http://www.irinnews.org/irin-fp.aspxUpdated everydayen-gbThu, 05 Nov 2009 15:53:59 GMTKABUL Thursday, November 05, 2009 (IRIN) - Over 50 people have been diagnosed as HIV-positive in Afghanistan over the past nine months, bringing the number of registered cases to 556, according to the National HIV/AIDS Control Programme.KABUL Thursday, November 05, 2009 (IRIN) -  Over 50 people have been diagnosed as HIV-positive in Afghanistan over the past nine months, bringing the number of registered cases to 556, according to the National HIV/AIDS Control Programme.

"Most of them have got the virus through intravenous drug use," Malika Popal, the Programme's advocacy and communications adviser, told IRIN, adding that three HIV/AIDS patients had died so far this year.

The Health Ministry estimates 2,000-3,000 people are living with HIV/AIDS in Afghanistan. The virus prevalence rate of about 0.5 percent is considered among the lowest in the world.

Armed conflict, lack of awareness of HIV/AIDS, lack of access to basic social services such as education and health, rising intravenous drug addiction, and the poor social status of women are among the factors which, experts say, could lead to a rapid spread of HIV/AIDS.

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http://www.irinnews.org/report.aspx?ReportId=86888SELEBI-PHIKWE Thursday, November 05, 2009 (IRIN) - On a recent Wednesday evening, Gillian Otsile, a volunteer at a local NGO, Men Sex and AIDS, approached a group of young men drinking cartons of traditional sorghum beer at a tavern in Selebi-Phikwe, a mining town in northeastern Botswana.SELEBI-PHIKWE Thursday, November 05, 2009 (IRIN) - On a recent Wednesday evening, Gillian Otsile, a volunteer at a local NGO, Men Sex and AIDS, approached a group of young men drinking cartons of traditional sorghum beer at a tavern in Selebi-Phikwe, a mining town in northeastern Botswana.

In a country where nearly one in four adults is infected with HIV, Otsile's focus is talking to the patrons of local drinking establishments about the risks of combining alcohol with sex.

Most of the group in the bar in Selebi-Phikwe are unemployed and rely on occasional piece-work to buy beers for themselves and any girls they meet. Tato, who is slightly older than the others and works as an electrician, confirmed that after buying a girl beers all night, he expected to go home with her.

Using a condom depended on how drunk he was. "If you're drunk, you lose half the sensation, so the only way you can do it is flesh-to-flesh. You forget about HIV."

Tato's comments echo the findings of several studies: heavy drinking is associated with an increased likelihood of engaging in sexual behaviours that put individuals at risk of HIV infection.

A 2006 study in Botswana found that both male and female heavy drinkers were above three times more likely to have unprotected sex than non-drinkers; their odds of having multiple partners and paying for or selling sex were also much higher. 

Need for policies

Alcohol use as a driver of HIV infections is evident throughout southern Africa, the region worst hit by the global HIV/AIDS pandemic, but few governments have implemented policies to address the problem.

However, in 2008 Botswana President Ian Khama's government acknowledged the link by legislating shortened hours for bars and slapping a 30 percent levy on alcohol. It is too soon to say whether these measures have changed drinking habits enough to have an impact on HIV infection rates.

Some commentators say people have simply switched to drinking traditional beer called Chibuku, which still sells for less than US$1 for a one-litre carton that can be shared between friends. One of Tato's friends pointed out that bars are also popular places to buy condoms, so "if the bars are closed, they're not going to find a condom."

The tavern adjacent to the office of District AIDS Coordinator Lamech Myengwa is still doing brisk business, especially at month-end. "In Botswana, drinking has become a pastime," he told IRIN/PlusNews.

Few small towns have a cinema or much else by way of recreational facilities. "Every evening people will go to the bars to socialise - that's where everybody mixes, young and elderly - no wonder there is this intergenerational sex going on."

Government figures from 2008 show that HIV infections in Selebi-Phikwe, as in most of Botswana and across southern Africa, are highest among young women and older men, demographics that tend to be replicated in the bars.

"The women are young girls, from 16 [years old]," said Dikgang Keabetswe, a project leader at Men Sex and AIDS, one of several community-based organizations receiving funding from Population Services International (PSI), a global health organization, to raise awareness about alcohol and HIV in local bars.

"Some [young women] go [to the bars] without a cent; they look for males to buy them something to drink, and even for transport money. Men mostly expect sex in return. The BCL guys [workers at the local copper and nickel mine] - those who have more money - are mostly over 25."

Employment opportunities for women in Selebi-Phikwe have shrunk since several textile factories closed in the late 1990s, and some have turned to commercial sex work, while others occasionally exchange sex for drinks or small amounts of cash.

On her way home from buying a bag of maize, Elizabeth, 27, has stopped at the tavern where Tato and his friends are drinking. "I want a drink but I don't have money, so I'm hoping someone will buy me one," she said, admitting that some men expected sexual favours in return.

"If I want, I go with him. Sometimes I use a condom, but if he says, 'I don't have a condom', and I see he has a lot of money, I'll agree ... In life, we need money."

She recently tested negative for HIV, but believes it is only a matter of time before she contracts the virus. "I think everyone nowadays has HIV," she said.

Tato and his friends have similarly fatalistic attitudes and a reluctance to change risky sexual behaviours; several said they slept with sex workers whenever they had money.

"I'm not afraid of HIV because there are ARVs [antiretrovirals] for free," said one, referring to the government ARV programme which reaches nearly 100 percent of those in need of the medication. "I'm afraid of it ... when I'm sober," laughed Tato.

Changing behaviours no easy task

Persuading people to reduce their alcohol consumption will have little effect on Botswana's HIV infection rates unless it is accompanied by fundamental changes in attitudes and behaviours.

The young volunteers doing the PSI-funded interventions at bars are trained to strike up conversations with people not only about drinking responsibly, but also about the common practice of having multiple concurrent partners (MCPs) - perhaps the biggest and most neglected driver of HIV infections in southern Africa, according to recent research.

PSI is providing technical assistance to Botswana's National AIDS Coordinating Agency (NACA) in an initiative launched earlier this year to raise awareness and eventually change behaviour.

The first phase is a mass media campaign featuring the slogan "o icheke" (check yourself), to get people to recognize the risks of having MCPs. Starting in December, a second phase will target demographic groups most likely to have MCPs with tailored messages, said Richard Matlhare, head of behaviour change at NACA.

"We looked at alcohol as one of the predisposing factors, and that's why the President has taken a stance on responsible drinking," Matlhare said. "We know people can't make informed judgements when they're drunk."

ks/hehttp://www.irinnews.org/report.aspx?ReportId=86899MBABANE Wednesday, November 04, 2009 (IRIN) - Swaziland not only has the world's highest HIV prevalence rate, it now also has the highest tuberculosis (TB) rate, but health officials warn that not enough is being done to integrate TB and HIV services. MBABANE Wednesday, November 04, 2009 (IRIN) - Swaziland not only has the world's highest HIV prevalence rate, it now also has the highest tuberculosis (TB) rate, but health officials warn that not enough is being done to integrate TB and HIV services.

Last week the Ministry of Health and Médecins Sans Frontières (MSF), the international medical humanitarian organization, brought together health experts to look at practical solutions for the small landlocked country.

One in four adults is infected with HIV; by the end of 2007 an estimated 170,000 people were living with HIV, and every year an estimated 13,000 people develop TB, the primary opportunistic disease in HIV-positive people.

"When you look at the history of TB in Southern Africa you see that it was considered a very serious disease in the 1950s, but seemed to be under control by the 1980s; but with the arrival of HIV and AIDS, TB rates have really gone out of control," said Prof Alan Whiteside, head of the Health Economics and HIV Research Division (HEARD) at the University of KwaZulu-Natal in South Africa.

Themba Dlamini, manager of Swaziland's National TB Control Programme, said 80 percent of Swaziland's TB cases were also HIV-positive.

But with governments focused on HIV/AIDS, TB has not been getting enough attention.

"Part of the problem is we've been very good at mobilizing for HIV and AIDS, and we sort of forgot about TB as we did that. Unfortunately, I don't think the people mobilizing for TB have been as articulate and as powerful as those mobilizing for HIV and AIDS - we need to put TB higher on the public agenda," Whiteside told IRIN/PlusNews.

Swaziland's Health Minister, Benedict Xaba, reminded delegates that although the country provided free TB medicines, other costs, such as hospital fees and transport, made it difficult for many people to access health services.

"There are several issues that Swaziland needs to face. Access to care is particularly important ... so people who show signs of symptoms can be checked immediately. Free consultation is absolutely imperative - we must think of free care from diagnosis to clinical cure," urged Dr Mario Raviglione, Director of the Stop TB Department of the World Health Organization (WHO).

Raviglione urged the country to step up efforts to integrate TB and HIV services. "It doesn't make any sense for a person taking TB drugs and ARVs [antiretrovirals, to treat HIV] to go to two separate doctors. These must be integrated."

About 58 percent of TB patients completed their six-month course of treatment last year, falling far short of the 85 percent target recommended by WHO. International guidelines also set a 70 percent detection target for TB, but in Swaziland the case detection rate is below 60 percent.

The good news is that, unlike HIV/AIDS, TB is curable. "I know people living with HIV and TB, and their TB has been dealt with," noted Whiteside. "It is a community message we need to get out - that we are capable of eliminating the scourge of TB in your community."

jh/kn/he http://www.irinnews.org/report.aspx?ReportId=86879GABORONE Wednesday, November 04, 2009 (IRIN) - Katlego Lally*, 17, belongs to a club for HIV-positive teenagers run by the Baylor Children's Clinic Centre of Excellence in Gaborone, Botswana's capital. She talked to IRIN/PlusNews about how the club has helped her overcome feelings of isolation and depression.GABORONE Wednesday, November 04, 2009 (IRIN) - Katlego Lally*, 17, belongs to a club for HIV-positive teenagers run by the Baylor Children's Clinic Centre of Excellence in Gaborone, Botswana's capital. She talked to IRIN/PlusNews about how the club has helped her overcome feelings of isolation and depression.

"I was born in 1992. Back then, there was no PMTCT [prevention of mother-to-child transmission] so I got the [HI-]virus from my mother, but I wasn't diagnosed then. I just grew up falling sick every time, and we didn't know why.

"In 2003 we did some tests and then they found out that I had the virus, and my mother also. I don't think I understood at that time ... But as time went by I came to understand the disease, and that's when I told my brain: 'Okay, this is a death sentence', and that's when I became depressed.

"I remember in 2007, I was falling sick often and my exams were about to come, so I was a bit down, always just kicking myself – 'Why? Why me? What have I done?' - I was just living in a dark tunnel, waiting for the day I would die.

"Then last year I was referred to Baylor [Children's Clinic] and that's when I think my life changed. The doctor told me about Teen Club; then I came and I saw a whole new world that I never knew.

"I didn't realize - I thought it was just me - but I saw a whole lot of excited and happy teenagers, and I also got that energy, that positive thinking, from them.

"This year I was elected to be a [Teen Club] leader. I have to be a role model to the younger teen members, I help with serving lunch, lead ice-breakers and train other teen leaders from satellite clubs.

"I've made a lot of friends - they're like my family. Everyone is open with each other, because when you're in the same situation you understand each other. We don't normally talk about HIV or medications here in Teen Club; we sometimes go on trips, listen to music, or sometimes we get life skills.

"Being a teenager is very hard - you have to keep up with the changing life, do what the others do. My school friends don't know [about being HIV-positive], but just like most people here generally in Botswana, especially teachers when they talk about HIV, they bring it up in a whole negative way.

"I have friends who drink, who have sex, and sometimes you try to tell them: 'this is not good'. But how are you going to make them understand? You'd maybe have to start by saying, 'I'm HIV positive and you don't want to be HIV-positive', and that would be like, ugh, so I just leave it.

"Teen Club helps me. I know I don't have to go to the bar and drink alcohol, I don't need drugs to get me high, because I have a happy life and I have a lot of goals for myself. First of all I want to be a lawyer, but if not law, then radio journalism, and if not, then accounting ... or I want to be a movie star.

"I go on dates, but sometimes I can just be out of the dating mode. I want a person I can spend the rest of my life with, but when the time comes for us to maybe have sex, how am I going to disclose my status?

"You never know what they'll think. What if that person is not that trustworthy? Once you tell him he'll get really angry and start to spread rumours about you, so I just have to leave it.

"Right now I'm writing my final exams so after then, that's when I'll start seeing what to do. If I fall in love with someone who's negative, I'll see if I disclose my status to that person, how they will react."

*Not her real name

ks/he http://www.irinnews.org/report.aspx?ReportId=86881NAIROBI Tuesday, November 03, 2009 (IRIN) - Three years after being diagnosed with HIV, Alice Mworia, 28, went for a routine medical check-up during which she told the nurse she had noticed an unusual vaginal discharge; a test revealed she had pre-cancerous lesions on her cervix that could develop into cancer if untreated.NAIROBI Tuesday, November 03, 2009 (IRIN) - Three years after being diagnosed with HIV, Alice Mworia, 28, went for a routine medical check-up during which she told the nurse she had noticed an unusual vaginal discharge; a test revealed she had pre-cancerous lesions on her cervix that could develop into cancer if untreated.

"I was experiencing a bad smell from my private parts and I wondered whether it was because I was HIV-positive; I could not keep quiet any more and I shared with one of the nurses and she referred me to the doctor," Mworia told IRIN/PlusNews. "I did not even know there was anything called cervical cancer, which I was informed can kill very easily."

According to the UN World Health Organization (WHO) [http://apps.who.int/hpvcentre/statistics/dynamic/ico/country_pdf/KEN.pdf], some 2,635 Kenyan women are diagnosed with cervical cancer every year, with 2,111 dying from the disease, making it the most prevalent cancer among women in the country. About 38.8 percent of women in the general population are estimated to harbour cervical human papillomavirus (HPV) infection [http://www.cancer.gov/cancertopics/factsheet/Risk/HPV] - a leading cause of cervical cancer - at any given time.

High risk, low knowledge

For cervical HPV infection to progress to cancer, certain co-factors must be in place, including smoking, long-term hormonal contraceptive use and co-infection with HIV.

"Women who are HIV-positive have weak immune systems and this makes them very susceptible to persistent human papillomavirus that develops into cancer of cervix," said Lucy Muchiri, a senior lecturer in human pathology at the University of Nairobi's College of Health Sciences and a member of the sub-Saharan Africa Cervical Cancer Working Group.

"It takes a relatively shorter time for the HPV virus to develop into full-blown cancer of the cervix for women who have the HIV infection … It would take relatively longer in women who are not infected with HIV."

Pap smear tests - which check for changes in the cells of the cervix - are available at most district health facilities in Kenya, but according to WHO, fewer than 6 percent of women access them.

"I think many women die from the disease for a number of reasons - one is ignorance because knowledge about the disease among women and in the general population is very low and it is mistaken for other diseases," she said. "It is appalling that despite most cancer-related deaths in women happening because of cervical cancer, it is the least talked about or even known by people, including women."

According to Francis Kimani, director of medical services at the Ministry of Health, Kenya is planning a screening programme for early detection and treatment of cervical cancer as well as a widespread education campaign.

Education gap

"I think our best bet is to carry out education to let people know about the disease and that early detection of it can be very helpful," Kimani told IRIN/PlusNews. "It is true that not many people - especially in rural areas - know about the disease."

Studies [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2631263] have shown that HPV is higher among women who have multiple sexual partners and unprotected sex.

"Maybe to prevent it in the first place, the same methods used in combating HIV, like condom use, abstinence and keeping to one faithful partner, should be encouraged in this case too," Muchiri suggested.

She noted that the government also needed to invest in making the HPV vaccine - which protects against four major types of HPV, including two types that are responsible for 70 percent of cervical cancers - widely available in public hospitals.

Vaccine availability

The Kenya Pharmacy and Poisons Board approved the sale of an HPV vaccine in the country in 2007, but its availability is extremely limited and it is still prohibitively expensive for most Kenyans.

"HPV is a sexually transmitted virus and with the vaccine in place, it is important to encourage parents to take their young girls between the ages of nine and 15 to be vaccinated before they debut into sex," she said.

A recent study by the local NGO, Centre for the Study of Adolescence, found that four in 10 Kenyan girls had sex before the age of 19, many of them as early as 12.

"Once they [women] become sexually active, it is important to encourage [them] to go for Pap smear tests or visual detection of the pre-cancerous lesions but even vaccination at this stage is still feasible so long as one has not contracted the virus," Muchiri added.

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http://www.irinnews.org/report.aspx?ReportId=86853GABORONE Tuesday, November 03, 2009 (IRIN) - Raging hormones, peer pressure and coming to terms with a changing body image - growing up is difficult enough without the added burden of living with HIV, and keeping it hidden from friends and classmates. GABORONE Tuesday, November 03, 2009 (IRIN) - Raging hormones, peer pressure and coming to terms with a changing body image - growing up is difficult enough without the added burden of living with HIV, and keeping it hidden from friends and classmates.

"Being a teenager is very hard; you have to keep up with the changing life, do what the others do," agreed Katlego Lally*, 17, in Botswana's capital, Gaborone, who was born with HIV but only learned of her status six years ago. "My school friends don't know; if you bring up HIV they're quite ignorant."

As one of the first countries in southern Africa to start rolling out a national antiretroviral (ARV) treatment programme that now reaches nearly 100 percent of those who need the medication, Botswana has a rapidly growing population of children infected at birth who are surviving into adolescence.

Simply referring these teenagers to adult clinics and ignoring their special needs could lead to a reversal in the gains Botswana has made in combating HIV, argues Ed Pettitt, coordinator of the Teen Club programme at the Botswana-Baylor Children's Clinic Centre of Excellence in Gaborone.

"Adolescence, as a period of development, has the highest risk for therapeutic failure - not just for ARVs, but any medication for a chronic illness," he told IRIN/PlusNews.

"I call it the 'inconvenient truth' of paediatric HIV - it's great that you can put children on ARVs, but you have to realize that one day they're going to grow up and become teenagers, and all the challenges and headaches that come with adolescence are going to impact on their behaviours."

Julia Rosebush, a doctor at the Children's Clinic, which provides care and treatment to HIV-infected infants and children through a partnership between the Baylor International Pediatric AIDS Initiative and the Botswana government, has already seen how teenage rebellion can translate into treatment failure. "A lot of kids throw away their pills - we're finding a lot who are failing first-line treatment already."

Pettitt said only three lines of drugs for treating HIV were available in Botswana, and if interrupted treatment caused resistance to these to develop during adolescence, "your long-term prognosis doesn't look good".

A whole new world

The first Teen Club started in Gaborone in 2005 with just 23 teenagers, but now has over 400; that number is expected to reach over 1,000 by 2012, and five satellite clubs have launched in other parts of the country.

Clinic staff and some of the older teenagers who serve as "teen leaders" run monthly events at the clubs, providing support and sanctuary to the vast majority of members who have never disclosed their status to anyone besides their caregivers.

"When there's only one other person that knows their status, they're leading kind of double lives," said Pettitt. "They can't even tell their best friend because they fear that friend will tell others, and they'll never be able to go back to school."

For Lally, who started coming to Teen Club last year, realizing that there were other teenagers like her was life changing. "I was just living in a dark tunnel, waiting for the day I would die," she said. "The doctor I was seeing told me about Teen Club and I saw a whole new world ... I thought it was just me, but I saw a whole lot of excited and happy teenagers."

She is now a teen leader and thinks of her friends at the club as "like my family". "Everyone is open with each other, because when you're in the same situation you understand each other," she said. Mostly they talk about "normal teen stuff" rather than their HIV status.

The monthly events are usually focused on fun and general life skills rather than HIV-related issues. Past activities have included pool parties, salsa classes and movie nights, although the most recent event focused on how to disclose one's status to friends and family.

After a panel discussion in which several adults and one teen leader shared their experiences of disclosure, the teenagers broke into small groups to act out skits where they practised disclosing to best friends, girlfriends, teachers and cousins.

Sexuality and relationships are particularly fraught for HIV-positive teenagers, but giving them tools for disclosing to romantic partners is vital if they are to use prevention methods, said Pettitt.

Mpho Mosala*, 17, another teen leader at the Gaborone Teen Club, has been dating the same girl at his school for the past two years but he has yet to tell her of his status. "Right now, I don't think it's so important because we're not doing anything that would expose her," he said. Lally has decided to stay "out of the dating mode", at least until she finishes school.

While younger club members attended the session on disclosure, older teenagers were busy clearing undergrowth from a plot across the street where a drop-in centre for HIV-positive adolescents is to be built. They were joined by volunteers from Barclays Bank, which contributes part of the funding for the programme as well as financial literacy training to the teenagers.

The centre will provide a much needed place where teenagers and their caregivers can come between clinic appointments and monthly events for counselling, training and sports, or just to hang out.

Model programme

The success of Botswana's ARV programme and its prevention of mother-to-child transmission (PMTCT) programme means that while the number of infants born with HIV is dwindling, the number of HIV-positive adolescents is growing every year. "In three or four years we'll pretty much be an adolescent clinic," said Pettitt.

Recognizing the growing need, Botswana's Ministry of Health is partnering with Baylor to develop an adolescent care package to train health care workers at government ARV clinics in how to cater for teenage patients.

While Botswana is slightly ahead of the curve, other countries in the region are also dealing with growing numbers of HIV-positive adolescents and looking for models they can adapt.

Baylor has launched similar clubs attached to its Children's Clinics in Swaziland, Lesotho, Malawi and Uganda, and a number of other countries and organizations have requested materials on adolescent care and support.

Pettitt welcomes the interest, saying: "A lot more attention and resources needs to be put towards finding ways to keep adolescents adherent and prevent them from infecting others."

*Not their real names

ks/he

http://www.irinnews.org/report.aspx?ReportId=86861HARARE Monday, November 02, 2009 (IRIN) - When Anna Matopodza, 55, from a village in the Buhera district of Manicaland Province, Zimbabwe, found out she was HIV-positive, she was anxious about who would look after her five children when she died. The thought of death haunted her for months; then she joined dance group and travelled around the world, teaching people about HIV/AIDS through song and dance. HARARE Monday, November 02, 2009 (IRIN) - When Anna Matopodza, 55, from a village in the Buhera district of Manicaland Province, Zimbabwe, found out she was HIV-positive, she was anxious about who would look after her five children when she died. The thought of death haunted her for months; then she joined dance group and travelled around the world, teaching people about HIV/AIDS through song and dance.

"I tested HIV positive in 1996, after the death of my husband. My husband had been sick for a very long time; we were always in and out of hospital but I had never got the opportunity to get tested. I got tested after some counselling from an organization called Family Care Trust-Nyanga (Fact-Nyanga).

"Back then, in 1996, we didn't have the New Start Centres that are now offering voluntary counselling and testing around the country, so for someone to get tested it was a very difficult and an expensive thing.

"The result came back positive. I didn't even know what that meant, except that I knew I had a disease that had no cure, no treatment, and that I would soon die in the same painful way my husband had died.

"My concern was for my four girls - I was afraid that after I had died they would be forced to get married early and also expose themselves to the disease. I lost a lot of weight just thinking about all these things.

"When I joined Tsungai ['be strong' in the Shona language] support group I had no idea what to expect; I just joined because I was probably looking for answers. I found peace at this support group because we were no longer talking in hushed tones about HIV/AIDS.

"While in this support group I heard about the Murambinda Peer Educators Dance Group and I decided to join them. I wanted to let others know about this disease before it was too late.

"The children I was worried about years ago are all grown up now. The four girls are married and have children of their own. They all completed their education and they have good jobs.

"I didn't think I would live to see my children grow up, or to see my 14 grandchildren. My fifth child - my only son - is still at home with me, doing his studies.

"Many people died of stress in the 1990s because there was not much information about HIV/AIDS ... this is why I am part of Murambinda Dance Group, as old as I am.

"When I tell people I am a grandmother, they do not believe me because when I dance I have so much energy - there is no old and young when we are fighting HIV!"

st/kn/he http://www.irinnews.org/report.aspx?ReportId=86834ADDIS ABABA Monday, November 02, 2009 (IRIN) - Being a university freshman is an exciting time for any young person, but many students get carried away, partying too hard and taking sexual risks.ADDIS ABABA Monday, November 02, 2009 (IRIN) - Being a university freshman is an exciting time for any young person, but many students get carried away, partying too hard and taking sexual risks.

"It's a chance to experience life; there is no family, there are no restraints," said Biniam Mohammed, project coordinator of the Modelling and Reinforcement to Combat HIV/AIDS (MARCH) [http://www.aau.edu.et/march] project in the Siddist Kilo Campus of Addis Ababa University (AAU). "Some use it in a good way but some do risky things, such as chewing khat [a mild stimulant] … having [unprotected sex] and using commercial sex workers.

"Some of these students will have limited awareness of the risks of HIV/AIDS, and then there is peer pressure as well," he added.

Ethiopia's overall HIV prevalence is a relatively low 2 percent, but prevalence in the capital, Addis Ababa, is 7.5 percent. According to the Federal HIV/AIDS Prevention and Control Office (FHAPCO), anecdotal evidence of widespread unsafe sexual practices suggests students may be among the more high-risk groups in terms of HIV vulnerability.

MARCH statistics show that 50 percent of AAU students are sexually active, but only half of them use condoms, said Biniam.

High-risk behaviour

"Often they do not use condoms… they are doing it emotionally, without any thought," said Selam, a 19-year-old AAU student.

Selam added that students coming to the city from the countryside usually had less information about HIV and were not as street-smart as Addis youth, leaving them unprepared to resist unwanted sexual advances or insist on protected sex.

Former student Girma Tesfaye, now Addis Ababa project coordinator for HIV-focused NGO Mekdim, says female students often fall prey to “sugar daddies”.

"There are lots of beautiful girls at university and older people with beautiful automobiles stop around the university and look for them," he said. "It is common to take students this way. They have lots of money; they will provide the girls with money and different [presents].

"The older 'daddy' may have three or four partners in such a way, which facilitates the spread of HIV," he added.

Selam agrees that this is a significant problem, noting that in the early evening, heavily made-up and scantily clad female students make their way to the area outside the main gates known as the Debab to try to find a rich boyfriend, usually one who already has a wife, and quite possibly a string of other girlfriends.

"If you have sex because of a threat, or you have a 'sugar daddy', it is one-sided and that makes them more at risk," said MARCH's Biniam. "Influenced or coerced sex is high risk."

Evidence also suggests that male students use local sex workers; a survey [http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/EthiopiaSynthesisFinal.pdf] of Addis-based sex workers found that 5.8 percent of their clients were students. Sex workers in the nearby Arat Kilo area confirmed that many of their clients were AAU students.

MARCH, with funding from the US President's Emergency Plan for AIDS Relief, produces Life 101, a quarterly photo graphic novel that follows the story of three students and one couple at AAU as they experience daily university and city life and deal with issues such as transactional sex, condom use, relationships, testing for HIV, and gender equity. MARCH also facilitates student-led entertainment events to stimulate discussion of the issues.

Recently, more than 20 Ethiopian university presidents initiated a request [http://hapco.gov.et/index.php?option=com_content&task=view&id=103&Itemid=2] to the Ministry of Education and FHAPCO for more HIV activities, including a national HIV/AIDS policy and strategy for universities, an HIV/AIDS research and information centre, gender and HIV/AIDS advocacy efforts and sustainable training and discussion forums.

wd/kr/mw

http://www.irinnews.org/report.aspx?ReportId=86837NAIROBI Monday, November 02, 2009 (IRIN) - A 22-year-old ban on people infected with HIV entering the US was officially lifted on 2 November, with the new rules taking effect in 60 days. AIDS activists have hailed the move as a major coup in the fight against stigma.NAIROBI Monday, November 02, 2009 (IRIN) - A 22-year-old ban on people infected with HIV entering the US was officially lifted on 2 November, with the new rules taking effect in 60 days. AIDS activists have hailed the move as a major coup in the fight against stigma.

"This comes as very good news for us," Michael Angaga, regional coordinator for the Network of African People Living with HIV/AIDS (NAP+), told IRIN/PlusNews.

"For so long HIV-positive people have felt isolated by one of the greatest nations in the world, which should be spearheading human rights." Angaga said he looked forward to seeing the new rules rapidly implemented in US embassies around the world.

In 1987 HIV was added to the list of communicable diseases that could prevent infected immigrants, students and tourists from obtaining visas to enter the US without special permission. President Barack Obama's announcement on 30 October marked the end of a process started in 2008 by then US President George W. Bush, who signed a law repealing these restrictions.

"We lead the world when it comes to helping stem the AIDS pandemic, yet we are one of only a dozen countries that still bar people from HIV from entering our own country. If we want to be the global leader in combating HIV/AIDS, we need to act like it," Obama was reported as saying.

Samuel Kibanga, national coordinator of the National Forum of People living with HIV/AIDS Networks in Uganda, commented: "This shows that America can now see the reality that people living with HIV are just like any other people, deserving of the right to free movement - the travel ban was discrimination of the highest calibre."

The UNAIDS International Guidelines on HIV/AIDS and Human Rights state that any restriction on liberty of movement or choice of residence based on suspected or real HIV status alone, including HIV screening of international travellers, is discriminatory.

Governments usually give two main reasons for imposing travel restrictions on HIV-positive people: to help control the spread of HIV, and save host countries the cost of HIV-related treatment, but Kibanga said these regulations merely drove the problem of HIV underground.

"People fear to reveal their status when travelling. It is better to be with someone who feels free to be open about their status than one who is hiding it," he said. "That way we can all fight AIDS as partners."

A June 2009 report [http://www.hrw.org/en/reports/2009/06/18/discrimination-denial-and-deportation-0] by watchdog organization Human Rights Watch, found that immigration laws and stringent requirements for accessing free health care often created insurmountable barriers to treatment and care for migrants living with HIV.

Kibanga said he hoped the US's move would serve as an example to other nations. According to UNAIDS, 59 countries impose some form of travel restrictions on people living with HIV.

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http://www.irinnews.org/report.aspx?ReportId=86840MASERU Monday, November 02, 2009 (IRIN) - Having more than one sexual relationship at the same time is driving the spread of HIV in small landlocked Lesotho. The health sector has long suspected this, but a new report by the National AIDS Commission (NAC), in partnership with UNAIDS and the Ministry of Health and Social Welfare, has confirmed it.MASERU Monday, November 02, 2009 (IRIN) - Having more than one sexual relationship at the same time is driving the spread of HIV in small landlocked Lesotho. The health sector has long suspected this, but a new report by the National AIDS Commission (NAC), in partnership with UNAIDS and the Ministry of Health and Social Welfare, has confirmed it.

The report, Gender and Multiple and Concurrent Sexual Partnerships in Lesotho, found that 76 percent of men and 82 percent of women knew that having only one partner reduced HIV risk, but they were reluctant to limit themselves.

Now a new awareness campaign aims to get people talking about the taboo subject of HIV and how to prevent it. "Changing behaviour begins with communication," said Ma-'Neheng Ninie Mopeli, the NAC's Director of Services.

"People know about HIV prevention but they are afraid to talk about it, so mothers do not discuss the practical application of their knowledge with their daughters, or husbands with wives."

Open and frank discussion cannot start soon enough; 23 percent of Lesotho's adult population are infected with HIV, the third highest prevalence in the world.

The study on multiple concurrent partners (MCPs), conducted in focus group discussions and interviews with participants of various ages and socioeconomic backgrounds at five sites in Lesotho, found that poverty was among the factors driving the practice. Young girls often engaged in sex with older men for financial reasons, providing HIV with a major entry point into the younger generation.

"Financial neglect, along with domestic discord, physical and emotional abuse, were mentioned as some of the reasons for seeking other partners," the report said. Marriage offered no protection from HIV infection; in fact, it was a major source of risk for women married to unfaithful husbands.

Cultural factors also played a role; men were considered the dominant partners in marriage by virtue of the dowry they traditionally paid to brides' families.

Unwillingness to use condoms stemmed from a perception that they implied a lack of trust. "It is critical to help people understand that condoms are used even in trusting relationships." The study also recommended "more focus on fidelity among married partners" if anti-AIDS efforts were to succeed.

Getting the word out

"Having the data is the starting point. We suspected that MCP is a major driver, and now we know; now we have the process of getting the word out," said the NAC's Mopeli.

Media organizations, sports organizations, faith-based groups, and youth groups will all be briefed on how to disseminate the study's findings. "Men need to talk to men, telling each other not to be ashamed to carry a condom, and women should talk to women about such things as being frank about sexual matters with their sisters, daughters and neighbours. Then we will bring those groups together," said Mopeli.

Health motivators often ran into obstacles, such as needing permission from parents to speak to children about sexual matters, but encouraging people to talk about HIV among themselves would help overcome these.

"Having different group discussions is also important for cultural reasons," Mopeli said. "It is inappropriate to discuss condom use and such matters with the elderly, but there are things they too must know."

Mohau Mokoatsi, a UNAIDS programme officer in Lesotho, said respect for cultural traditions would be vital to successfully getting the message out. "We have revised our national strategy to incorporate chiefs and traditional leaders; it is these authority figures who will take the message to their subjects," he told IRIN/PlusNews.

Lacking large numbers of facilitators, the government is relying on existing programmes to spark a nationwide debate about MCPs. "When the agriculture ministry agents go out to talk with the farmers about fertilizer and irrigation, then they can also talk about AIDS. We will train them to spread the message," Mopeli said.

The next step will be to ensure that people know where to find condoms and counselling services so they can apply what they have learned.

jh/ks/he http://www.irinnews.org/report.aspx?ReportId=86842WINDHOEK Friday, October 30, 2009 (IRIN) - In Onamutenya village, northern Namibia, the Shigwedha household leaves their homestead at the crack of dawn to make the monthly four-hour walk to fetch antiretroviral (ARV) medication from the local clinic.WINDHOEK Friday, October 30, 2009 (IRIN) - In Onamutenya village, northern Namibia, the Shigwedha household leaves their homestead at the crack of dawn to make the monthly four-hour walk to fetch antiretroviral (ARV) medication from the local clinic.

Wilbard Shigwedha, 9, who is HIV-positive and an old hand at this early-morning routine, willingly gets up at 4 a.m. to make it in time to the clinic. By the time he and his mother Krestina, 35, who is also living with the virus, get to the packed health facility in Onayena after walking 20km, his brown pin-striped three-piece suit is coated in dust.

A return trip by minibus-taxi would have cost them 40 Namibian dollars (US$5) - too expensive for an employed widow and mother of four, two of whom are HIV-positive - and the sandy roads are tricky to negotiate by car, so taxis are also infrequent.

Distance and transportation are among the major challenges in rolling out HIV treatment in Namibia, a vast country, with wide open spaces and a population density of less than 2 people per square kilometre.

About 15 percent of the 2.1 million people in the country are estimated to be living with the HI virus.

The long distances compelled the team of healthcare workers running the Shanamutango HIV clinic at the Onanjokwe Lutheran Mission hospital, in the Oshikoto region, to launch their outreach project to bring HIV services to remote clinics like the one in Onayena.

Northern Namibia is one of the poorest and most isolated parts of the country, where social services, employment opportunities and infrastructure are thin on the ground.

"Our patients travel as far as 100km. We don't provide transport ... a trip to come here can cost them 30 to 50 Namibian dollars one way, so our outreach programme is bringing the service closer to them," said Tutaleni Shilyomunhu, acting nursing manager at Shanamutango.

The Shanamutango HIV Clinic - funded by the US President Emergency Plan for AIDS Relief (PEPFAR) - is one of the largest treatment sites in the country, providing ARVs to 8,000 of its 12,500 HIV-positive patients.

"[The country] is doing pretty well. The government has managed to roll out ARVs in a relatively short period of time ... it's a major achievement," Dr Robert Bennoun, the UNAIDS country coordinator, told IRIN/PlusNews.

The government set out to treat 70 percent of all HIV-positive adults in need of ARVs as part of its goals to provide universal access to care, treatment and prevention; over 55,000 Namibians - more than 80 percent of those in need - are now receiving the life-prolonging medication.

Food, floods and alcohol

The programme still has many obstacles, with lack of food security and transport among the biggest. At the Onanjokwe Lutheran mission hospital, principal medical officer Dr Sithembile Chinyoka commented: "We see it on a daily basis; the great distances our patients travel ... most of the children we admit are chronically malnourished."

Things are not much better in the rest of the country. "Everywhere we go the HIV-positive people we meet are crying of one thing - hunger," said Bernard Kamototo, who works for Lironga Eparu, the national network of people living with HIV/AIDS.

Most Namibians live on less than US$2 a day; having enough to eat is a constant burden, while water scarcity, erratic rainfall and poor soils have made subsistence agriculture even harder in recent years.

Chronic malnutrition is rising: figures from a recent demographic health survey indicate that 30 percent of Namibian children under five are so malnourished that their growth is stunted - in 2000 the stunting rate was 24 percent.

Dr Agostino Munyiri, chief of health and nutrition at the UN Children's Fund (UNICEF), noted that "nutrition is an area we are all grappling with ... the health system doesn't know how to approach this subject."

The worst floods to hit Namibia in four decades have also hampered crop production, affecting more than 350,000 people in six regions with some of the highest HIV-prevalence rates in the country.

Bennoun told IRIN/PlusNews that the treatment of HIV-positive people in the flood-affected regions had been interrupted because they were cut off from health facilities and had no money to travel.

In the Caprivi Strip, a finger of territory bordered by Zambia in the north and Botswana in the south, widespread flooding when the Zambezi River burst its banks meant the only option was to go through Zambia to access ARVs, but most people had no travel documents or cash, he said.

Floods and lack of food were not the only reasons people defaulted on their therapy: colourfully-painted shebeens (unlicensed bars) are a common sight in Namibia's towns and townships, where they sell cheap local brews that have led to high levels of alcohol abuse.

"Too many people are unemployed and struggling, and the only thing they can do to make themselves feel better is to drink ... but that is when the problems start," said Kamototo, who visits shebeens to raise awareness about how to prevent HIV and treatment adherence.

Prevention: the weakest link

The country's treatment success story has been largely due to external funding. Two-thirds of the treatment programme is financed by key donors such as PEPFAR and the Global Fund to fight AIDS, Tuberculosis and Malaria, while the rest of the bill is picked up by the ministry of health. "[The government] is moving towards sustainability, but they're not picking up as much as they can," Bennoun acknowledged.

Namibia is classified as lower-middle-income country, causing it to lose out on some much-needed donor funds; in the current global economic crisis, the country's health budget was going to be placed under even more pressure, he warned.

With the number of new infections still stubbornly high, the treatment programme might not be successful for very much longer. "This is one of the many reasons for the urgency of doing a hell of a lot better on prevention," Bennoun pointed out.

Implementing a treatment programme was always going to be easier than dealing with more complex human behaviour. For instance, the numbers of people being tested for the HI virus are still well below the universal access targets, and there has been no significant decline in HIV prevalence.

There is hope that the new national strategic plan covering 2010 to 2015, which is "very much evidence-based and results focused", will address inadequate prevention efforts.

"[The treatment programme] is a major achievement; the ministry of health is extremely active, vocal and visible," Bennoun told IRIN/PlusNews. "They haven't done well on prevention, but recognise that and are taking steps to lift their game."

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http://www.irinnews.org/report.aspx?ReportId=86812NAIROBI Friday, October 30, 2009 (IRIN) - The use of mid-level health workers rather than doctors to prescribe antiretroviral treatment (ART), a strategy called task-shifting, has enabled Mozambique to triple the number of facilities providing medication within six months, according to a new study.NAIROBI Friday, October 30, 2009 (IRIN) - The use of mid-level health workers rather than doctors to prescribe antiretroviral treatment (ART), a strategy called task-shifting, has enabled Mozambique to triple the number of facilities providing medication within six months, according to a new study.

The report, published in the in the latest edition of the Journal of Acquired Immune Deficiency Syndromes, by Kenneth Sherr from the University of Washington and officials in Mozambique's Health Ministry, found that patients from rural and disadvantaged areas could also access quality ART services as a result of the task-shifting.

Shortly after independence in 1974, the majority of physicians - mostly Portuguese nationals - departed from Mozambique, leaving fewer than 80 physicians to care for a population of 10.6 million.

Since then the country has largely relied on 'técnicos de medicina' - non-physician clinicians who undergo training for 30 months - to provide the clinical and managerial tasks ordinarily carried out by doctors.

Political instability and economic structural adjustment programmes in the 1980s hit Mozambique's health system hard, forcing the closure of up to 50 percent of public health centres. HIV prevalence reached 15 percent in 2003, yet only one percent of people had access to treatment; the government again looked to técnicos to fill the gap.

Rapid expansion

"Because the numbers of existing physicians were inadequate to cover the large number of facilities in the rapid scale-up, the national plan included a renewed effort to train new técnicos as an essential element of workforce expansion for HIV care," the report noted.

By mid-2006, the first wave of newly graduated técnicos had been deployed at health facilities; about a year later 167 health centres covering 147 Mozambican districts and municipalities were providing treatment.

The scale-up also integrated ART into public healthcare, so physicians and técnicos would attend to all patients, not only those infected with HIV.

"Deployment of newly trained técnicos provides opportunities to staff rural and smaller urban clinics with clinical cadres that are more likely to continue to work in public healthcare. Furthermore, training, salaries, and benefits cost less for técnicos than for physicians," the authors said.

"Supported by the integrated care approach, the number of facilities with ART tripled over a six-month period, including predominately small, rural, and peri-urban health centres, 45 percent of which were managed by a técnico de medicina."

A continuing effort

Mozambique is also increasing its number of trained physicians; student intake at the country's main medical school has doubled, and two new medical schools have been opened. According to the study, the quality of care provided by técnicos is equivalent to or better than that provided by medical doctors.

However, an evaluation of the técnicos' training found that they were not sufficiently prepared for actual clinical responsibilities, especially where health system resources were inadequate, and the health workforce would have to be multiplied several-fold to achieve the United Nations Millennium Development Goals.

Nevertheless, the report concluded that "Using a mix of physicians and responsible task-shifting to non-physician providers, the Mozambique health system can maintain its momentum in ART scale-up while strengthening the wider public healthcare system."

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http://www.irinnews.org/report.aspx?ReportId=86813NAIROBI Thursday, October 29, 2009 (IRIN) - Malawi's successful use of a well-known tuberculosis (TB) treatment system to scale up antiretroviral treatment (ART) for HIV could improve chronic disease management in other African nations, experts say.NAIROBI Thursday, October 29, 2009 (IRIN) - Malawi's successful use of a well-known tuberculosis (TB) treatment system to scale up antiretroviral treatment (ART) for HIV could improve chronic disease management in other African nations, experts say.

Directly observed treatment short course (DOTS), has been used to successfully deliver tuberculosis treatment in some of the world's poorest countries.

The main elements of DOTS include political commitment, case detection, standardized treatment with supervision and patient support, an effective drug supply and management system, and a monitoring and evaluation system.

"The key to rapid and massive scale-up [in Malawi] was to keep the principles and practices of ART delivery as simple as possible," said the authors of an article on scaling up antiretroviral therapy, in the latest edition of the Journal of Acquired Immune Deficiency Syndromes.

Solid systems

"A standardized system was put in place so that the same system of assessing patients for ART eligibility, initiating treatment, and registering and reporting cases and outcomes was followed wherever ART was being delivered - from central hospital to health centre, and from public health facility to private clinic," the authors said.

Malawi began its national ART rollout in 2004 with just nine health facilities providing the medication to about 3,000 people. Using the DOTS framework, by the end of 2008, 170 health facilities in the public health sector had registered 215,449 patients.

A study published in 2008 in the British medical journal, The Lancet, found that rapid scale-up of free ART in rural Malawi had led to a decline in adult mortality that was detectable at the population level.

The article's authors attribute the success of Malawi's ART scale-up to government commitment and leadership; clear national ART guidelines, with emphasis on the system of registration, monitoring and recording of results; intensive training of clinical officers and nurses in ART guidelines, with practical experience at ART sites; an efficient drug-supply chain to prevent stock-outs.

Taking DOTS further

They note that with the rise in prevalence - even in resource-poor sub-Saharan Africa - of non-communicable diseases such as heart attacks, strokes, cancers, diabetes and respiratory diseases, there is a need to put in place simple yet effective systems to give people access to treatment.

The World Health Organization (WHO) forecasts that deaths from non-communicable diseases are likely to increase by 17 percent globally over the next 10 years, with the greatest increase projected in Africa.

"Although patients with these non-communicable diseases usually need chronic care and treatment over their lifetimes, it is simply not provided in most resource-poor countries, outside a few centres of excellence, and there are no systems to monitor patient access or outcomes," they stated.

"The system put in place in Malawi to facilitate the management and monitoring of lifelong ART can also be used for patients with non-communicable diseases."

If handled properly, HIV and chronic disease management systems could be used to strengthen health systems in resource-poor nations, particularly by improving laboratory infrastructure and service delivery, monitoring, supervision, quality assurance, and rational drug forecasting and procurement.

"Any attempt to better the management and monitoring of special diseases must include a vision of how the work will improve the health sector and health care delivery as a whole," they said.

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http://www.irinnews.org/report.aspx?ReportId=86792DAR ES SALAAM Tuesday, October 27, 2009 (IRIN) - HIV-positive Tanzanians are not taking advantage of the availability of life-prolonging anti-retroviral medication in hospitals around the country, says a senior government official.DAR ES SALAAM Tuesday, October 27, 2009 (IRIN) - HIV-positive Tanzanians are not taking advantage of the availability of life-prolonging anti-retroviral medication in hospitals around the country, says a senior government official.

"We have an adequate supply of ARVs in our hospitals and other outlets, but there are few people who are turning out for this important service," David Mwakyusa, Health and Social Welfare Minister, told IRIN/PlusNews.

An estimated 250,000 people are taking ARVs, while another 190,000 who need them are not accessing them. In 2008, the government re-affirmed its commitment to achieving universal access to ARVs by 2010.

"We are working hard to encourage people to check their HIV status and those infected to go for further medical attention and when necessary start taking ARVs, which are in good supply," the minister said.

Mwakyusa also bemoaned the fact that few pregnant women made use of prevention of mother-to-child transmission (PMTCT) services available at antenatal clinics; just 33 percent of pregnant women who require PMTCT services access them, according to UNAIDS.

Research [http://www.ncbi.nlm.nih.gov/pubmed/16987051] has found that although HIV-positive Tanzanians welcome anti-retroviral therapy, they fear that transportation and supplementary food costs, ill-treatment at hospitals and difficulties in sustaining long-term treatment all act as barriers to accessing treatment. Fear of stigma as well as HIV denial, which often led patients to seek treatment from alternative healers, and inadequate numbers of trained medical personnel, also prevented patients from accessing healthcare.

"Multi-faceted interventions are required to promote regular HIV clinic attendance, including ongoing education, counselling and support in both clinic and community settings," authors of a recent study [http://www.ncbi.nlm.nih.gov/pubmed/19444672?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed] by the Centre for Population Studies and the London School of Hygiene and Tropical Medicine recommended.

Mwakyusa noted that Tanzania was planning to cut the cost of ARVs by producing them locally. He said it was important for the country to become more self-sufficient, especially in the face of the global economic downturn.

"We are praying that despite the global financial crisis, donors will continue supporting our efforts," he said. "The financial crisis is clearly affecting the capacity of donors to fund international programmes on AIDS."

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http://www.irinnews.org/report.aspx?ReportId=86756MBABANE Tuesday, October 27, 2009 (IRIN) - Thandi Xaba, 23, an aspiring actress living with HIV, belongs to an itinerant theatrical group in Swaziland who perform plays dealing with HIV/AIDS, often spiced with humour to engage the rural audience who sit beneath trees to watch the shows. MBABANE Tuesday, October 27, 2009 (IRIN) - Thandi Xaba, 23, an aspiring actress living with HIV, belongs to an itinerant theatrical group in Swaziland who perform plays dealing with HIV/AIDS, often spiced with humour to engage the rural audience who sit beneath trees to watch the shows.

"In our story [the play] a family farm is on the border [between South Africa and Swaziland], and when they put up a border fence the family is cut in two; the whole community is split this way.

"It gets serious when some community members get HIV and there is a shortage of ARVs [antiretrovirals] on the Swazi side, so they try to go to their neighbours on the South African side.

"Then the flow of people is reversed when there are food packages delivered on the Swazi side that are needed by people who are taking ARVs, because you have to be well-nourished for the drugs to work.

"I know this because I am HIV-positive, so I identify with the people in the story. When I am acting and showing the emotions of fright or anxiety I am just replaying what I experienced myself when I learned from the test that I was HIV, and worried how people would react.

"But I am more fortunate than most. I am educated and I know how to read instructions and understand the literature - I can explain things to others.

"What is really giving me a positive spirit is that I am doing what I want to do. If you feel good about life and you are optimistic, this helps you stay healthy.

"I really like acting - I don't get paid, we have to provide our own costumes - but it is a way for me to perform in front of people. I am learning, and one day I will go to Jo'burg and audition for real theatrical productions, where they have stage lights and make-up. Now our stage lights are the car and truck headlamps, or candles if the wind isn't blowing.

"People understand about AIDS from our shows. They see stories about real people and they relate; they laugh and applaud, and that is rewarding."

jh/kn/he http://www.irinnews.org/report.aspx?ReportId=86767NAIROBI Tuesday, October 27, 2009 (IRIN) - Replacing manual data with electronic health records would significantly improve the quality of care and enable African HIV treatment programmes to be scaled up more efficiently, say the authors of a new article on the subject. NAIROBI Tuesday, October 27, 2009 (IRIN) - Replacing manual data with electronic health records would significantly improve the quality of care and enable African HIV treatment programmes to be scaled up more efficiently, say the authors of a new article on the subject.

"Talkin' About a Revolution", published in the latest edition of the Journal of Acquired Immune Deficiency Syndromes, looked at the Academic Model for Providing Access to Healthcare (AMPATH), a programme that uses electronic health records in care and treatment services for around 100,000 HIV-positive patients at sites across western Kenya.

"Scaling up treatment programmes requires timely data on the type, quantity and quality of care being provided," the authors said. "Health care is an information business; managing patient care requires managing patients' data at many levels ... health care systems the size of AMPATH (or larger) cannot effectively be managed without ... [electronic] data."

More efficient care

The health data system can help programme managers avoid medical errors and stock-outs of key medicines, while enabling clinicians to monitor and care for their patients more effectively.

"Electronic records help us store data efficiently, retrieve it when we need it, and monitor and evaluate the progress of our programmes much more easily than if we were using manual systems," said Erica Kigothe, AMPATH's programme manager in charge of data management.

"When a patient comes to a clinic for a visit, instead of poring over large files, the clinician has one summary sheet that contains all the vital patient information and should he or she need more information, they can always go back to the patient's computerized file," she told IRIN/PlusNews.

A previous study comparing an AMPATH clinic before and after the adoption of electronic health records found that patient visits were 22 percent shorter, provider time per patient was reduced by 58 percent, and patients spent 38 percent less time waiting.

Kigothe noted that assessing disease trends was also easier with electronic records, as was collating data for the purposes of research and new directions in programme development.

Electronic health systems have been successfully used in the care and treatment of HIV in Lesotho, Malawi, Rwanda, South Africa and Uganda, but few African countries have adopted the systems on a large scale.

"Programme implementers in low-income countries sometimes see clinicians' recording of patient data and the management of those data as secondary to providing good care, or even a distraction," the article's authors commented.

Not all smooth sailing

The programme has not been without its difficulties. "In one of our sites in Busia [town on the Kenya-Uganda border] they have very frequent power outages, so they have had to find ways to work around it, inputting data when power is on, even if that is at night," Kigothe said.

Finding people with computer skills is not always easy in the developing world, particularly in rural areas, and "like any equipment, computers break down from time to time and require repair or replacement, which can cause some problems" and incur additional expenses, she said. "In addition, the data collectors are human, and therefore prone to the occasional error."

Electronic systems are not cheap; they require considerable investment in computers, training data collectors and hiring information technology experts. However, according to the study, AMPATH's total cost of care is under US$100 per patient per year, making the system financially feasible even in resource-poor settings.

"You're going to have to spend quite a lot of money to set up the system," Kigothe said. "But looking at the big picture, it saves so much in the long run - for example, each of our data collectors manages 2,000 patients' information, something that would be impossible using manual data collection."

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http://www.irinnews.org/report.aspx?ReportId=86768JOHANNESBURG Monday, October 26, 2009 (IRIN) - The billions of donor dollars spent on combating HIV/AIDS in the last decade, often at the expense of other fatal diseases, have done little to strengthen weak national health systems, some global health experts argue.JOHANNESBURG Monday, October 26, 2009 (IRIN) - The billions of donor dollars spent on combating HIV/AIDS in the last decade, often at the expense of other fatal diseases, have done little to strengthen weak national health systems, some global health experts argue.

On the contrary, say others, the HIV/AIDS epidemic has sparked massive increases in international aid for health that have benefited a range of health issues and systems. The debate over prioritizing HIV/AIDS in global health spending received fresh impetus after recent data from the World Health Organization (WHO) and the UN Children's Fund (UNICEF) highlighted the millions of children's lives lost to easy-to-treat diseases like diarrhoea.

Worldwide, diarrhoea kills an estimated 1.5 million children under the age of five every year, but receives less than 5 percent of all funding available for disease research and treatment. A WHO diarrhoea specialist noted that huge progress made in the 1980s had stagnated as attention was diverted to AIDS, tuberculosis and malaria.

Meanwhile, funding for HIV/AIDS rose from 5.5 percent of health aid in 1998 to nearly half of it in 2007, according to an analysis published in a special supplement of the journal, AIDS, focusing on the impact of the HIV scale-up on health systems in developing countries. Total funding for health nearly tripled between 1998 and 2007.

An article by Jeremy Shiffman and others at Syracuse University in New York challenges the argument that the focus on HIV/AIDS has generated greater attention and resources for all health issues.

A comparison of donor funding for four major public health issues - HIV/AIDS, health systems strengthening, population and reproductive health, and infectious disease control - found that the amount spent on HIV/AIDS and, to a lesser extent, infectious disease control, grew rapidly from 1998 to 2007, while funding for strengthening health systems, and population and reproductive health, declined steeply.

In another article, Samuel Lieberman and others from the World Bank's Global HIV/AIDS Programme take the view that the "unprecedented challenge of AIDS" helped generate the overall increase in health funding and mobilized an international push for more equitable health care access.

Martha Embrey and others from Columbia University maintain that global AIDS initiatives have significantly improved the procurement and distribution of drugs, not only for AIDS but for many other diseases.

Organizations like the Clinton HIV/AIDS Initiative and UNITAID have secured substantial price reductions for drugs, while other donor initiatives have helped countries improve their systems for drug procurement and supply chain management, they point out.

HIV-support programmes have contributed to building the skills of pharmacists to provide adherence counselling while pharmacy assistants and nurses in primary health care clinics have been trained to dispense antiretrovirals and drugs for other chronic diseases.

Ruth Levine and Nandini Oomman, of the Centre for Global Development in Washington, in the US, focus not on whether HIV/AIDS has received a disproportionate share of donor funding but on how best that money can be spent both to improve access to HIV treatment, prevention and care and to strengthen health systems.

Several AIDS donor organizations have begun shifting their efforts to strengthening health systems, based on the realization that weak health systems are frustrating their AIDS-related goals. President Barack Obama's administration has announced that the US President's Emergency Plan for AIDS Relief (PEPFAR) intends to widen its focus to include maternal and child health and tropical diseases.

The authors suggest that donors will need to "align their actions with the priorities and approaches of partner governments and other national stakeholders" to achieve a broader focus on health-related issues.

In an introduction to the supplement, Wafaa El-Sadr, of Columbia University, and Kevin De Cock, director of HIV/AIDS at WHO, caution against encouraging competition between health issues.

"There is strength in diversity and debate, yet there is also danger of fragmentation," they note. "Global health needs global financing, and there is enough money in the world to assure it."

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http://www.irinnews.org/report.aspx?ReportId=86754ADDIS ABABA Friday, October 23, 2009 (IRIN) - With non-skilled jobs in the Ethiopian capital, Addis Ababa, paying as little as US$16 per month, the financial incentives to engage in commercial sex work are overwhelming - earning 30 times a domestic worker’s salary.ADDIS ABABA Friday, October 23, 2009 (IRIN) - With non-skilled jobs in the Ethiopian capital, Addis Ababa, paying as little as US$16 per month, the financial incentives to engage in commercial sex work are overwhelming - earning 30 times a domestic worker’s salary.

Many of the women entering into sex work in Addis are rural migrants who have failed to secure formal employment, or are escaping poor-paying jobs in the city or unwanted marriages in the country, according to a 2008 article [http://download.interscience.wiley.com/cgi-bin/fulltext?ID=119387830&PLACEBO=IE.pdf&mode=pdf] published by the UK's Royal Geographical Society.

Teguest, a 16-year-old girl from Gonder, a town 700km northwest of Addis Ababa, fled to the capital four months ago after the death of her parents and a dispute with her brothers.

The relative she contacted in the capital was already engaged in sex work, so the decision to enter the trade was an easy one. Teguest charges 10 Ethiopian Birr or $0.80 per client and has sex with as many as 20 men a day in her tiny room; she is adamant that under no circumstances would she have unprotected sex.

"No, I would not do that for any money. I need my life," she said. "They sometimes offer 200 Birr [$16] and beg me, but life is more important than money."

Teguest says in the past four months, at least 10 men have asked her for unprotected sex at a higher fee.

The good news, according to research by Wise-UP - a condom-promotion project implemented by local NGO Timret Le Hiwot [http://timretlehiwotet.org] and funded by social marketers DKT-Ethiopia [http://www.dktethiopia.org] - is that 99 percent of sex workers in 42 Ethiopian cities said they used a condom with their last paying partner, compared with 91 percent in 2002.

Shame factor

But according to health workers, not all sex workers are as fastidious about condom use as they claim. When Abeje Israel, monitoring and evaluation officer at Wise-Up, posed as a paying customer for random surveys, some women did agree to have sex without a condom for a higher fee.

A 2006 study [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576726] published in the British Medical Journal found that results of sex worker studies obtained using surveys and questionnaires may be biased as they will not always reveal the truth because of "pride, fear, or shame".

"They may say that they do not have sex without a condom, but the reality may be different; they may pretend and not show the real circumstances," Abeje said.

"All these [sex] workers are very vulnerable," he added. "They are not very powerful and they receive a very small sum of money; if you offer them more money, they may be willing to have sex without a condom."

Education vital

Further investigation makes it clear that the city's sex workers still need education on protecting themselves from sexually transmitted infections.

Meron, 25, also says she would never have sex without a condom, but added that she took the “precaution” of insisting her clients used two condoms - a practice roundly advised against as it increases the chances of a condom tearing.

Low levels of education and alcohol use also affect the likelihood of female sex workers using condoms, according to a study [http://ejhd.uib.no/ejhd-v20-n2/93_98_EJHD_20%20no%202%20final.pdf] by Addis Ababa University.

Wise-UP aims to achieve 100 percent condom use among sex workers in the capital, which has an HIV prevalence rate of 7.5 percent, almost four times the national average of 2.1 percent.

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http://www.irinnews.org/report.aspx?ReportId=86718JOHANNESBURG Thursday, October 22, 2009 (IRIN) - The recent news that for the first time an HIV vaccine had shown some protective effect generated widespread excitement, until it emerged that the results were based on the most promising of three different analyses of the trial findings.JOHANNESBURG Thursday, October 22, 2009 (IRIN) - The recent news that for the first time an HIV vaccine had shown some protective effect generated widespread excitement, until it emerged that the results were based on the most promising of three different analyses of the trial findings.

The trial team in Bangkok, Thailand's capital, announced on 24 September that a combination of two vaccines had reduced the rate of HIV infection by 31 percent in about 8,200 volunteers, compared to around the same number who were given a placebo.

A few weeks later, researchers who had seen full data from the trial told Science magazine that an analysis based only on participants who had received all six doses of the vaccine at the right times did not show a statistically significant protective effect.

It was hoped that the release of more details from the trial to coincide with the AIDS Vaccine 2009 conference taking place in Paris this week would settle the question of whether the vaccine results were really as significant as the initial announcement had suggested or a mere fluke. Instead, full results of the study, published online yesterday in the New England Journal of Medicine (NEJM) raised more questions than they answered.

The 31 percent efficacy in the initial announcement was based on a "modified intention-to-treat" analysis that included all the 16,402 trial participants, except for seven who were found to have contracted HIV before receiving any vaccinations.

A second analysis included those seven, while a third "per-protocol" analysis involving 12,452 participants - the one cited in Science magazine - found that the vaccine was only 26 percent effective. This was not enough to be statistically significant, meaning that the difference between the vaccine and the placebo arms of the trial was so small that it could have been a coincidence.

Different interpretations

Dr Jerome Kim of the US Military HIV Research Programme, who helped lead the trial, yesterday told reporters at the vaccine conference in Paris that the modified intention-to-treat analysis was the most accurate, but others disagreed.

A statistician quoted in a New York Times report placed more emphasis on the analysis that included the seven HIV-positive participants, while another did not believe that any of the analyses provided sufficient evidence the vaccine worked.

In an editorial accompanying the article, NEJM editor Raphael Dolin said that "although the merits of each type of analysis can be debated, all three yielded a possible, albeit modest, effect of the vaccine in preventing HIV infection."

The study authors also argued that, taken together, the three different analyses of the results were "consistent with a modest protective effect of vaccine", but could not explain why other findings from the trial indicated that the vaccine's efficacy appeared to decrease over time, or why it was less effective among participants at high risk of infection.

They were also unsure whether it was one of the two vaccines that produced a potentially protective effect, or the combination of the two. Dolin noted that the findings raised "a number of questions that have important implications for future directions in vaccine research", and recommended that the duration of the vaccine's effect be addressed by following up the trial participants, as well as by future trials.

According to a report by a South African news service, Health-e, Colonel Nelson Michael of the US Military HIV Research Programme, another lead investigator of the Thai trial, told a press conference in Paris that a further study of the vaccine may be conducted in South Africa, which has a much higher HIV prevalence than Thailand. The vaccine would have to be modified to contain the strain of HIV most common in sub-Saharan Africa.

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See also: GLOBAL: First positive results from an HIV vaccine

http://www.irinnews.org/report.aspx?ReportId=86685JOHANNESBURG Thursday, October 22, 2009 (IRIN) - The availability of antiretroviral (ARV) treatment and legislation prohibiting discrimination have helped turn HIV/AIDS into just another chronic disease, but an HIV-positive status can still be an obstacle to getting a loan or buying insurance.JOHANNESBURG Thursday, October 22, 2009 (IRIN) - The availability of antiretroviral (ARV) treatment and legislation prohibiting discrimination have helped turn HIV/AIDS into just another chronic disease, but an HIV-positive status can still be an obstacle to getting a loan or buying insurance.

Most life insurance companies in southern Africa still require applicants to take an HIV test and deny cover to those who test positive. Without life insurance as security, financial institutions are reluctant to lend money to buy a house or start a business.

"The denial of life cover inflicts on other rights," said Amon Ngavetene, coordinator of the AIDS Unit at the Legal Assistance Centre (LAC), a non-profit legal advice organization in Namibia.

The LAC has called on the Namibian government to pass legislation prohibiting insurers from discriminating against people living with HIV, but so far to no effect.

Ngavetene noted that HIV-positive individuals were discriminated against even after their deaths. Those who contract HIV after taking out life cover and fail to notify the insurance company run the risk of having their policies invalidated if their death certificate shows they died of an AIDS-related illness.

"A person could be paying for 15 years, and then when they die their family can't get a penny," Ngavetene told IRIN/PlusNews. "It's unconstitutional but very difficult to challenge because it becomes an issue of the terms of the contract."

Insurance companies in Botswana also require applicants to take HIV tests, but Linny Keorapetse, an assistant legal officer at the Botswana Network on Ethics, Law and HIV/AIDS (BONELA), said at least one company, Metropolitan Life, would cover HIV-positive people, although at a much higher cost.

Those who test negative are required to re-test every five years, but a positive result at a later stage means the policy is automatically converted from life insurance into pure savings.

Botswana's constitution does not provide for socio-economic rights that could form the basis for a court case, said Keorapetse. "The only thing we can do is to make noise about it; we can say it's discriminatory because it's the only medical test [insurance companies] ask for, yet there are riskier conditions."

Botswana has the second highest HIV prevalence rate in the world, with nearly one in four adults living with the virus, but it also has one of the most extensive ARV programmes in the region, with free treatment reaching about 90 percent of people who need it. "Nowadays, people living with HIV who take treatment can live another 20 years," Keorapetse pointed out.

A different approach

Instead of discriminating against people living with HIV, Ross Beerman, managing director and co-founder of AllLife, a South African company, decided to take advantage of this gap in the market to specialize in providing HIV-positive people with life cover.

"We have a very different operating model," he told IRIN/PlusNews. "In a standard model, you price policies based on historical behaviour ... we price on forward-looking behaviour: if you're HIV positive, we don't really care how you behaved in the past, we care about you staying healthy in the future."

Policyholders must commit to going for regular blood tests and starting ARV treatment when their CD4 count [a measure of immune system strength] drops below 200. Once on ARVs, AllLife closely monitors a client's adherence via links with healthcare providers, and regular cellphone text message reminders and warnings if appointments are missed.

Premiums are between two and five times higher than normal life insurance policies (an average monthly payment of about US$40 buys $40,000 worth of life cover), but can be used to secure home loans and start businesses.

In addition, being a policyholder appears to have a positive health effect. "Just by virtue of being our clients they're going for regular monitoring," said Beerman. "They actually get approximately 15 percent healthier after six months; the realization they can have an impact on their longevity means they start behaving in more healthy ways."

In contrast, HIV-positive people in Botswana are steered towards funeral policies or advised to join burial societies. "Currently, there's no company that offers life insurance specifically for people living with HIV," said Keorapetse.

AllLife relies on fairly sophisticated administrative and IT systems to function efficiently, which would be difficult to replicate in less developed countries in the region where, for example, blood test results are not captured electronically.

Nevertheless, Beerman said, people living with HIV have the right to participate in the mainstream economy "in a normal way".

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http://www.irinnews.org/report.aspx?ReportId=86698MBABANE Wednesday, October 21, 2009 (IRIN) - A search for ways to curb the spread of HIV in Swaziland has led to a public debate on legalizing sex work, which would have been unheard of 10 years ago in this poor, food-insecure country.MBABANE Wednesday, October 21, 2009 (IRIN) - A search for ways to curb the spread of HIV in Swaziland has led to a public debate on legalizing sex work, which would have been unheard of 10 years ago in this poor, food-insecure country.

The woman at the centre of the debate is Senator Thuli Mswane, who is also director of Hospice at Home, a local home-based care organization headquartered in Matsapha, between the capital, Mbabane, and the country's industrial centre, Manzini.

Swaziland's new tourism developments lie in the Ezulwini area, east of Mbabane, and the combined lure of large population centres and foreign visitors has inevitably given rise to a thriving sex industry.

Mswane has announced her intention to champion the cause of legalized sex work by requesting that the justice ministry introduce a bill legalizing the sex trade as a means of controlling the spread of HIV; Swaziland has the highest prevalence rate in the world.

"Studies have shown that the trade of prostitutes [in countries where it is legal] is not risky to clients, as sex workers protect themselves; hence my appeal for government to consider legalizing brothel ownership and sex work," said Mswane.

Her announcement has created a sensation in this small conservative country. Although roadside sex workers have been a fixture in Matsapha and Ezulwini for years, the illegal profession has gone largely unacknowledged by health officials and ignored by the police.

Last year the first media exposure of an operating brothel was thought a shocking story; moreover, underage girls were found living and working there. The girls dispersed to other homes - later to resume their trade - and no arrests were made.

The incident also exposed a growth in prostitution that has mirrored rising poverty and the continuing marginalization of women. Traditional views on the role of women prevail in Swaziland's deeply patriarchal society.

"In most instances, women are the ones who engage in the trade as a result of abuse meted out by their [male] partners at home ... whilst also struggling to earn a living," Mswane noted.

Sex work does exist

Mswane's call to legalize the sex trade has been welcomed by some NGOs. "If we don't legalize sex work, women will continue to be exploited and violated, so legalizing it would mean their protection is guaranteed," said Cebile Henwood, director of the Manzini-based Swaziland Action Group against Abuse (SWAGAA).

"These people [sex workers] have rights, and deserve to be protected just like anyone else ... If sex work is legalized then women will have access to services such as health ... they will be able to insist on protection such as ensuring clients use condoms."

Because sex workers engage in an illegal activity, reporting abuse to SWAGAA or gaining access to the justice system, as other victims of abuse could, was extremely difficult, she added.

Emmanuel Ndlangamanda, executive director of the Council of Non-Governmental Organisations (CANGO), told IRIN/PlusNews that the illegal nature of sex work made it difficult for sex workers to access health facilities, but they were at higher risk of HIV as they did not receive adequate support and education.

The proposed Sexual offences and Domestic Violence Bill, which sparked Mswane's campaign, would outlaw brothel ownership and impose a 10-year prison sentence; anyone caught residing in a brothel would also be breaking the law.

"The Bill criminalizes running of a brothel and outlines a fine for it - in other countries sex workers are part of the economy, as they are taxed and assessed on a continuous basis," Minister of Justice and Constitutional Affairs Ndumiso Mamba admitted to MPs.

However, he dismissed any suggestion that his ministry would pursue decriminalization. "Based on Christian principles, government cannot be seen to be condoning it," he said.

Most Swazis seem to agree. A non-scientific on-line poll conducted by the Swazi Observer, a local newspaper, found that 87.5 percent of respondents did not want prostitution legalized, compared to 12.5 percent who supported decriminalization.

The Council of Swaziland Churches, an umbrella body, has slammed Mswane's call to decriminalize sex work. "As a faith-based organization we cannot be seen promoting sex work," said Khangezile Dlamini, secretary-general of the umbrella body.

"Sex workers are responsible for the spread of HIV and while ... [they do not have] multiple concurrent partners, [they have] a number of clients. Besides being Biblically wrong, in Swazi culture sex work has never been ... [condoned]."

The debate has, at least, established the reality of sex work, and highlighted the exploited lives of the women who make their living from it, even if government and the traditional authorities have shown no desire to entertain, much less pursue decriminalization of the trade.

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http://www.irinnews.org/report.aspx?ReportId=86667JOHANNESBURG Wednesday, October 21, 2009 (IRIN) - When a place is so remote that you can only reach it on foot or horseback, a cash-in-transit operation is a real challenge - but Lesotho's Child Grants Programme (CGP) has overcome it with air support.JOHANNESBURG Wednesday, October 21, 2009 (IRIN) - When a place is so remote that you can only reach it on foot or horseback, a cash-in-transit operation is a real challenge - but Lesotho's Child Grants Programme (CGP) has overcome it with air support.

In Thaba Khubelu, a tiny village in the mountainous district of Qacha's Nek, about 400km from the capital, Maseru, some 250 households eagerly watched as a military helicopter touched down to deliver their first quarterly instalment of 360 maloti (US$48) each.

"It is a gift from the sky! Now I can buy clothes for myself and my brothers so we will look like all the other children when we go to school," said Mamello, 16, who received the cash in phase two of the CGP, launched on 20 October.

"I am so happy to get this money, we need it so much," she said. The programme aims to supplement the income of the poorest households caring for orphans and other vulnerable children (OVC) to ease the poverty that has prevented them from having enough to eat, staying healthy and going to school.

Unfortunate to be so lucky

Yet even with the free money Mamello was hardly the envy of the village: she lost both her parents and now has to care for two younger brothers. "They [parents] were very sick and it was painful to see them suffer. I had to stay out of school for some time," she said.

Speaking at the launch, Ahmed Magan, Lesotho representative of the UN Children's Fund (UNICEF), said: "We need to ensure the most needy families and children are the ones that are being reached and that benefit from social protection programmes."

This is not easy, considering the depth of poverty in this tiny landlocked country. UNICEF has noted that over half the population live below the poverty line and in a state of chronic food insecurity, which has been worsened by the global economic crisis.

Mphu Ramatlapeng, the Minister for Health and Social Welfare (HSW), said: "The grant is meant to benefit the most vulnerable and disadvantaged, not anyone else."

According to his department, Lesotho has more than 180,000 orphaned children, of which 55 percent have lost one or both parents to HIV/AIDS-related illnesses. About 23.2 percent of the country's nearly two million people are HIV positive - one of the highest prevalence rates worldwide.

Ambitious scale-up

The project started in April 2009 with payments in the western district of Mafeteng, where access was not an issue. Now, having covered the most remote of the three pilot districts, the government hopes to extend the programme throughout the country.

Mohemmad Farooq, a UNICEF social policy specialist who helped design the project, said the current budget was expected "to take the programme to five districts of the country, and reach around 24,000 OVC in approximately 8,000 households by 2011". The European Commission donated $7.3 million to the initiative and UNICEF is providing technical assistance.

The pilot phase would help develop and test the systems for targeting, enrolment and payment of beneficiaries; monitoring, procurement and financial management; training stakeholders, public information and education. "Lessons learned will guide refinement of the Cash Grant in preparation for expanding into other districts," Farooq told IRIN.

"Social cash transfer programmes provide a predictable income for the poorest and most disadvantaged families to alleviate the burden of poverty, meet their basic needs and invest in children ... it will [also] create economic activity to contribute to the overall development of the country," he said.

"The Government is already looking at strategies for fund-raising, and for absorbing the cost of the programme in their national budget."

Ramatlapeng was optimistic that the project could be rolled out sustainably: "Through the grant, the government is aiming to reach about 60,000 children and ensure they attend school, access services and receive counselling and nutrition support."

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http://www.irinnews.org/report.aspx?ReportId=86677DURBAN Tuesday, October 20, 2009 (IRIN) - Just over three years ago, a group of HIV-infected inmates at Westville Correctional Centre, near the South African port city of Durban, won a High Court battle that forced the government to provide them with life-prolonging antiretroviral (ARV) treatment.DURBAN Tuesday, October 20, 2009 (IRIN) - Just over three years ago, a group of HIV-infected inmates at Westville Correctional Centre, near the South African port city of Durban, won a High Court battle that forced the government to provide them with life-prolonging antiretroviral (ARV) treatment.

Judge Thumba Pillay ordered the national Department of Correctional Services to provide the medicines to the 15 prisoners, as well as to any other inmate in need of them.

He also ordered the department to adopt a comprehensive HIV/AIDS plan for the jail to ensure that inmates would receive not only ARVs, but adequate nutrition, regular and ongoing counselling, and access to health facilities. The government appealed the verdict but it was upheld, allowing thousands of prisoners across South Africa to receive treatment.

Yet many HIV-positive inmates at Westville say that while most of those who qualify for treatment are getting it, the prison authorities take little interest in their health and are not complying fully with the court order.

"Prisoners now have access to ARVs, but the support services are still not there," said Frank Ntombela, chairman of the Westville HIV/AIDS Support Group, which was instrumental in taking the department to court.

"Good nutrition, which is one of the requirements for people taking these drugs, is unavailable. We get the regular staple food, consisting mainly of rice and soya-bean stew, which is often not good enough," and the prison authorities did not allow inmates' families to provide them with healthier food.

Ntombela's section of the prison houses more than half the total prison population of 7,800, but has only four doctors and four nursing sisters, who only see patients on Tuesdays.

"Sometimes there are more than 50 people who want to see the medical staff, but they force us to choose only seven prisoners who are going to be seen for that week - the others would only get a chance next time, unless they are in an emergency," said Ntombela.

Another member of the support group who did not wish to be named, told IRIN/PlusNews that the ARVs were helping HIV-infected prisoners. "There was a time between 2005 and 2006 when an average of 140 prisoners died of AIDS a year - we saw corpses leaving the prison hospital every week."

However, because of overcrowding many HIV-positive prisoners still contracted tuberculosis (TB), including drug-resistant strains of the disease. The support group member estimated that about 60 HIV-positive inmates now died at the prison every year, with very few granted medical parole.

"Many people end up dying lonely deaths here, yet there is a legal provision which allows terminally ill prisoners to be paroled in order to die dignified deaths with their families."

After their court victory the support group was allocated an office for meetings and treatment and awareness programmes, but prison authorities recently closed down the office after gang violence claimed the lives of two inmates.

"I think they used the gang wars to get to us, because they always resented the fact that we had won the court battle," said the support group member. "As a result, most of our programmes came to a halt."

The number of Westville inmates living with HIV is unknown but the prison is located in KwaZulu-Natal, the province with South Africa's highest HIV prevalence rate. According to the latest government survey, 39 percent of women attending antenatal clinics were infected.

Pastor Leon Assenderpe of the Family Support Group, a faith-based organisation that runs AIDS awareness and care programmes in prisons throughout the country, described the HIV/AIDS situation at Westville as "dire".

"I know that the government is trying to implement a treatment plan but they are overwhelmed because of the number of prisoners needing treatment," he said.

Nana Mpungose, the Westville coordinator of Treatment Action Campaign, the national AIDS lobby group that helped the inmates bring their case to court, said her organisation was concerned about the number of complaints from HIV-positive prisoners at Westville and other facilities.

"We are also concerned that the department is not fully compliant with the court order," she said. "When we ask for permission to meet with prison authorities, or to speak to prisoners, we are denied that opportunity."

The Department of Correctional Services could not be reached for comment.

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http://www.irinnews.org/report.aspx?ReportId=86660NAIROBI Monday, October 19, 2009 (IRIN) - Julia Nyaberi's* "clinic" in Majengo, a slum in Kenya's capital, Nairobi, caters to one type of client only - pregnant women seeking abortions.NAIROBI Monday, October 19, 2009 (IRIN) - Julia Nyaberi's* "clinic" in Majengo, a slum in Kenya's capital, Nairobi, caters to one type of client only - pregnant women seeking abortions.

Young women writhe in pain on the floor of the poorly lit house; the neighbours all know what happens here and have become immune to the moans and wails.

"They come to me and each pays me 50 shillings [US$0.70]," Nyaberi told IRIN/PlusNews. "Most of them are sex workers who operate here in Majengo and have conceived by mistake."

She uses a concoction of herbs to induce abortion, and admits there have been fatalities. "Even qualified drivers at times cause accidents; I do not do this job to kill anyone, but at times some are unlucky and go together with the child they came to abort," she said.

Diana Awuor*, 21, is a sex worker in Majengo, and fell pregnant after unprotected sex with a regular client.

"Not that I have sex without a condom every day but there are some regular clients you can excuse at times and I think that is how I became pregnant," she said. "We cannot do our work while pregnant because nobody will want you, so I have to abort to stay in business, and also, I don't want a baby."

Back-street clinics

Ministry of Health statistics put the number of Kenyan girls and women who have abortions every year at 300,000; abortion remains illegal so many of these take place in back-street clinics like Nyaberi's. According to the International Planned Parenthood Federation, http://www.ippf.org/NR/rdonlyres/8D4783F5-D516-47D3-8B34-61F6D510202A/0/Death_Denial_unsafe_abortion_poverty.pdf, unsafe abortions account for between 30 and 50 percent of maternal deaths in Kenya.

"One person attending to up to even five women without sterilizing whatever instruments are being used can spread HIV," said Jacky Abuor, a counsellor at the faith-based Kenyan NGO, Crisis Pregnancy Ministries, which works with young women dealing with unwanted pregnancies.

The legalization debate

A recent study by the local NGO, Centre for the Study of Adolescence (CSA), http://www.csakenya.org found that four in 10 Kenyan girls had sex before the age of 19, many with multiple partners and often in exchange for gifts such as mobile phone airtime or food. Along with the predictable public outcry, http://allafrica.com/stories/200910131192.html the report re-ignited the legalization debate.

Women's rights groups have long urged the government to legalize abortion to prevent the high number of maternal deaths from unsafe procedures. A Reproductive Health and Rights Bill proposing that "safe and accessible abortion-related care" be enshrined in the constitution as a reproductive right was tabled in Parliament in 2008 by the Federation of Women Lawyers and the Coalition On Violence Against Women; MPs have yet to vote on the issue.

The country's anti-abortion movement has powerful backers, from religious leaders to politicians, such as Vice-President Kalonzo Musyoka.

Sex education

"When you say four out of 10 girls have engaged in sex, how do we keep the remaining six from being lured into early sex? The window lies in counselling and education," said Anne Muisyo, “Abstinence and worth the wait” programme coordinator at Crisis Pregnancy Ministries.

"Sex education at the early stages of life and especially targeting young people can significantly turn the tide and prevent new cases of HIV," Paul Mitei, head of gynaecology in western Kenya's Nyanza Provincial Hospital.

Kenya's Ministry of Education has an HIV/AIDS prevention and sex education curriculum that focuses on upper-primary and secondary school, but no specific time is set aside for this during the school day, leaving teachers and school heads to fit in the subject at their discretion.

Speaking at a recent meeting in Nairobi, Kenya's director of public health, Shanaaz Sharif, admitted that opposition from parents, religious groups and some civil society bodies had led to a "censored sex education campaign" in schools.

Agnes Odawa, in charge of guidance and counselling at the education ministry, told IRIN/PlusNews the government had plans to introduce a more detailed sex education package as part of the school curriculum.

Responding to the CSA's findings, the head of the National AIDS Control Council, Alloys Orago, said the government was also looking into the promotion of condom use among teenagers.

Currently the government's HIV prevention programme for teens revolves around the promotion of abstinence, with a nationwide media campaign urging young people to "chill", or abstain, from early sex.

"Many young girls and even boys in rural areas and poor settings do not really know about contraception; those of them who use the condom only know it as a means of preventing HIV," said Mitei. "There is a need to promote condoms to young people both as an HIV preventive measure and birth control measure."

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* not her real name

http://www.irinnews.org/report.aspx?ReportId=86641MBABANE Monday, October 19, 2009 (IRIN) - Archie Muntu Simelane, a construction worker in Mbabane, Swaziland's capital, talked to IRIN/PlusNews about how his HIV-positive status led him to becoming a health motivator at his place of work.MBABANE Monday, October 19, 2009 (IRIN) - Archie Muntu Simelane, a construction worker in Mbabane, Swaziland's capital, talked to IRIN/PlusNews about how his HIV-positive status led him to becoming a health motivator at his place of work.

"People tell me it must be very frightening to climb up on the girders, but when I am on the job I don't think of the danger.

"But I got scared when I got the test results that I was HIV positive. I know all the safety precautions at work - we are trained. The danger is right there, and you are aware; with HIV, you can't see the danger.

"I couldn't believe it was me when I got my test results. I was sick and that is why I got a test, but I asked for a re-test. The results were the same; I had HIV, but I was prepared in my mind by then.

"I have friends at work - I think if I am HIV, they can be too, but they won't test, it's too scary for them. I take the medication; if I live right I can live a long time.

"But these guys who don't test aren't taking any medication; they can go just like that! People get these diseases quickly and lose weight fast, and then they are gone. We lose a lot of guys at work, young guys. I am losing friends.

"My counsellor, who gave me my test results and also spoke to my girlfriend, asked if I wanted to be a health motivator at work. I said I would do that for my co-workers. Some of them act differently toward me now that they know I am HIV, but I know they are also probably HIV. One guy is sick - I see the symptoms - but he won't test.

"My employer gave me time off to take the training; he says he is losing many workers. Talking man-to-man is the best way to communicate things. Everyone listens; they may not test, but they want to know. Some guys are getting tested, though; that is an accomplishment for me, because I directed them where to go and how to prepare mentally.

"I tell these guys that we don't remember ever hearing of someone falling off the girders, but every day these guys are 'falling off girders' to their deaths having sex, because they don't wear condoms."

jh/ks/hehttp://www.irinnews.org/report.aspx?ReportId=86643