Report on the 13^th International AIDS Conference
Durban, 9 – 14 July 2000
Summary Report of Major Issues, Conclusions and Recommendations

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1. OPENING REMARKS

The 13^th International AIDS Conference held in Durban from 9 – 14 July 2000 presented a very important opportunity to focus on HIV/AIDS in the developing world, as South Africa was the first developing country to host the Conference. It also demonstrated clearly that South Africa is capable of hosting major international events.

Right from the beginning when South Africa decided to bid to host the Conference, we were clear that South Africa was looking for much more than just being a physical location for the event. We wanted to ensure that the conference has a strong African imprint and that it confronts issues pertinent to our continent and other developing countries.

Previous International AIDS Conferences were not only hosted in the north, but also focused on the challenges of the developed world. The Durban conference was different, and was a success in terms of the goals set by the government. Most importantly, it had a strong African character as evidenced by the participation of more than 4000 African delegates out of a total of about 12,300. Also striking was a strong African contingent amongst the media representatives who enhanced the prospects of wider coverage of the events within our continent.

This Conference, started and driven by the International AIDS Society (IAS), is primarily aimed at international researchers, as the main content is scientific in nature. The South African Conference Organising Committee managed to bring a more balanced perspective to this Conference by adding a track on Rights, Politics, Commitment and Action, as well as community programmes.

2. PROGRAMME

The programme was very full, and many attendees found it difficult to decide between the parallel oral sessions, poster presentations and community programmes. The programme was divided into 5 tracks, namely:

Track A: Basic Science

This addressed virology, microbiology, immunology, and molecular biology research relevant for the diagnosis, treatment and prevention of HIV/AIDS. The research topics were related to basic retrovirology, evaluation of new diagnostic techniques, animal models for pathogenesis, vaccines and treatment, opportunistic pathogens associated with HIV/AIDS, and vaccine research.

Track B: Clinical Science

Track B focused on clinical research, including topics such as the clinical course of HIV infection, prevention and treatment of opportunistic diseases, antiretroviral therapies, and clinical trials for preventing mother-to-child transmission, gene therapy, and provision of care.

Track C: Epidemiology, Prevention and Public Health

Track C covered research on descriptive and molecular epidemiology of HIV, determinants of HIV transmission and risk factors, natural history, progression of the disease and survival, evaluation of biomedical and behavioural interventions, and public health strategies.

Track D: Social Science

Track D was devoted to social and behavioural sciences, including Economics, Anthropology, Psychology and Sociology. This track concerns the social theory that underpins response to the HIV/AIDS epidemic.

Track E: Rights, Politics, Commitment and Action

Track E explored how policies and programmes are created, debated, applied and evaluated. The roles and responsibilities of governments, intergovernmental organisations and the private sector were addressed.

In discussing the major outcomes from the Conference, the following major themes will be addressed:

• Prevention
• Treatment
• Vaccines
• Mother-to-Child HIV Transmission and Breastfeeding
• TB and HIV
• Pathogenesis and Diagnostics
• Care and Support

3. PREVENTION

The area of prevention mainly focused on those interventions that have shown to be successful. The main interventions were:

3.1 The Female Condom

Several papers that were presented highlighted the cost-effectiveness of the female condom in preventing the transmission of HIV and STDs, especially in specific target groups.

The attitudes of healthcare providers have a significant impact on acceptability of the female condoms in the community.

Strategies to expand access to and use of the female condom should include:

• Assessing and differentiating between "novelty" demand and actual demand and use over time
• Fostering public-private partnerships for sustainable product procurements, promotion and distribution
• Involving men in the introductory strategy
• A comprehensive introductory programme, including integration into existing reproductive health services and training for healthcare providers.

 

Recommendations: Continue to explore strategic ways to expand access to the female condom. Seek additional funds via the International Partnership Against AIDS to procure more female condoms.

3.2 Male Condoms

More focus is needed on expanding access through non-traditional outlets. This would include expanding social condom marketing.

There is also a need for monitoring quality standards and estimating realistic condom requirements to maximise potential cost earnings and ensure less condom wastage.

Generally male condoms are widely accepted, both for prevention of STDs and HIV. The only limiting factor is the fact that they are "male controlled" devices – women often cannot negotiate condom use in both stable and unstable relationships.

South Africa is unusual in that it has such a large-scale distribution of free condoms. This factor has made it difficult for social marketing to develop on the scale seen in other countries. The Department supports the Society for Family Health (SFH) in local social marketing of both male and female condoms. SFH also receives funding from the UK Department for International Development (DFID).

 

Recommendations Continue to encourage partner organisations (e.g. private sector) to procure male and female condoms for free distribution to reduce their dependence on the public sector supply. However, partners should also be encourage to explore means of facilitating the expanded role of social marketing of male and female condoms to individuals who are able to afford to pay for their condoms. In most developing countries, this is the niche filled by social marketing in the segmentation of the condom market. It is counterproductive and unsustainable to provide free condoms to those who can pay while free condoms remain less accessible to the poor, the unemployed and those in more remote rural areas that are unlikely to be serviced by social marketing programmes. Publicise the fact that social marketing will be promoted increasingly to reduce the unsustainable financial burden of South Africa's dependence on free public sector condoms. Seek advice from the Barrier Methods Task Force on the way forward. Seek additional funding for SFH from the national and provincial departments, international partners and the private sector.

3.3 Microbicides

It is a known fact that the HIV/AIDS epidemic is driven by social, cultural and economic factors as well as gender imbalances. Despite this knowledge many of the prevention strategies such as condom use and reduction of sexual partners often cannot be controlled by women. Microbicides and products used vaginally to prevent infection would offer the potential for women to protect themselves.

Scientists are using two general approaches to microbicide development: developing and testing new substances, and investigating the potential microbicidal activity of existing spermicidal products and reformulations of these products. The latter approach is a potentially fast-track strategy since such products are already licensed for use as vaginal spermicides. These approached focus on microbicide products that act in one of the following ways or that combine different mechanisms in one product:

• Killing or inactivating infectious pathogens – examples include detergent-like chemicals that disrupt the lipid membranes of cells and the envelopes (surface) of HIV. Products in this category include the existing spermicides nonoxynol-9 and benzalkonium chloride, menfagol and N-docosanol.
• Blocking attachment to target cells and entry of infection pathogens – these compounds may prevent infection by blocking the attachment of pathogens to the mucosal surface of target cells. Examples include sulphated and sulphonated polymers such as PC-515 (carrageenan), Pro-2000 and Dextrin 2 Sulphate.
• Preventing infection from taking hold – examples include antiretroviral agents like PMPA gel, which prevents HIV from replicating in cells, and plantibodies, anti-HIV antibodies genetically engineered from plants that would combat pathogens before infection occurs.
• Enhancing vaginal defence mechanisms – this approach seeks to enhance the vagina’s naturally acidic environment and production of hydrogen peroxide, both of which are hostile to pathogens including HIV. Examples include BufferGel and Acidform, which help the vagina to maintain natural levels of acidity in the presence of semen, and suppositories containing lactobacillus, which lives normally in the healthy vagina and which produces hydrogen peroxide.

One major trial using nonoxynol-9 showed a negative outcome. Previous studies with N-9 have been disappointing, either being inconclusive or showing N-9 to be harmful by actually increasing the risk of acquiring HIV infection. It is unlikely that further studies will use N-9 as a candidate microbicide.

Many other studies presented at the conference were more encouraging. For example, animal studies with sodium dodecyl sulphate (SDS) have demonstrated low virutant effect and lethality against STD pathogens, including papilloma viruses. Should such agents display the same positive outcomes in human studies, they may have the potential to prevent HIV and herpes injections. By inactivating HPV, they could also have a major impact on the most common cancer in South African women, cervical cancer.

 

Recommendations: The problems around N9 and impact on viral transmission need to be clarified. Continue supporting research on safe microbicides.

3.4 Male Circumcision

A growing body of scientific publications suggests that male circumcision is associated with a reduced risk of HIV infection in sub-Saharan Africa. Thus, some investigators are considering male circumcision as a potential intervention in the prevention of sexually transmitted HIV infection, even though this procedure has profound cultural implications and carries the risk of complications, and its benefits might be realised only many years later.

It has been determined that there is considerable evidence supporting a protective effect of male circumcision on HIV infection in men in sub-Saharan Africa. It was also concluded that there are many unknowns. These relate to:

• The mechanisms and the role of the foreskin in the acquisition of HIV infection by men
• The existence of, as yet, unexplored confounders in the attribution of causality, and
• The expected effect of male circumcision on HIV infection in different populations.

In addition, little is known about the impact and cost-effectiveness of male circumcision among high-risk versus lower-risk seronegative men, while questions remain about the relationship between age of circumcision and risk of HIV infection.

There is very little experience concerning the practicality, feasibility, acceptability and cost-effectiveness of male circumcision as an HIV intervention. The effect of male circumcision on male and female risk behaviour and condom use is not known, but behavioural changes related to circumcision status that result in reduced protection and increased risk-taking could well eliminate or reverse the beneficial effect of male circumcision.

 

Recommendation: While it may be premature to recommend male circumcision in currently non-circumcising communities, research on male circumcision should be done in populations where circumcision is currently practised, and acceptability studies can be done elsewhere.

3.5 Sexually Transmitted Diseases (STDs)

Several papers emphasised the already established fact that high rates of STDs enhance HIV transmission and acquisition.

The impact of nutritional deficiency on viral shedding through the vaginal mucosa was demonstrated in several studies. Women who had significantly decreased levels of nutrients and vitamins shed more viruses through cervical secretions.

Several studies continued to show that among STD clinic attendees, knowledge of HIV and access to condoms did not impact on risky sexual behaviour. Strategies to effect sustainable behaviour change need to be developed as a matter of urgency. Other risk factors such as dry sex and vaginal douching are associated with STDs and increased risk of HIV transmission and thus need to be discouraged.

 

Recommendation: 1) Strengthen strategies to effectively treat STDs, especially the training of healthcare workers on the syndromic management of STDs 2) Include STDs on behavioural surveys as a critical component of our overall surveillance system so as to better understand the impact of our interventions.

3.6 Life Skills

The conference provided a platform for the sharing of prevention strategies that have been proven to be successful. Several authors reported on school-based initiatives and suggested that a comprehensive sexuality education package, rather than HIV/AIDS education in isolation, has proven to be more effective. Several others supported this approach and presented some results of the effectiveness thereof.

Interactive approaches, as opposed to traditional one-way teaching strategies, are recommended.

Peer education approaches in different sectors of the community, including in and out of school youth, sex workers, people at their places of employment, etc, also received support from several authors. Peer education is described as "the key to mass awareness programmes". A model for youth-friendly prevention interventions using activities like sport, campaigns, debate teams, quiz competitions, etc. was also presented.

The importance of Life Skills programmes in schools was highlighted. Some of the shortcomings of these programmes were highlighted, including their passive nature, the lack of interaction, time constraints in the schooling environment, and the availability of trained life skills teachers. Some of the creative solutions include:

• Participatory peer group discussions
• Focus group discussions

The limitations of materials (leaflets) and radio messages in terms of their passive nature were highlighted.

The issue of lack of programmes in institutions of higher learning was also addressed. This can be overcome by an interdisciplinary, credit-bearing university course. Such a programme could be coordinated by Dentistry, Medicine, Nursing, Pharmacy and Public Health. This would emphasise the interdisciplinary approach needed for the working environment.

One of the papers addressed the education of children or youth with disabilities (e.g. deafness, blindness, mental disability), but more information is needed in this area.

 

Recommendations: Present life skills as a component of school curricula in a non-threatening way, shifting away from a health focus (e.g. present impact of HIV/AIDS on development, economics, accounting etc.) Focus more on peer education – invest more in the learner than in the teacher. Develop education material for children/learners with disabilities. Promote the systematic and focused involvement of parents and the community. Ensure a more participatory rather than passive approach.

4. TREATMENT

The main emphasis was on HAART and other antiretroviral therapies.

4.1 HAART and Antiretroviral Therapies

Research was presented on the reconstitution of the immune system and new concepts such as structured intermittent therapy. A number of new antiretrovirals are in development, including drugs in existing classes with activity against resistant strains, as well as new drug classes.

The issue of access to treatment received a lot of attention in the Conference from a variety of presenters. Here the stark differences between the developed and developing world became very clear.

Strategies for developing countries to access affordable antiretroviral (ARV) treatment, such as parallel importing, compulsory licensing and local production were discussed.

The importance of infrastructure, laboratory support and adherence strategies in terms of the provision of ARV treatment in developing countries was also highlighted.

a) Compliance Issues

• Compliance to HAART is influenced by many psychosocial factors, which needs to be understood so as to avoid possible problems in future. It was reported that the presence of side effects influenced the rate of compliance. Patients who experienced symptoms were more likely to report that they have not followed the treatment taking instructions. Social support was also found to be having an influence on whether clients comply or not, with those having a sound support-base being more likely to comply.
• A survey was conducted with clients on HAART. Many of these reported that they did not fully comply and stated reasons like difficulties in making room for midday doses, undesirable side effects, treatment "burnout" etc.
• Questions have also been raised as to whether ART will have an impact on safer sex practices or not in HIV positive individuals.
• Several models for promoting adherence were presented. Most of these focused mainly on providing psychosocial support through either support groups or dedicated counsellors.

b) Other findings relating to HAART

• Drug interaction between Rifampin and some protease inhibitors and NNRTIs require special caution if HAART is provided to patients on TB treatment. Ritonavir and Rifampin can be concomitantly administered in HIV infected TB patients. This combination was not associated with increased liver toxicity. The CDC recommends substitution of rifabutin for TB patients on HAART.
• Fungemias in HIV patients have declined with the advent of HAART
• HAART does not induce the development of visceral leishmaniasis
• The pharmacology of HAART interferes with TB drugs
• BID compared to TID dosing of Nelfinavir improved patient compliance and reduced viral load
• HAART was associated with a higher proportion of undetectable viremia at delivery
• HAART reduces viral loads to undetectable in 86% of patients after 3 months
• In the US, women with increased stress and depression, less social support are at increased risk of early failure to HAART
• ARV treatment interruptions in Senegal were more related to economic difficulties compared to lifestyle issues in developed countries.

4.2 Disease Progression

Several studies have highlighted the impact of antiretroviral therapies on disease progression in the developed world. Mortality from AIDS has declined significantly. It is clear that the profile of AIDS defining illness is different from those in the developing world.

Studies from developing countries also showed different survival times from seroconversion to AIDS defining illness to death:

Uganda	:	survival of 6 – 7 years
India	:	7.2 years
Tobago	:	4.5 years

The common defining illnesses also varied:

Uganda	:	Wasting syndrome, oesophageal candidiasis
Cote d’Ivoire	:	Oesophageal candida, wasting syndrome
South Africa	:	TB, bacterial pneumonia, cryptococcal disease
Zimbabwe		Wasting disease, TB

A study in Malawi showed that among children infected at birth:

33% had died by age 1 year

90% had died by age 3

Only 1% was asymptomatic by age 5

4.3 Post-Exposure Prophylaxis (PEP)

a) Health care workers

Strengthening programmes to reduce needlestick and other occupational injuries with a risk of infection can massively reduce the costs of PEP for health workers exposed to HIV and other blood borne pathogens.

 

Recommendation: Expand in-service training of health workers in principles and practices of infection control, particularly the use of 'universal precautions' Consider disciplinary action for staff found to be ignoring basic harm reduction messages (e.g., continuing to recap needles) and Consider the large-scale purchase of injection and related equipment that prevents health workers from dangerous practices (e.g., needles and syringes with retractable needles, simple 'guard' devices that can be attached to needle etc).

b) Post-sexual assault

Few studies have assessed the efficacy of PEP in this context. Such studies are ethically and logistically very difficult to conduct. However, in the absence of strong evidence of efficacy of PEP in sexual assault, some countries have approved policies for the use of ARVs for PEP in sexual assault. These countries have based their decisions on data from indirect studies of the efficacy of ARV in occupational PEP. The lack of sufficient data on the efficacy of ARV in non-occupational PEP has prompted the CDC to report that:

"Because of the lack of efficacy data for the use of antiretroviral agents to reduce HIV transmission after a possible non-occupational exposure, the PHS is unable to recommend for or against this therapeutic approach."

"Research is needed to establish if and under what circumstances antiretroviral therapy following non-occupational HIV exposure is effective" (CDC, 1998).

From the data presented at the Conference, the situation has not changed much since the CDC made that statement in 1998. There is still limited data available on this topic and the results of the papers presented at the conference are not such that any policy decision could be made based on that alone.

A few studies reported some efficacy of the post-exposure use of ARV in non-occupational exposure to HIV. Sexual exposure was only part of the situations covered and in most cases, sexual exposure subjects constituted only a small fraction of the total sample. In one study a total of 1731 exposures were reported with only 425 of these being sexual exposures. Although no seroconversions were noted in this study, it does however raise the issue of compliance and side effects. Approximately 67% of all the subjects in this study that received ARVs reported experiencing side effects.

In another study 85 subjects who presented for PEP were enrolled. From these, 75% reported side effects and only 45 of the 62 that reported for the 4-weeks followed up had completed their treatment and were fully compliant. This study reported no seroconversions although almost 50% of the subjects reported that their contact was with known HIV-positive individuals.

Another study recruited 54 subjects. Three refused treatment and from the 51 that signed up for the study and agreed to be treated, 69% came for the day-3 follow up, 44% came for the one month follow up and only 9 came for the 3-month follow up. Although no serious side effects were reported, 33 interrupted treatment early on themselves.

The results of a 2-year surveillance in Switzerland were that the prescription of PEP was questionable in two thirds of the cases with the absence of any significant exposure. Although 85% of the cases in this report completed treatment, there were 2 cases of severe side effects (nephrolithiasis with sepsis and toxic hepatitis respectively).

In the light of the above information, there is still a need for more studies to shed more light on this topic. Some countries have developed policies based on indirect data, but the need to investigate the efficacy of ARV in such situations remains a priority.

 

Recommendation: Collaborate with other relevant departments to explore the feasibility of introducing PEP for individuals who have been sexually assaulted. Facilitate observational studies of the outcomes of the use of PEP in individuals who have been sexually assaulted.

4.5 Other Key Findings

a) Co-Factors

Some abstracts suggest that there is a link between HIV and HCV infections as risk factors for both infections are similar. This does not mean that HCV is a co-factor for HIV infection. Some of these findings include:

• Human herpes virus 8 (HHV8) is an etiologic agent for Kaposi’s sarcoma and is a common infection in patients with HIV infection.
• HHV8 can be sexually transmitted.
• The coinfection of HIV and Hepatitis viruses is a growing problem.
• In an Ethiopian study there was a strong link between HIV and HCV suggesting that the route of transmission for both infections may be similar.

b) Viral Resistance

• Rate of viral mutations among drug naive patients is high. This finding may have an impact on prophylactic AZT use. Resistance testing may be important for drug selection
• HIV-1 infected women can transmit drug resistant virus to their offspring. Drug resistant testing should be applied before initial therapy is administered in seroconverted neonates
• In treated individuals in Uganda, emergence of drug resistance was common and may be associated with sub-optimal treatment or poor adherence

c) HIV Infection in Children

• PCP is an important AIDS defining illness in children in South Africa. HIV positive children with pneumonia have a higher mortality compared to HIV negative children
• S. Pneumonia is replacing H Influenza type B as the dominant cause of meningitis in children in South Africa
• The volume of breastmilk and length of exposure are factors in breastmilk transmission of HIV. High maternal plasma viral loads were associated with higher breastmilk infectivity
• Formula feeding can be safety used for HIV-1 infected women in Africa if provided with appropriate education and support
• Tracking, networking and community support are essential to providing care for orphans and vulnerable children. Focus groups are very effective to identify objectives, indicators and outcomes for children
• In babies under 15 months with severe pneumonia, a positive HIV antibody test has an 88% predictive value for true HIV infection. Intensive care may not be justified in resource poor settings.

d) General

• Based on a number of studies presented at the above conference, there seems to be a strong relationship between HIV infection and cervical anomalies. It was recommended that appropriate policies be formulated to promote and increase access to screening and care for all HIV-positive women. Some even suggested that there is a need for research on alternative screening methods that will be cheaper and reliable, thereby allowing women in resource-deprived situations to also access this necessary service. In one study cervical cancer was found to be the only AIDS-defining condition in 90% of the women enrolled in a study in Europe and USA. Another found no correlation between the administration of HAART and the presence of cervical cancer in women with HIV/AIDS.
• Treatment of Candida vaginitis decreased HIV vaginal shedding.
• Genital ulcers increases vaginal shedding of HIV
• Bacterial vaginosis increases proinflammatory cytokine levels which increases HIV replication
• Itraconazole successfully treated oral candiasis
• Valaciclovir is cheaper and as effective as acyclovir for herpes and varicella zoster
• Although the initial results of an Ivory Coast study suggested the efficacy of cotrimoxazole, a randomised placebo-controlled study in Dakar showed no difference in the study and placebo groups.
• In Uganda, mortality rates from severe opportunistic infection are very high. There is need to increase access to preventive and curative treatments for the opportunistic infections, as they are the leading causes of death in Uganda. Lack of affordability, awareness and availability mainly hinder accessibility to drugs in Uganda. Education and mass awareness about prompt treatment is crucial to encourage patients to seek treatment whenever they are not feeling well. Pharmaceutical companies should encourage and assist developing countries to produce some of the essential drugs.
• The majority of patients in Southern Africa with access to private forms of health insurance were unable to use this resource to pay for antiretrovirals. This is due to the lack of HIV specific cover offered by these schemes. Those that are able to offer an HIV benefit are, by and large, unable to afford triple regimens.
• A Senegalese Governmental Initiative illustrated the feasibility and efficacy of antiretroviral therapy in Sub Saharan African countries. Its sustainability depends on reducing the price of ARV. Access to ARV therapy is more a financial and solidarity challenge than a technical problem.

5. VACCINES

The importance of developing an HIV vaccine was stressed, as evidenced by the large number of abstracts on this topic. Types of vaccines at the forefront of this initiative include both prophylactic (live of DNA-based) vaccines and therapeutic vaccines.

5.1 Vaccine Development

This topic enjoyed considerable attention in the Conference in this track, and this was also seen as the first Conference that brought more clarity in the field of vaccine development.

The South African AIDS Vaccine Initiative (SAAVI) reports that 8 candidate vaccines are being developed and are currently being evaluated. Three candidate vaccines are almost ready for phase I testing.

Other major findings were:

• Four sites, two of them new ones, in the HIV life cycle were the targets for new or improved antiretrovirals. These include entry inhibitors, Tat inhibitors, second generation NNRTIs and second-generation protease inhibitors.
• Candidate vaccine in South Africa will be a mixture of Venezuelan equine encephalitis (VEE) replicon. Phase 1 clinical evaluation in the US and South Africa will occur in 2001.
• Phase 1/II trials of AIDSVAX B/E rgp 120 HIV Vaccine in Bangkok, Thailand was safe and generated immune response. A phase III efficacy trial is currently being conducted.
• Protocol development/approval for the first HIV vaccine trial in Africa required 3 years. Major hurdles were government regulations and infrastructure development. No community concerns have occurred.

5.2 Ethical Considerations in Vaccine and Microbicide research

• Following vaccine trials in Africa, a research agency in France recommended: peer review of proposed projects in originating and host countries; local ethical review; signed agreements; and special consideration of selected issues such as informed consent, access to therapy after the trial is completed, and best standard of care.
• An investigation in Cape Town revealed some confusion in participants on the objective of the trial. Obtaining truly informed consent is challenging and an ongoing process.
• Improved oversight of research in correctional facilities; provision of standard treatment to both inmates and non-inmates; elimination of incentives that would unduly influence prisoners to participate.
• There is a need for community research ethical committees in addition to Committees organized by academic institutions.
• The use of western ethical norms for the protection of human subjects in vaccine trials was found to be inappropriate and the need to consider cultural context and diversities was raised.
• In preparations for vaccine trials, several authors assessed what they call "vaccine preparedness" in clients and different settings. There is a relationship between willingness to participate and the level of trial knowledge.

5.3 Cross-clade cellular immune responses

In an investigation in Uganda it was shown that cross-clade cellular immune responses exist in HIV-1 persons. This suggests that that vaccines developed against one clade may promote immune responses in HIV infected persons of another clade. It is possible that vaccines developed against clade A or B might be effective against the predominant clade C in Southern Africa.

In Israel both clade B and clade C are prevalent and both are treated with HAART. The frequency of certain mutations was found to significantly differ between patients infected with clade B and clade C virus. This may impact the utility of specific drugs in patients with a different clade virus. The investigators suggested additional study on this issue.

 

Recommendation: Continue to support the SA AIDS Vaccine Initiative Create a communication campaign around the development of an AIDS Vaccine in South Africa

6. MOTHER-TO-CHILD HIV TRANSMISSION

6.4 New Studies of Antiretroviral Treatments for the Prevention of MTCT

a) SAINT (South African Intrapartum Nevirapine Trial)

The first results from SAINT were presented at the Conference. The primary objective of the multicentre study was to compare the efficacy of Nevirapine (NVP) versus ZDV + 3TC in reducing peripartum maternal to child transmission of HIV, when administered in active labour and again post delivery.

The primary analysis focused on the incidence of peripartum infections, defined as infection intra-partum and post-partum up to 8 weeks. The peri-partum infection rates were 5.6% and 3.6% for NVP and ZDV/3TC respectively.

The secondary endpoints showed that the overall transmission rates as follows:

At 4 weeks 11.9% NVP 8.6% ZDV/3TC

At 8 weeks 14.1% NVP 10.8% ZDV/3TC

The safety data showed that 10 infant deaths occurred in the NVP arm and 17 in the ZDV/3TC arm. None were judged by the investigators to be related to the study therapy. In addition 4 mother dies, though none were judged by investigators as drug-related.

These results were deemed to be comparable with previous results of NVP in HIVNET012 and with ZDV/3TC in the PETRA arm B. With expected transmission rates in excess of 20%, both regimens demonstrate efficacy in prevention of mother-to-child transmission of HIV-1.

Both NVP and ZDV/3TC regimens were safe and well tolerated. No serious drug related events occurred in either group. There was no evidence of serious rash or hepatic events with NVP. Low rates of treatment related events occurred.

b) Perinatal HIV Prevention Trial (PHPT), Thailand

This multicentre, randomised, 4 arm, double-blind equivalence trial compared safety and efficacy of maternal ZDV starting at 28 weeks gestational age and 6 weeks infant treatment (long) and 35 weeks gestational age and infant 3 days (short). Infants were formula fed. The transmission rate for the study period was 6.7% (long) and 5.7% (short).

Secondary analysis showed that shortening the maternal treatment was associated with reduced overall efficacy and higher infection rates at birth.

c) BMS094 Study, South Africa

This study provided preliminary data from the investigator-initiated Phase II trial of nucleoside analogues previously not researched for the prevention of MTCT.

Treatment was initiated at 34-36 weeks’ gestation, continued during labour and postpartum for the infants for 6 weeks. The study regimes were Stavudine, Didanosine, Didanosine & Stavudine, and Zidovudine.

The preliminary analysis of HIV transmission, performed at 6 weeks, demonstrated a significant reduction of MTCT to 3.6% in the overall study population. The comparable MTCT rates were 4.2% (stavudine), 1.9% (didanosine), 2.0% (stavudine & didanosine) and 6.3% (zidovudine).

Maternal and infant safety evaluation demonstrated no significant treatment-associated toxicities. HIV resistance data have been collected and will be reported with the final study results.

d) HIVNET012, Uganda

Preliminary results of the Uganda HIVNET012 trial of short-course Nevirapine (NVP) versus short-course AZT to prevent perinatal HIV transmission were reported in 1999. Final HIV- transmission rates up to 14-16 weeks were presented at the Conference, as well as safety and efficacy data.

The final HIV transmission rates in 311 infants in the NVP and 308 infants in the AZT arms were:

At birth 8.1% NVP 10.3% AZT

At 6-8 weeks 11.8% NVP 20.0% AZT

At 14-16 weeks 13.6% NVP 22.1% AZT

Serious adverse events were not significantly different between NVP and AZT groups in either women or infants.

The PETRA trial is a randomised, double-blind, placebo-controlled study, conducted under the auspices of UNAIDS in South Africa, Tanzania and Uganda. The study regimens used ZDV/3TC in three arms (providing the treatment at different times) and a placebo arm.

Transmission and mortality rates at 6 weeks varied from 9.2% (arm A) to 19.2% (placebo), and at 18 months between 20.7% (arm A) and 26.6% (placebo).

As the study population is predominantly breastfeeding, the loss of efficacy of all regimens at 18 months of life is likely to result from a high number of HIV-1 infections in breastfed children.

6.5 Infant Feeding in the context of HIV

a) Breastfeeding

There were several presentations highlighting the complex issues around breastfeeding. It is well-established fact that HIV transmission does occur through breastfeeding. Most studies seemed to show a loss of efficacy of ARVs after 3 months when breastfeeding is prolonged. However, transmission rates in infants exclusively breastfed were lower than those on mixed feeding.

One debate concluded that exclusive breastfeeding may be the feeding option of choice for HIV-infected women in developing countries. However, it was also indicated that exclusive breastfeeding is uncommon, and that social and cultural norms promote the use of mixed feeding. Any strategy to promote exclusive breastfeeding to reduce postnatal transmission of HIV-1 should thus target mothers, and those supporting them, in the antenatal and early neonatal periods.

In South Africa exclusive breastfeeding is not feasible for most women, due to the socio-economic and cultural context in which they live.

b) Pasteurisation of Breastmilk

In communities where HIV-infected mothers have very limited options other than breastfeeding, pasteurisation of human milk may be an option. Some of the innovative ways to achieve this was a home-based method of pasteurisation by passive heat transfer, the use of solar energy, and the use of Alkyl sulphates to inactivate HIV in milk.

 

Recommendation: Conduct further research on the impact of breastfeeding on transmission of HIV Formulate feeding strategies that support mothers and reduce transmission rates.

7. TB AND HIV

HIV increases the risk of tuberculosis (TB) in tuberculin skin test positive people (RR=100) and increases TB mortality (RR=31,3). Although pulmonary TB remains the most common form of TB in HIV+ patients, smear-negative pulmonary TB and extra-pulmonary TB are more common in HIV+ than in HIV- patients. The clinical presentation in HIV+ TB patients may differ with a higher likelihood of hilar adenopathy and diffuse lung infiltrates rather than cavity formation in the lungs. HIV+ TB patients are more likely to develop side effects to anti-TB drugs, particularly to thiacetazone that can cause severe epidermal necrolysis (Stevens Johnson syndrome). For this reason, most countries with a high prevalence of HIV no longer use thiacetazone in their anti-TB regimens. Sputum conversion and cure rates are the same in HIV+ and HIV- TB patients treated with short course rifampicin-containing regimens. There is no evidence that HIV infection decreases absorption of TB drugs.

A study in gold mine workers in South Africa showed that in a setting with a high risk of TB infection and high HIV seroprevalence, HIV infection increases the risk of recurrent TB from reinfection (Hazard Ratio = 18,9) but does not increase the risk of recurrent TB from reactivation. One implication for TB control is that lifelong TB preventive therapy may be indicated in people living with HIV to protect them from reinfection.

TB is associated with decreased survival in HIV+ clients possibly through immune activation, expression of cytokines and increased viral replication. HIV+ TB patients have a higher viral load at any CD4 count than HIV- clients. Cytokine inhibitors (e.g. methyl prednisolone) decreases HIV viral load in TB/HIV patients.

Gender based violence makes women more vulnerable to HIV and HIV makes them more vulnerable to violence. Microfinance initiatives are being started in one TB/HIV Pilot District to determine if they will impact on women’s empowerment and HIV incidence.

In summary, HIV and TB worsen each other. Suggested interventions to decrease TB/HIV morbidity and mortality include TB preventive therapy, antiretroviral therapy and cytokine inhibitors.

 

Recommendations: TB education should be incorporated in HIV post-test counselling and DOTS should be provided by home based carers. Voluntary HIV counselling and testing (VCT) services should be strengthened in TB facilities and the TB programme should implement guidelines for the prevention and management of opportunistic infections. TB treatment outcomes in South Africa should be stratified by HIV status in sentinel sites, possibly in TB/HIV training districts. Studies to evaluate the impact of microfinance on women’s empowerment, economic status and HIV incidence should be supported. Gender training should be incorporated in the curriculum of health care staff to address HIV/AIDS.

7.2 TB Preventive Therapy (TBPT)

A meta-analysis of several clinical trials has shown that isoniazid given daily to HIV+ clients for 6 months decrease the incidence of TB by 40%. Rifampicin-containing regimens were found to have equal efficacy. The benefit of TBPT is greatest in clients with a positive tuberculin skin test (PPD+).

There is a trend towards decreased TB incidence in PPD- clients but it is not statistically significant. There was no significant toxicity (0.8% incidence of hepatitis) and no indication that preventive therapy increased isoniazid resistance in clinical trial settings. TB preventive therapy is recommended by the Joint United Nations on HIV/AIDS (UNAIDS) and the World Health Organisation (WHO) as part of a comprehensive package of care for people living with HIV/AIDS in Africa.

A debate was held on whether all HIV+ clients should be offered TBPT. A suggestion was made that only high risk groups such as TB contacts (especially children), health care workers and mine workers should be targeted. There are several problems with using tuberculin testing to screen for eligibility to receive TBPT. Tuberculin testing lacks specificity for TB and has less utility for identifying latent TB in HIV+ clients due to anergy from the loss of delayed type hypersensitivity. In a population of STD attenders in Zambia, 70% of HIV- adults with no evidence of clinical TB were PPD+ compared to 30% of HIV+ adults with no clinical TB. The use of tuberculin testing to screen for TBPT would increase the cost of TBPT for patients in terms of transport money and time to the health centre and for the health centre in terms of staff time and other costs. In Uganda, 19% of people did not return for their tuberculin tests to be read. In areas with a high prevalence of TB it should be assumed that a large proportion of the HIV+ population will already be exposed to TB and therefore at risk of developing reactivation disease and should be given TBPT without tuberculin testing. Exclusion of active TB is a prerequisite and can be done based on symptoms and radiology although routine chest x-rays may not be necessary.

Botswana is planning to link the provision of TBPT to its interventions to prevent mother to child HIV transmission. In Lusaka, Zambia, adherence to TBPT was low (21%).

Despite its proven benefit, isoniazid preventive therapy (IPT) is difficult to implement via VCT. Reasons for not starting IPT include only undergoing HIV test when the client is already sick or suffering from TB, lack of interest and loss during the screening process. Screening for active TB has previously been found to be the biggest barrier to provision of IPT. Encouragement of early counselling and testing and education to improve the client and counsellor’s perception of the benefit, combined with the use of a symptomatic screen alone may improve uptake of this important intervention.

In the TB/HIV pilot districts in South Africa 466 (41%) of 1141 HIV+ clients have been started on TBPT and adherence is being measured.

Currently, only one of the four TB/HIV Pilot Districts uses tuberculin testing and chest x-rays to screen for eligibility of TBPT. The cost-effectiveness of tuberculin screening and chest x-ray screening will be assessed. It will be more feasible to implement TBPT in South Africa if tuberculin testing and chest x-rays are not done.

 

Recommendations: Consideration should be given for implementation of TB preventive therapy on a wide scale in South Africa if it is shown to be feasible in the TB/HIV Pilot Districts. Clinical trials to evaluate the efficacy of life long TB preventive therapy for HIV-positive clients in South Africa should be supported. The evaluation of screening algorithms to detect active TB in HIV+ clients should be supported in the TB/HIV Pilot Districts.

7.3 Cotrimoxazole Prophylaxis

Two studies done in Ivory Coast have shown that cotrimoxazole prophylaxis is beneficial to HIV+ clients. One study showed that cotrimoxazole prophylaxis decreased mortality by 48% in HIV+ TB patients and the other showed that cotrimoxazole decreased hospitalisations in HIV+ clients with symptomatic HIV disease.

Based on these studies, UNAIDS and WHO have just released recommendations on the use of cotrimoxazole prophylaxis. The recommendations are that "Cotrimoxazole should be used for prophylaxis in adults and children living with HIV/AIDS in Africa as part of a minimum package of care." In adults, it should be offered to HIV+ adults with symptomatic HIV disease (stage 2,3 or 4 of the WHO classification of HIV infection and disease), asymptomatic individuals with a CD4 count of 500 or less or total lymphocyte count equivalent and pregnant women after the first trimester.

In Senegal, cotrimoxazole is offered to all HIV-positive patients with a CD4 count below 500. The country has developed materials to measure adherence and is planning to monitor antimalarial and antibacterial resistance patterns.

A study in Malawi showed that it is possible to implement VCT and cotrimoxazole prophylaxis in a rural setting and it appears to decrease mortality in smear-positive TB patients.

Adherence to cotrimoxazole prophylaxis in HIV-infected TB patients in Abidjan remains good even after 24 months of therapy. Although these results pertain to a clinical trial, they suggest that even in a population with low levels of formal schooling and employment, a cotrimoxazole prophylaxis program can be well adhered to.

 

Recommendations: South Africa should include cotrimoxazole prophylaxis in the guidelines for clinical management of HIV in adults and children and implement it on a wide scale. UNAIDS/WHO recommendations for monitoring and evaluation should be followed.

7.4 LIFE Initiative

The Centers for Disease Control and Prevention (CDC) gave a presentation on the LIFE (Leadership and Investment for Fighting an Epidemic) Initiative. The CDC has $35 million to support countries in Africa including South Africa in primary HIV prevention, community/home based care and treatment and the development of capacity and infrastructure. These funds could support increased availability of VCT and implementation of TB preventive therapy and cotrimoxazole prophylaxis.

 

Recommendations: Work with CDC mobilise funds from the LIFE Initiative for increased access to VCT and implementation of guidelines for the prevention and management of opportunistic infections (including TB preventive therapy and cotrimoxazole prophylaxis) in South Africa. Funds should also be mobilised to evaluate the impact of these interventions through behavioural surveillance and HIV incidence studies.

8. PATHOGENESIS AND DIAGNOSTICS

8.5 New Diagnostic Techniques

a) Rapid Tests

A number of papers confirmed the accuracy of rapid tests. These are appropriate for developing countries where the infrastructural support is poor and clients do not return for test results.

There were several abstracts on rapid HIV testing in South Africa, Uganda, Malawi, Kenya and the USA. Most patients (94% in one study) preferred rapid HIV testing compared to standard laboratory-based testing. The sensitivity of different rapid tests evaluated varied from 91.8% to 90% and the specificity varied from 99.6% to 90%.

In the absence of rapid HIV testing the proportion of people receiving HIV test results varied from 10% to 66,7%. With rapid HIV testing, 99%-90% of people received their HIV test results. The time from collection of the sample to receiving results varied from 15 to 68 minutes with rapid tests and from 1 to 22 days with lab-based tests.

A study in Malawi using a 2 rapid test strategy showed 90% concordance of results with lab-based testing in 178 patients. The advantages of rapid HIV testing are that it is time saving, easy to perform and interpret, does not require highly trained staff or expensive laboratory infrastructure, it simplifies the handling and disposing of blood specimens and can facilitate the timely engagement of HIV+ clients into care and support. In Brazil, only 20% of women eligible to receive free antiretrovirals to prevent mother to child HIV transmission receive it. One reason for this is limited access to HIV voluntary counselling and testing services. Brazil is implementing rapid HIV testing to overcome this obstacle.

 

Recommendation: South Africa should continue with its plans to provide rapid HIV testing in all primary healthcare facilities Policy issue: How often should people test for HIV infection?

b) Dried Blood Spot RNA & DNA

A few studies confirmed the accuracy of specimens collected onto filter paper from HIV-exposed infants for detecting HIV DNA and RNA. These tests obviously cuts down on costs for blood collection and transportation.

c) Saliva Tests

Different kits using oral fluids for HIV tests were evaluated. Sensitivity for these ranged from 96% - 90%. Further modifications may be necessary to explore some of these.

Urine tests were also less sensitive.

Urine/saliva testing was viewed to be more acceptable to patients in focus group discussions than blood HIV testing. In another set of focus group discussions, rapid saliva tests and rapid finger stick tests of whole blood were preferable to tests from blood drawn from a vein. Saliva testing was used in a cross-sectional survey of HIV prevalence in Thailand and positive results were confirmed with EIA and Western Blot.

No abstracts reviewed the sensitivity and specificity of rapid tests from saliva and urine.

 

Policy issue: Is there sufficient basis for wide scale use of saliva tests or should we continue to review the literature?

8.6 Replication, Pathogenesis and Evolution

Many of the key abstracts in this track were those related to the modification of HIV replication properties, viral tropism and viral fitness. These included correlations between viral fitness and both disease progression and drug resistance, as well as the growing awareness of the influences of genetic factors on HIV pathogenesis, such as increases in CCR5 co-receptor.

New light on the origins of HIV-1 group M as well as studies showing the emergence of complex geographical patterns of HIV subtypes were presented.

An examination to phylogenetic trees based on poL and ENV sequences showed the origin of subtype B to be around 1970, the subtype B/subtype separation occurring around the late 1940s and the HIV-1 group M around the 1930s. These results shed new light on the origins of the AIDS pandemic while helping to dismiss the proposal that humans became infected through oral polio vaccinations contaminated with SIV.

The importance of genetic diversity in Eastern and Central Africa was also reviewed, including subtype distributions and the circulation of recombinant HIV strains.

9. CARE AND SUPPORT

9.1 Voluntary HIV Counselling and Testing

Many presenters emphasised the need for this service to form part of the continuum of HIV/AIDS prevention and care. The reasons that motivate people to use this service include that they were asked to do it by others, they were uncertain due to past experiences, they experienced actual exposure or they felt vulnerable due to condom misuse or non-use. The need for this service in both rural and urban settings was stressed.

An understanding of the cultural context regarding how people live and react to situations is important in developing effective counselling strategies.

9.2 Other Key Issues

• Caring for PLWAs is a psychologically draining responsibility. Programmes for caregivers that focus on the psychosocial support necessary to prevent burnout in both family members and volunteer care givers were presented.
• Research confirmed many of the stresses faced by carers. More systematic research of coping strategies is needed. Without addressing the stress of HIV/AIDS care, and the contextual factors that maintain them, we risk losing precious resources in the fight against HIV/AIDS.
• An AIDS rehabilitation and palliative care approach can contribute to cost effective care for people living with HIV/AIDS in resource limited settings.
• Despite the massive education in Uganda some PWAs decline to go to health care settings because of stigma. There is an ongoing need for education about living positively.
• A home care kit (including urine pot, bleaching powder, napkins, gloves, antiseptic lotions, etc) improved participation of family and decreased hospital visits in Uganda.
• Transforming traditional case management to disease management includes a multi-layered team approach increases medication adherence and decreases morbidity and mortality.
• The importance of establishing partnerships for more cost-effective and sustainable care programmes has been demonstrated in several studies and through several models. There is an urgent need for collaboration between government and other important stakeholders like the private sector, non-governmental organisations, civil society, international and regional agencies, etc.
• With the increasing number of people requiring HIV/AIDS care and the emergence of various strategies for providing that care, quality assurance becomes an important issue to consider. A presentation showed how the use of non-monetary incentives, such as affirmation and recognition, for providers could help enhance the quality of HIV/AIDS care.
• Many authors reported the physical and psychosocial effects of living with HIV/AIDS. This ranged from PWAs sharing their life experiences to several models for providing medical and psychosocial care to them. Several authors, including PWAs, stressed the important role that can be played by PWAs in promoting prevention, sensitising health care workers to the needs of people with AIDS to deal with the negative attitudes of providers as well as in forming support groups and self-help groups to help each other cope.

10. LEGAL AND HUMAN RIGHTS

This was the first time that such a track had been added to the International AIDS Conference, and as such provided an opportunity for discussion on several key issues to ensure that our response to HIV/AIDS was placed in a broader legal, ethical, political, socio-economic and cultural context.

In terms of legal and human rights issues, in brief, Track E tended to show that:

On the negative side:

• Discrimination and human rights abuses on the basis of HIV status are still widespread, particularly in the "developing world"; and
• Various countries still have legal systems that discriminate or fail to address HIV/AIDS and human rights issues.

But we have seen that:

• Various countries have begun to develop enabling legal environments to protect and promote human rights in the context of HIV/AIDS;
• Various countries have begun to use the law and human rights instruments to lobby for real change in the national response to HIV/AIDS.

Key challenges that were highlighted were:

• To begin to measure the effect of human rights protection and rights-oriented legislation on the HIV epidemic - that is, how effective is promoting human rights, in terms of reducing the impact and preventing the spread of the epidemic? Is there a public health benefit?
• To begin to use the law creatively to lobby for access to socio-economic rights such as health care services, social services, poverty alleviation
• To begin to strengthen our monitoring and enforcement mechanisms, so that the protective legal framework actually benefits people; and
• To begin to move beyond changing laws, to changing norms, so that our communities begin to be more open and accepting of HIV/AIDS.

The following were the major themes.

a) The appropriate regulation of HIV testing to ensure that it is undertaken with informed consent

• Papers presented indicated that there was a need for the South African government to ensure that all HIV testing within the SANDF took place in a manner which protected the constitutional rights of soldiers
• Governments needed to ensure that HIV testing was not misused in the insurance industry; and HIV testing needs to be regulated through national policy.

b) Expanding the government’s HIV/AIDS response through empowerment, advocacy and activism

• Papers were presented on how impact assessments could be used to mobilise government departments
• Training strategies to develop political leadership on HIV/AIDS

c) Dealing with notification reporting and disclosure in a manner that protects and promotes the rights of all people affected by HIV/AIDS

• Papers indicated that notification of HIV or AIDS is only relevant in the developed world.
• Issues for developing countries included encouraging voluntary disclosure to sexual partners and promoting openness

Regarding the statement that "notification of HIV or AIDS is only relevant in the developed world", the following: The reason for this statement is that HIV notification data is typically used for epidemiological surveillance to:

• Monitor the burden of disease in the community;
• Plan for future service delivery and
• Assess the impact of prevention programmes

HIV notification is able to fulfill such functions only under certain conditions. The data needs to represent the pattern of disease across the country without biases due to access to voluntary testing and counselling (VCT). In South Africa, access to VCT in very limited and is typically not available at all in most non-urban centres. In this situation, HIV notification data, if collected, will suggest that HIV is a disease of affluent people who live in cities. Clearly, the annual antenatal surveys provide strong evidence that the epidemiology of HIV infection in South Africa is not of this nature.

In many industrialised countries, HIV testing is easily accessible and HIV notification data closely follows the real profile of the epidemic.

In resource limited settings, it is generally recommended that HIV epidemiology can be best assessed through regular prevalence studies of representative populations (e.g., pregnant women as an relatively unbiased surrogate for women in the community or military recruits as a surrogate for men in the community).

Similarly, other means of assessing the impact of prevention programmes include:

• STD surveillance from sentinel clinics
• Regular surveys of risk behaviour in selected populations (e.g., taxi drivers, military personnel, and high school students).

d) The role of criminal law in combating HIV/AIDS

• A number of papers dealt with the use of criminal law in a national response to HIV/AIDS and how it should be used only to prevent "harmful behaviour"
• A number of papers dealt with issues relating to sex work and the need to decriminalise this industry.

e) Using law, ethics and human rights to protect trial participants in HIV trials

Two poster presentations were done on the role of law, ethics and human rights in regulating HIV vaccine developed. Both posters emphasised the role of the state in regulating such research.

• Conflicting opinions around ethical standards of care for vaccine trial participants were argued, with the UNAIDS Guidelines arguing for the best attainable standard of care, and a Brazilian author arguing for the best proven method of care.
• RSA needs to develop its own accepted guidelines on ethical standards regarding HIV vaccine research, relevant to our own context.

f) The need for the government to become involved in developing the capacity of all stakeholders to measure and evaluate their responses to HIV/AIDS

Papers identified the need to develop the capacity to measure the effectiveness of various interventions

• To ensure that evaluation and review procedures were integrated into all programmes
• To date it appeared that most effort had gone into developing the legal and policy framework and the focus now needed to be on implementation

g) The need to ensure that gender issues are mainstreamed into all HIV/AIDS programmes

• International trade agreements can be challenged as one strategy of reducing drug prices
• Intellectual property laws need to be reviewed to ensure that they do not deny people living with HIV or AIDS access to drugs.

i) Public health and human rights

• We need to move beyond simply stating that human rights are important for public health, to start asking questions about how the law and legal structures affect health, and how we measure (monitor) the success of the legal framework in complex social processes such as health seeking behaviour
• We also need to measure the impact of the law in reducing vulnerability to HIV and for potentially addressing deeper social causes of illness (e.g. poverty) in the population

j) Ethics of care: Strategies for improving care

The session highlighted several legal and human rights strategies which we could use to improve our health care delivery, most notable being:

• Drug laws and policies;
• Ethics of vaccine research;
• HIV testing and pregnancy;
• Challenging constitutional guarantees of access to health care;
• Legal and ethical protocols for patient management

k) Preventing stigma and discrimination

• Many countries still face a wide range of discrimination and human rights abuses on the basis of HIV/AIDS
• Some countries have adopted progressive laws to combat this - however this does not always prevent ongoing discrimination. Governments should seek to ensure that creating the legal framework is not the end in itself. Need to develop models of social surveillance to improve responses of society.
• Sectors in society such as the private sector have often tended to block progressive legislative development, for economic reasons
• Government should ensure that it is not influenced by the same considerations as the private sector (i.e. economics) in developing public policy for HIV/AIDS

Potential solutions to the personal and political problems associated with HIV/AIDS raised during the Conference were programmes caring for children and orphans affected by HIV/AIDS, responsible media coverage, awareness of HIV/AIDS in the workplace, and individual investment in communities.

11. PUBLIC HEALTH ISSUES

11.1 Surveillance

a) New Advances

Detection of recent HIV infection using the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS)

The long period between acquisition of HIV and manifestation of disease hinders prevention efforts. In this scenario, we find ourselves trying to prevent an epidemic that happened long ago, missing emerging epidemics and the chance to interrupt transmission. HIV prevention would benefit from a simple means to identify recent infection, characterise factors that lead to transmission and pinpoint where transmission is occurring right now for precise targeting of prevention.

Such a tool, the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) is now available.

The Department of Health and the University of Natal are investigating the STARHS approach. In particular specimens from the National HIV Antenatal Survey are being evaluated for this method.

The Conference showed that surveillance could be improved in the following ways:

• Ensuring periodic serosurveillance among specific groups
• Incorporating questionnaires in the Antenatal Survey that include for instance the age of partners and occupation. This information could be used to extrapolate prevalence in men.
• Conducting regular STD surveillance
• Collecting data on indicators of community risk, such as migrancy, access to condoms, commercial sex worker points, number of bards, and demography.

c) AIDS Morbidity and Mortality

Several studies highlighted the importance of collecting mortality and morbidity data. Reports from Africa, including South Africa, confirmed that TB is the commonest opportunistic infection and predictor of survival. One study highlighted cryptococcal meningitis as the main cause of death among people with AIDS.

Such data is important to assess the impact and usefulness of prophylaxis.

a) Prisoners

Several papers addressed the problem of HIV in prisons. As demonstrated through several intervention models and assessments, prisons offer a great opportunity of HIV/AIDS prevention and care. Various presenters described the nature and extent of high-risk behaviours that prisoners indulge in. These range from unprotected anal and oral sex, to drug use. Prisons also have a high prevalence of drug users and there is admission by most prisoners that they do or have indulged in high-risk behaviours. A strong recommendation that HIV prevention and care services be made available to inmates.

Some authors presented models for intervention, ranging from needle exchange programmes for intravenous drug users, peer education models.

Important highlights include:

• Prisons are unique – they provide a fertile environment for the transmission of STDs and HIV
• Risky behaviours prevail, including sodomy, tattooing, sharing devices for shaving etc., and drug use
• Lack of knowledge of HIV/AIDS transmission and prevention is rife

To address this, appropriate strategies include:

• Provision of condoms in prisons
• Access to treatment for STDs
• Access to voluntary counselling and testing
• Information and education targeting for both prisoners and prison personnel

b) Discordant Couples

A need for VCT centres to establish special counselling strategies for discordant couples was raised, such as group counselling and other interventions to increase condom use in these couples. The discordant couples experience major psychosocial problems and counsellors can play a significant role in helping them to cope.

c) Men having Sex with Men (MSM)

A relationship between this practice and intravenous drug use was found in several studies. These suggest that there is a need for intensive interventions that are culturally tailored, with community involvement in those interventions. Comprehensive models for interventions aimed at MSM that included training, networking, support, involvement of partners where feasible, is necessary.

 

Recommendation: Conduct prevalence studies to determine the scale of sex among MSM in South Africa

d) Drug Users

It has been established that drug use is associated with high-risk behaviour. In the struggle against the HIV/AIDS pandemic, the predominant argument is that comprehensive drug use prevention strategies should incorporate HIV/AIDS prevention and care.

Peer education strategies were shown to be effective.

 

Recommendation: Conduct prevalence studies to determine the scale of injecting drug use and non-injecting drug use (e.g. crack cocaine and dagga) in South Africa

e) PLWAs

Several studies presented recommendations for alternative more cost-effective and even better quality approaches for providing care for PLWAs. Early diagnosis and care, HAART and care by expert physicians were all found to increase both cost and outcome effectiveness.

11.3 The Economics of HIV/AIDS

As the Conference was held in South Africa, the country with the fastest growing HIV/AIDS epidemics in the world, much of the discussion in this track focused on the ability of resource-constrained countries, especially in sub-Saharan Africa, to afford the prevention, treatment, care and support interventions required.

It was stressed that higher medical costs can be expected for HIV in comparison to other chronic and terminal illnesses. High costs of medical care and clinical management of HIV/AIDS can be expected far beyond the capacity of lower and middle-income countries. It was stated that families might find themselves spending up to 70% of their incomes on HIV related care.

This increases the need for alternate forms of healthcare financing for lower-income countries.

Several models were presented on how the impact of HIV/AIDS can be measured. It was cautioned that the value of these models depends on the quality and accuracy of information fed into it.

11.4 The Care of Children

There were several interesting discussions on models of orphan care, both within facilities and communities. However, it was also acknowledged that some countries, like South Africa, have not yet seen the full impact of AIDS orphans in society. Concern also existed as to the saturation levels of extended families with orphan children.

In South Africa there is a strong need to have a good, multisectoral programme that addresses this issue, and also allows for the integration of orphan care into existing community programmes.

One study showed that the projections and prediction of the numbers of orphans requiring care using projection models are not always accurate and that they exclude an overwhelming majority of orphans, especially those in the temporary care of extended family members. Some also expressed the need for treating AIDS orphans like all other orphans and not making special arrangements for them so as to avoid discrimination.

11.5 AIDS Education

An issue highlighted is that linking MTCT prevention programmes with a community mobilisation and education component improves the uptake of interventions.

Another issue addressed is aspects that influence women’s decision-making, namely:

• Socio-economic context of their lives
• Personal relationships
• Cost of feeding options
• Ambiguous information from healthcare providers

a) Training of Healthcare Providers

One report showed that the quality and cost-effectiveness of HIV/AIDS care increased after training PHC providers and supplying them with protocols. This was supported by several others who suggested that providing a continuum of care using all levels of care that include day care hospitals and home-based care by community workers, volunteers and family members is cost-effective. The patient can be referred as appropriate within this continuum.

The effectiveness of training local church leaders in providing community home based care in a rural setting was also demonstrated.

Other authors recommend that proper training of nurses, who in any way provide most of that care, will increase access to care, increase the quality of care as well as reduce the cost of such care. The Bristol Meyers Squibb funded "Secure the Future Initiative", in collaboration with some countries in the SADC region (including RSA), has developed and pilot-tested a curriculum for the training of nurse educators, who will train nursing students to train community members in caring for people with HIV/AIDS.

b) Knowledge, Attitudes and Behaviour (KAB) Studies

Several of these were presented, covering a wide spectrum of groups. In the prison services, low level of knowledge and the resultant engagement in the high-risk behaviour was reported among prisoners as well as prison staff. The levels of knowledge and the negative attitudes of prison staff often result in discrimination against HIV positive inmates.

Poor knowledge has also been associated with risky behaviour among hospital staff in Cape Town where universal precautions were not adhered to fully and protective devices were not readily available.

University and other tertiary institution students also demonstrated inadequate levels of knowledge, especially with regards to the transmission of HIV. Misconceptions were found to be common amongst them. Even medical and paramedical practitioners have knowledge deficits and sometimes have negative attitudes towards HIV/AIDS patients and caring for them.

11.6 Intersectoral Collaboration

• The need for cross-border collaborative strategies for people travelling across national borders was raised. A programme called "Air Bridge" was presented as a model for such intervention and how it could address the problem of disparity, accessibility and continuity of care for people living with HIV/AIDS.
• The effectiveness of multisectoral collaboration, the empowerment of women and communities, as well as community-based approaches have all been supported as being effective prevention strategies. Projects demonstrating the effectiveness of different strategies focused on the inclusion of all sectors of communities, including religious and other faith-based organizations and rural communities.
• Although the need for multisectoral collaboration has been demonstrated, there are some barriers that might hinder this if not properly approached. There is a need for various strategies, including regulation, the involvement of professional bodies, material incentives, etc to facilitate the effective involvement of the private sector. Decentralisation was also strongly suggested but issues of structural rigidity, lack of local capacity, influence of donors, etc might present barriers in the ability of district health services to participate as full partners.
• The need to address cultural issues when offering HIV prevention services was also highlighted, and especially the potential of using traditional leaders in communities and the acknowledged traditional community structures in the prevention of HIV.
• Several presenters highlighted the role of art and other forms of mass communication strategies in spreading prevention messages.

12. Concluding Remarks: Lessons from the Conference

• PREVENTION WORKS. The Department of Health clearly is following effective prevention strategies and has prioritised essential components in the area of prevention (e.g. STD management, provision of condoms, information, education & communication). However, even small failures of management, such as with male and female condoms or STD management, could result in people becoming HIV infected.

The key elements of an effective prevention strategy are: awareness campaigns, appropriate education for behaviour change, effective management of STDs, consistent condom use, and access to voluntary HIV counselling and testing. These elements require a joint approach from both government and other civil society sectors.

• ARVs reduce HIV transmission without documented toxicity, but extended breastfeeding counterbalances the benefits. However, with conflicting studies on the issue of breastfeeding, more research is needed on this issue.
• A number of community-based projects were presented from other countries who are further on in the epidemic than South Africa. Replication and piloting of projects with the aim of massive duplication and roll-out should be considered.
• Greater emphasis should be placed on involving both the youth and PLWAs in planning and implementation of HIV/AIDS policies and programmes.
• The link between the HIV/AIDS epidemic and development issues, especially poverty, malnutrition and food security, was acknowledged. Addressing these require commitment and resources from several stakeholders, including government, big business and donor agencies.
• Creative strategies for introducing common themes must be actively sought and promoted.
• Cost-effective care and support issues are clearly identified and if effectively implemented can result in marked quality of life improvement.
• Effective delivery structures that can more effectively deliver financial resources into communities must be considered.
• The key components for ensuring effective HIV/AIDS programmes include:

• Political leadership and commitment
• An early start, when infection rates are low
• Adequate resources
• Large-scale implementation involving relevant sectors (including PLWAs)
• Coordination of policies and programmes between the most important stakeholders
• Sound technical strategies
• Good sources of evaluation data

Presenters from Uganda also highlighted the importance of:

• Openness
• District-based programmes
• Effective coordination at national, regional and local level

13. KEY RECOMMENDATIONS

Summarised, some of the key recommendations are:

1. Continue and enhance those prevention strategies that are known to be successful (e.g. provide condoms, ensure effective management of STDs, life skills education, and providing information, education and communication materials).
2. Improve the integration between HIV and TB programmes at district level.
3. Continue to support the South African AIDS Vaccine Initiative.
4. Conduct and promote further research on:

• Post-exposure prophylaxis and sexual assault
• Use of saliva tests and dried blood spot for HIV testing
• Microbicides
• Female condoms
• Mother-to-child transmission and breastfeeding
• Issues of drug resistance

5. Expand care interventions (e.g. home-based care and support for PLWAs)
6. Take policy decisions on:

• Provision of ARVs to pregnant women
• Use of saliva HIV tests

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