http://www.Plusnews.org Updated every day en-gb Thu, 18 Mar 2010 12:27:08 GMT United Nations Integrated Regional Information Networks, http://www.Plusnews.org JOHANNESBURG, 17 March 2010 (PLUSNEWS) - As more HIV-positive people access treatment and live longer, the number of people suffering from HIV-related mental disorders is growing, but mental health remains an ethical, legal and clinical minefield, where many doctors and nurses fear to tread – and fear to test. http://www.IRINnews.org/images/2010/201002221404000797t.jpg JOHANNESBURG, 17 March 2010 (PLUSNEWS) - As more HIV-positive people access treatment and live longer, the number of people suffering from HIV-related mental disorders is growing, but mental health remains an ethical, legal and clinical minefield, where many doctors and nurses fear to tread – and fear to test. "We're moving away from seeing patients on their death beds towards patients who are living longer, and are being affected by mental disorders that have real impacts on their life and work," said Dr Greg Jonsson, a psychiatrist at the Luthando Psychiatric HIV Clinic at the Chris Hani Baragwanath Hospital, in Johannesburg. Various studies have shown a higher than average prevalence of mental illness among people living with HIV. A 2005 study by South Africa's Human Sciences Research Council found that about 44 percent of the 900 HIV-positive individuals surveyed suffered from a mental disorder. The links between HIV and mental illness are complex, but factors include the effects of the virus on the central nervous system, as well as difficulties in dealing with HIV-related stigma and discrimination. South Africa has the world's largest ARV programme to counter an HIV prevalence rate of about 18 percent, according to UNAIDS, and about 920,000 people are on ARV treatment. No easy choices Doctors and nurses in clinics often find it daunting to test mental health patients for HIV. "People who are not trained in psychiatric disorders are scared of getting consent from patients with mental disorders," Jonsson told IRIN/PlusNews. "People should not assume that mentally ill or even psychotic patients are incapable of understanding [testing] and consenting." However, Jonsson added that there would be times where doctors would need to make tough calls about testing severely mentally ill patients who could not consent to HIV testing and whose families may not be approachable to consent on their behalf. "If you can't obtain informed consent, you need to weigh up the potential harm and benefit to the patient - ask yourself whether this test is going to change your diagnoses or your treatment," he suggested to health workers at an annual symposium held by the Aurum Institute, a non-profit medical research organization. "I think if the answer is 'yes' to either, then go for it. It is really the right of the patient to be offered effective HIV treatment," said Jonsson, who pointed out that doctors should be aware of possible interactions between mental health medications and antiretroviral (ARV) drugs. He advised doctors to document the process and counsel patients throughout, especially about how to reduce risk, given the prevalence of substance abuse among mental health as well as HIV patients. "Psych is hard because the 'three ticks equal this' approach doesn't really work, and that's why people are so scared of it," Jonsson told IRIN/PlusNews. No right answers Once a mental health patient started taking ARVs, healthcare providers would have to evaluate whether mandating a "treatment supporter" – a friend or family member to help the patient adhere to treatment - would be appropriate. Again, there may not be a right answer. "We need to draw up protocols and put them in primary healthcare, but the problem with protocol-based system is that people don't think outside the box - with mental health patients it really is on a case-by-case basis," Jonsson told the symposium audience. "I tell most of my patients, 'If you can get treatment support, go for it', but I don't insist on it - disclosing to a patient's family is difficult and ... at my clinic, our patients on treatment are already so stigmatized and victimized." The Luthando Psychiatric HIV Clinic has a treatment default rate – patients who discontinue ARVs – that is the same as institutions in Johannesburg that mandate treatment supporters, Jonsson added.  llg/he http://www.plusnews.org/report.aspx?ReportID=88461 http://www.plusnews.org/report.aspx?ReportID=88461 TESO, 17 March 2010 (PLUSNEWS) - While the public response to Kenya's national HIV testing drive has been enormous, many women are not keen to be tested, knowing that a positive result could mean the breakdown of their marriages, loss of home and more. http://www.IRINnews.org/images/2008/2008112622t.jpg TESO, 17 March 2010 (PLUSNEWS) - While the public response to Kenya's national HIV testing drive has been enormous http://www.plusnews.org/Report.aspx?ReportId=87551, many women are not keen to be tested, knowing that a positive result could mean the breakdown of their marriages, loss of home and more. Isabella Omoto, who lives in western Kenya's Teso district, was recently forced by her husband of seven years to go for an HIV test; the result was positive. "I revealed it to my husband and he just started beating me; he said I had been sleeping with other men," she told IRIN/PlusNews at her mother's home, where she now lives. "He threw my things out and told me to go back to my mother with all our children. "He won't take me back because to him I am a prostitute," she added. "Today he has another wife and he has inherited another - I don't want to interfere with them." According to Teso District AIDS and sexually transmitted diseases coordinator Nelson Andanje, men in the area - too afraid to go for HIV tests themselves - have been forcing their wives to get tested, believing their status will reflect their own. "Here, like in many areas, it is women who come for HIV tests and you will see very few men," he said. "The man believes that if his wife is positive or negative then the same results apply to him." Rights issues In December 2009, Human Rights Watch warned [http://www.plusnews.org/Report.aspx?ReportId=87598] of the possibility of human rights violations during the mass testing drive. "It a gross violation of a woman's human rights to force her to go for HIV tests and then use the same tests to decide whether she should continue to live with you or not when, ridiculously, you don't even know your own status," Andanje said. Statistics from the district AIDS coordinator's office show that over the past year, 10,838 women were tested; only 183 were accompanied by their husbands. According to the Kenya AIDS Indicator Survey [http://www.aidskenya.org/public_site/webroot/cache/article/file/Official_KAIS_Report_20091.pdf], an estimated 45 percent of women have been tested for HIV, against just 25 percent of men. "The high number of women who test more than men could be attributed to antenatal testing, but even in this you never see their husbands accompanying them, which should ideally be the case," he noted. Teso district's HIV prevalence is 24 percent; health authorities have identified high levels of polygamy and wife inheritance, aided by strong cultural beliefs, as some of the key drivers of HIV transmission. "Strong cultural beliefs make men believe it is beneath them to go for voluntary counselling and testing and women are solely responsible for HIV transmission," Andanje said. Discordance "Many people still do not know about discordance," he added. An estimated 6 percent of Kenyan couples - about 344,000 - are HIV discordant, while just 22 percent of couples knew the HIV status of their sexual partners. According to the Kenya National Strategic Plan for HIV/AIDS, "social norms regarding relationships, gender roles/imbalances, stigma and discrimination, fear and risk-perception, and fertility intentions present difficult prevention challenges”. Andanje says the district authorities are trying to sensitise the community about discordance and to encourage women to speak out if they are being forced to take a test. "We are using the local administration to reach out to men and let them know the benefits of individually going for an HIV test; we want them to know that they may be in a discordant union," he said. "When a woman comes alone or a man comes alone, it is difficult to know whether they are in a discordant union and you can't therefore give them services adequately. "Men must be made to know that there is nothing feminine or masculine in testing for HIV. It is purely a health issue," he added. ko/kr/mw http://www.plusnews.org/report.aspx?ReportID=88456 http://www.plusnews.org/report.aspx?ReportID=88456 NAIROBI/DAR ES SALAAM, 16 March 2010 (PLUSNEWS) - New maps pin-pointing the exact location of "wellness centres" in sub-Saharan Africa are improving truck drivers' access to treatment and care for HIV and other sexually transmitted infections (STIs). http://www.IRINnews.org/images/2010/201003161246420665t.jpg NAIROBI/DAR ES SALAAM, 16 March 2010 (PLUSNEWS) - New maps pin-pointing the exact location of “wellness centres” in sub-Saharan Africa are improving truck drivers' access to treatment and care for HIV and other sexually transmitted infections (STIs). Oil giant Shell, with risk specialist Maplecroft http://www.maplecroft.com/ and the North Star Alliance [http://www.northstar-alliance.org/], which builds roadside clinics at truck stops, have developed and printed 20,000 maps for distribution to truck drivers in Kenya, South Africa, Cote d'Ivoire, Burkina Faso, Togo, Tanzania, Uganda, Botswana, Guinea, Mali and Namibia. The maps show the locations of more than 160 clinics. "Many of us want treatment but at times you might not know where to get it when you are on the road but these maps can help us now," Eliud Musili told IRIN/PlusNews at Mlolongo, a truck stop in the Kenyan capital, Nairobi. "Now you can even advise other drivers where to get [health services]." In East and Central Africa, the maps are being distributed to truckers at “SafeTStops” [http://www.fhi.org/en/HIVAIDS/Video/redso.htm] where wellness centres provide a range of services, including screening of STIs, HIV testing and counselling and tuberculosis screening, for truck drivers and communities with whom they interact. "The wellness centres have been put up in areas where these high-risk groups converge to provide information about HIV and other STIs, prevention methods like condoms, diagnosis of STIs and testing and counselling," says Dorothy Muroki, project director for the Regional Outreach Addressing AIDS through Development Strategies II, a project of the NGO, Family Health International (FHI). "For high-risk groups, information is critical." There are eight SafeTStops serving an estimated 230,000 people annually in Djibouti, Tanzania, Rwanda and Uganda. Living dangerously For more than six years now, Julius Mwapele*, 35, a father of five, has worked as a loader at Dar es Salaam port; three months ago, he visited a clinic to treat a persistent rash on his penis. "At first I wanted to [ignore] it but when it continued, I decided to go to a clinic here at the port," he told IRIN/PlusNews. "At the clinic, they told me I had gonorrhoea; I was afraid but they told me it can be treated." While his job is not particularly well paid, compared with many of the residents around the port, Mwapele is well-to-do. He suspects that he contracted the STI from a local woman. "I have three mistresses here - I buy food from them," he said. "I get into sexual relationships with them so that at times I can get free food when I don't have money but when I get money, it is my turn to give them a treat." Sex stops Sex work is widespread at truck stops along sub-Saharan Africa’s transport corridors; a 2006 University of Manitoba study [http://sti.bmj.com/content/83/3/242.full#ref-3] found an estimated 8,000 female sex workers on the trans-Africa highway from Kenya's coastal city of Mombasa to the Ugandan capital, Kampala. It also reported that truckers and their assistants had high rates of reported STIs and many exhibited high-risk sexual behaviour. The SafeTStops aim to provide truck drivers and sex workers with information and other services in a non-judgmental way. "Women do not get into commercial sex work for fun but due to economic needs, just like truck drivers seek sexual services from commercial sex workers because they are rarely with their spouses," said FHI's Muroki. The centres are also a source of entertainment. "We provide facilities like pool and offer reading material and TV so when one walks in, nobody knows for sure what has brought them except the clinic personnel," said Victoria Jonathan, head of the wellness centre in the port of Dar es Salaam. "This gives a sense of privacy; the uptake of the services is very impressive. Alcohol a factor "The centres are alcohol-free to send the message that alcohol abuse is one of the key drivers for risky sexual behaviour," she added. Ben Manyala, an HIV-positive trucker in Dar es Salaam, agreed that alcohol was an important factor in HIV transmission among truck drivers. "Alcohol is contributing [to the spread of HIV]; we have a joke that after five bottles of beer, every woman is beautiful," he said. ko/kr/mw * Not his real name http://www.plusnews.org/report.aspx?ReportID=88443 http://www.plusnews.org/report.aspx?ReportID=88443 JOHANNESBURG, 15 March 2010 (PLUSNEWS) - New research suggests that the poor knowledge and attitudes of doctors and healthcare workers in South Africa are limiting access to preventative tuberculosis (TB) therapy. http://www.IRINnews.org/images/2007/200702151t.jpg JOHANNESBURG, 15 March 2010 (PLUSNEWS) - New research suggests that the poor knowledge and attitudes of doctors and healthcare workers in South Africa are limiting access to preventative tuberculosis (TB) therapy. The qualitative study by the health research non-profit, the Aurum Institute, found that many doctors and health workers shied away from prescribing isoniazid preventative therapy (IPT), in which daily doses of the antibiotic isoniazid are administered for at least six months to reduce TB risk in HIV-positive people. The reasons most often cited by health professionals for not prescribing IPT included an inability to rule out active TB, little knowledge about IPT's benefits, and little confidence that patients would continue taking the medicine, said Dr Salome Charalambous, HIV/AIDS Programme Director at Aurum, who presented the research at the institute's annual symposium for health workers in Johannesburg. IPT can reduce the risk of active TB in people living with HIV by about a third, according to the World Health Organization (WHO). South Africa has had national guidelines for administering IPT since 2002, but coverage has been estimated at below 1 percent. Health workers interviewed for the study also said they felt the Department of Health had not done enough to communicate the current IPT guidelines to them. The WHO lists TB as the leading killer of people living with HIV, and South Africa has an HIV prevalence rate of about 18 percent. The country also shoulders one of the world's highest TB burdens, according to the WHO. "It's not to say everyone must be started on IPT, but there are a whole lot of people who could benefit from IPT but are not," Charalambous told IRIN/PlusNews. More about the professionals, less about the patients International and national guidelines caution doctors to avoid issuing preventative TB therapy in people who have active TB. Charalambous said the difficulty in diagnosing active TB, which can hide in tissue outside of the lungs, deterred many health professionals from using IPT. "Standard pulmonary TB is not [present in] more than 30 percent of our patients, so sputum, abscess, lymph nodes, x-rays are very often negative. I would never use [isoniazid] on my patients for this reason alone,"  said a doctor quoted in the study. Other doctors were not convinced of the value of giving IPT to patients already on antiretroviral (ARV) medication. Little research has been done on the effects of IPT on patients taking ARVs, but new findings presented by Aurum at the recent 2010 Conference on Retroviruses and Opportunistic Infections showed that IPT drastically decreased mortality in newly initiated ARV patients. Aurum's qualitative study showed that health workers' attitudes to patients influenced their willingness to prescribe IPT. "It was interesting that staff felt that patients would not understand the concept of taking medication while feeling well, but when we asked patients they didn't say taking a preventative tablet would be a problem," Charalambous commented. The researchers recommended that the Health Department clarify the screening process and initiation requirements for IPT, and that patients be educated about treatment options for preventing TB. llg/kn/he http://www.plusnews.org/report.aspx?ReportID=88432 http://www.plusnews.org/report.aspx?ReportID=88432 JOHANNESBURG, 12 March 2010 (PLUSNEWS) - The executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Michel Kazatchkine, sat down with IRIN/PlusNews at the launch of the organization's 2010 report, where he answered some hard questions on what may be a turning point in HIV/AIDS funding. http://www.IRINnews.org/images/2010/201003121448070025t.jpg JOHANNESBURG, 12 March 2010 (PLUSNEWS) - The executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Michel Kazatchkine, sat down with IRIN/PlusNews at the launch of the organization's 2010 report, where he answered some hard questions on what may be a turning point in HIV/AIDS funding. QUESTION: Is AIDS still exceptional? Is it still the threat we once thought it was? ANSWER: It's a huge threat; it's the largest epidemic the world has witnessed in history. It's about 34 million people living with HIV worldwide, and there are about 2 million deaths every year [from it] – deaths that should be preventable. Why has the world focused so much on AIDS? It's about the dimension of the epidemic and the number of deaths - but because of the strong evidence that this epidemic was hitting people in the most productive age of life it was having huge societal, micro-economic and macro-economic [effect] ... So that has led to this concept of 'AIDS exceptionalism'. Q. What would you say to arguments that we've invested too much in HIV and AIDS, to the detriment of other illnesses? A. You may think [this has been] unfair to the other diseases but ... [the concept of AIDS as exceptional] has helped mobilize - as we've never seen before - resources that go to AIDS. I want everyone to understand they're not just buying condoms or antiretroviral [ARV] drugs; these resources, in Africa, have allowed us to make progress when it comes to infrastructure, health worker training, to drug procurement ... Over a third of the overall funding of the Global Fund is actually going to strengthening health systems." Q. How has the global recession affected HIV programmes? A. None of our donors have not honoured their pledges to the Fund, despite the hard times. Where the impact may be the strongest is often in the [poor] countries. People may not realize that poor countries have suffered disproportionally more from the crisis than rich countries, because their exports have been going down and the price of imported goods has not decreased. Poor countries, in times of crisis, have been struggling with keeping up their social investments ... their priorities are in the social sector. We've achieved significant progress that is very fragile. We know what we could achieve if we were to sustain or expand the funding ... now the challenge is our 2010 replenishment, and what will happen for the next three years. Q. What is the future of HIV funding? A. The Global Fund and PEPFAR [the US President's Emergency Plan for AIDS Relief] together are providing 100 percent of the funding for ARV treatment in the developing world. The United States is the highest contributor to the Global Fund, contributing about 29 percent of Global Fund income. To me all news about flat-lining support is worrying. Flat-lining will not take us far enough in treatment or prevention – we need to expand. Q. Are countries overly reliant on the Global Fund? Does that put national programmes at risk of funding delays? A. I would argue that countries ... cannot deal with 24 donors. If you have to report to 24 people separately, countries ... [would be] drowning [in reporting commitments]. By having a Global Fund, we have a global political commitment ... and we significantly decrease transaction costs. I am aware of a number of programmes where the money ... [has been delayed] ... Most often it's because we do not receive the request on time. There are bureaucratic reasons ... this is why we have a large amount of money channelled through civil society. Q. Is there anything countries should be doing now in order to prepare themselves for a worst-case funding scenario? A. No - countries have to build their ... plans to scale up prevention and treatment, and demonstrate what the macro- and micro-economic and societal impacts will be, to build a case for the donors. Never give up. llg/kn/he http://www.plusnews.org/report.aspx?ReportID=88413 http://www.plusnews.org/report.aspx?ReportID=88413 ADDIS ABABA, 12 March 2010 (PLUSNEWS) - On stage in the Ethiopian capital, Addis Ababa, Mestihet Temane, 27, enacts the story of how, after the death of her parents, a young woman winds up alone on the streets with no money, no confidence and no support. http://www.IRINnews.org/images/2003515t.jpg ADDIS ABABA, 12 March 2010 (PLUSNEWS) - On stage in the Ethiopian capital, Addis Ababa, Mestihet Temane, 27, enacts the story of how, after the death of her parents, a young woman winds up alone on the streets with no money, no confidence and no support. "Sometimes I cry when I'm singing and so do a lot of the people listening," she told IRIN/PlusNews. Mestihet is a member of Mekdim Ethiopia National Association, a local NGO that performs HIV-related dramas at offices, colleges and community centres. The drama and music club members who put on the plays are a mixture of orphans and people living with HIV - their harrowing stories of abandonment and discrimination are often semi-autobiographical. Despite public attempts to tackle the subject of HIV, the status of many of Mekdim's actors is not revealed to audiences; many of them also keep their HIV status secret in their personal lives. "A colleague said, 'if I knew you had HIV I would not have swapped clothes with you'," Dawit*, a 21-year-old actor said. "Even now there is a problem with HIV and discrimination." Mickey*, a dancer, says he suffers psychologically when his colleagues discuss the HIV-positive status of other dancers in a derogatory manner; Fatiya*, 17, has kept her infection hidden from her landlord due to fear of eviction. According to Tilahun Sheko, Mekdim's programme manager, while the plays have significantly increased the number of visitors to the voluntary counselling and testing clinics that accompany the performances, many in Addis, particularly the wealthy, are still "more worried about their reputation than getting treatment". Alemu Anno Ararso, the director of the multi-sectoral response coordination directorate at the Federal HIV/AIDS Prevention and Control Office, said just like the government's "community conversations" - where participants are encouraged to discuss and share their experiences, including traditionally taboo issues - the Mekdim plays were a useful tool in demystifying HIV. "They tell the stories and how it is transmitted," he said. "They are giving their life experiences; no one can know more than they can." However, Alemu acknowledged that despite the government's efforts to tackle stigma, the problem persists. "Ethiopians prefer to keep silent. We don't want to disclose ourselves. If I have a problem, I don't want to talk about it," he added. "That is why the community conversation strategy has been used. They listen to their friends and everything comes out." Alemu further noted that the issue of stigma affected HIV programming. "We have problems of uptake of services and it revolves around stigma. If you're found to be HIV-positive you will be discriminated against, so people decide not to get tested," he said. "We can understand the effect by proxy; it's all because of discrimination. A local NGO, Network of Networks of HIV Positives in Ethiopia, is working on a stigma index - due to be completed this year - that will reveal the root causes and extent of stigma in the Horn of Africa nation. "HIV is everybody's business, so everybody has to talk about it; you can fight HIV by improving knowledge and behaviour," he added. wd/kr/mw * Not their real names http://www.plusnews.org/report.aspx?ReportID=88404 http://www.plusnews.org/report.aspx?ReportID=88404 JOHANNESBURG, 10 March 2010 (PLUSNEWS) - In the aftermath of Haiti's 7.0 magnitude quake, one of the Caribbean's largest antiretroviral (ARV) programmes is struggling to resurrect itself from the rubble. http://www.IRINnews.org/images/2010/201001261219400562t.jpg JOHANNESBURG, 10 March 2010 (PLUSNEWS) - In the aftermath of Haiti's 7.0 magnitude quake, one of the Caribbean's largest antiretroviral (ARV) programmes is struggling to resurrect itself from the rubble. The Haitian government estimated that 24,000 Haitians were accessing ARVS before the quake, now, fewer than 40 percent of those on treatment have been able to access ARVs, according a recent UNAIDS situation assessment. Reports by UNAIDS, the World Health Organization and key ARV providers in Haiti paint a picture of uneven treatment access in the early recovery period, and fears of new infections and drug resistant HIV and tuberculosis (TB) are rising. Haiti has an estimated HIV prevalence rate of 2.2 percent, second only to that of the Bahamas and one of the world's highest outside of sub-Saharan Africa, according to UNAIDS. Treatment disruptions A joint assessment by UNAIDS and the Ministry of Public Health found that ARV treatment centres were still not fully functional in three of Haiti's hardest hit departments (administrative districts) - Ouest , Sud-Est and les Nippes. A UNAIDS report released late last week said although the three departments housed the bulk of the country's ARV sites, they were all reporting low attendance. UNAIDS spokesperson Sakuya Oka said community workers and networks of people living with HIV no longer had the resources to trace lost patients. Prevention of mother-to-child transmission (PMTCT) services in these departments has also been affected, some for as long as two weeks. "In institutions assessed by the [joint] team, it was reported that in many instances babies and mothers have not received ARV drugs during and after delivery," Oka said. "The major challenge was that the maternity buildings were damaged, and deliveries were taking place under suboptimal standards, making the PMTCT process impossible to implement." UNAIDS said it would take an immediate injection of USD$70 million to keep HIV services running for the next six months, but Oka noted that the US President's Emergency Plan for AIDS Relief (PEPFAR) has already pledged its annual commitment to Haiti. She also noted that there are indications that USAID will increase its commitment later in the year. The Global Fund to Fight AIDS, Tuberculosis and Malaria made money available in the immediate aftermath of the disaster and was looking at ways to adapt their programming in Haiti to post-quake conditions. In contrast, the recent assessment found that clinics in these departments operated by the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), one of the oldest medical NGOs fighting HIV/AIDS, were operating at 80 percent capacity. Treatment under fire GHESKIO provides HIV and TB treatment nationally and its ARV patients include 60 percent of those enrolled in Haiti's national ARV programme, according to its director, Dr Jean William Pape, who said the organization had been able to account for most of the patients across its 28 ARV sites nationwide since the quake. Pape credited experience and planning for this success. "You need to plan for crises - we've had political uprisings, periods of violence [and] hurricanes, so we regularly give patients two weeks of additional drugs, including TB drugs, because these crises usually last a couple of weeks." Managing disasters and averting potential disruptions is part of treatment literacy at GHESKIO, where patients are given emergency phone numbers and told where alternative treatment sites are located in case it becomes too dangerous to visit their usual clinic. The organization has been able to reach most of its patients via their mobile phones, but Pape added that GHESKIO also uses what it called the "correspondent" system - using neighbours to trace lost patients - although this has worked less well since the earthquake, as people have moved out of hard-hit Port-au-prince. The organization has also broadcast information on how to access treatment on national radio. GHEKIO is fortunate to have retained capacity that many other sites have lost, such as the ability to perform CD4 counts – a measure of the immune system's strength required for starting treatment. Pape said treatment initiation has slowed since the earthquake, and that many people had come to GHESKIO's field hospital in need of care for fractures, wounds and other injuries. A population in flux Partner in Health (PIH), another medical organization, works in departments such as Artibonite, which were farther from the quake's epicentre. Joia Mukherjee, medical director of PIH, said most of their patients had not missed ARV doses, and that with post-quake migration out of Port-au-Prince she expected their patient load would rise. CD4 count testing is also available at PIH facilities. "We are still seeing migration out of Port-au-Prince and I think this will eventually become circular," she said. "What some of our colleagues are saying is that many [are returning to the capital but] are choosing to leave their children behind because they feel the city isn't safe for kids." PIH has started issuing patients with health passports – pocket-sized versions of recent medical records – to facilitate treatment across departments. "We are probably going to see a lot of people going back and forth as they try to put their lives back together, and that's always a risk factor for HIV," Mukherjee told IRIN/PlusNews. New realities, new risks Since the earthquake, PIH has temporarily moved into four major camps for the displaced in the capital, Port-au-Prince, working alongside GHESKIO to help service an estimated 80,000 people. Mukherjee said there was little time to lose in addressing the new paradigm of HIV risk caused by displacement, and averting new HIV infections. "In the camps we're finding new cases and are referring those people to GHESKIO ... clinics where they can access treatment in the long run. If you see the way people are living, there's no way that sex is not being exchanged for things like money, food, shelter or security," Mukherjee told IRIN/PlusNews. PIH has launched a prevention campaign aimed at young people in the camps, and UNAIDS has called for prevention programmes to be revitalized and tailored to post-disaster circumstances. As part of the prevention push, the United Nations Populations Fund (UNFPA) has begun distributing post-exposure prophylaxis kits to rape survivors in and around Port-au-Prince, but the UNPFA Regional Communications Adviser, Trygve Olfarnes, said demand has been low. Haiti has the highest per capita TB burden in Latin America and the Caribbean, according to the World Health Organization. Mukherjee said poor living conditions and problematic access to food made TB a looming threat. Pape has set up a TB field hospital, as GHESKIO has the only laboratory that can perform even basic TB tests such as smear sputum microscopy. The government of Haiti is working with GHESKIO to set up TB services in camps housing the city's displaced people. llg/kn/he http://www.plusnews.org/report.aspx?ReportID=88377 http://www.plusnews.org/report.aspx?ReportID=88377 NAIROBI, 10 March 2010 (PLUSNEWS) - Violet Tinah, 40, a resident of Korogocho slum in the Kenyan capital, Nairobi, is living with HIV and was recently diagnosed with tuberculosis, but her biggest problem today is not disease - but hunger. http://www.IRINnews.org/images/2010/201003100815240322t.jpg NAIROBI, 10 March 2010 (PLUSNEWS) - Violet Tinah, 40, a resident of Korogocho slum in the Kenyan capital, Nairobi, is living with HIV and was recently diagnosed with tuberculosis, but her biggest problem today is not disease - but hunger. "When I went for the results that informed me that I had TB, I was very hungry; I'd had no breakfast and lunch and could barely walk," she told IRIN/PlusNews. "I had to be supported and put in a wheelchair to collect the drugs. "Often I go without food and during such times I feel dizzy and nauseous after swallowing the [TB and HIV] drugs," the formerly prosperous carpenter added. "Putting food on the table is like a dream." On the day she spoke to IRIN/PlusNews, Tinah had had only a cup of black tea for breakfast and no lunch; a concerned neighbour has brought her some porridge "to help me swallow my drugs". Tinah was hoping her unemployed nephew would pass by later with a little food. Many of the slum's residents live on food salvaged from a nearby rubbish dump and sold on the streets of Korogocho. According to a 2009 World Bank poverty assessment, the poor in Kenya spend 70 percent of their income on food on average - those in the poorest 20 percent of the population spend 77 percent. Sharp increases in the price of staples in 2008 - maize flour rose by as much as 130 percent between 2008 and 2009 - and a national food crisis in 2009 mean poverty has been on the rise. The urban poor, most of whom do not farm, have been particularly hard hit. Korogocho location chief Rebecca Balongo told IRIN/PlusNews that many programmes supporting HIV-affected households had collapsed. "It is not unusual to have a family share only a plate of food in a day," he said. Little help The Kenya Network of Women with AIDS, which until 2009 provided food assistance to about 4,000 HIV-positive people in slums in central Kenya, has had to shut down its feeding programme due to lack of funding. "We are no longer giving food at our drop-in centres in Korogocho, Kiambiu, Soweto and Mathare slums in Nairobi, Kiandutu slums in Thika and Kiawara slums in Nyeri town," said KENWA advocacy programme officer James Ndung'u. "KENWA is only providing highly nutritious porridge to the very weak and bedridden clients. "The slums have high HIV prevalence rates and without food there are challenges; our nurse has reported clients failing to collect ARVs on schedule - they say they are busy looking for work to buy food," he added. "ARVs require one to have a proper diet, but on an empty stomach, there is a tendency to default and consequent risk of drug resistance." A few programmes continue to provide support in the form of food or cash transfers. Concern Worldwide has started a cash transfer programme in Korogocho to provide food subsidies of about US$20 per month to 2,000 extremely vulnerable households, including bed-ridden HIV-positive people. However, Concern's programme is due to end in June, after which the government is expected to take it over. Slum residents and officials are not optimistic; chief Balongo says the government did not send any food support to her area in 2009. Employment is scarce for the slum's residents, especially if they are weak. Frederick Egesa works as a watchman, earning about $47 a month. He walks to work, has no days off and is docked two-and-a-half days’ pay for every day he misses work. "Look at my many dependents - I spend 1,000 shillings [$13] on rent and have 200 shillings [$2.60] daily for food, so we have to skip eating at times," he said. "When I collect my ARVs, I am advised to eat well, but how do I manage a balanced diet?" wm/kr/mw http://www.plusnews.org/report.aspx?ReportID=88373 http://www.plusnews.org/report.aspx?ReportID=88373 NAIROBI, 9 March 2010 (PLUSNEWS) - Global funding shortfalls for fighting AIDS could make it impossible for developing countries to implement new World Health Organization treatment guidelines, activists have said. http://www.IRINnews.org/images/2007/2007081411t.jpg NAIROBI, 9 March 2010 (PLUSNEWS) - Global funding shortfalls for fighting AIDS could make it impossible for developing countries to implement new World Health Organization treatment guidelines, activists have said. WHO released new guidelines on antiretroviral therapy (ART) in December 2009, raising the CD4 count - a measure of immune strength - at which HIV-positive people should start ART from 200 to 350. Research has shown that starting ART earlier reduces the rate of death and opportunistic disease. "WHO's new recommendations are excellent in theory, but they did not give us a practical way of implementing the guidelines - already we have shortages of drugs in trying to put people with CD4s below 200 on treatment," said James Kamau, coordinator of the Kenya Treatment Access Movement. "How will we now put so many more people on ARVs? The increased number of people on drugs means not just more drugs, but more labs, more health centres and health workers, more general care - the expense is enormous." An estimated four million people around the world are currently on ART - a 10-fold increase since 2003, when the drugs became widely available - but this figure still represents just over one-third of the people who need the medication. "If WHO's new recommendations are not implemented, the international community risks subsidising less expensive yet sub-standard care for developing countries," said Sharonann Lynch, MSF's HIV/AIDS policy advisor, in a press release. "Avoiding this will depend on the willingness of donors to make new commitments. Although this is not easy in today's financial environment, donor countries cannot back away from supporting the promise of universal access to treatment made five years ago." "The situation is now an emergency" In Uganda, where the government plans to release new treatment guidelines reflecting WHO's recommendations, officials said the number of people needing treatment would rise from 300,000 to about 750,000. The country recently suffered drug shortages in its public health sector, partially caused by funding problems. "The numbers will be too great for us to manage," said Dr David Kigawalama, head of prevention services at the Uganda AIDS Commission. "We need to sit with our AIDS development partners to forge a way forward." Ahead of a high-level meeting between Group of Eight (G8) leaders and AIDS advocates in London on 10 March, AIDS activists met with British International Development Minister Gareth Thomas on 9 March and called on the world's wealthiest nations to honour their 2005 Gleneagles pledge to achieve universal access to HIV prevention, treatment and care by 2010. "Instead of building on progress, some donor nations and governments of highly affected countries are backing away from the universal access commitment with a series of poorly funded half-measures on AIDS," the executive director of the International AIDS Society, Robin Gorna, said in a press statement. "The situation is now an emergency: new treatment enrolments in many countries are coming to a standstill, the risk of drug resistance is increasing, and fragile gains made over the last 10 years may soon erode, with potentially serious consequences for future efforts to control this epidemic." The activists singled out Canada - the only G8 nation firmly opposed to the Financial Transactions Tax, a tiny tax on financial transactions that could raise the billions of dollars needed to fulfil the universal access pledge. The global economic downturn forced the Global Fund to Fight AIDS, Tuberculosis and Malaria, the world's largest funder, to cut disbursements by 10 percent in 2008, while the US President's Emergency Plan for AIDS Relief (PEPFAR) has flat-lined funding to many countries, limiting the growth of PEPFAR-funded treatment programmes. kr/kn/he http://www.plusnews.org/report.aspx?ReportID=88368 http://www.plusnews.org/report.aspx?ReportID=88368 JOHANNESBURG, 8 March 2010 (PLUSNEWS) - Achieving targets to eliminate mother-to-child transmission of HIV and halve tuberculosis rates hang in the balance as donor commitments to the Global Fund to Fight AIDS, Tuberculosis and Malaria Fund come up for review. http://www.IRINnews.org/images/2008/2008050510t.jpg JOHANNESBURG, 8 March 2010 (PLUSNEWS) - Achieving targets to eliminate mother-to-child transmission of HIV and halve tuberculosis rates hang in the balance as donor commitments to the Global Fund to Fight AIDS, Tuberculosis and Malaria Fund come up for review. For the past seven years, the Geneva-based Global Fund has made some of the largest contributions to health aid in history, said the Fund's executive director, Michel Kazatchkine. International donors will meet in October 2010 to decide whether, and how much money, they will give the international financing organization. Kazatchkine said progress so far had put the world on track to reaching important health milestones by 2015, but reaching these goals would depend on renewed funding. "The next replenishment will be absolutely key to where the world will be in 2015. If we continue to scale up we should be able to reach or surpass some of the health-related Millennium Development Goals (MDGs), such as containing the spread of multidrug-resistant TB (MDR-TB), and virtually eliminating mother-to-child transmission by 2015," Kazatchkine told IRIN/PlusNews. UNAIDS executive director Michel Sidibe agreed. "Without a fully-funded Global Fund, our shared dreams of universal access to HIV prevention, treatment, care and support could become our worst nightmare, putting the lives of millions currently on treatment in jeopardy." The October replenishment meeting comes at a time when donors like the United States and the UK Department for International Development (DFID) have backed away from increasing their HIV funding commitments. The US President's Emergency Plan for AIDS Relief (PEPFAR) contributes one-third of all Global Fund monies. A new 126-page report, "The Global Fund 2010: Innovation and Impact", released this week, details progress made by Fund-suported programmes, including increased access to antiretrovirals (ARVs), improved TB cure rates, and reduced levels of AIDS-related mortality and new HIV infections. According to the report, 2.5 million people have received ARV treatment since 2002 through the Fund, which provides half of all ARVs dispensed in developing countries; the Fund also accounts for two-thirds of TB funding worldwide. In sub-Saharan Africa, the organization is the single largest multilateral funding mechanism in the health sector, and its support has meant that countries like Namibia, Rwanda and Zambia are likely to reach their MDG targets for universal ARV access. The Fund recently awarded South Africa about US$43 million as part of its Round 9 of grants. South African Health Minister Dr Aaron Motsoaledi said the country relied heavily on partners like the Global Fund to provide treatment to the 920,000 people enrolled in the country's public-sector ARV programme. Funding the Fund Kazatchkine said he hoped donors would renew or increase their commitments, come October, and that developed nations would realize that the economic downturn plaguing their domestic constituencies had often been felt much harder in countries with a high disease burden and export-driven economies. Sisonke Msimang, executive director of the Open Society Initiative for Southern Africa, told guests at the report launch that international donors needed to bear in mind that funding HIV also meant funding broader goals, such as strong civil societies, improved health systems, and better health outcomes. The report noted that the introduction of HIV services in Rwanda was followed by an increase in the uptake of primary health care services. Sidibe said highlighting the wider benefits of funding could be the way to secure donor money for HIV in future. "The Global Fund has helped us to change completely the architecture of aid - it has changed completely the governance system of aid; it has created an alternative service delivery approach that has expanded government's capacity to deliver." "We need to leverage resources to push broad health objectives, and this means integrating, bringing in the links between reproductive health, maternal and child health," he told IRIN/PlusNews. "We need to take HIV/AIDS out of isolation." llg/kn/he http://www.plusnews.org/report.aspx?ReportID=88357 http://www.plusnews.org/report.aspx?ReportID=88357 JOHANNESBURG, 4 March 2010 (PLUSNEWS) - Delays in registering antiretroviral (ARV) medication may keep cheaper, more patient-friendly drugs out of reach as South Africa prepares to launch the world's largest tender for medicines. http://www.IRINnews.org/images/2010/201003011506120160t.jpg JOHANNESBURG, 4 March 2010 (PLUSNEWS) - Delays in registering antiretroviral (ARV) medication may keep cheaper, more patient-friendly drugs out of reach as South Africa prepares to launch the world's largest tender for medicines. In a letter to Dr Aaron Motsoaledi, the Minister of Health, the South African HIV Clinicians Society called on the country's drug registration body, the Medicines Control Council (MCC), to fast-track the approval of certain ARVs, the generic versions of others, and fixed-dose ARV combinations that combine multiple ARVs into a single pill. The new ARV tender will allow pharmaceutical companies to bid for supplying the biggest HIV treatment programme in the world, but drugs without MCC approval are unlikely to be accepted. Many activists have said that excluding unapproved drugs will make the tendering process less competitive, push up prices and deprive patients of fixed-dose combination therapy. "My biggest concern is that the MCC is just not functioning well - they're trying to repair the system but they're not giving priority to these drugs," said Dr Francois Venter, president of the Clinicians Society, who noted that some drugs had been awaiting approval for more than two years due a backlog in the MCC. "These drugs need to be pushed to the front of the queue; these are not experimental drugs we are talking about here, these drugs have been registered in Europe for more than a year," Venter told IRIN/PlusNews. According to the HIV Clinicians Society's letter, all fixed-dose combinations, some of which are likely to form part of first-line regimens, and new, heat-stable paediatric formulations are among the drugs awaiting registration. "I cannot think of another drug that is more important drug than ARVs," Venter said. "If the MCC can't fulfil its role as a registering body then, frankly, it must get out of the way." South Africa has an HIV prevalence of about 18 percent, and its national ARV programme reaches an estimated 1.7 million people, according to UNAIDS. Dealing with the backlog The MCC has taken steps to address the backlog, but the organization remains understaffed said Jonathan Berger, a senior researcher at the AIDS Law Project and a member of the MCC, who spoke to IRIN/PlusNews in his personal capacity. Long delays in registering new drugs have prompted calls by the Joint Civil Society Monitoring Forum (JCSMF) - a civil society body that monitors implementation of the government's National Strategic Plan for HIV and AIDS - for the government to waive the registration process for drugs already approved by stringent regulatory bodies such as the US Food and Drug Administration and the World Health Organization. South African law prohibits this, but Berger said the health department might not have ruled out switching to an abbreviated review process for some drugs that have already been approved overseas. What it means Andy Gray, a pharmacist at the Centre for the AIDS Programme of Research in South Africa (CAPRISA) at the University of KwaZulu-Natal, said adherence and provision were a lot harder without fixed-dose combinations. "If these [fixed combinations] aren't registered, we won't be able to take advantage of them as we increase the number of patients on treatment, and as we increase the number of sites providing ARVs, and as we increase the use of nurses to provide treatment," he told IRIN/PlusNews. "There are great advantages to using fixed-dose combinations – they reduce errors with prescribing them, they're quicker for pharmacies to dispense, and they're easier for patients to comply with." llg/he http://www.plusnews.org/report.aspx?ReportID=88315 http://www.plusnews.org/report.aspx?ReportID=88315 NAIROBI, 2 March 2010 (PLUSNEWS) - Medical male circumcision is now widely recognized as an important HIV prevention tool, and several African countries have included it in their national HIV strategies. http://www.IRINnews.org/images/2009/200912041010050720t.jpg NAIROBI, 2 March 2010 (PLUSNEWS) - Medical male circumcision is now widely recognized as an important HIV prevention tool, and several African countries have included it in their national HIV strategies. IRIN/PlusNews lists the progress of 13 nations in eastern and southern Africa identified as priority countries for male circumcision scale-up by the UN World Health Organization. Kenya: An estimated 85 percent of men are circumcised, but just 40 percent of those in Nyanza province, which has the country's highest prevalence, have had the procedure. In 2008 the government launched a national campaign and by the end of 2009 more than 90,000 men had been circumcised, 40,000 of them during a two-month "rapid results" initiative in Nyanza. The government aims to have all uncircumcised men - an estimated 1.1 million http://www.plusnews.org/Report.aspx?ReportId=87074 - undergo the procedure by 2013. Kenya is the only African country to have successfully rolled out male circumcision on such a large scale. Zambia: Male circumcision prevalence is 13 percent, and Zambia aims to circumcise about 250,000 men every year. More than 16,000 men were circumcised at 11 sites in 2009, and the goal is to have 300 sites offering the services by 2014. Swaziland: The Ministry of Health and Human Services plans to provide circumcision to 80 percent of men aged 15 to 24 by the end of 2014 http://www.plusnews.org/Report.aspx?ReportId=86444. Just eight percent of Swazi men are circumcised. The country - which has the world's highest HIV prevalence - developed a male circumcision strategy in 2008; by the end of 2009 more than 5,000 men had undergone the surgery. Botswana: Five centres of excellence have been identified to scale-up circumcision services, and Botswana's Ministry of Health aims to reach at least 460,000 HIV negative men and boys below the age of 49 by 2012. More than 4,300 men have been circumcised since April 2009. Zimbabwe: In April 2009 the pilot phase of service delivery began, during which 1,818 men were circumcised at four sites. A national male circumcision policy was launched in November 2009. Rwanda: Since 2008 the government has been rolling out male circumcision in the army, where prevalence is 4.5 percent compared to a national rate of three percent. A recent study http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000211 suggested that Rwanda should also be scaling up circumcision across a broad range of age groups, especially the very young, where the procedure was found to be highly cost-effective. South Africa: The government has been criticized for moving too slowly http://www.plusnews.org/Report.aspx?ReportId=87315 in developing a national circumcision strategy. By December 2009 the country had a draft policy but no mechanisms for training, quality assurance, or monitoring and evaluation. South Africa has the world's largest HIV-positive population. About 35 percent of men are circumcised. Data from the only site currently providing free circumcision - Orange Farm, near Johannesburg - reveals that 14,253 men were circumcised in 2009. Namibia: A draft policy was submitted to parliament and training of surgical health professionals is underway. Five circumcision pilot sites have been identified, two of which are in operation. A 2009 field analysis http://www.malecircumcision.org/programs/documents/Namibia11209.pdf showed that the unit cost per procedure was very high: US$88 for adults and $72 for newborns. Lesotho: About 4,000 men are circumcised annually at government and private clinics. A policy has been approved but is yet to be launched, and formal scale-up has not yet started. The Puisano Outreach Organization, a local NGO, is engaged in male circumcision campaigns throughout the country. Tanzania: A 2009 situation analysis http://www.malecircumcision.org/programs/documents/TanzaniaMaleCircumcisionSituationAnalysis_September_09.pdf found male circumcision was accepted, even among traditionally non-circumcising communities, and 70 percent of Tanzanian men were circumcised. A national policy is being developed and three demonstration sites have been set up. Mozambique: No formal policy for male circumcision has been developed, but an existing operational plan for HIV prevention includes circumcision. Five pilot sites have been selected for scale-up in 2010. A 2008 study found that rolling out adult male circumcision in Mozambique would put undue pressure on health workers, which would limit the scale and effectiveness of the programme. Malawi: The country is conducting data analysis to inform its male circumcision strategy. A local NGO, Banja la Mtsogolo, http://www.banja.org.mw is providing male circumcision services in its clinics, where it has 19 trained clinicians performing the procedure. Uganda: This is one of the three countries where studies showed the link between male circumcision and HIV, but only 25 percent of men are circumcised and HIV prevalence is rising. There has been some criticism for failing to start male circumcision quickly enough - the country still has no policy, nor has it started service delivery. A 2009 situational analysis http://www.malecircumcision.org/programs/documents/MC_situation_analysis_Uganda_full.pdf found that most practitioners would need additional training to perform male circumcision. kr/he http://www.plusnews.org/report.aspx?ReportID=88286 http://www.plusnews.org/report.aspx?ReportID=88286 KAMPALA, 2 March 2010 (PLUSNEWS) - More than 450,000 people have signed an online petition urging Uganda's parliament to drop a bill that would impose the death sentence for the crime of "aggravated homosexuality" - when an HIV-positive person has sex with anyone who is disabled or under the age of 18. http://www.IRINnews.org/images/2010/201003020959060644t.jpg KAMPALA, 2 March 2010 (PLUSNEWS) - More than 450,000 people have signed an online petition https://secure.avaaz.org/en/uganda_rightsurging Uganda's parliament to drop a bill that would impose the death sentence for the crime of "aggravated homosexuality" - when an HIV-positive person has sex with anyone who is disabled or under the age of 18. Presenting the petition to the speaker of Uganda's Parliament, Edward Ssekandi, on 1 March, AIDS activists - including founder of national NGO, The AIDS Support Organization, Noerine Kaleeba and Canon Gideon Byamugisha, the first religious leader to publicly declare that he was living with HIV - said if the bill was passed, it would roll back the gains made in fighting HIV in Uganda. Responding to the petition, Ssekandi said it could not be withdrawn at this stage, not even by the MP who tabled it; but he assured the activists that their concerns would be passed on to the legislature. The Anti-Homosexuality Bill 2009 - a private member’s bill first tabled by ruling party MP David Bahati in October 2009 - is due for discussion this month. Homosexuality is illegal in Uganda, but the new law would impose more stringent punishments for homosexual activity, while compelling people in authority with knowledge of such activity to report it or face criminal charges. "The bill creates a situation where [homosexual] people living with HIV will be denied treatment," said Major Rubaramira Ruranga, a retired army officer who has lived publicly with HIV for more than two decades. "We do not need a new law that picks one section of society and says this should be punished," he added. However, Ruranga said there was one positive aspect to the controversy. "[The bill] is an opportunity - whether it is passed or not - because people will begin to talk about sexuality," he said. Stigma "It is not easy to access medical services; we have private people who treat us but they charge us [a great deal] because they are very few," said Julian Pepe Onziema, programmes coordinator of the rights group, Sexual Minorities Uganda. "When you go to the doctor you have to give them a medical history; the bill will make this even harder." AIDS activists also argue that the continued stigmatization of homosexuality will drive homosexuals and bisexuals further underground, reducing their access to HIV prevention and care services and increasing their vulnerability to HIV. Men who have sex with men are considered a most at-risk population, but there are no national HIV strategies addressing their needs. "If the government does not come out to help minorities, HIV is coming back; I know many married people who are bi-sexual," said Dennis Wamala, programmes coordinator for Ice Breakers, a local gay rights organization. "Family values" Debate on the bill will go ahead despite Uganda's President Yoweri Museveni distancing himself from it amid calls from international leaders for its withdrawal. President Barack Obama in February referred to the bill as "odious", noting that it was "unconscionable to target gays and lesbians for who they are". Despite international outrage, the bill has remained fairly popular in Uganda, where proponents argue that homosexuality goes against the country's "family values". In February, hundreds of residents of the eastern city of Jinja held a demonstration supporting the bill, with protesters’ signs admonishing western leaders such as Obama to "leave Uganda alone". The bill’s agenda is to strengthen the nation's capacity to deal with "emerging internal and external threats to the traditional heterosexual family" and to protect Uganda's "cherished culture". Roman Catholic and Anglican leaders have rejected the bill, but have said they will back it if the death penalty clause is removed. en/kr/mw http://www.plusnews.org/report.aspx?ReportID=88275 http://www.plusnews.org/report.aspx?ReportID=88275 JOHANNESBURG, 1 March 2010 (PLUSNEWS) - When a crisis strikes, access to antiretroviral (ARV) drugs can be among the first casualties, particularly in countries where many people are on treatment. http://www.IRINnews.org/images/2008/200802043t.jpg JOHANNESBURG, 1 March 2010 (PLUSNEWS) - When a crisis strikes, access to antiretroviral (ARV) drugs can be among the first casualties, particularly in countries where many people are on treatment. But experience in Southern Africa has shown that although preventing treatment disruptions may be wishful thinking, preparing for them has become a pressing need. New research by the Health Economics and HIV/AIDS Research Division (HEARD) at South Africa's University of KwaZulu-Natal compared three recent crises that caused treatment disruption - Mozambique's 2008 floods, Zimbabwe's ongoing public healthcare crisis, and South Africa's 2007 public sector strike – to identify potential strategies for keeping patients on treatment during emergencies. The HEARD report, Unplanned ARV Treatment interruptions in southern Africa: what can we do to minimise the long-term risks?, identified poor planning as the biggest weakness in responding to gaps in treatment access, and suggested that doctors and patients receive better training on what do during disruptions. "Despite crises – whether political, economic or environmental – being relatively common in southern Africa, there has been very little systematic planning for them within ARV programmes," said HEARD's Andy Gibbs, who co-wrote the report. The region's weak health systems were often the cause of disruptions. "Strong health systems have strong planning capacity, an ability to monitor what's happening and [to mobilize] the skills and resources to cope with unexpected issues," Gibbs said. Research has linked disrupted treatment to increased risks of drug resistance and treatment failure. Weathering the storm Southern Africa has some of the highest HIV prevalence rates in the world, while droughts, floods and cyclones typically spark humanitarian emergencies in this chronically vulnerable region. The Southern African Development Community (SADC) has pushed member states to integrate ARV treatment into national disaster preparedness planning. The UNAIDS regional humanitarian response advisor for East and Southern Africa, Mumtaz Mia, said Mozambique, Zimbabwe and Namibia had taken the lead in ensuring that people did not miss ARV doses amid disasters. Mozambique experienced some of the worst flooding in the country's history in 2007, and more than 56,000 people were affected by floods in 2008, but Mia noted that planning by UNAIDS, the national AIDS council and the National Institute for Disaster Management had helped minimize treatment disruptions. HEARD found that Mozambique had mapped the location of ARV patients in flood-prone areas, and had educated community outreach workers in the vicinity in ARV provision ahead of the devastating floods in 2008. Dr Mit Philips, a health policy analyst at the international medical and humanitarian organization, Medicines Sans Frontiers (MSF), pointed out the importance of giving patients information before and during treatment interruptions. MSF has been working in Mozambique, Zimbabwe and South Africa, and also provided ARV treatment during Kenya's 2008 post-election violence. "When the [post-election violence] happened in Kenya, we set up a free hotline, we used radio spots and peer networks so that patients knew how to find us to pick up their pills and continue treatment," she told IRIN/PlusNews. "You don't need to go and find patients, you need to make sure patients know how to go and find you. If you can foresee it, it's important that the patients know how to deal  with possible disruptions at their usual health centres – it should be part of treatment literacy." When the public sector isn't so public In 2007, South Africa was rocked by a public servant strike that lasted for a month and affected up to half a million employees, including health workers. Data from South Africa's Gauteng Province showed that the number of patients initiated on treatment in areas like Johannesburg's inner city dipped to one of the lowest in four years. Testimony gathered in the Western Cape Province by Treatment Action Campaign, an AIDS lobby group, showed that during the strike some pharmacies were so short-staffed they were only able to fill 25 percent of orders. Patients and doctors used varying coping strategies to deal with the treatment disruptions and the South African HIV Clinicians Society released guidance on how to cope with treatment interruptions. Some patients were able to get more than one month's supply of drugs. HEARD researchers argued that the South African authorities could have foreseen such an interruption and provided both patients and doctors with better training on what to do when ARVs cannot be obtained. In Zimbabwe ARV treatment in the public health sector has also seen its share of hard times. The economic crisis sparked migration among doctors and nurses as well as patients, while hyperinflation and high levels of unemployment meant the tests required before starting ARVs were often unavailable or prohibitively expensive. To help migrants continue treatment in other countries, MSF gives patients portable copies of their medical records, including which ARV regimen they are on. SADC has received funding to implement a similar regional "health passport" system, but national health ministers would have to get draft legislation passed to implement it. Access to treatment, even for documented migrants like asylum seekers and refugees, is problematic. Funding flows pose their own threat MSF's Philips said interruptions in financial flows posed as big a threat to ARV programmes as any flood or bout of civil unrest, and might become a threat of increasing importance as HIV and AIDS funding constricted in the global financial crisis. "What we have been seeing in the last six months to one year are increasing disruptions to programmes ... many of these are due to delays in funding, or delays in the supply chain," she commented. "IN a way, it's more difficult to prepare for these [than for natural disasters] because the information on the risk of treatment disruption isn't always shared with implementing partners in a transparent way ahead of time." In 2009, South Africa's Free State Province experienced widespread treatment disruption due to a combination of funding problems and allegations of poor management. Philips noted that several countries including Malawi, Mozambique and Uganda  had experienced problems with funding or drug procurement, and were more vulnerable to disruptions not only because of weak health systems but also because of a heavy reliance on a single funding source. According to an MSF report, Punishing Success, the bulk of Malawi's ARV funding as of 2009 came from the Global Fund to Fight AIDS, Tuberculosis and Malaria. "What we are seeing is that quite a lot of donors seem to see the Global Fund as a main channel of international funding for HIV treatment. If there is only one channel and something happens, there's nothing you can do," she said. "Countries depend on the timely arrival of supplies; when money for drugs was delayed in Malawi, there was no buffer." Few countries carry ARV buffer stocks - surplus drugs kept aside and used in the event of a drug shortage. Philips said this strategy was successfully employed in the Democratic Republic of Congo, which put a pool of donor-funded ARVs under World Health Organization management. Fareed Abdullah, director of the Fund's Africa Unit, said the Global Fund had begun addressing funding delays after the issue was raised at the organization's highest level. "Clearly, the reasons behind stock-outs are multi-factorial, and responsibility for them lies with various donors and implementing agencies, not least of all, governments," he told IRIN/PlusNews. "Having said that, there are certainly a number of steps within our financing process where the Global Fund considers the risk of drug stock-outs." The Fund offers countries emergency disbursements to cover unexpected treatment shortages, and allows two years of gap funding to cover ARV treatment specifically, between grant disbursements, Abdullah said. The Fund has also taken on additional responsibilities in an effort to reduce treatment disruptions due to problematic procurement. "Sometimes we finance drugs that make their way to the central store, and they don't get from the central store to the clinics – that's really for countries to address, alongside implementing partners," Abdullah commented. "However, in some countries we have a failure of procurement and, even though we have resisted taking over those functions because we believe in country ownership, we now have a mechanism where we will procure drugs for a country." llg/kn/he http://www.plusnews.org/report.aspx?ReportID=88272 http://www.plusnews.org/report.aspx?ReportID=88272 DAR ES SALAAM, 1 March 2010 (PLUSNEWS) - A Tanzanian project is integrating family planning and HIV messages via community health workers who teach HIV-positive couples how to avoid unwanted pregnancies or infecting their unborn children. http://www.IRINnews.org/images/2009/200912151317590968t.jpg DAR ES SALAAM, 1 March 2010 (PLUSNEWS) - A Tanzanian project is integrating family planning and HIV messages via community health workers who teach HIV-positive couples how to avoid unwanted pregnancies or infecting their unborn children. “I talk to them and they tell me they are afraid,” Margaret Mapunda, a trained community health worker in Tanzania’s commercial capital, Dar es Salaam, told IRIN/PlusNews. “Some want [children] but they don’t know what to do and just conceive and go to traditional birth attendants to deliver. “Many are taking antiretrovirals and they don’t even know which contraceptives are good and bad,” she added. “They do not ask because of stigma. Some say they are abused at health facilities.” Since 2008, more than 3,000 couples have received family planning services from home-based care service providers in the areas of Dar es Salaam, Arusha and Kilimanjaro under the Tutunzane – Swahili for “let’s care for each other” - project, run by reproductive health NGO, Pathfinder International [http://www.pathfind.org/site/PageServer?pagename=Programs_Tanzania_Projects_Tutunzane]. Family planning needs A 2009 study [http://journals.lww.com/aidsonline/pages/articleviewer.aspx?year=2009&issue=11001&article=00004&type=abstract] conducted in the northern Tanzanian region of Mwanza and published in the journal, AIDS, found numerous potential benefits of offering family planning counselling as a part of antenatal services, particularly in clinics offering HIV testing. According to Children and AIDS, Fourth Stock Taking Report 2009 [http://www.unicef.org/aids/files/B230stocktaking_06Nov09_FINAL_loRes.pdf], by the UN Children’s Fund, as many as 130,000 HIV-positive Tanzanian women become pregnant every year; 53 percent of these have access to prevention of mother-to-child transmission services. A study carried out by Pathfinder International in 2008 found that 90 percent of home-based care providers were willing to add family planning services to their activities but lacked adequate training. So far the project has trained about 250 community health workers to integrate family planning messages into their HIV counselling. “Community home-based care service providers are very low cost and they interact more with people living with HIV than anybody else; they therefore provide a perfect opportunity to reach out to them, including with family planning services,” said Judith Rwakyendela, reproductive health and family planning programme officer at Pathfinder International. “When you give people antiretrovirals, the objective is to make them live longer, yet many of them become strong, active and engage in sex without necessarily aiming at having a baby,” she added. “It is important that they are given the opportunity to prevent unwanted pregnancies, which plays the twin role of improving their health and preventing mother to child transmission.” Johannes and Vivian Murliryianga*, from the Dar es Salaam suburb of Sinza, have five children; they are now receiving counselling from a community health worker as they try to prevent more pregnancies. Unfortunately, they learned about prevention of mother-to-child transmission too late to stop their youngest child from contracting HIV. “I normally did not go to a government hospital, I just had my babies at a clinic run by some lady to whom we give small money and she allows you to give birth at her place. We just call her shangazi [auntie],” Vivian said. “I was surprised when my child tested positive; I didn’t even know children could get HIV.” Under the Pathfinder programme, couples like Vivian and Johannes are given family planning advice according to their situation and needs. “As you know family planning methods are many - we just give them choices depending on what they prefer and the situation,” Mapunda said. “You will get some married couples telling you they prefer condoms, especially among discordant ones; some want pills. We counsel them on the merits and demerits of each.” Involving men She noted that while counselling had been largely successful, encouraging men to participate had been a challenge. “We have seen more success where fathers agree to join the programme but not all are willing and it becomes very difficult because it means the mother does many of the things secretly,” she said. “Imagine trying to give these services to a woman who fears disclosing her status or whose husband’s status is unknown; it is a challenge but we try what we can,” she added. ko/kr/mw http://www.plusnews.org/report.aspx?ReportID=88263 http://www.plusnews.org/report.aspx?ReportID=88263 KIGALI, 26 February 2010 (PLUSNEWS) - Rwandan nurses will soon be authorized to start HIV-positive patients on life-prolonging antiretroviral treatment (ART), a move Ministry of Health officials say will speed up the rollout of ART in the East African nation. http://www.IRINnews.org/images/200511303t.jpg KIGALI, 26 February 2010 (PLUSNEWS) - Rwandan nurses will soon be authorized to start HIV-positive patients on life-prolonging antiretroviral treatment (ART), a move Ministry of Health officials say will speed up the rollout of ART in the East African nation. "Task-shifting will reduce the number of cases requiring the presence of a doctor, thereby reducing the number of treatment-eligible patients that have not initiated ART because they have to wait for the doctor's visit," Aimable Mbituyumuremyi from TRAC Plus, the Centre for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, told IRIN/PlusNews. At present, starting on ARVs requires a medical consultation and prescription from a physician. Nurses are responsible for regular patient follow-up and can refill existing ARV prescriptions. Physicians are generally based at district hospitals and visit health centres once a week. According to officials from TRAC-Plus and the Ministry of Health, the new programme aims to train two nurses from every health centre offering HIV services. By the end of May, 600 nurses will be trained on the theoretical and practical aspects of ART prescription. Training will be followed by a three-month mentorship period, where physicians from district hospitals will conduct follow-up visits to each health centre to guide nurses on patient management. By September the nurses will be authorized to prescribe ART in uncomplicated cases requiring first-line drugs. Cases with significant complications that may require second-line ART will continue to be referred to physicians. Doctors and supervisors from the district hospitals will continue to monitor nurses during their quarterly formative supervision visits to health centres. A 2009 study http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000163 by the NGO, Family Health International, and the Ministry of Health, evaluating nurse-centred ART in rural health centres in Rwanda found that nurses could "effectively and safely prescribe ART when given adequate training, mentoring, and support". Rwanda suffers from a severe shortage of health workers; according to the UN World Health Organization http://www.who.int/whosis/whostat/EN_WHS09_Full.pdf, the country has approximately one physician per 10,000 population and four nurses and midwives per 10,000, compared with 13 physicians per 10,000 globally and 32 physicians per 10,000 in the European region. The country's limited number of health workers has been put under enormous stress by the rapid scale-up of ART. According to TRAC, clients on ART increased from approximately 34,000 at end-2006 to more than 75,000 at end-2009 - an increase of 120 percent - while the number of health centres providing ART increased from 133 to 252 during the same period. The latest Rwanda National Strategic Plan for HIV/AIDS aims to have all health facilities in Rwanda able to provide a full package of HIV services, including ART, by 2012; it also intends to put 90 percent of eligible patients on HIV treatment. The plan envisages task-shifting as critical to achieving these goals. rj/kr/mw http://www.plusnews.org/report.aspx?ReportID=88243 http://www.plusnews.org/report.aspx?ReportID=88243 MOMBASA, 24 February 2010 (PLUSNEWS) - Amina* and Rajab*, in their mid-twenties, spend most of their days getting high on heroin; when broke, Amina injects herself with Rajab's blood as soon as he has mainlined his heroin, for a second-hand hit. http://www.IRINnews.org/images/2010/201002240959410156t.jpg MOMBASA, 24 February 2010 (PLUSNEWS) - Amina* and Rajab*, in their mid-twenties, spend most of their days getting high on heroin; when broke, Amina injects herself with Rajab's blood as soon as he has mainlined his heroin, for a second-hand hit. "Rajab is the one who first introduced me to the idea of transfusing myself with his blood whenever we'd run out of the drug and the cash to buy [more]," she told IRIN/PlusNews from her home in Majengo, a low-income estate in Kenya's coastal city of Mombasa. "I just wanted to feel how Rajab used to feel. I draw his blood using a syringe, then inject it into myself, making me feel high as well." According to government officials and NGOs in Mombasa, blood sharing, commonly known as “flash blood”, is becoming increasingly common in Mombasa. Both Amina and Rajab have tested positive for HIV and are on life-prolonging anti-retroviral therapy; this has not stopped them from using heroin or sharing blood, despite the risk of re-infection. According to the latest Kenya National Strategic plan for HIV/AIDS (KNASP), intravenous drug use (IDU) is responsible for almost a third of new HIV infections in Coast Province, and 3.8 percent of new infections nationally. High risk The flash blood technique was first reported in 2005 in East Africa among female sex workers injecting heroin in Tanzania's commercial capital, Dar es Salaam. "[Flash blood] is a new phenomenon that is, in a sense, a dangerous exaggeration of needle-sharing that magnifies HIV transmission risk," Sheryl McCurdy, of the University of Texas, wrote in a 2005 letter [http://www.bmj.com/cgi/content/full/331/7519/778-a] to the British Medical Journal. "If the first injector is infected with HIV or hepatitis C, the amount of virus directly transmitted into the bloodstream by the second injector could be quite large." A 2009 assessment by the NGO, Darat HIV/AIDS International Agency, of more than 100 narcotics users in Mombasa, a majority of whom were IDUs, identified flash blood as a likely cause of high levels of HIV and hepatitis C - 50 percent and 70 percent respectively - among participants. All those who tested positive for HIV were IDUs. According to the KNASP, intravenous drug use is on the rise in Mombasa; a 2007 survey identified an estimated 12,200 heroin users, 5,680 in Nairobi Province and 6,520 in Coast Province - approximately 10 percent of whom were IDUs. None was receiving any HIV prevention or drug dependence treatment services. Prevention strategies The strategy points out that although this high-risk group has a high potential of infecting the general public with HIV, it has been difficult to conduct programmes for IDUs, mainly because of insufficient data, the criminal nature of drug use and marginalization and intolerance, even from policy-makers. "It is important to scale up, revitalize and initiate programmes among these populations through peer outreach, condom promotion and distribution, tailored sexual healthcare and community empowerment," the 2009 Kenya Modes of Transmission Analysis [http://www.unaidsrstesa.org/files/u1/Kenya_MoT_Country_Synthesis_Report_22Mar09.pdf] recommended. "In the entire province, there exist only four centres, which makes it hard to address the issue extensively," said Sheikh Juma Ngao of the National Campaign Against Drug Abuse. He added that the success rate of the existing centres was poor. For most drug addicts, poor and unemployed, getting high is their only escape. Ahmed, who left prison six months ago after serving time for possession of heroin, says the drug is a “tiba”, or treatment, for the hardships he faces daily. "Only by injecting myself is when I can get some relief... the drug definitely becomes part of your body system, your life," he told IRIN/PlusNews. "Not even the police or the fear of contracting HIV can scare you off." *Not their real names jk/kr/mw http://www.plusnews.org/report.aspx?ReportID=88221 http://www.plusnews.org/report.aspx?ReportID=88221 JOHANNESBURG, 23 February 2010 (PLUSNEWS) - New national treatment guidelines are set to make the world's largest antiretroviral (ARV) programme even bigger as South Africa extends treatment to more HIV-positive infants, pregnant women and people battling HIV-tuberculosis (TB) co-infection. http://www.IRINnews.org/images/2007/2007081411t.jpg JOHANNESBURG, 23 February 2010 (PLUSNEWS) - New national treatment guidelines are set to make the world's largest antiretroviral (ARV) programme even bigger as South Africa extends treatment to more HIV-positive infants, pregnant women and people battling HIV-tuberculosis (TB) co-infection. Dr Nono Simelela, CEO of the South African National AIDS Council (SANAC), confirmed that the revised guidelines were in the final stages of editing and would go to print in a few days; implementation is scheduled to begin on 1 April 2010. Major changes to the guidelines include providing ARVs to all HIV-positive infants less than one year old regardless of their CD4 count, which measures immune system strength. Pregnant HIV-positive women will be able to start treatment at a new, higher CD4 count of 350, as will all TB/HIV co-infected patients, rather than having to wait until their CD4 counts fell to 200 or below as was previously the case. TB remains the leading cause of death among people living with HIV. The shifts in treatment could significantly reduce infant and maternal mortality due to HIV, and lower the rate of new infections. "Although the cost implications are huge, the treasury has already committed the additional resources to cover the expansion and we also have support from PEPFAR [US President's Emergency Plan for AIDS Relief]," Simelela told IRIN/PlusNews. The balancing act South Africa has lagged behind most countries in the region in adopting a CD4 count of 350 as the threshold for starting treatment to all those living with HIV and many activists said they had hoped the revised guidelines would bring South Africa in line with this international standard. However, indications are that the new, revised CD4 threasholds of 350 will apply only to infants younger than one year, HIV-positive pregnant women, and people co-infected with TB/HIV, and will not be universally extended. The country's nine provinces have begun drafting plans to implement the guideline revisions - the first in about five years - that are the result of strong lobbying by both SANAC and civil society, some of whom expected new guidelines to be released much sooner. Simelela said the guidelines were delayed for a number of reasons, including capacity constraints and the need to reconcile competing views on treatment within the HIV and AIDS sector. "Protracted processes [were undertaken] to achieve consensus on some of the regimens," she said. "A tricky balance had to be struck between the top-range [drug] regimens, which are costly, versus some regimens that are cheaper but have more side effects." According to media reports, the guidelines indicate that the ARV stavudine, associated with an increased number of side effects in many patients, could be phased out and replaced by tenofovir.   llg/kn/he * This article was amended on 22 February 2010. South Africa’s new treatment guidelines do not do away with polymerase chain reaction (PCR) tests, as originally reported, as these tests remain the only way to confirm whether HIV-exposed infants are HIV-positive. Instead, new guidelines call for any child under one year of age to receive ARVs regardless of CD4 count and remove CD4 count testing as a pre-requisite for treatment initiation in infants. http://www.plusnews.org/report.aspx?ReportID=88207 http://www.plusnews.org/report.aspx?ReportID=88207 JOHANNESBURG, 22 February 2010 (PLUSNEWS) - New research could bolster arguments for a controversial approach that could eradicate HIV transmission in South Africa within five years, said Dr Brian Williams of the South African Centre for Epidemiological Modelling and Analysis (SACEMA). http://www.IRINnews.org/images/2010/201002221404060391t.jpg JOHANNESBURG, 22 February 2010 (PLUSNEWS) - New research could bolster arguments for a controversial approach that could eradicate HIV transmission in South Africa within five years, said Dr Brian Williams of the South African Centre for Epidemiological Modelling and Analysis (SACEMA). The "test and treat" approach is based on mathematical modelling and pairs aggressive HIV testing campaigns with almost immediately putting people found to be HIV positive on treatment. In theory, this model would use early treatment to lower viral load (the amount of virus in the blood), and lower the likelihood of transmission, eventually cutting HIV prevalence rates. A report published in the current issue of AIDS, the Journal of the International AIDS Society, is based on a study that followed about 14,000 new mothers in Zimbabwe for about two years from 1997 to 2000 after the birth of their children. The research showed that HIV-positive new mothers were at much greater risk of dying than their HIV-negative peers, even when the positive women had a CD4 count (which measures immune system strength) of 600 to 1,000 and was equal to or higher than that of HIV-negative women. Although the research was conducted before antiretrovirals were available in the public sector, the data may have answered a crucial question in the test and treat debate. "One of the questions around doing [the test and treat model] has been that even if you accept that there is public health benefit of testing and treating everyone, what does that do for the individual?" Williams told IRIN/PlusNews. "The study's authors showed that even at CD4 counts of up to 1,000, mortality among the HIV-positive women was about 50 times higher, [and] it's in the patient's interest too, to start treatment early," said Williams, who spoke in favour of test and treat at the Conference on Retroviruses and Opportunistic Infections (CROI), and the annual meeting of the American Association for the Advancement of Science, both in the Untied States. John Hargrove, co-author of the report, said the study was one of a very few that had compared the mortality rate of untreated HIV-positive adults to their HIV-negative peers and had tied this to CD4 counts - the research could never be ethically replicated in today's expanded treatment environment. However, there are concerns that the approach is unrealistic, given low testing uptake globally, and that putting more people on treatment earlier may lead to poor adherence and contribute to drug resistance. The approach is being implemented on a trial basis in high HIV prevalence areas of the United States, including the District of Columbia and New York City. The US infection rate is about 0.6 percent, according to UNAIDS. Testing and treating, funding and debating Williams said doing away with specific requirements like the need to verify CD4 counts would reduce costs, but estimated that it would still cost a country like South Africa at least US$2 billion a year to implement the test and treat strategy nationally. "Costings show that the cost of providing ARVs will be roughly balanced by the costs saved in [relation to] opportunistic infections and hospitalisations," he said. "We need a big investment initially, but in the long term we are going to be saving money. It's the only real prospect for actually stopping the epidemic." However, in a debate about test and treat in late 2009, Dr Francesca Conradie, deputy director of the University of Witwatersrand Clinical HIV Research Unit, argued that money was not the only issue, and that test and treat models ignored current realities, including low testing uptake. According to the 2008 South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, only about half the people 15 years and older have been tested for HIV. Conradie also argued that the US had low HIV prevalence, whereas South Africa's HIV population was simply too big to meet the treatment targets cited by current test and treat models to make the approach affective - the country would have to reach more than eight times the number currently on treatment to meet the targets. With an HIV prevalence rate of about 18 percent and more than half a million people on treatment, South Africa runs the world's largest ARV treatment programme. llg/he http://www.plusnews.org/report.aspx?ReportID=88200 http://www.plusnews.org/report.aspx?ReportID=88200 DAR ES SALAAM/MOROGORO, 22 February 2010 (PLUSNEWS) - Elias Sempindo, 72, thought he would spend his twilight years doting on his grandchildren; instead, the retired medical officer is back treating patients at a clinic in Morogoro, 190km west of Tanzania's commercial capital, Dar es Salaam. http://www.IRINnews.org/images/2010/201002221259120344t.jpg DAR ES SALAAM/MOROGORO, 22 February 2010 (PLUSNEWS) - Elias Sempindo, 72, thought he would spend his twilight years doting on his grandchildren; instead, the retired medical officer is back treating patients at a clinic in Morogoro, 190km west of Tanzania's commercial capital, Dar es Salaam. "When I first served as a medical officer, I used to deal with ordinary diseases, but today I am dealing with HIV/AIDS and tuberculosis, which are very complicated," he told IRIN/PlusNews at a clinic in Morogoro. "I can't pretend it is easy, but it is what I have to do... it is a calling." Sempindo, a clinical officer who retired in 1992, is part of a pilot project, "Retired but not tired" [http://www.fhi.org/en/CountryProfiles/Tanzania/res_Retired_but_not_Tired_Tanz.htm], run under the Tunajali - Swahili for “we care” - programme by the NGO, Family Health International (FHI) and accounting firm Deloitte, funded by USAID. “The increased uptake of HIV counselling and testing brought about by increased HIV/AIDS awareness campaigns has come with increased pressure on government health facilities," said Elisanguo Shao, director of the project. "If we have been that successful in encouraging people to go for HIV testing, then we must also find ways of ensuring they are treated." As many as 1.5 million Tanzanians are HIV-positive; close to 300,000 are currently on HIV treatment, says the government. According to the World Health Organization, Tanzania has one of the worst physician-to-patient ratios in the world, with just 0.02 doctors and 0.35 nurses and midwives per 1,000 people. "Tanzania has a relatively young retirement age and this means many of those retired still have the energy and the skills to serve in various sectors, including the medical sector - this is the opportunity we have utilized within the retired officers' programme," said Dr Eric van Praag, FHI Tanzania country director. Tanzanian health workers now retire at the age of 60; until 1999, they retired at 55. Easing the burden FHI facilitates the employment of the retired workers but they remain government employees and are recruited through government systems. Once employed, their pensions are suspended; they earn about 10 percent more than they would if they were directly employed by the government. They work exclusively in HIV care and treatment clinics, freeing up regular medical staff to handle other illnesses. According to Shao, nearly half of all hospital visits in Tanzania are HIV-related. "We train them in different aspects of HIV care, management and treatment so that they are up to speed with current requirements in managing the disease and other opportunistic infections that come with it," he said. "They have greatly relieved staff and they have also imparted skills because they have the experience," said Meshack Massi, Morogoro regional medical officer. "They are a source of motivation to younger staff; now HIV patients and others do not have to wait for long to be served." New challenge For many of the older health workers, returning to work has been a refreshing change. "I think I made the best decision... I am delighted to see we are a source of encouragement for others," said Martha Ng’habi, a nurse at Morogoro hospital. "The desire to serve gives the strength to go on, even when your age is advanced." So far, the pilot project – undertaken at the government's request - has hired 30 clinical officers and nurses in five regional hospitals in Iringa, Dodoma and Morogoro, areas with some of the highest HIV prevalence levels in Tanzania; the five facilities have more than 5,000 HIV-positive people under their care. "Initially, the response wasn't overwhelming because many of these retired people resort to a quiet life and others join agriculture or they just want to run their businesses after retirement, but we have managed to get some of them," Van Praag said. Expansion Following the success of the pilot, the Tanzanian government has directed regional authorities to put aside funds to re-employ retired health workers to manage HIV care and treatment centres. "The government is very enthusiastic about the programme and it will put money aside in its health budget to continue this programme once the donors and other private stakeholders pull out," Shao said. "The government further has promised to recruit more healthcare workers and there are plans to increase the retirement age to deal with the health worker shortage," he added. ko/kr/mw http://www.plusnews.org/report.aspx?ReportID=88194 http://www.plusnews.org/report.aspx?ReportID=88194 HARARE, 19 February 2010 (PLUSNEWS) - A new Zimbabwean short film on multiple concurrent sexual partnerships (MCPs) runs for just 24 minutes, but the producers are hoping that its message will last much longer http://www.IRINnews.org/images/2008/2008021314t.jpg HARARE, 19 February 2010 (PLUSNEWS) - A new Zimbabwean short film on multiple concurrent sexual partnerships (MCPs) runs for just 24 minutes, but the producers are hoping that its message will last much longer. The film, "Big House, Small House" is the latest offering from the OneLove Campaign, which works to reduce HIV prevalence and MCPs in 10 southern African countries. The title refers to the colloquial expression "small house", used to denote long-term, illicit sexual relationships in Zimbabwe. The film was produced by the Action Institute for Environment, Health and Development Communication (ACTION), a local NGO, in partnership with the Soul City Institute for Health and Development Communication, a South African NGO, and Zimbabwe's National AIDS Council (NAC). Television stations around southern Africa will air the movie as part of a series of 10 films – one from each of the campaign's focus countries – highlighting the dangers of MCPs. MCPs have been identified by both UNAIDS and regional leaders as one of the key drivers – along with inconsistent condom use and low levels of male circumcision – of southern Africa’s HIV epidemic and Zimbabwe is no exception. Although the country has experienced a decline in HIV prevalence within the last decade, attributed to mortality and behaviour change, HIV prevalence remains high at about 15 percent, according to UNAIDS. Localising the story Using regional research on MCPs conducted in 2007, ACTION worked with partners to develop the script, which focuses on Simba and his wife, Shingi, who seemingly have the perfect relationship after 10 years of marriage – until Shingi finds that Simba has been having a long-term affair with a much younger woman. "The film is about how their story unravels, and about some of the cultural challenges [like those] that say it's okay for men to have more than one 'wife'," said ACTION's Caroline Majonga. "It's about the discovery of betrayal, the complexities around sexual networks, how HIV comes into the picture, and how the couple deals with it." Jasen Mphepho, who plays Simba in the film, said men were sometimes pressured into taking up a "small house" by friends and family. "Men want to be seen to conform to what they think is the norm; they want to please their friends and relatives, but in the process they end up hurting the ones they love. I hope those who watch the film will be moved enough to protect the ones they love." Although regional partner Soul City has stepped in to help train and sensitise local film-makers, according to Harriet Perlman, Soul City senior executive for the region, the movie reflects Zimbabwe's unique message on MCPs. Majonga said regional research had shown that people in southern Africa generally engaged in MCPs for the same reasons, like seeking sexual satisfaction, but Zimbabwe and other countries covered by the OneLove Campaign had now crafted their own messages on the topic and presented them in films like "Big House, Small House". "A lot of the dissatisfaction [highlighted in research] was because people weren't able to communicate their expectations to one another. We want to show people how communicating would improve the quality of relationships," Majonga told IRIN/PlusNews. "Our main message in Zimbabwe has been that we want to encourage people [to know] that it's possible to have a relationship that is both emotionally and physically satisfying with one person." bt/llg/he http://www.plusnews.org/report.aspx?ReportID=88169 http://www.plusnews.org/report.aspx?ReportID=88169 NAIROBI, 19 February 2010 (PLUSNEWS) - Many HIV-positive African patients are starting treatment too late for it to be effective, new scientific studies have shown. http://www.IRINnews.org/images/2007/200708208t.jpg NAIROBI, 19 February 2010 (PLUSNEWS) - Many HIV-positive African patients are starting treatment too late for it to be effective, new scientific studies have shown. Studies [http://app2.capitalreach.com/esp1204/servlet/tc?c=10164&cn=retro&e=12359&m=1&s=20431&&espmt=2&mp3file=12359&m4bfile=12359] from South Africa, Uganda and Zimbabwe presented at the 17th Conference on Retroviruses and Opportunistic Infections in San Francisco (ending 19 February), all found late enrolment of patients on life-prolonging antiretroviral treatment (ART) to be a significant barrier to treatment programmes. "Over each calendar year, we see increasing numbers of patients [enter] the programme," said Susan Ingle, from the University of Bristol in the UK, who co-authored a study on pre-treatment mortality in South Africa's Free State Province. "However, there are still many deaths that occur in the period while waiting to start treatment; these deaths are most likely to occur in the most immuno-suppressed patients." Patients with stronger immune systems - measured by a higher number of CD4 cells per cubic millilitre of blood - were not monitored frequently enough to enrol them for treatment at the correct time, Ingle said. During the study, almost 3,000 of 22,000 participants had CD4 counts better than 250 - the then nationally stipulated threshold - and so did not start treatment immediately. "The median time to their next CD4 measure was six months; however, within this time patients had experienced a median CD4 cell decline of 113," Ingle added. "By the time these patients were assessed again, a large proportion of them would have dropped to well below the treatment eligibility threshold." Patients with CD4 counts below 200 are at high risk of opportunistic infections. The World Health Organization (WHO) recently reviewed its treatment guidelines to recommend that treatment start sooner, at a CD4 level of 350. Ingle noted that "loss to follow-up" - where patients starting HIV care turn up for a first visit and are not seen again - was also a significant problem. Late enrolment, poorer results Presenting findings from a Development of Anti-Retroviral Therapy (DART) in Africa trial [http://www.ctu.mrc.ac.uk/dart/default.asp] in Uganda and Zimbabwe, Paula Manderi from the Uganda Virus Research Institute [http://www.iavi.or.ug/] said patients starting treatment with very low CD counts were unable to see their immune counts recover to levels above 250. "If a patient still had a CD4 count of below 50 cells after a year of treatment, there is only a 9 percent chance that they would ever attain 250 cells," she said. A CD4 cell count of below 125 after a year of treatment was identified as the cut-off point at which patients were unlikely to reach 250. "Our data highlights the importance of expanded earlier diagnosis and earlier initiation of treatment at higher CD4 counts," Manderi said. Ingle suggested that pre-ART mortality could be reduced by fast-tracking the most immune-deficient patients, raising the treatment eligibility guidelines in line with the new WHO recommendations, and improving monitoring and retention of patients not yet eligible for ART. According to the WHO, almost three million people in sub-Saharan Africa are enrolled in ART programmes, which represents 44 percent of people who need treatment. kr/mw http://www.plusnews.org/report.aspx?ReportID=88168 http://www.plusnews.org/report.aspx?ReportID=88168 JOHANNESBURG, 18 February 2010 (PLUSNEWS) - Cervical cancer is a leading killer among women living with HIV, but a low-cost screening programme developed in Zambia is proving that simple techniques can go a long way in saving lives. http://www.IRINnews.org/images/2007/200711071t.jpg JOHANNESBURG, 18 February 2010 (PLUSNEWS) - Cervical cancer is a leading killer among women living with HIV, but a low-cost screening programme developed in Zambia is proving that simple techniques can go a long way in saving lives. New research presented this week at the 17th Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco has shown that cervical cancer screening among HIV-positive women prevented one death for every 32 women screened. Presented by Dr Groesbeck Parham of the University of Alabama at Birmingham, the research originated from a pilot study of about 6,600 HIV-positive women examined as part of the Cervical Cancer Prevention Programme in Zambia (CCPPZ), an ongoing low-cost screening project. More than half the women had abnormal results, and about 20 percent were diagnosed as having lesions at varying stages from pre-cancerous to advanced cancer. According to the World Health Organisation, cervical cancer - which is caused by the human papilloma virus (HPV) - is the second biggest cause of female cancer mortality worldwide. It is thought that women living with HIV are at a higher risk of cervical cancer, but the number of women being screened for the cancer remains low, especially in developing countries. Results raising awareness Dr Mulundi Mwanahamuntu, CCPPZ co-director alongside Parham, said screening was virtually nonexistent before the programme was set up. "The [cancer] was still found, but usually at a stage where it was untreatable," he told IRIN/PlusNews. "In Zambia, cervical cancer is the biggest gynaecological burden we have, and the numbers of doctors that are equipped to handle it are few." He said the programme had helped propel cervical cancer onto the national health agenda, and had prompted high-level discussion about the possible introduction of the HPV vaccine in the public health sector. Screening by the programme's service costs about US$1 as compared to pap smears that cost about $15 and remain prohibitively expensive even in richer countries like South Africa. To keep costs this low, the programme enables health workers and nurses to carry out screening and treatment, allowing doctors - already in short supply - to perform other tasks. The technique has been implemented nationally by training staff members at organizations like the Marie Stopes clinics for women's health, and the Zambian armed forces. The screening programme has also drawn interest from other countries, including Botswana, Tanzania and Cameroon, which have sent delegations for training. The benefit of early cervical cancer screening seems to be undeniable, but Mwanahamuntu said questions remained as to how the cancer progressed in HIV-positive women, and how women at different clinical stages of HIV reacted to treatment for cervical cancer. llg/he http://www.plusnews.org/report.aspx?ReportID=88156 http://www.plusnews.org/report.aspx?ReportID=88156 KIGALI, 18 February 2010 (PLUSNEWS) - Rwandan health authorities have embarked on a campaign to sensitize the country's prisoners - considered high risk for HIV – on how to protect themselves from contracting and transmitting the virus. http://www.IRINnews.org/images/2005814t.jpg KIGALI, 18 February 2010 (PLUSNEWS) - Rwandan health authorities have embarked on a campaign to sensitize the country's prisoners - considered high risk for HIV – on how to protect themselves from contracting and transmitting the virus. "We have adopted new measures of sensitizing people in correctional facilities as high-risk sexual behaviour in Rwandan prisons seems to be a major contributing factor to the increase in the spread of HIV," said Anita Asiimwe, executive secretary of the National AIDS Control Commission, CNLS. The new strategy will use peer educators to teach prisoners about HIV; they will also encourage prisoners to attend voluntary counselling and testing for HIV so that those who are already HIV-positive can access treatment. "We put emphasis on providing care to those inmates that are HIV-positive," said Antoine Semukanya, deputy executive secretary of CNLS. Like other countries in the region, including Kenya and Uganda, Rwanda's HIV policy regards prisoners as a group that is "most at-risk" of contracting and transmitting HIV. Risk factors "Prison grounds offer ideal conditions for the transmission of HIV, especially through homosexuality," Dative Mukanyangezi, director-general of Kigali Central Prison - where 16.5 percent of imprisoned women and 15 percent of male prisoners were HIV-positive, according to 2006 data - told IRIN/PlusNews. She noted that practices such as intravenous drug use and the sharing of non-sterile sharp instruments for tattooing were widespread in Rwanda's prisons. According to a 2009 study by the Ministry of Health and its partners, prisoners in Kigali's Kimironko Prison reported having sex with sex workers, girlfriends and wives while out of prison on work detail. "Considering all these practices and [the fact that] most prisoners are sexually active males between the ages of 19 and 30, this could explain why prisoners are a most-at-risk population for HIV," Mukanyangezi added. The study also found structural issues such as over-crowding - Rwanda has one of the highest prison populations in the world, with an estimated 604 out of every 100,000 people in prison - short and complicated visitation rights, and insufficient food to be risk factors for HIV in prison. It recommended conjugal visits for some prisoners The case for condoms CNLS's Semukanya noted that the illegal nature of sex behind bars meant that the new strategy would not include the provision of condoms or water-based lubricants, recommended for use along with condoms to prevent lesions during anal sex. However, experts recommended the use of condoms in prison. A 2009 report by TRAC-Plus, the Centre for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, found there was a need to strengthen HIV prevention in prisons, especially condom promotion. "Behaviour change communications could be more appropriate than sanctions to prevent MSM [men who have sex with men], and should focus on increasing risk perception, de-stigmatizing condoms, and promoting other strategies for sexual gratification," said the ministry's study. at/kr/mw http://www.plusnews.org/report.aspx?ReportID=88152 http://www.plusnews.org/report.aspx?ReportID=88152 KIGALI, 16 February 2010 (PLUSNEWS) - Doreen Uwimana, in her early 20s, carries condoms in her bag even when she goes to classes at a college in an upmarket suburb of the Rwandan capital, Kigali. http://www.IRINnews.org/images/2008/2008021212t.jpg KIGALI, 16 February 2010 (PLUSNEWS) - Doreen Uwimana, in her early 20s, carries condoms in her bag even when she goes to classes at a college in an upmarket suburb of the Rwandan capital, Kigali. "You never know," she told IRIN/PlusNews. "I carry them just in case I find myself in a difficult situation... I don't want to get pregnant or ill." Uwimana learned the consequences of unprotected sex the hard way. Five years ago, a sexual encounter without protection left her pregnant. Unable to care for her daughter in the city, she had to send her to live at her parents' home up-country. "The father is at school out of the country and I am a mere student who is equally struggling," she told IRIN. "There was no way I could cope, so my parents are helping out." But despite her best intentions, she admitted to occasionally failing to use protection. "Sometimes, it depends and sometimes one gets so excited," she said. High awareness, low use Uwimana is typical of many young Rwandans who have heard about HIV and condoms, but still fail to use them consistently. According to a 2008 health ministry survey, sexually active Rwandans use, on average, just three condoms every year. A 2005 survey by social marketing NGO, Population Services International [http://www.psi.org/], found that more than 80 percent of Rwandans had seen a condom, had heard about condoms, and were aware of them as an HIV prevention method. Officials say awareness about HIV has increased, but infection rates have not declined by the same proportion. Rwanda's HIV national HIV prevalence is just over 3 percent - 2.2 percent in rural areas and 7.3 percent in urban areas. A three-month campaign to advance the condom agenda and distribute 10 million condoms ends this month, but senior government officials say it is only the beginning of national efforts to popularize condom use. Intensifying the campaign "The use of condoms is a new national strategy," Anita Asiimwe, executive secretary of the National AIDS Control Commission, CNLS, told IRIN/PlusNews, adding that the idea was to make sure "condoms are available when needed and that they are correctly and consistently used". According to Minister of Health Richard Sezibera, the target is young people because studies [http://ajph.aphapublications.org/cgi/content/abstract/97/6/1090] show that youngsters who use condoms the first time they have sex are more likely to engage in subsequent protective behaviour and experience fewer sexually transmitted infections than those who do not. The current campaign involves a raft of activities, including condom distribution by village health workers, as well as in offices and health centres; and installing vending machines in “hot spots” such as bars and night-clubs. In Kigali, posters have sprouted at various places across the rolling hills to encourage condom use and warn against risky sexual behaviour. “Nkoresha Agakingirizo... Ni uburenganzira bwanjye kwirinda” – “I use a condom... it's my right to protect myself”, they proclaim. Some of the city's residents say the message is slowly taking root. "More and more people are using them... it is not worth the risk," said Kigali taxi driver Joseph Barigye. eo/at/kr/mw http://www.plusnews.org/report.aspx?ReportID=88121 http://www.plusnews.org/report.aspx?ReportID=88121