Ending HIV/AIDS in Africa: Reflections from the Clinic, Field and Classroom
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Date
2023-08-10
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University of Ghana
Abstract
The first case of AIDS was first identified in early 1980 in Los
Angeles, USA with patients showing evidence of severe
immunosuppression. In 1981, the syndrome was described and
the virus was subsequently isolated in 1983.
There are two types of HIV. HIV-1 is the predominant type found
all over the world. In addition, HIV 2 is found in the West Africa
region. HIV 2 is less virulent compared to HIV 1. In Ghana HIV 1
accounts for almost 98% whilst HIV 2 alone or in combination
with HIV1 account for approximately 2%.
The origins of HIV range from several conspiracy theories to
divine retribution.
Viruses related to HIV-1 have been isolated from the common
chimpanzee and several monkey species. There are different
clades of HIV -1. Ranging from main group M made up several
clades to the outlier O group.
Simian immunodeficiency virus of sooty mangabeys (SIVsmm) is
recognized as the progenitor of human immunodeficiency virus
type 2 (HIV-2).
SIV infection in humans has been documented. A paper by
Marcia Kallish on Emerging Infectious Disease in 2005 among
Central African hunters, showed a prevalence of 17.1% in the
most exposed, that is those who hunted and butchered or kept
non-human primates.
There are about 39million people living with HIV. 20.8 million
of them are in East and Southern Africa, 4.8million in West and
Central Africa. UNAIDS update in 2023 estimates that a life is lost every minute due to HIV. This is equivalent to 650,000
HIV related deaths. In addition, there are 4,000 new infections
daily. Every week, 4,000 adolescent girls and young women get
infected, while 84,000 children died of HIV last year. Subsaharan
Africa accounts for 51% of all new infections. 76% of people living
with HIV are on treatment. Unfortunately for children, only 57%
are on treatment. Key populations account for less than 5% of
the world population but 70% of new infections occur among
them and their sexual partners, underlying their vulnerability
and a call to action.
In 2002, the HIV treatment project called START was birthed
through a collaboration of Family Health International and the
Ministry of Health. The funding was to start the first 100 patients in
St. Martin’s Hospital in Agomanya and Atua Government Hospital
in Atua in the Manya Krobo District, on antiretroviral therapy.
Following the overwhelming success in the pilot project, the
then UK Department for International Development moved to
support the programme. Subsequently the national treatment
programme secured funding from USAID, Global Fund and the
World Bank. The success was attributable to the commitment
of health care workers, facilities, and use of evidence based
approach.
The experiences in treating persons living with HIV from the
pilot project allowed the development of practice guidelines
on the management of side effects like anaemia, peripheral
neuropathy, hepatoxicity among others. Antiretroviral therapy
made a huge difference in the life of individuals. There was a
reduction in morbidity and mortality. It was clear that patient
level strategies at the clinic was effective, however many persons
living with HIV did not have access to treatment. This required
radical change in mindset to transfer the benefits observed at the
clinic to the population level, particularly in countries with high
HIV prevalence or population. This influenced our intervention strategies particularly in Eastern, Southern Africa and Nigeria
and marked an important transition in my career by moving the
advantages observed in the clinic to the population level.
In Zambia, we implemented the adherence support worker
strategy to address the human resource challenges. Adherence
Support (Models of Hope in Ghana) are persons living with HIV
who are trained to offer adherence counseling and follow up.
We showed that the adherence counselling provided by these
lay providers was comparable to that provided by nurses.
We were also able to demonstrate that HIV testing using lay
providers was comparable to testing service by nurses. This
important evidence provided a strong basis for task shifting
efforts to expand access to HIV services across sub-Saharan
African countries.
HIV in children is a blot on the conscience of humanity. This is
because we have the knowledge and the strategies to eliminate
pediatric HIV Elimination of Mother to Child Transmission in
Africa. Mother to child transmission of HIV can take place during
pregnancy, labour and delivery and during the breastfeeding
period.
In an observation study of over 28,320 HIV positive mother baby
pairs from 317 facilities and 40 districts in Zambia, we observed
that HIV transmission was lowest among those where baby and
mother received prophylaxis and highest among those who did
not attend antenatal clinic. In addition, mothers who received
the drugs were less likely to transmit HIV to their babies. Women
who practiced mixed feeding were likely to transmit HIV to the
babies. Other early infant diagnosis studies that we conducted
in Kenya and Malawi affirmed this fact. Majority of pregnant women screened at the antenatal clinic
would test negative. Unfortunately, several of them would seroconvert during the pregnancy because of repeated sexual
exposure. In our published work in JIAPAC, we were able to show
that pregnant women who seroconverted during pregnancy
were four times more likely to transmit the infection to the
baby. HIV re-testing among seronegative mothers is essential in
eliminating HIV.
Key populations are defined groups who, due to specific higher risk behaviors, are at increased risk of HIV, irrespective of the
epidemic type or local context. Also, they often have legal
and social issues related to their behaviors that increase their
vulnerability to HIV. The key populations are important to the
dynamics of HIV transmission. UNAIDS describes five main
groups as key population. They include the following; sex
workers, men who have sex with men, transgender people,
persons who inject drugs and prisoners as well as other
incarcerated people. Key populations account for less than 5%
of the world’s population but about 70% of new infections in
2021. In sub-Saharan Africa, 49% of new infections are among
the general population, 41% are among sex workers, clients of
sex workers and sexual partners of other key populations and
6% among men who have sex with men. In terms of relative
risk, for persons who inject drugs the risk is 7X higher, 4X higher
among sex workers, 11X among men who have sex with men
and 14X among transgender people.
A strong HIV programme can only do well in a strong health
system.Globally, official development assistance for HIV from
bilateral partners apart from the US Government has declined.
The World Bank projects that 52 countries, home to 43% of people
living with HIV, will experience a significant drop in their public
spending capacity through 2026. The role of domestic financing
of HIV programmes will become very crucial. Ghana must make
urgent steps to increase its domestic contribution to HIV not
only to provide services to its people but also demonstrate its commitment to the national response. The approval and
operationalization of the National HIV/AIDS fund will be a step
in the right direction. As a teacher, building capacity of the next
generation of implementers and scientists in HIV programming,
is an area of great importance. Currently our training grants and
scholarships, programme related research and evaluations seek
to give hands on experience in programme implementation to
our beneficiaries.
The use of long-acting agents in HIV treatment is another
interesting area. Evidence from LATTE 1&2, FLAIR and ATLAS
studies has shown that long acting Carbotegravir and Rilpivirine
administered monthly or bimonthly are effective compared to
the standard of care for treatment. Carbotegravir and Rilpivirine
also known as Carbenuva, was approved by the US FDA in
January 2021 for two monthly dosing. Lenacapavir is an exciting
new drug that was approved in the European Union and UK,
recently, in August 2022 for drug resistant HIV. It belongs to
capsid inhibitors group. It can be given 6 monthly.
Can we end AIDS in Africa? To get into the right trajectory to
end AIDS in Africa, we need to attain the state of epidemic
control. Epidemic control of HIV is when the number of new HIV
infections in less than the number of HIV deaths. This will lead
to a gradual decline of persons infected with HIV. In 2022, West
and Central Africa had 160,000 new HIV infections with 120,000
HIV deaths. In Eastern and Southern Africa there were 500,000
new infections and 260,000 deaths. Back home in Ghana, there
were 17,000 new infections and 9,900 deaths in 2021. Eswatini,
Botswana, Rwanda, Tanzania and Zimbabwe have achieved the
95-95-95 whilst eight others are on track to reach the target.
Achieving epidemic control requires systematic reduction of
new infections in the Africa region.
Description
Inaugural lectures