Rectal Microbicides Open New Frontier in Turning HIV Tide

By Chief K. Masimba Biriwasha | OpEd

Microbicide research has gained momentum in recent years with focus largely on products to prevent HIV during vaginal sex. However, there is a growing momentum to develop rectal microbicides for women, men, and transgender individuals around the world who engage in anal intercourse.

Microbicides are products designed to prevent or reduce the sexual transmission of HIV or other sexually transmitted infections when applied inside the vagina or rectum. Most vaginal microbicides are being tested as gels or rings, while rectal microbicides are primarily being tested as gels.

Rectal microbicides are products – that could take the form of gels or lubricants – being developed and tested to reduce a person’s risk of HIV or other sexually transmitted infections from anal sex. In spite of the public health need for rectal microbicide research, there is serious institutional, socio-cultural and political stigma around the issue.

According to estimates, the risk of becoming infected with HIV through anal sex is 10 to 20 times greater than vaginal sex because the rectal lining, the mucosa, is thinner and much more fragile than the lining of the vagina.  Because the rectal lining is only one-cell thick, the virus can more easily reach immune cells to infect.

Although the rate of new infections is stabilizing in many countries around the world, HIV continues to disproportionately affect racial minorities and men who have sex with men. It is estimated that five to ten percent of the world’s population engages in anal sex.

Globally, men who have sex with men are 19 times more likely to be infected with HIV than the general population. Unprotected anal sex is the primary driver of the HIV epidemic among this population.

For decades, the primary approach to HIV prevention for anal sex has been consistent and correct use of male condoms. Male condoms are an extremely effective method to prevent HIV, but many people are unable or reluctant to use them.

Rectal microbicides are products – that could take the form of gels or lubricants – being developed and tested to reduce a person’s risk of HIV or other sexually transmitted infections from anal sex.

If proven effective, rectal microbicides could protect against HIV in people who are unable or reluctant to use condoms. Unlike condoms, they could provide an alternative way to reduce risk that is not controlled by one’s sexual partner and possibly enhance sexual pleasure, helping to motivate consistent use.

Rectal microbicides could offer both primary protection in the absence of condoms and back-up protection if a condom breaks or slips off during anal intercourse. Such an alternative is essential if we are to address the full spectrum of prevalent sexual practices and the basic human need for accessible, user-controlled HIV and STD prevention tools

Rectal microbicides research is in the early phase of clinical development due in part to scientific challenges related to the biology of the rectum, and cultural reluctance to address anal sex.

Most critically testing the safety and acceptability of microbicides designed specifically for rectal use is key to ensuring their effectiveness in preventing HIV infection among people who engage in anal sex.

Researchers need to first be sure rectal microbicides are safe and then conduct additional studies to find out whether they are effective against HIV.

Gender Based Violence Drives HIV Epidemic Among Women: US Study

By Chief K.Masimba Biriwasha | Global Editor At Large

Washington DC, US – One out of every four people living with HIV in the US is a woman according to a new study by the University of California, San Fransisco (UCSF). Further, it is estimated that 30 percent of women living with HIV in the country experience post traumatic stress disorder compared to 5,2 per cent in the general population.

The study has broad implications to efforts to turn the tide against the AIDS epidemic across the world in that its expected to shape the discussion on the impact of violence on women’s vulnerability to the disease.

“Women are dying unnecessarily. They can live with HIV, but are dying from the effects of violence in their homes and communities. HIV policies and programmes must prevent and address the effects of gender based violence that weave through women’s lives,” said Gina Brown, a woman openly living with HIV.

 

According to the study, which focused on approximately 6,000 women living with HIV, intimate partner violence is a disproportionately high cause of death for HIV positive women in the US.

The study concluded that traumatized  women fare worse in AIDS treatment more than women who have not suffered traumatic stress. Trauma also puts women in situations where they are more likely to spread the virus.

“For a long time we have been looking for clues as to why so many women are becoming infected with HIV and why so many are doing so poorly despite availability of effective treatment. This work clearly shows that trauma is a major factor in the HIV epidemic among women,” said Edward Machtinger, Director of the Women’s HIV Programme at UCSF in an interview.

Specifically, the study demonstrated that HIV positive women who report recent trauma had more than four times the odds of experiencing virologic failure, a situation where the HIV virus becomes detectable in the blood despite being on antiretroviral mediations.

The study also revealed that women who had suffered recent trauma were almost four times more likely to have had sex with someone without the virus or whose HIV status was unknown to them, and to not always use condoms with these partners.

“Women who report experiencing trauma often do not have the power or self-confidence to protect themselves from acquiring HIV. Once infected, women who experience ongoing abuse are often not in positions of power to effectively care for themselves or to insist that their partners protect themselves. Effectively addressing trauma has the potential to improve the health of HIV positive women and that of the community.”

Domestic Resources Missing in Africa’s AIDS Response

By Chief K.Masimba Biriwasha Biriwasha | DevAge Global Editor At Large

HARARE, Zimbabwe – Ninety per cent of AIDS programmes in Africa are foreign funded, a situation that is highly unsustainable especially in the face of the global economic crisis, Director of the UNAIDS Regional Support Team for East and Southern Africa, Professor Sheila Tlou revealed in an exclusive interview at the inaugural GlobalPOWER Women Africa conference held recently in Harare, Zimbabwe.

“There are individual variations among countries but indeed in a lot of our programmes continent-wide, ninety-percent of the funding comes from external sources, for example, the Global Fund, PEPFAR and other development partners. There is an AIDS dependency on the continent,” she said, adding that Africa needs increased domestic resources targeted towards the AIDS response.

“We need to have domestic resources because if every country can own the epidemic and say that it’s ours – that can do quite a lot.”

She attributed the continent’s AIDS dependency to the history of epidemic which has been largely characterized by foreign funding of AIDS programmes.

“When HIV came, I would say, a lot of donors were willing to pour a lot of money in, and maybe the situation could have continued had the world not experienced the global economic crisis,” she said.

Tlou said that though African governments have long-recognized that they need to dedicate domestic resources to the AIDS response, there was still a lack of political commitment to implement declarations.

“In 2001, African presidents met in Abuja and made a declaration to devote 15 per cent of national budgets to health but it’s happening in a very few countries. If we can have at least every African country saying we’re going to put 15 per cent of their national budgets to health, we would be far much better off,” she said, pointing out that countries such as Botswana, Mauritius, Namibia and South Africa had committed fifteen percent of their national budgets to the health sector with tangible improvements in the response to AIDS.

“The political commitment needs to be there. Fifteen percent is not a magical bullet but it shows that countries have goodwill to respond to the epidemic whereby donors can say we are helping those who’re helping themselves.”

Tlou added that AIDS programmes in Africa currently exist in silos, far removed from each other, lacking in integration and a holistic approach.

“The real problem is that the AIDS response in Africa is disintegrated. We need to take AIDS out of isolation and make sure that it is integrated into the whole healthcare system,” she said.

Zimbabwe’s AIDS Success Was Doubted: UNAIDS Executive Director

By Chief K.Masimba Biriwasha | iZiviso Global Editor At Large

HARARE, Zimbabwe – UNAIDS Executive Director, Michel Sidibe, said that no-one believed that Zimbabwe could succeed in responding to the AIDS epidemic at the inaugural GlobalPOWER Africa Women Network conference held recently in Harare, Zimbabwe. 

According to UNAIDS, Zimbabwe has achieved one of the sharpest declines in HIV prevalence in Southern Africa, from 27% in 1997 to just over 14% in 2010. With 10 times fewer resources for AIDS per capita than other countries in sub-Saharan Africa, Zimbabwe has expanded coverage of antiretroviral treatment among adults, from 15% in 2007 to 80% in 2010. At the end of 2011, nearly half a million people in the country were receiving lifesaving HIV treatment and care.

“No-one was beliving that Zimbabwe could be a success story with all the difficulties the country was facing but Zimbabwe managed to demonstarte that they can reduce by 52 percent the adult infection rate during the last ten years. Zimbabwe managed to increase the number of people in need of treatment by 50 percent during only the last two years which is important for us to underline,” Sidibe said

He added that Zimbabwe was also a success story because it introduced innovative ways to mobilize internal resources. Zimbabwe’s AIDS Levy, a tax on income to increase domestic resources for the national HIV programme has enabled the country to diversify its domestic funding for its AIDS response, raising an estimated US$ 26 million in 2011. This year the levy is expected to raise US$ 30 million.

However, the majority of people on antiretroviral drugs continue to be supported by the donor community: 76 percent of the 347 172 people on treatment are supported by donor funding.

“In general, any data, you put out is questioned. When we mentioned in our report for the first time that Zimbabwe was making progress, they were reducing the number of new infections and increasing the number of people on treatment, death was going down, people questioned us how that could happen. Many aspects about the country pointded otherwise,” he said.

He said that question surrounding the fact that the country was undergoing serious economic problems made people question the results.

“We asked the one of the best institutes in the world, Imperial College, to come and validate our data. They did all the epidieological analysis and caem up with the validation of the dats. Any place where HIV has success response record, its about leadership at all levels. Secondly, what happeend in Zimbabwe is change in behaviour.

He said that the AIDS levy had played a key part in the Zimbabwean AIDS response, and UNAIDS used it as best practice in raising locals resources for the AIDS response.

“Today, its only 13 percent of the formal sector paying for the levy. We could really look at the informal sector, it will even bring more resources. Zimbabwe’ efforts during the last two years to increase treatment in the past two years is one of the best practices,” he said.

“The Zimbabwe AIDS Levy is an excellent example that demonstrates to other African countries how to generate domestic resources to maintain and own their national AIDS responses. I encourage the Government of Zimbabwe to explore how this initiative could be expanded to tap into the informal sector to boost the resources of the trust fund.”

TB in Children: Why Zimbabwe Must Act Now

By Chief K.Masimba Biriwasha | iZiviso Editor-in-Chief

Harare, Zimbabwe – Tuberculosis (TB) is a major public health problem in Zimbabwe yet very little is known about the impact of the disease on children. Without a functional health-care system and research into pediatric TB, Zimbabwe is likely to continue losing its children to this hidden epidemic.

Among African nations, Zimbabwe is one of those most heavily affected by TB. The 2009 Global Tuberculosis Control Report from the World Health Organisation (WHO) ranks Zimbabwe 17th among 22 countries worldwide with the highest TB burden.

Zimbabwe had an estimated 71 961 new TB cases in 2007, with an estimated incidence rate of 539 cases per 100,000 people. While, Zimbabwe has fought TB fairly successfully since attaining statehood in 1980, in the past few years the disease has re-emerged as a leading killer, especially among people living with HIV, who are often not identified through long-established TB tests. Put simply, the TB control programme has been adversely affected by a lack of adequate financial, human and material resources.

As it is, there’s very little epidemiological data on the extent of TB among children in the country. Experts say that child TB is widely under-reported and can represent as much as 40% of the TB caseload in some TB high burden settings such as Zimbabwe. Children are at high risk of TB, are prone to disseminated disease and the diagnosis of paediatric TB may be difficult, since complaints often are unspecific and contacts may not been known.

To make matters worse, the HIV epidemic has affected TB in children enormously, as it has adults. It has increased the risk that infants and young children will be exposed to TB, since many adults with TB-HIV are young parents.

HIV-infected children have a 20-fold risk of developing TB compared to HIV-uninfected children. It also makes diagnosis and treatment more complicated and increases the risk of TB-related death about 5-fold.  The HIV epidemic has also orphaned many children (with or without TB-HIV themselves).

Unfortunately, Zimbabwe’s national tuberculosis programme has historically not given child TB high priority because of diagnostic challenges (e.g., children under 10 have difficulty producing enough sputum for microscopy and the majority are smear-negative); children are not a major source of the spread of the disease; resources are limited; recording and reporting forms did not include boxes for recording ages 0–4 and 5–14 until 2006.

“Our ability to even assess the magnitude of the problem is severely hampered by the lack of diagnostics in children. The problem is that diagnostic tools, both current and in development, do not adequately take into account the special requirements for assessing children,” said Dr Steve Graham, chair of Stop TB’s Child TB Subgroup of the DOTS Expansion Working Group.

Once infected with TB, infants and young children are at greater risk than adults for developing active TB disease, as well as of having the TB disseminate throughout the body, including to the brain, where it causes meningitis. This type of TB is often fatal or leaves the child with major disability.

Many health workers regard the management of a child with suspected TB as ‘difficult cases’, especially with regard to diagnosis. Children are thought of as needing specialised care.

Against this background, TB case-finding efforts should target children under 5 years of age living in a household with a sputum-smear positive adult. If the children are well, they should receive isoniazid preventive treatment (IPT) to help prevent their developing active TB disease.  If they are not well, TB treatment should be considered and a clinical examination is recommended.

Suggestions for national tuberculosis programmes include:

• Establish a dedicated child TB working group that includes National Tuberculosis Control Programme (NTP) staff and national child TB experts.
• Use the working group to set practical priorities and goals, develop guidelines, implement activities for child TB, support health workers managing child TB and raise awareness through advocacy and health education.
• Include the needs of child TB in routine NTP activities, such as training, drug procurement, strategic plans and recording and reporting.

TB/HIV poses challenges for Zimbabwe

By Chief K.Masimba Biriwasha

Harare, Zimbabwe – Charles Raradza, 44, fell seriously ill in 2001, coughing uncontrollably. He went to get tested for tuberculosis (TB) at a nearby hospital but the bacteria was not detected in his sputum.

Unconvinced, Raradza went to another hospital where a sputum and lung X-ray test revealed that he was indeed TB-infected.

“I was immediately enrolled into the hospital’s directly observed treatment therapy (DOTS), and had to take 13 tablets a day. The tablets were very painful. I guess because I love life so much I never defaulted during the six months that I was on the course,” said Raradza.

After two years, Raradza started coughing again. He went to get tested for TB again.

“At the hospital, it was discovered that I had TB, so I was given 60 injections and tablets – its was painful but I stuck through it. I was put on the 6-month long DOTS programme again,” he said.

In 2005 Raradza said he went to a Voluntary Counseling and Testing centre to get tested for HIV.

“It was unheard of then for anyone to go and get tested but I gathered my courage and went to the testing centre. I tested HIV positive, and was enrolled into the anteritroviral programme,” he said.

After noticing Raradza’s poor response to the AIDS drugs, Raradza said that a doctor-friend of his recommended another TB test. For a third time in his life, Raradza had TB, and he had to go through the treatment regimen of 60 injection and tablets.

According to Dr Tonderai Murimwa, an official in the Ministry of Health and Child Welfare’s AIDS and TB Unit, Raradza’s case of failed detection of TB is not unique and is attributed to changing epidemiological patterns in Zimbabwe.

“Diagnosis of TB is usually straightforward, the best test is sputum microscopy. But HIV changes the way the body reacts to infections. That’s why X-ray is now required but it is very expensive technology and the country cannot afford it at the moment,” said Dr Tonderai Murimwa, an official in the Ministry of Health and Child Welfare’s AIDS and TB unit.

Murimwa added that the drug distribution in the country had experienced severe challenges over the past decade due to lack of material resources such as transport, fuel and personnel.me

TB is a leading cause of illness and death for people living with HIV—about one in five of the world’s 1.8 million AIDS-related deaths in 2009 was associated with TB. The majority of people living with HIV and TB are in sub-Saharan Africa. The risk of developing tuberculosis (TB) is estimated to be between 20-37 times greater in people living with HIV than among those without HIV infection.

According to UNAIDS, TB places a heavy burden on people living with HIV including significant illness that requires at a minimum six months of treatment, with the associated economic costs to the individual, his or her family and the health-care system.

Among African nations, Zimbabwe is one of those most heavily affected by tuberculosis (TB). The deadly combination of TB and HIV epidemics is igniting a silent and uncontrollable epidemic of drug resistant TB that will negate previous national health gains.

The 2009 Global Tuberculosis Control Report from the World Health Organization (WHO) ranks Zimbabwe 17th among 22 countries worldwide with the highest TB burden. Zimbabwe had an estimated 71,961 new TB cases in 2007, with an estimated incidence rate of 539 cases per 100,000 population.

For the past 20 years, Zimbabwe has fought TB fairly successfully, providing free access to WHO-recommended treatments. In the past few years, however, the disease has re-emerged as a leading killer, especially among HIV positive people, who are often not identified though long-established TB tests.

An estimated two-thirds of Zimbabweans with TB are also infected with HIV. As a consequence, Zimbabwe has a staggering six times more TB cases than it did 20 years ago. According to statistics, the success rate of directly observed treatment is just 74 percent, far below the WHO recommended rate of 85 percent.

“In Africa, HIV is the potent factor in the progression of latent TB. People living with HIV are susceptible to TB infection. TB is the most common serious infection associated with HIV infection. The two diseases go hand in hand. This call for an integrated and collaborative approach in dealing with the two conditions,” said Dr. Patrick Hazangwe, a WHO official.

In Zimbabwe, the TB problem is compounded by the fact that patients often fail to complete treatment because they cannot afford the transport costs to and from health centers. The lack of access to health services in remote or rural parts of the country adds to the likelihood that large numbers of TB infections are going undetected and untreated.

To complicate matters, the brain drain of qualified front-line health care workers from Zimbabwe has resulted in poor healthcare delivery. Leck of medical practitioners coupled with obsolete machinery has also worsened the problem.

According to Betty Chikava, Member of Parliament for Mt Darwin East, poor financing of the health ministry is a key hindrance to an effective response to TB and other diseases.

“The Ministry of Health and Child Welfare has received paltry funding – only 7 percent of its projected budget; medical personnel in the hospitals and clinics are seriously overworked. The Ministry of Finance needs to be brought into the picture so that they can finance the health ministry adequately,” she said.

No Condoms in Schools, Says Parirenyatwa

By Chief K.Masimba Biriwasha

Harare, Zimbabwe – Former Health and Child Welfare Minister, David Parirenyatwa said that distributing condoms at schools was a non-starter.

Adding his voice to the controversial proposal by the National AIDS Council (NAC) to distribute condoms at schools, Parirenyatwa said what is needed is schools is strengthening of sex education which could start as early as second grade.

“Let’s not entertain that debate of condoms in schools. It’s a non-starter. Let’s forget about putting condoms in schools. Of course, we can have condoms in tertiary institutions such as universities and colleges but in schools it’s a complete no-no,” said Parirenyatwa. “What we need instead is comprehensive sex education, and that can start quite early within the school system.”

The issue of putting condoms at schools recently hogged the media limelight following revelations by NAC that a consultant hired to review HIV and Aids policies in Zimbabwe had made the recommendation. Zimbabwe uses condoms as one of its HIV preventative measures. As a result of that the country has managed to reduce its HIV prevalence rate from over 20% to 14,2% in five years.

“In as much as we teach our children about protected sex, we need as well to provide them with the protection we will be teaching them. So we are saying condoms should be made available even in primary schools, because from the research we as UNFPA recently did it came out clearly that sex is happening in primary schools, with either teachers abusing young girls or even among the school children,” said Samson Chidiya, an official with the United Nations Population Fund (UNFPA).

Neighbouring country, South Africa,  introduced the Children’s Act which gives children 12 years and older the right to access contraceptives in 2007.

But locally, the issue has been controversial to say the least. According to media reports, some parents said that such a development will negatively affect the education system, arguing that schools should not be allowed to become bases for sexual activities.

“It will worsen sexual activities among school pupils, so we do not want to permit such behaviour at schools. If condoms are given to them, that is the end of abstinence as school pupils will take it as a sign that we condone sexual behaviour at schools,” said one parent.

Deputy Minister of Education, Sport, Arts and Culture, Lazarus Dokora said that his ministry will not give room for such a development as it is not government policy.

AIDS: Wheregoes the Money?

JUST how much money are the recipients of AIDS funds putting into programmes that have a real impact on communities affected by the disease without hip- hopping around the world or engaging in endless AIDS workshops? It appears that unless there is serious public account of where exactly AIDS dollars are going, we are in for a long ride with the epidemic.

Caregivers Come At A Cost

While community home based care is the preferred means of providing care for people living with HIV in many parts of Southern Africa, it comes with massive costs especially to caregivers in terms of time, effort and commitment, according to a study published recently in the Journal of the International AIDS Society.

According to the study which focused on Botswana, providing caregivers with financial and material support is an urgently required public health imperative. The study revealed that providing caregivers of people living with HIV and AIDS with financial and material support will ensure that caregivers are not demoralized in rendering care services to their clients as well as attract more people into caregiving.

AIDS funding falls likely to increase burden on care providers

The dip in funding levels for HIV and AIDS programmes will undoubtedly put paid years of progress in the response to the epidemic in sub Saharan Africa. Reduced funding will not only cause more deaths, but also in more offloading of responsibility to poor and marginalized communities. Persons in need of care will increasingly have to resort to already over-burdened community and home based care providers, mainly women and girls.

Given that the financial drawback for AIDS programmes is occurring at a time when two million people are still dying each year in sub-Saharan Africa due to the disease, the consequences for will be drastic particularly at community and familial levels.

“The donor turn-around will not make the patients in need of life-saving treatment go away. On the contrary, it is likely to increase the numbers of people in urgent need of care and will negatively impact their family, community and the health care system. In the end, the cost of inaction will be far higher than that of action,” states a recent report by Medecins Sans Frontieres titled, “No Time to Quit: HIV/AIDS Treatment Gap Widening in Africa.”