Behaviour change happens but this is not necessarily the result of HIV prevention campaigns, top HIV clinician Professor Francois Venter declared in a debate today about whether HIV prevention actually works and how to measure this.
South Africa has 18% of the worldwide HIV epidemic and still has high rates of new infections despite efforts to prevent them, said Venter at the 5th SA AIDS conference.
Behaviour change campaigns are well resourced but not scientifically driven, he stated.
Venter said, for example, current HIV prevention campaigns are targeting multiple concurrent partnerships as a problem driving the HIV epidemic but a review of the research finds no evidence that these partnerships explain the high rates of infections in sub-Saharan Africa.
He said behaviour change needs to be driven by scientific evidence to be effective and that its track record so far was not convincing.
“Maybe we have not tried the right behaviour change,” said Venter, observing that clinicians do understand how hard it is to get patients to change health behaviours, such as stopping smoking or losing weight.
Dr Saul Johnson, the head of the Health Development Agency, and Richard Delate of Johns Hopkins Health and Education in SA both challenged Venter and painted a brighter picture of what’s going on with HIV prevention in SA.
Johnson said Venter was wrong that:
1) Communications programme don’t work. Johnson said there is evidence, for example with condom use, that they do;
2) If they did work South Africa wouldn’t have such a high HIV epidemic. Johnson said SA got off to a slow start and these efforts take a long time to get results;
3) Randomised controlled trials are needed to prove efficacy. They are not the best tool to assess this and are not implementable, he said;
4) SA must measure success by the rate of new infections. Johnson said lab tests are not 100% reliable and there may be better end points for measuring behaviour change; and
5) SA could get better value from funding “test & treat”. Johnson said that we are not going to be able to treat our way out of our epidemic given its scale.
Delate disputed that prevention campaigns have failed, saying that 80% of South Africans are HIV negative and “it is our job to keep them negative.”
The demand for HIV testing and condoms had increased in the last few years said Delate, suggesting this was linked to behaviour change campaigns.
He pointed out nobody had measured the rate of new infections at the start of the National Strategic Plan in 2006 so it’s hard to assess in 2011 whether it has succeeded in reducing incidence.
The goal was to cut new infections by half by 2011.
Johnson said: “We think we know what works, we just need to do it properly at this point.”
FIFA needs to support the HIV prevention efforts of South African HIV/AIDS activists, major organisations affiliated to the SA National AIDS Council stated today.
The organisations expressed concern about the blockages around condom access and health promotion with only days to go before kick off.
They want FIFA to support the distribution of condoms at Fan Fests in all cities, and to allow the promotion of all condoms including CHOICE, Trust and Lovers Plus.
Activists appealed to FIFA to promote condom use and HIV testing and to make sure that fans had easy access to information, such as details for the AIDS Helpline (0800-012-322).
“We wish for the success of the World Cup. But we also wish for an HIV free generation and that FIFA would join hands with local AIDS organisations to exploit the opportunity that the World Cup presents to greatly strengthen and deepen our response to HIV/AIDS. It is not yet too late. But it soon will be,” the organisations declared.
The statement was issued by the AIDS Consortium, Community Media Trust, Johns Hopkins Health and Education in South Africa (Brothers for Life), National Religious Association for Social Development, Peri-Natal HIV Research Unit, Reproductive Health Research Unit (RHRU), Right to Care, SA HIV Clinicians Society, Section 27, Society for Family Health, Sonke Gender Justice Network (Sonke), Soul City, Treatment Action Campaign.
Mark Heywood, SANAC deputy chairperson, endorsed the statement.
The South African Communist Party Youth League has praised President Jacob Zuma’s constructive approach to HIV, while slamming his predecessor Thabo Mbeki and former health minister, Dr Manto Tshabalala-Msimang for their failures.
Young Communists League leader Buti Manamela even wants Mbeki and Tshabalala-Msimang – not named but referred to as the “people” who presided over government as president and minister of health and refused to provide antiretrovirals – charged with genocide.
“Those who have denied the existence of HIV/Aids must be brought before the commission and tried for genocide,” he said.
Many of us would like to see justice done for their catastrophic denialism while in power.
A Harvard study showed some 330 000 deaths could have been avoided between 2000 and 2005 if Mbeki and Tshabalala-Msimang had rolled out the lifesaving medicines sooner.
Risky and violent sexual practices, from transactional sex to many casual partners, are common among men who perpetrate intimate partner violence– and lay the groundwork for HIV to spread.
Dr Rachel Jewkes,head of the MRC’s Gender and Health Research Unit, told IAS 2009 today that building gender equity was essential in preventing HIV.
She also raised the need to overturn female complicity and subservience, to challenge male dominance that rules in much of South Africa.
She reported how intimate partner violence, physical and sexual, seemed to be an even greater problem when it came to HIV transmission in South Africa than rape – which is also shockingly common.
A quarter of men in an MRC study reported ever raping a woman or a girl.
Jewkes referred to the Stepping Stones study, which her team conducted in the Eastern Cape, to illustrate her points.
This intervention did not impact on HIV rates but did reduce herpes rates (HSV-2) and influence behaviour.
“Gender inequity is very linked to HIV,” said Jewkes, stating that large prevention efforts had failed because they didn’t tackle the gender context.
“Gender equity is possible and will extend human rights and human development,” she said, adding however that their resources were severely and disproportionately limited.
“This conference should be to one to say thank you very much d4T (Stavudine), goodbye and never come back again,” Dr Pedro Cahn, a past president of the International AIDS Society, told IAS 209 today.
D4T, 3TC and Nevirapine are the drugs (triple therapy) provided to patients starting antiretroviral treatment in South Africa, and most developing countries.
But d4T has problems with toxicity and lipoatrophy that discourage patients from starting treatment, said Cahn. Back in 2004, the World Health Organisation recommended it be phased out in favour of less toxic drugs.
Cahn said HIV/AIDS is the first disease in history to overcome the “too complex-too costly” paradigm in public health.
In 7 years, some four million people have been put on antiretroviral treatment – leading to a remarkable reversal in disease and death.
But at least six million more people need treatment.
Cahn said the time had come for changes in treatment, including:
I don’t like having my photo taken but today I overcome that barrier to join the Infected & Affected project, a cool anti-stigma project running at IAS 2009.
With the sutitle Portraits of a Community Combating Stigma, this is a photographic project to capture people’s feelings – individually and collectively – about HIV/AIDS stigma and take a stand against it.
The photographer Joan L. Brown took portraits of nearly 600 people from 67 countries as the 12th International AIDS Conference in Mexico City last year and she has taken hundreds more in South Africa on this trip – both at IAS and at a Crossroads Clinic and Groote Schuur Hospital.
She said it was very intense for her.
Carol Metcalf – a South African epidemiologist at the HSRC who was waiting to have her photo taken – said her research including studies on men having sex with men and serodiscordant couples had demonstrated to her what a problem stigma still was.
The magazine POZ is supporting the project.
“We need less AIDS for the money and more money for AIDS,” declared Dr Stefano Bertozzi, the executive director of a UNAIDS collaborating centre in Mexico, at the plenary on the second day of IAS 2009 in Cape Town.
Bertozzi made a strong case for implementing HIV prevention strategies that are strategic, focused, effective and have a long-term vision.
“It is time to stop implementing large-scale interventions of uncertain value without measured effectiveness,” he said, pointing out, for example, that nobody has measured the efficacy of abstinence education.
In 2007 an estimated 2.7million people were newly-infected, only one sign that prevention on a large-scale is not yet working.
Bertozzi suggested that delegates visit aids2031.org to contribute to the long-term vision to stop HIV.
HIV patients in SA – and at least five more African countries – who need antiretroviral drugs are at risk of dying before they can get the tablets, Medecins San Frontieres declared today on the eve of the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009).
“All around us, clinics are stopping enrolling patients because there are just not enough ARV supplies,” Eric Goemaere, MSF Head of Mission in South Africa stated in a release on the problems with drug funding and supplies.
“The waiting lists are growing by the day, risking that patients die before they start ARVs. It’s unbelievable that a relatively well-functioning ARV programme has been allowed to be crippled in the space of just a few weeks.”
A cut in SA’s health budget has severely worsened existing problems.
MSF warned that shortfalls in funding and disruption to supplies or stockouts have led to the “delay, suspension, or risk of suspension of the supply of life-saving HIV drugs” in South Africa, Malawi, Zimbabwe, Uganda, the Democratic Republic of Congo and Guinea — and that this could be catastrophic.
MSF appealed governments, donors and their partners “to take urgent and concrete measures” to end the crisis.
Up to 5000 HIV experts are converging on Cape Town for the 5th International Aids Society Conference on HIV Pathogenesis, Treatment and Prevention, which opens on Sunday night.
IAS 2009 is the world’s biggest open scientific conference and attracted 2400 abstracts. The pre-conference meetings kick off tomorrow.
A new track known as “Operations Research” – focused on improving the quality and implementation of HIV programmes – has been added to the Basic Sciences, Clinical Sciences and Biomedical Prevention tracks.
Plenary and session topics range across hundreds of topics from HAART as prevention, PMTCT, XDR-TB, drug resistance and toxicity, early vs late ART initiation, nurses are ART providers, Hepatitis B&C, TB vaccine developments and the latest on microbicides, vaccines, PrEP and male circumcision.
South African specialists including Dr Louise Kuhn (PMTCT) and Dr Rachel Jewkes (gender, sexuality) are among those presenting on plenary platforms.
One of the world’s most influential HIV scientists, director of the US Institute for Allergy and Infectious Diseases Dr Anthony Fauci, and the newly-appointed US Global AIDS/PEPFAR co-ordinator, ambassador Eric Goosby, will speak at a special session.
South African HIV activists are among thousands of people around the world mourning the death this month of Thembi Ngubane, 24.
Thembi was a true hero who spoke out about living with HIV and recorded a year-long radio diary that was broadcast in 12 countries and five languages.
Radio Diaries executive producer, Joe Richman, said: “She thought the virus should be scared of her, rather than the other way around. She drew pictures of her virus. She talked to it in the mirror. She gave it orders.”
Thembi was on antiretroviral treatment but she struggled with drug-resistant TB, which devastatingly claimed her life on June 5.
Thembi was courageous and honest. She met world leaders but never lost touch with her own community in Khayelitsha, where she lived in a shack.
She will be missed by her soulmate Melikhaya Mpumela and daughter, Onwabo (4).
A tribute to Thembi by prominent HIV activists Prudence Mabele and Sipho Mthathi will be published in the Sunday Times on June 28.