AIDS and COVID-19 in southern Africa.

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

Planning and sustaining HIV response in the countries of the "risky middle".

This paper focusses on high-HIV middle-income countries termed the "risky middle", i.e. characterised by a typology based on HIV burden and gross national income (GNI), according to which seven countries - Lesotho, Eswatini, Kenya, Zimbabwe, Tanzania, Namibia and Zambia - are identified. There is particular concern for "people left behind", the factors determining a country's ability to mobilise resources in the context of multiple development needs - including economic disparities; the political economy of fiscal decision-making; levels of health investment; health and community systems; political will; and currency fluctuations. While donors will support lower-income countries and higher-income countries can compensate from domestic resources, there is a risk that some high-burden, lower middle-income countries will be unable to sustain a response. Continued growth means that there are countries transitioning to higher World Bank income classification - an important criterion for allocating development assistance for health. Our concern is that countries may face external funding reduction once their income category improves, and those in the risky middle will be unable to compensate from domestic resources. We conclude, with guidance from UNAIDS, the international community should step up support for "risky middle" countries. In addition these countries need to recognise the threat and develop measures to counter it, including improved accountability. Funding declines should be reversed through funding benchmarks that relate to both GDP and HIV prevalence. Finally, risky middle countries could constitute themselves as a special interest group, to protect their HIV funding and AIDS response.

Twenty Years Of Antiretroviral Therapy For People Living With HIV: Global Costs, Health Achievements, Economic Benefits.

Since the introduction of azidothymidine in 1987, significant improvements in treatment for people living with HIV have yielded substantial improvements in global health as a result of the unique benefits of antiretroviral therapy (ART). ART averted 9.5 million deaths worldwide in 1995-2015, with global economic benefits of $1.05 trillion. For every $1 spent on ART, $3.50 in benefits accrued globally. If treatment scale-up achieves the global 90-90-90 targets of the Joint United Nations Programme on HIV/AIDS, a total of 34.9 million deaths are projected to be averted between 1995 and 2030. Approximately 40.2 million new HIV infections could also be averted by ART, and economic gains could reach $4.02 trillion in 2030. Having provided ART to 19.5 million people represents a major human achievement. However, 15.2 million infected people are currently not receiving treatment, which represents a significant lost opportunity. Further treatment scale-up could yield even greater health and economic benefits.

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

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

Political commitment for vulnerable populations during donor transition.

The responsibilities for the programmatic, technical and financial support of health programmes are increasingly being passed from external donors to governments. Programmes for family planning, human immunodeficiency virus, immunization, malaria and tuberculosis have already faced such donor transition, which is a difficult and often political process. Wherever programmes and services aimed at vulnerable populations are primarily supported by donors, the post-transition future is uncertain. Overreliance on donor support is often a reflection of limited domestic political commitment. Limited commitment, which is frequently expressed as the persecution of vulnerable groups, poses a risk to individuals as well as to the effectiveness and sustainability of health programmes. We argue that, for reasons linked to human rights, the social contract and the cost-effectiveness of health promotion, prevention and treatment programmes, it is critical that governments sustain health services for vulnerable populations during and after donor transition. Although civil society organizations could help by engaging with government stakeholders, pushing to change social norms and supporting mechanisms that demand accountability, they may be constrained by economic, political and social factors. Vulnerable populations need to be actively involved in the planning and implementation of donor transition - to ensure that their voice and needs are taken into account and to establish a platform that improves visibility and accountability. As transitions spread across all aspects of global health, transparent conversations about the building and sustainment of political commitment for health services for vulnerable populations become a critical human rights issue.

Aujourd'hui, les responsabilités pour le soutien programmatique, technique et financier des programmes de santé sont de plus en plus souvent transférées de donateurs extérieurs aux gouvernements. Les programmes liés à la planification familiale, au virus de l'immunodéficience humaine, aux vaccinations, au paludisme et à la tuberculose ont déjà amorcé ce type de transition, qui constitue un processus difficile et souvent politique. Partout où des programmes et services ciblant des populations vulnérables sont principalement financés par des donateurs, le futur post-transition est incertain. La sur-dépendance à des donations externes traduit souvent un engagement politique national limité. Or, un engagement limité (qui se manifeste fréquemment par la persécution de groupes vulnérables) crée un risque pour les individus mais aussi pour l'efficacité et la pérennisation des programmes de santé. Selon nous, pour des raisons liées aux droits de l'homme, au contrat social et à la rentabilisation des programmes de promotion, prévention et traitement de santé, il est crucial que les gouvernements soutiennent les services de santé destinés aux populations vulnérables, pendant et après cette transition qui affecte les sources de financement. Même si les organisations de la société civile peuvent être utiles, en s'engageant auprès des acteurs gouvernementaux et en faisant pression pour changer les normes sociales et promouvoir des mécanismes de responsabilisation, elles sont parfois entravées dans leur action par des facteurs économiques, politiques et sociaux. Les populations vulnérables doivent être activement impliquées dans la planification et la mise en œuvre de la transition des sources de financement pour que leurs voix et leurs besoins soient pris en compte et pour créer une plate-forme qui améliore la visibilité et la responsabilisation. À l'heure où ce type de transition s'étend à tous les domaines sanitaires mondiaux, la tenue de débats transparents sur la création et le maintien de l'engagement politique en faveur des services de santé destinés aux populations vulnérables devient un enjeu essentiel en termes de respect des droits de l'homme.

Cada vez más, las responsabilidades del apoyo programático, técnico y financiero de programas sanitarios se pasan de los donantes externos a los gobiernos. Los programas de planificación familiar, del virus de la inmunodeficiencia humana, de la inmunización, de la malaria y de la tuberculosis ya han experimentado dicha transición de donantes; se trata de un proceso complicado y, a menudo, político. Allí donde los programas y servicios diseñados para poblaciones vulnerables reciben, principalmente, el apoyo de los donantes, el futuro después de la transición es incierto. El exceso de confianza en el apoyo de los donantes suele ser un reflejo del escaso compromiso político nacional. Un compromiso escaso, que suele expresarse como la persecución de grupos vulnerables, supone un riesgo para los individuos, así como para la eficacia y sostenibilidad de los programas sanitarios. El argumento ofrecido es que, por razones vinculadas a los derechos humanos, el contrato social y la rentabilidad de los programas de fomento sanitario, prevención y tratamiento, es fundamental que los gobiernos mantengan los servicios sanitarios para poblaciones vulnerables durante y después de la transición de donantes. A pesar de que organizaciones de la sociedad civil pueden ayudar colaborando con los participantes gubernamentales, fomentando normas de cambio social y apoyando mecanismos de rendición de cuentas, pueden verse limitadas por factores económicos, políticos y sociales. Las poblaciones vulnerables necesitan involucrarse de forma activa en la planificación y la implementación de la transición de donantes a fin de garantizar que su voz y sus necesidades se tengan en cuenta y para establecer una plataforma que mejore su visibilidad y su responsabilidad. Conforme las transiciones se van ampliando en todos los aspectos de la sanidad global, las conversaciones transparentes sobre la construcción y el mantenimiento de un compromiso político ante los servicios sanitarios para poblaciones vulnerables se han convertido en un asunto de derechos humanos fundamental.

"We Smoke the Same Pipe": Religion and Community Home-Based Care for PLWH in Rural Swaziland.

We draw on a study of a church-run community home-based care organization in Swaziland to explore how individuals living with HIV perceived caregivers' impact on well-being. Our primary concern was to examine how religion, as a heuristic practice of Christian-based caregiving, was felt to be consequential in a direly underserved region. Part of a larger medical anthropological project, we conducted semi-structured interviews with 79 community home-based care clients, of whom half (53%) said they would have died, some from suicide, without its services. We utilized a critical phenomenological approach to interpret semantic and latent themes, and explicated these themes within a 'healthworld' framework. Participants were resolute that caregivers be Christian, less for ideological positioning than for perceived ontological sameness and ascribed traits: "telling the truth" about treatment, confidentiality, and an ethos of unconditional love that restored clients' desire to live and adhere to treatment. Findings are intended to help theorize phenomenological meanings of care, morality, health, and sickness, and to interrogate authoritative biomedically based rationalities that underwrite most HIV-related global health policy.

What does sustainability mean in the HIV and AIDS response?

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

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

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

Reconciling the science and policy divide: The reality of scaling up antiretroviral therapy in South Africa.

With the world's largest national treatment programme and over 340 000 incident cases annually, the response to HIV in South Africa is hotly contested and there is sometimes a dissonance between activism, science and policy. Too often, policy, whilst well intentioned, is informed only by epidemiological data. The state of the healthcare system and sociocultural factors drive and shape the epidemic and its response. By analysis of the financial, infrastructural, human resources for health, and governance landscape in South Africa, we assess the feasibility and associated costs of implementing a universal test and treat programme. We situate a universal test and treat strategy within the governance, fiscal, human resources for health, and infrastructural landscape in South Africa. We argue that the response to the epidemic must be forward thinking, progressive and make the most of the benefits from treatment as prevention. However, the logistics of implementing a universal test and treat strategy mean that this option is problematic in the short term. We recommend a health systems strengthening HIV treatment and prevention approach that includes scaling up treatment (for treatment and prevention) along with a range of other prevention strategies.

The end of AIDS: possibility or pipe dream? A tale of transitions.

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

Modeling scenarios for the end of AIDS.

At the end of 2012, 3 decades after the human immunodeficiency virus (HIV) was first identified, neither a cure nor a fully preventive vaccine was available. Despite multiple efforts, the epidemic remains an exceptional public health challenge. At the end of 2012, it was estimated that, globally, 35 million people were living with HIV, 2.3 million had become newly infected, and 1.6 million had died from AIDS-related causes. Despite substantial prevention efforts and increases in the number of individuals on highly active antiretroviral therapy (HAART), the epidemic burden continues to be high. Here, we provide a brief overview of the epidemiology of HIV transmission, the work that has been done to date regarding HIV modeling in different settings around the world, and how to finance the response to the HIV epidemic. In addition, we suggest discussion topics on how to move forward with the prevention agenda and highlight the role of treatment as prevention (TasP) in curbing the epidemic.