HIV trials and tribulations

By Dr. Ananya Mandal, MDFeb 13 2011

Zimbabwe HIV progress

A report published online February 8 in PLoS Medicine shows that mass behaviour changes could be credited with helping to remarkably reduce the number of people infected with HIV in Zimbabwe in recent years. These changes include declines in extramarital, commercial, and casual sexual relations, as well as a decline in multiple partners. These have been triggered by increased awareness of AIDS deaths and fear of infection and to some extent by the country’s economic deterioration.

HIV prevalence in Zimbabwe increased rapidly in the early to mid-1990s, reaching a plateau in the late 1990s. By 1997, the estimated adult prevalence of HIV in the country was 29%. However, HIV prevalence declined after 2000, and in 2007 it was estimated to be 16%.

First author Daniel Halperin, lecturer on global health at Harvard University School of Public Health in Boston, Massachusetts said, “Some HIV experts think the main reason for the decline in Zimbabwe is the economic collapse…While we think that it’s an important factor, it appears to be a secondary one. As in Uganda, behaviour change (and mainly partner reduction), due mainly to fear of dying of AIDS, seems to be the most important factor.”

The study commissioned by the United Nations Population Fund and the United Nations HIV-AIDS Program was undertaken to understand the reasons for the marked decline in HIV rates in Zimbabwe in the context of social, political, and economic disruption. Simon Gregson, from the School of Public Health at Imperial College London, United Kingdom, and senior investigator on the study said, “Given the continuing, and worrying, trend for high HIV/AIDS infection rates in many sub-Saharan African countries, we felt it was important to understand why the disease has taken such a dramatic downturn in Zimbabwe….Very few other countries around the world have seen reductions in HIV infection, and of all African nations, Zimbabwe was thought least likely to see such a turnaround. This is why there was such an urgent need to understand its direct and underlying causes,” he noted.

Results from nationally representative Demographic and Health Surveys from 1999 and 2005/2006 suggest an approximately 30% reduction in the proportion of men reporting extramarital partners. The data also suggest substantial reductions in the proportion of men reporting concurrent partnerships, as well in the number paying for sex.

The report reads, “High AIDS mortality appears to have been the dominate factor for stimulating behaviour change.” The researchers write that Zimbabweans “consistently reported personal exposure to AIDS mortality and the resulting fear of contracting the virus to be the primary motivation for changes in sexual behaviour, particularly reductions in casual sex and other multiple sexual partnerships.”

Other underlying factors found to distinguish Zimbabwe from neighbouring countries and that have contributed to changes in behaviour include the nation’s well-educated population and high rates of marriage, especially among urban men, among whom the greatest level of behaviour change seems to have occurred. The researchers say, “It appears that this unique combination helped facilitate a clearer understanding and acceptance of how HIV is sexually transmitted and a greater ability to act upon ‘be faithful’ messages.”

HIV medicines difficult to access

Many low-income Illinoisans who have the AIDS virus could find lack of enough HIV medicines as the state continues to deal with an unprecedented budget crunch amid increased demand and high drug prices.

The number of medications available to patients and the amount spent on them has been capped through a state assistance program. Patients need to enrol in the state-run AIDS Drug Assistance Program, which pays for medicines for poor and low-income Americans. In Illinois, the number of patients enrolled in ADAP has jumped 14 percent in the past year, to 6,000.

Until now Illinois has been able to stave off putting patients on a wait list, a trend that is growing in at least 10 states. More than 6,000 patients nationwide were waiting for drugs as of early February, with the largest number in Florida, and hundreds more are at risk of being dropped from programs, according to the National Alliance of State and Territorial AIDS Directors.

Michael Weinstein, president of AIDS Healthcare Foundation, a national advocacy group based in Los Angeles said, “We’re calling it a death warrant.”

According to the U.S. Centers for Disease Control and Prevention, more than 1 million Americans are estimated to be living with HIV/AIDS. Anti-retroviral drugs lower the amount of HIV in the blood to undetectable levels, increasing patient survival rates and reducing the chances of transmitting the virus. But HIV medications are expensive. Some pill regimens can cost $2,000 or more a month, particularly for newer drugs.

Spokeswoman Kelly Jakubek said, “The Illinois Department of Public Health recognizes the importance of programs like ADAP… The department will continue to do what it can to provide low-income and underinsured individuals living with HIV/AIDS the life-saving drugs and treatment they need.”