Highlights of the AAAO archives

By Linda Scott The AAAO archived newsletters, starting in 2004 through to the present, provide a fascinating record of a country grappling with a rapidly escalating epidemic and all the foreseen as well as unforeseen socio-economic consequences. The trend in antenatal statistics tells the stark story of the HIV pandemic in South Africa. In 1990 0.8% of pregnant women were HIV-positive; by 1995 this had reached 10.4% and then more than doubled to 24.5% by 2000. In 2005 it hit 30.2% and continues to hover around this unacceptably high percentage. 2004 The first AAAO was launched in April 2004 and covered the growing problem of HIV disease and life cover and the many insurance underwriting dilemmas around AIDS. The impact of antiretroviral treatment on future underwriting trends was evaluated as the government had just initiated its first pilot treatment programme in the Western Cape. The June 2004 issue covered the launch by the South African Business Coalition on HIV/AIDS (SABCOHA) of its workplace toolkit to help the country’s small and medium size businesses implement an HIV and AIDS programme. Also in this issue Gavin George of the Health Economics and AIDS Research Department (HEARD) at the University of KwaZulu-Natal analysed various corporate AIDS programmes to see whether they were working. He concluded that while the provision of antiretroviral treatment to infected employees is not a cheap option for companies it has been proven that ‘the more you treat the more money you save’, and that it is always in the interests of the company to treat infected employees earlier rather than later when they are likely to become AIDS-sick and therefore less productive. A further issue in September 2004 comprehensively examined the possible impact of the widespread and worrying myth that having sex with a virgin can cure a person of AIDS. 2005 In the April 2005 issue the complexities of trying to implement behavioural change, the crux of all successful prevention campaigns, were explored as well as the issue of underreporting of AIDS deaths in national statistics. Pam Groenewald and Debbie Bradshaw from the Medical Research Council clearly demonstrated that misclassification of deaths was making it difficult to estimate the actual number of deaths due to AIDS. When the HIV status of the deceased is unknown and access to medical records is difficult, misclassification of the immediate cause of death (e.g. tuberculosis, pneumonia, diarrhoea etc.) often occurs. In addition, it was found that doctors were often reluctant to state AIDS as a cause of death because of concerns about confidentiality and the potential impact on bereaved families in terms of social stigma and the loss of funeral policy or life insurance benefits. These remain problems today although various methods are now used to adjust the statistics to reflect AIDS mortality more accurately. The November 2005 issue tackled the grim choice for unemployed people with AIDS in South Africa – the disability grant or antiretroviral therapy? If you are sick enough to qualify for a disability grant, you are sick enough to qualify for antiretroviral treatment. This will then make you well enough to disqualify you from getting a disability grant, which is the only source of income for many families. 2006 In the March 2006 issue Dr Warren Parker of the Centre for AIDS Development Research and Evaluation (CADRE) investigated the burning issue of whether widespread and expensive prevention campaigns were having any effect on the prevalence of HIV in South Africa, especially in the light of around 500 000 new infections each year. Reducing HIV prevalence (the total number of HIV-positive people) is not easily achieved, given that prevalence generally only decreases if there are major reductions in HIV incidence (new infections) amongst youth and/or increases in deaths of people with HIV and AIDS. The evidence suggested that prevention campaigns were having a minimal impact although other indicators, such as the uptake of Voluntary Counselling and Testing (VCT) and reported condom use, were increasing markedly. He argued that as sexual behaviour involves a complex interplay of psychological, cultural and contextual factors any prevention programmes that focus mainly on a rational choice model or on ABC (Abstain, Be faithful, Condomise) type messaging will always be inadequate. Parker concluded that if HIV prevention efforts are to work the country needs to move beyond the same old theories and communication campaigns that focus exclusively on individual behaviour. Prevention interventions need to be embedded in an understanding of risk, with a particular emphasis on addressing issues of power, disempowerment and contextually determined vulnerability. Dr Pren Naidoo, HIV Programme Manager of the City Health Directorate in Cape Town, examined critical issues around VCT programmes in the May 2006 issue, especially given that only 10% of South Africans were then estimated to know their HIV status. The basis for promoting VCT is that it enables individuals to initiate or maintain behaviours that prevent both acquisition and transmission of the virus. From a community perspective, the widespread availability of VCT services helps to normalise HIV, reduces denial and stigma, and encourages communities to mobilise support to address local needs. Naidoo presents a strong case for a major paradigm shift with regard to VCT, arguing for routine testing and for HIV disease to be framed within a chronic disease model. The emphasis would then be on a range of care and support interventions that commence early in the disease and promote wellness. 2007 In the November 2007 issue Peter Doyle, then CEO of Metropolitan Holdings, examined the role of leadership in HIV and AIDS from a corporate perspective. The 2007 Labour Force Survey estimated that only 12.6 million people of a total population of 47.5 million were employed. Those 12.6 million have to generate sufficient wealth to feed and develop the whole nation and it is vital that they remain healthy. Effective workplace programmes, to both prevent and address HIV disease, are therefore essential for the economy of this country. The Siyakhana Project, also profiled in this issue, offers comprehensive counselling, testing and treatment services to around 20 participating businesses. It was started in response to the economic reality that while small and medium size businesses in South Africa provide half the employment opportunities in the private sector and contribute nearly half of the country’s GDP, very few have implemented even rudimentary HIV and AIDS interventions in the workplace. In the first two years of its operation the Siyakhana Project provided VCT to over 3,000 employees, of which approximately 10% were positive. The Project is widely viewed as an international benchmark, and expanded significantly in 2008. Participating companies pay a nominal fee to benefit from this extensive programme. 2008 In the December 2008 issue Linzi Smith, Managing Director of Education, Training and Counselling (ETC), provided an in-depth summary about the workplace management system standard, SANS16001: 2007. This standard is an excellent tool to help all businesses achieve best practice in their HIV and AIDS workplace programmes and was launched in July 2007 by the South African Bureau of Standards as a comprehensive workplace response to the epidemic. 2009 In the January 2009 issue Dr Lize Hellström described the success of the Stellenbosch and Mbekweni after-hours clinics in the Western Cape, which opened in 2007. To make HIV testing and support truly accessible it is necessary for these services to be available after working hours and to take into account men’s needs. Around 70% of patients at HIV state clinics are women and many of these clinics are reputed to appear unfriendly to men’s requirements. Men who are HIV-positive therefore tend to present late for treatment, which adversely affects the outcome. Both men and women are attending these after-hours clinics in approximately equal numbers where they are seen without an appointment. Clients are largely working people and, particularly in Stellenbosch, students. In Mbekweni, predominantly young men (56%) aged 18-25 are accessing the VCT service, which illustrates the vital need for such clinics. The March 2009 issue covered the launch of the B the Future cell book at the Fourth South African AIDS Conference in 2009. The book is an HIV and AIDS information resource that can be downloaded onto a cell phone (in less time than it takes to download a ring tone), allowing people to access important information easily and privately. Given that 80% of the country has access to a mobile phone whereas only 10% has access to the Internet, this represents an important communication channel. Mobile phone users simply need to SMS the word HIV to 32907 at a cost of R1 in order to receive the full cell book with detailed information on: HIV prevention and testing; counselling and support; how to live positively with HIV; support services; and frequently asked questions. The information is written in plain English and, once downloaded, B the Future is always available with or without a signal or airtime. The June 2009 issue provided a summary of the Fourth 2009 South African AIDS Conference in Durban. More than 60 presentations were made in six different tracks under the overarching theme of ‘Scaling up for Success’. The six tracks included Basic Sciences; Clinical Sciences; Epidemiology; Prevention and Public Health Systems; Social and Economic Sciences, Human Rights and Ethics; and Best Practice and Programmes. This biennial conference has become an important think-tank and networking opportunity which is attended by around 4000 delegates, most of whom are from African countries. In the penultimate issue, September 2009, Professor Courtenay Sprague of the Graduate School of Business at the University of the Witswatersrand looked at the impact of the HIV epidemic on the women of sub-Saharan Africa. Sub-Saharan African women of reproductive age are disproportionately affected by HIV, with women in younger age groups being four times more likely to be HIV-infected than men. Recent statistics in South Africa showed that the incidence (number of new infections) of HIV among females peaked in the 20-29 year age group at 5.6%, more than six times the incidence found in the equivalent male age group (0.9%). Among the 15-24 age group, females accounted for a staggering 90% of recent HIV infections. Women’s greater vulnerability to HIV disease is both biological and social. Biologically, women are more susceptible to contracting sexually transmitted infections, including HIV, than men. Socially, African women’s unequal status and position in society makes them further vulnerable. High-risk sexual behaviour is associated with an inability to negotiate condom use, peer pressure to have sex, and ‘coercive’ male-dominated relationships. Studies have demonstrated that social context and position, as well as cultural factors and norms, have been significant in increasing HIV transmission among African women. The recurrent themes and problems in the AAAO newsletters have revolved around an inadequate uptake of VCT and ineffective prevention campaigns, which are doing little to reduce the number of new infections, especially amongst the female youth. It has become clear that without the massive scale-up of contextually-appropriate prevention interventions amongst men and women of all age groups, South Africa will continue to experience the scourge of the HIV epidemic. It is therefore very encouraging that the Department of Health is currently launching a massive campaign aimed at encouraging millions of South Africans to test for HIV. Dubbed the HCT or HIV Counselling and Testing campaign, the initiative will roll out in April this year. The target is to have around 15 million South Africans tested for HIV by June 2011. The HCT approach differs from VCT in that health workers will now offer all patients a routine HIV test, irrespective of whether symptoms of HIV are present. The campaign will be launched in Gauteng before being rolled out to other provinces. While the business and scientific responses to the HIV epidemic are now well developed and have been documented by AAAO over the last seven years, it is the community response to the socio-economic problems that remains fractured and less well developed. It is therefore appropriate to make way for a different kind of newsletter which will report on the Metropolitan Foundation’s Live the Future programme that aims to mobilise and motivate leaders and communities to collaborate in their responses to HIV and AIDS. Linda Scott read Human Sciences at Oxford University and recently gained an MSc in Nutritional Medicine with a research project on the role of nutrition in HIV disease. She currently manages the AIDSbuzz.org website which provides up-to-date information and directories to help communities and individuals address the socio-economic problems of the epidemic. She co-founded Mothers for All, a non-profit organisation which trains and supports the caregivers of children orphaned or made vulnerable by AIDS.