Effective HIV Programming In Any African Country Must Target Foreigners, Asylum Seekers, Refugees And Immigrants Too: Lessons From Botswana

There are lessons, African countries can draw from Botswana: immigrants or refugees to any country need to be targeted if HIV Programming were to be effective and successful.

In a study by Daniel J Escudero et al ( 2019), they found that Botswana has the highest level of HIV viral suppression globally, yet HIV incidence remains > 1% per year in adults aged 15 to 49. 

"Although causes of this continued elevated incidence have been postulated, a firm understanding remains elusive, especially in the presence of a highly successful HIV treatment programme in Botswana. 

Although Botswana provides free antiretroviral therapy (ART) for all citizens living with HIV through its national HIV programme, the first free national ART programme in sub‐Saharan Africa, non‐citizen immigrants (documented/undocumented) are currently ineligible for treatment within the national programme. Documented refugees living with HIV in camps do have free access to ART as long as they remain within the confines of the camp. Private HIV treatment is available, but remains prohibitively expensive for many non‐citizens. In addition to gaps in treatment coverage among men and young people, the lack of free treatment for non‐citizens may contribute to elevated HIV incidence in Botswana, as suggested by research in other settings. There is precedent for providing government‐sponsored HIV treatment to non‐citizens in Botswana. In 2014, a court ruling found that denying non‐citizens in prison access to ART violated their right to receive basic health services, as guaranteed by the Botswana Constitution. 

They concluded by asserting that “substantial research is needed to inform potential expansions in non‐citizen testing and treatment coverage. Data may be needed prior to significant policy changes since Botswana already self‐funds at least two‐thirds of its HIV response, and further strain on the country's programme capacity may be detrimental without increased donor input. This research should be nationally‐representative and address the extent of disease burden in the migrant population, and the population‐level benefits of viral suppression in vulnerable migrants. Policy decisions should also consider how to ensure undocumented non‐citizens may share in the benefit of treatment expansion. Preliminary review of these three important questions confirms that the HIV epidemic in this vulnerable population remains largely hidden, and its impact on the overall HIV epidemic in Botswana cannot be known without further study. Furthermore, the impact that expanded coverage may have on overall HIV incidence will require even further investigation into long‐term HIV treatment outcomes and antiretroviral resistance among immigrants, as well as patterns of sexual mixing between migrant and citizen communities.”

Avoiding Forward Transmission And Ensuring Viral Load Suppression: Lessons From Zimbabwe

A study in Zimbabwe highlighted why there was high risk of death among adolescents while awaiting ART.

Reporting earlier for testing, taking up ART and ensuring ART-adherence are a sure way for suppressing viral load and ensuring longevity among those living with HIV. Mortality among HIV-positive adults awaiting antiretroviral therapy (ART) has previously been found to be high as reported by Shroufi et Al ( 2015). They compared adolescent pre-ART mortality to that of adults in a public sector HIV care programme in Bulawayo, Zimbabwe.

Methods: In this retrospective cohort study, we compared adolescent pre-ART outcomes with those of adults enrolled for HIV care in the same clinic. Adolescents were defined as those aged 10-19 at the time of registration. Comparisons of means and proportions were carried out using two-tailed sample t-tests and chi-square tests respectively, for normally distributed data, and the Mann-Whitney U-tests for non-normally distributed data. Loss to follow-up (LTFU) was defined as missing a scheduled appointment by three or more months.

Results: Between 2004 and 2010, 1382 of 1628 adolescents and 7557 of 11 106 adults who registered for HIV care met the eligibility criteria for ART. Adolescents registered at a more advanced disease stage than did adults (83% vs. 73% WHO stage III/IV, respectively, p and the median time to ART initiation was longer for adolescents than for adults [21 (10-55) days vs. 15 (7-42) days, pMortality among treatment-eligible adolescents awaiting ART was significantly higher than among adults (3% vs. 1.8%, respectively, p=0.004).

Conclusions: Adolescents present to ART services at a later clinical stage than adults and are at an increased risk of death prior to commencing ART. Improved and innovative HIV case-finding approaches and emphasis on prompt ART initiation in adolescents are urgently needed. Following registration, defaulter tracing should be used, whether or not ART has been commenced.

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Effective HIV Prevention Services Targeting Sex-Workers Include Their Voices in All Planning Stages

Magnitude, behavioural patterns, contributing factors, current interventions have an impact on participation by Sex workers in HIV prevention in Malawi.

This Report "captures the voices, perceptions, views and experiences of close to 950 sex workers, along with their clients and other stakeholders from 10 Districts in a situation analysis on the Magnitude, Behavioral Patterns, Contributing Factors, Current Interventions and Impact of Sex Work in HIV Prevention in Malawi.

The study was commissioned by the Family Planning Association of Malawi (FPAM) with funding from the United Nations Population Fund (UNFPA). Using participatory, quantitative and qualitative approaches, the study involved a counting of the sex workers; engagement of what the sex workers know about HIV and AIDS; the legal and policy issues surrounding sex work; and their problems, priorities, and experiences with service providers. The study also interrogated the sex workers on what could be done to ensure the effective implementation of interventions relating to sex work in the context of HIV prevention.

UNAIDS estimates that by the end of 2009, they were 33.3 million people living with HIV globally. In 2009 alone, there were 2.6 million new HIV infections (WHO, 2010). Sub Saharan Africa continues to experience high new infections. It is estimated that 1.8 million people in Sub Saharan Africa became infected in 2009 (WHO, 2010). UNAIDS further indicates that heterosexual intercourse is the main mode of HIV transmission in the region. For example, in Swaziland, transmission through heterosexual contact accounted for 94% of new infections. In Lesotho, between 35% and 62% of new infections in 2008 were noted among people who had at least a single heterosexual contact, and in 2006 heterosexual intercourse within a stable sexual relationship accounted for 44% of all new infections in Kenya (UNAIDS 2009). 

Sex workers are defined as: “Female, male or transgender adults and young people who receive money or goods in exchange for sexual services either regularly or occasionally, and who may or may not consciously define those activities as income generating,” (UNAIDS 2010). 

For purposes of this study, the operational definition adopted for a sex worker in the context of the study was: a female aged between 16-49 years, who has received money in exchange for sex either regularly or occasionally up to 12 months prior to the survey, and who may or may not consciously define those activities as income generating. 

There are two main legal approaches to sex work and these are: Criminalisation and decriminalization. The former approach is informed by the goals of: protection of health and safety; ancillary crime. prevention; protection from exploitation; preservation of society morals; achievement of eradication of the practice through deterrence; and realisation of human rights. This approach is largely grounded in feminist theory premised on the viewpoint that prostitution victimises women and objectifies women’s bodies and sexuality. This theory argues for the criminalisation of sex work on the grounds that it inherently perpetuates the patriarchal devaluation of women, while the other alternative of decriminalising and legalising it does not hold promise for affording women with safety. This viewpoint asserts that the criminalisation should only be with respect to the actions of the one providing the services, and that the criminal laws should not punish the one who procures. The theory is supported by other schools of thought such as the conservative moral school of thought, the paternalistic or protectionist approach and the abolitionist approach.

The public health approach converges with the human rights-based approach and argues that policy responses on sex work should reflect current knowledge of the social determinants of health, and move away from intensified repression to a comprehensive agenda of medical and social support to improve sex workers access to health care, reduce their social isolation and expand their economic options. This entails a multi-pronged approach that reinforces access to medical services for marginalized people, but also tackles the structural factors that expose vulnerable groups to disproportionate health risks in the first place. Prime areas for structural intervention include gender equity, education, and economic empowerment. This means pursuing two simultaneous, mutually reinforcing priorities, i.e. bringing health services and prevention interventions to sex workers in a participatory manner, advancing universal access to HIV prevention, care, and treatment, and protecting sex workers and the general population against HIV and STIs; while at the same time accelerating policies in appropriate sectors to address the structural issues of poverty and gender discrimination that currently leave female sex workers with few credible paths to alternative livelihoods.

Recommendations 

 There is an urgent need to build the capacity (knowledge and skills) of service providers working in sex work programming.

  There is an urgent need for outlining proper institutional set-ups for the steering, coordination and supervision of sex work interventions in Malawi. It is important that the mandates of relevant government institutions should be analysed in terms of their linkages with sex work in order to identify the lead institution.

  Sex work interventions should, wherever possible, be distinctly designed, planned, funded, implemented and monitored and evaluated. Currently most of them are implemented under the rubric of SRH thereby getting less attention in some institutions, particularly government.

  Collaboration among stakeholders is essential for the effective implementation of interventions given the constraints with resources, competing needs and capacity limitations. The limited collaboration that exists among stakeholders involved in sex work interventions is a major setback. There is a need for collaboration to be harnessed in order to have a platform for the identification of synergies, coherence and complementarities relating to sex work interventions in order to improve efficiency and effectiveness. 

 Livelihood services should be preceded with needs assessments. 

 The female condom provision programmes are not matching their utilization. There is an urgent need for a special study to critically analyze factors for the low utilization of female condoms notwithstanding their availability. The analysis should inform complementary initiatives to ensure increase in the utilization of female condoms by female sex workers. 

 Implementing and funding agencies need to effectively streamline sex work in their programmes by among other things adopting public health and human rights based approaches. 

 Sex workers need to be assisted so that they get organized and form an alliance which could be used as a platform to voice out their concerns for appropriate action from relevant authorities. The lack of such a network makes it impossible for sex workers to channel their concerns, thereby remaining a marginalized and neglected population, despite the availability of victim support units throughout the country.

 While it is clear that the debate on decriminalizing sex work in settings such as Malawi is far from settled, the legal complexities surrounding sex work derail the effective planning and implementing of interventions in sex work. This requires harnessing capacities on public health and human rights on the part of implementing institutions. 

 In future, population size estimation for hidden populations should be separated from social and behavioural related aspects in order to allow more time for each." For more follow this link please.

With Increasing Privatization And A Young Population Explosion In Africa, Micro-Credit Extension Can Play Quality Life Improving Roles

As governments increasingly privatize, microcredit extension can be used to foster development and increase SRH And RMNCAH uptake among Ugandan Youths 13-35 years.

Background: African Governments need to increasingly use Microcredit or Micro finance services as precursors and catalysts for many other social services and development goals. This has outcome implications in many areas including:HIV, SRH, RMNCAH and increasing household level living standards. The aim of the report is twofold: explore the categories that made Microcredit a catalyst for quality life practices; how Key Populations (KP) can use Microcredit to engage in quality life improving practices.

Methods: Community immersion, literature review and key informant interviews were used to generate the report between December 2015-February 2019 in 15 Ugandan Town Councils. 230 respondent were eligible out of 330. Eligibility was based on age; 5-7 months grace period after first loan withdrawal; small interest on loans ranging 0.002-0.009%; membership to more than one group or social collateral; did not have to deposit money in bank as collateral; plans set aside to ensure food sustenance; number of months in business between 6 months and 3 years; had plans for long term investments; and requested first/kick-starter loan equal to or below Ugx. 2,000,000.00. 

Results: All 230 with median age 26(IQR (13-35) reported self employment for past two years, flexibility to innovate, engage in self care and saved for food. One hundred seven (107/230) tested for HIV at least five times in 2018. A disaggregation of respondents: 101 Straight females; 90 Straight males; 22 Transgender; 7 Lesbians; 20 Gay males. All respondents were below 35 years. 53 with median age 22 (IQR13-35) were living with HIV among whom 7 are Transgender; 5 are Gay males. Microcredit supports participation in quality life practices, ability to form, maintain collateral viable groups and links businesses in the service sector that follow market demands. These businesses were linked into food consumption (72) operated a food kiosk- and a side grocery) with median age 27 (IQR 23-35); telephone kiosks operation (25) with median age 19 (IQR 13-35); attire and shoes (22) with median age 20(IQR 13-35); movie kiosk (8) artisanry (12); brick-making (32); carpentry (9); Boda-riders (7) with median age 23 (IQR 13-35); event planning and hosting (23) with median age 30(IQR 23-35); stationery (27) with median age 25 (IQR22-35); grocery shops (20) with median age 27 (24-35); and commitment to nurture goodwill and credibility e.g. return the money. 

Conclusions and Recommendations: Young people can be empowered to engage in SRH uptake. Microcredit extension catalyzes market linkage, increases citizen self preservation provisions, is linked to opportunities for social integration, through entrepreneurship and wealth creation. It increases Household income base, a precursor for self care. Age is linked to service sector start-ups and ventures. More younger people are living with HIV. The role party politics plays in addressing young persons’ concerns needs further study.