Treatment as prevention: preparing the way.

Potent antiretroviral therapy (ART) reduces mortality and morbidity in people living with HIV by reducing viral load and allowing their immune systems to recover. The reduction in viral load soon after starting ART has led to the hypothesis that early and widespread ART could prevent onward transmission and therefore eliminate the HIV epidemic in the long term. While several authors have argued that it is feasible to use HIV treatment as prevention (TasP), provided treatment is started sufficiently early, others have reasonably drawn attention to the many operational difficulties that will need to be overcome if the strategy is to succeed in reducing HIV transmission. Furthermore, international public health policy must be based on more than theoretical studies, no matter how appealing. Community randomized controlled trials provide the gold standard for testing the extent to which early treatment reduces incidence, but much still needs to be understood and the immediate need is for operational studies to explore the practical feasibility of this approach. Here, we examine some of the issues to be addressed, the obstacles to be overcome, and strategies that may be necessary if TasP is to be effective. Studies of this kind will provide valuable information for the design of large-scale trials, as well as essential information that will be needed if early treatment is to be incorporated into public health policy.

Cross-cultural adaptation of the Child Depression Inventory for use in Tanzania with children affected by HIV.

Understanding the impact of the acquired immune deficiency syndrome (AIDS) epidemic is critical for developing appropriate interventions to create supportive environments for orphans and vulnerable children (OVC). Unfortunately, there are very few studies on the psychosocial wellbeing of children orphaned by AIDS in Africa, and even fewer in Tanzania. It has been difficult to make generalizations across studies and to identify and track children suffering from mental health difficulties, given the lack of culturally sensitive, standardized screening scales and diagnostic procedures. As a contribution to filling that gap, the current study demonstrates the applicability of an existing depression screening instrument (CDI) to evaluate both the needs of OVC as well as the effectiveness of interventions designed to support them.

Learning how to measure the well-being of OVC in a maturing HIV/AIDS crisis.

The HIV/AIDS epidemic in Africa is frequently referred to as a crisis while the principal U.S. program to address it is labeled emergency relief. These terms trigger specific policy responses and corresponding evaluation activities. In this article, three stages in the response to HIV/AIDS are distinguished: awareness, emergency, and structural integration. In the awareness phase, emphasis is on defining and then estimating the affected population. In the emergency phase, evaluation activity is focused on demonstrating accountability for the assistance provided; and finally, in the structural integration phase, concern shifts to demonstrating the impact of assistance on improving the recipients' well-being. The shifting focus of evaluation is discussed in terms of how to measure the impact of aid on the well-being of orphaned and vulnerable children. A case study based on work in rural Tanzania is presented and then discussed in term of its broader implications for evaluating future aid.