned to CHBC. Detailed study of CHBC operations and practices is helpful also for advancing government and donor HIV/AIDS strategies; especially with respect to health services decentralisation; in Swaziland and similarly profiled settings

What does Sustainability Mean in the HIV and AIDS Response?

Immense progress has been made in the fight against HIV and AIDS. Achieving and exceeding the AIDS targets for the Millennium Development Goals (MDGs) was accomplished; in large part; due to an unprecedented financial investment from the international community. Following an $800 million dip in donor disbursements in 2010; the discourse has since shifted to the need for greater sustainability of funding. But what does sustainability mean? Current efforts focus heavily on fiscal imperatives such as increasing domestic funding. This is important - needs are increasing at a faster rate than donor funding; especially with increased treatment coverage. The problem is that measures of financial sustainability tell very little about the actual sustainability of specific programmes; disease trajectories or enabling environments. Recognising that current definitions of sustainability lack clarity and depth; we offer a new six-tenet conceptualisation of what sustainability means in the HIV and AIDS response: (1) financial; (2) epidemiological; (3) political; (4) structural; (5) programmatic; and (6) human rights. Based on these; we examine examples of donor transitions for their approach to sustainability; including PEPFAR in South Africa; the Global Fund in Eastern Europe; and the Bill and Melinda Gates Foundation in India (Avahan). We conclude that sustainability must be understood within a broader framework beyond funding stability. We also recommend that certain interventions; such as programming for key populations; may have to continue to receive external support even if affected countries can afford to pay

The End of AIDS: Possibility or Pipe Dream? A Tale of Transitions

Globally; in the last 20 years health has improved. In this generally optimistic setting HIV and AIDS accounts for the fastest growing burden of disease. The data show the bulk of this is experienced in Southern Africa. In this region; HIV and AIDS (and tuberculosis [TB]) peaks among young adults. Women carry the greater proportion of infections and provided most of the care. South Africa has the dubious distinction of having the largest number of people living with HIV in the world; 6.4 million. HIV began spreading from about 1990 and today the prevalence among antenatal clinic attendees is 29.5. A similar situation exists in other nations of the region. It is an expensive disease; requiring more resources than are available; and it is slipping off the global agenda; both in terms of attention and international funding. Those halcyon days of the decade from 2000 to 2010 are over. This paper explores the concept of three transition points: economic; epidemiological and programmatic. The first two have been developed and written about by others. We add a third transition point; namely programmatic; argue this is an important concept; and show how it can become a powerful tool in the response to the epidemic.The economic transition point assesses HIV incidence and mortality of people infected with HIV. Until the number of newly infected people falls below the number of deaths of people living with HIV; the demand for treatment and costs will increase. This is a concern for the health sector; finance ministry and all working in the field of HIV. Once an economic transition occurs the treatment future is predictable and the number of people living with HIV and AIDS decreases. This paper plots two more lines. These are the number of new people from the HIV infected pool initiated on treatment and the number of people from the HIV infected pool requiring treatment. This introduces new transition points on the graph. The first when the number of people initiated on treatment exceeds the number of people needing treatment. The second when the number initiated on treatment exceeds the new infections.That is the theory. When we applied South African data from the ASSA2008 model; we were able to plot transition points marking progress in the national response. We argue these concepts can and should be applied to any country or HIV epidemic

Principes directeurs applicables aux etudes de l'impact social et economique du VIH/sida

Ce document presente les concepts fondamentaux pouvant aider a reflechir sur les consequences economiques et sociales du sida mais aussi sur des idees et techniques pour planifier les ripostes a apporter a l'impact social et economique du VIH/sida a moyen et long termes.Il comprend trois parties. La premiere constitue une introduction expliquant en quoi le sida est unique pour meriter des etudes impact. La deuxieme partie expose les principes directeurs de base sur la maniere de conduire une evaluation des effets sociaux et economiques du VIH/sida. La troisieme partie presente un cadre conceptuel applicable a de telles etudes