27-10 Asia and Africa: Different Trajectories - Vanessa Dang

Although all three articles were interesting, in particular Jon Cohen’s Asia and Africa: On Different Trajectories? made me realize the extent to which we, as a population, have enabled HIV/AIDS to spread quickly from individual to individual. After learning a little about epidemics and their relation to ecology in the HumBio core, I really appreciated what this article reported. First of all, if we return to the beginning of this course when we learned how human expansion allowed for the transmission of SIV to humans, then I think we can see how devastating some of our behaviors have been to ourselves. This article expands on this idea by contrasting how HIV affects Asia and Africa differently – and how our (different) behaviors in both continents contribute to the continued spread of HIV. Joh Cohen identifies a number of high-risk groups and behaviors that put China and India in a category of potential disaster; but the drivers that put Asia at risk are different than those in Africa.

While we have already learned quite a bit about these different risk factors, I was particularly struck by the prevalence of intergenerational sex in Papa New Guinea: 30% of sexually active women between the ages of 15 and 24 report having sex with men who are older by 10 years. On the other side of the fact that we have contributed to the spread of various epidemics, we can also change our behaviors to prevent further spread – whether we realize it or not. For example, Masahiro Kihara’s studies show that Japanese and Thai women between 15 and 21 are more sexually active than previous generations. However, one person points out that if these women are having sex with men their same age, and there is actually an increase in the number of women having sex, then presumably fewer men their age are going to sex workers. Consequently, since a larger clientele for sex workers corresponds with faster HIV transmission, the increase in women having premarital sex could actually result in a lower transmission rate.

The second example I found interesting was the two different cities, relatively close in proximity to one another, that each had a different subtype of HIV. This example especially points to the connection between our behaviors and the propagation of epidemics: both cities lie on two different main roads, which are primary routes for heroine trafficking. Thus, we have a case of human movement and human culture (drug-use) that have worked together in spreading HIV/AIDS.

In either case – Asia or Africa – we seem to do things that contribute to the spread of HIV/AIDS. At the same time, if we can ensure safe sex and other safe behaviors through prevention and intervention programs, especially in up and coming areas, then we can hopefully prevent HIV/AIDS from spreading to currently unaffected areas.

10/28

I was shocked by the variety of adverse events that can occur during HAART treatment. In under-served populations already lacking in basic adequate healthcare, some of these deficiencies could prove almost as harmful to quality of life as infection with the HIV virus in the first place. Some, like hepatitis, pancreatitis, and anemia, could interfere with basic health by limiting proper nutrition through inadequate digestive function. Others, like a rash, seem less harmful from a medical standpoint, but could contribute to the augmentation of the preexisting sigma surrounding HIV positive individuals. Indeed, 79.3% of individuals who developed a rash (arguably less dangerous than many of the other conditions) stopped treatment within the first month.

I did not know what some of the adverse events mentioned in this article were; so I did some research. Lactic acidosis, experienced by 24.4% of women who stopped treatment, is a buildup of lactic acid in the blood that can cause gastrointestinal symptoms. The underlying cause of this phenomena when caused by antiretroviral drugs is mitochondrial toxicity. Apparently, NRTIs can interfere with an enzyme needed in the production of mitochondria, leading to a significant decline in their number, and less efficient conversion of cellular energy as a result.

SJS, also mentioned in the article, is an epidermal disease that is also caused in most cases by adverse drug reactions. The disease is often misdiagnosed early on as the patient develops lesions in the mucous membranes, and then the patient's skin can actually begin to separate from the lower layers of the dermis. The condition can be life-threatening if not diagnosed and treated in time.

Lipodystrophy is an often unavoidable side-effect of antiretroviral treatments, wherein the patient precipitously loses fat from the face, sometimes developing lumps in the back of the neck.

Peripheral neuropathy is damage to the peripheral nervous systems. In this case, the toxicity exhibited by many of these drugs leads to neurochemical dysfunction. This can manifest itself in a variety of ways, from numbness or tingling to loss of function and partial paralysis. Certain antidepressant drugs meant to work in the CNS have been shown to reduce the incidence of pain related to peripheral neuropathy, but, once again, diagnosis is key.

As stressed by Kumarasamy et al. in this article, it is clearly critical for clinics to monitor for early signs of toxicities in their patients. Admittedly in resource-limited regions, this prospect seems daunting at best.

Katie Nelson

Restoring Zimbabwean’s Health Care.

Kesaobaka Modukanele

BLOG POST FOR TUESDAY OCTOBER 27 2009

Rebuilding an entire nation from scratch is a daunting thought. What took 29 years to be established is definitely not going to take a few years to re-establish. This article focuses on ways to revive Zimbabwe’s health care through a national and international approach. Some of the international initiatives that this article proposes include international advocacy from resources such as the Global Fund, the UN and the WHO. At national level, the article’s focus lies in encouraging doctors that had emigrated from the country to return,“retaining user fees at local level”, launching a “100-day action plan and craft a budgeted, medium-term health-care recovery plan” , training healthcare professionals, and tackling the country’s human rights issues. All of these are excellent proposals in my view. However, I fear that it might be a bit idealistic to tackle health care issues from a national level. I will focus my discussion on the unrealistic proposal of "encouraging” doctors to return to Zimbabwe.”

In a place where a government doctor’s salary has fallen to a mere $1 per month, where doctors are harassed for treating some victims of violence, holding on to the hope that “the Government will remove bureaucratic hurdles” is not enough to encourage the return of professional Zimbabwean doctors. Zimbabwe has now become to Africa, America’s Haiti, which faced very similar problems of political upheaval drowning the country’s health care system. In such countries, it is not worth it trying to impact health care change from a national level, but rather from a community based approach, a point that this paper only makes in passing. In Haiti, doctors like Paul Farmer, who took a personal risk of restoring healthcare have really made an impact. It was through his initiative to found Zanmi Lasante, that adopted a community based approach at healthcare did change became evident. Paul Farmer’s Partners in Health intiative made access to primary health care more accessible by firstly, getting rid of user fees, which usually resulted in empty clinics. Furthermore, PIH incorporated community members, who could be “family members, friends, or even patients, to provide health education, refer people who are ill to a clinic, or deliver medicines and social support to patients in their homes (PIH)”. These community health workers acted as an interface between the clinic and community. Also, PIH tried to address basic social and economic needs of communities in addition to tackling their health problems. I believe that change is not dependent merely on availability of funds and doctors, however, it also lies in the work of social workers who meet the community’s needs through public service.

For these reasons and many more, I believe that a Zimbabwe’s approach should be more community based rather than national. Obviously it would take brave doctors like Dr Paul Farmer, who are willing to take such risks, to implement initiatives like this. However, talking about change on a governmental level is not worth it at this point.

10/28 Readings: HIV/AIDS in Asia vs. Africa

Most of the stories that exist about HIV/AIDS only talk about how it has been ravaging Africa but many forget that this disease is a pandemic, that is has been affected other countries that are only a close scale to some African countries when it comes to limitted resources and social and economic infrastructure. India and China are obviously not on the same scale as most African countries but they do have large populations of people who live at a poverty level and in these societies, HIV/AIDS comes with almost as much baggage as it does in Africa: the stigma, limited resources, limited access to effective treatment that is expensive, just as many opportunistic infections. The Adverse Effects articles was interesting because it focused on two subjects that are not the public eye does not always see in the literature: negative affects of some antiretroviral treatment cocktails and its patterns in India. I had no prior knowledge of the negative effects of the generic HAART drugs; one only hears that they inhibit the HIV retrovirus at many points and that they increase a person's survivorship, which they do but not without negative consequences. The others continually expressed that it was generic HAART initiation that caused adverse affects (56%) in a cohort study where 50% developed anemia, 41% IRS, 42% rash, 76% SJSand 60% hepatis all within 12 weeks of initiation. And yet, the World Health Organization only recommends checking hemoglobin and liver enzymes if symptoms develop? Unfortunately, by the time symptoms develop, the patient might be more at risk; for instance, anemia is a significant precursor of AIDS disease progression and increases the HIV patient's risk of death. Therefore there needs to be earlier monitoring of hemoglobin and liver cells as the authors conclude.
The second article "Asia and Africa: On Different Trajectories" I found very interesting. It went more indepth into the HIV/AIDS path in Asia than any article i've read about HIV/AIDS in Asia. It is definitely an eye opener because when you think of HIV/AIDS spreading across the world, you, the average person, might assume that it is the same from continent to continent. But just as it is different from country to country in Africa, it is different from continent to continent primarily because it is more concentrated in high risk groups such as IV drug users, sex workers and gay men in Asia. It is interesting to thing that even if HIV/AIDS does not become an general population epidemic in Asia as it has in Africa, the number of people with HIV/AIDs in Asia could possibly surpass that of HIV+ positive Africans just because most Asian countries are densely populated and a mere 4% of the population actually represents a huge 25 million people. The big difference between the HIV/AIDS distribution in Africa as opposed to Asia teaches us alot about the dynamics of this virus: how it takes advantage of the resources(IV drug users, sex workers, gays, heterosexual sex) that are available: it seems to know which "resource" is more common from country to country and continent to continent and which will spread the disease the most number of people.

10/28 readings

I found the article Asia and Africa: On Different Trajectories? more intriguing than Spectrum of Adverse Events After Generic HAART in Southern Indian HIV-Infected Patients. Spectrum of Adverse Events outlined the side effects of HAART in a group of Southern Indians, showing how results from previous studies, such as that females are less likely to develop hepatitis as males, may not apply to Southern Indians. The study also broke down different chemicals used for treatment and their individual side effects, such as those of AZT and Nephirapine. I found the other article more interesting because I thought this article, although it offered more solid statistics and data as proof, showed that the chemicals used to treat HIV can have various side effects, something that I already knew. It is why treatment cannot be started at the onset of HIV (Inducing mutation of the various strains of HIV is another reason). On the other hand, the article contrasting Asia and Africa concluded that AIDS in Asia may not necessarily follow the same path and reach as high of a prevalence as in Africa. First, HIV in Asia is more concentrated, mostly in drug users and sex workers, groups that can be targeted specifically for HIV prevention. Another reason is because Asia was hit after Africa, which makes all the difference since now we understand various ways on how to prevent an AIDS epidemic. This is one of the points that John Iliffe made in his book The African AIDS Epidemic. I thought the article was relieving to read since I was worried, after the very first reading assignment, that Asia may be the next to experience a full blown AIDS epidemic that can be as horrifying as Africa. Though the article does not necessarily conclude that AIDS cannot possibly have as high of a prevalence in Asia as Africa, it expresses hope that something, such as targeting specific groups, can be done so that this will not happen in Asia. That was what I found most intriguing about this article, though it may not offer a detailed study like the other one did.

10/28 Readings

In attempting to discuss the future of healthcare in Zimbabwe, Todd, etc. first discuss the dramatic decline in health services and national health statistics between 2000 and 2005. The deterioration of health infrastructure in particular struck me as incredibly dramatic; from the statement that "hospitals in the country were hardly operating" to the fact that Zimbabwe's primary medical school was in fact closed for six months. This article focuses on infrastructure throughout its discussion of Zimbabwe's healthcare future, whether that infrastructure be directly related to health facilities or indirectly related to healthcare. As the authors point out, progress in improving national healthcare will be severely limited unless Zimbabwe's political situation stabilizes and the country is able to re-establish its agricultural infrastructure and its education and water systems. While international funding can quickly supply short term supplies and drug supplies, the key to Zimbabwe's future lies in the process of rebuilding its medical training systems, its health facilities, and its overall basic infrastructure as a country. The authors emphasize the importance of a broad-based, interdisciplinary approach to the problem, identifying the need for human rights organizations and political legislation in the struggle towards improved healthcare. Overall, the article makes it clear that the road to quality healthcare in Zimbabwe will be difficult; however, with a multi-disciplinary approach and significant international support, Zimbabwe's healthcare system can begin to recover. 

Before reading "Spectrum of Adverse Events After Generic HAART..." I was unaware of the extensive appearance of severe side effects due to anti-retroviral drugs. The authors of this study allude to the issue of side effects and their impact on patient adherence to drug regimens, and this is an issue that would be interesting to explore further. I am curious as to how improvements in ARV drugs that could eliminate side effects would impact adherence rates. Improved drugs could potentially dramatically increase adherence and thus success of ARV treatment while also preventing the resistance that results from inconsistent adherence to drug regimens. 

10/28 Reading (Jon Cohen Article)

From this week’s Jon Cohen article, it’s unclear as to Asia’s future in the HIV AIDS epidemic. In fact, reports can go drastically from one end of the spectrum to the other. Some, like Berkley’s James Chin, believe that a huge Asian outbreak in HIV AIDS isn’t possible, while others, like Tim Brown, believe that given some time – and not that much time at that – Asian will rival Africa in HIV AIDS infections.

Both sides offer good supporting evidence. Chin states that many of the factors involved in the high spread rate in Africa don’t apply to Asia, such as: male circumcision, high rate of multiple sex partners (except for small pockets, which are huge, like sex workers). In addition, Chin explains that heterosexual sex has not been a huge contributing factor in Africa, so why should it be in Asia? However Brown has a different theory. He claims that at the very least the numbers of HIV AIDS infected people will be the same. Perhaps this large number masquerades in a low statistic, but that’s just because China is so large. 15% of China is still almost 200 million people. That’s far more than Africa’s 35 million.

Although both contradicting arguments bring lots of good evidence to the table, they share one thing in particular. Both attribute the large influx in Asia’s HIV AIDS epidemic in recent years to injected drug users (IDUs). This is clear through statistical proof from both sides, no matter what is proposed for the future. Although future plans for China and India in particular are unknown and with differing predictions, with this information, it is imperative that countries with low HIV AIDS rates begin preventative measures with IDUs. No matter what Asian countries with high HIV AIDS prevalence now has in the future, those without can be helped now, by addressing and helping preventative measures with IDUs.

Reading Response for 10/28

Paying attention to drugs' side-effects is always important, but judging by the implications mentioned in the Kumarasamy paper, attending to side-effects seems particularly important in HIV/AIDS cases. After experiencing adverse reactions to HAART, many patients discontinued, changed, or interrupted their drug regimen. Not only does this harm the patients' health, but it also can allow the HIV virus to develop resistance, which in turn makes effective treatment even more difficult and/or costly. The article referenced increased hepatitis cases for patients taking NVP regimens - what kind of hepatitis is referred to? Is it the viral A/B/C varieties or is it some other kind of liver disease? It is clear that these potent drugs are pretty hard on a person's liver already, so the development of hepatitis in addition must be quite serious. My other question in regard to this article is if there is any significant difference between the generic HAART that was the subject of this study and the "name brand" HAART that is given in developed countries.

Two of the most interesting statements from the Cohen article were "Whatever we come up with, we always find a big exception in Asia" (Peter Piot, head of UNAIDS) and "It would be wise to assume the worst rather than best" (Richard Feachem, epidemiologist with The Global Fund). The first statement speaks very well to the complexity of the HIV/AIDS epidemic, especially as people attempt to apply lessons learned in one region of the world to a completely different cultural context. Perhaps some of the "exceptions" come up because Asia is anything but a simple entity unto itself. Though this statement seems to lump "Asia" into one category, I thought the article did a pretty good job at exploring the cultural and epidemiological nuance within Asia.

I found the second statement by Dr. Feachem interesting because of its implications for policy. Clearly it is a good idea to be prepared for the spread of the epidemic, but I can see that some people would be quick to point out the practical disadvantages of "assuming the worst." Policy makers have to weigh the risk of the HIV/AIDS epidemic against the risk of other public health problems. Limited resources (which are even more limited in the less developed countries in Asia) mean that everything put into HIV/AIDS prevention or treatment programs cannot be used as easily for other public health goals. Ideally, HIV/AIDS measures would contribute to health in other areas as well (i.e. families have access to clinics, people are more aware of sexual health issues, etc), so perhaps the "limited resources" argument is a bit ill-founded. In any case, this statement caused me to wonder if over-preparedness is necessarily a good thing.

Reading for 10/21

I found the reading for this week interesting in the sense that it highlights the difficulty of making a direct conclusion from a set of collected data. For instance, the report starts out by mentioning that even in Uganda, there are controversies surrounding whether the decline in HIV prevalence was directly correlated with behavioral change because of the representativeness of data from pregnant women attending antenatal clinics, saturation of infection and mortality within high risk groups, and paucity of data linking the decline in HIV prevalence to the adoption of safer sexual behaviors. These possibilities could undermine the connection between a decline in HIV prevalence and change in sexual behaviors that we have based most of our policies to reduce the amount of HIV incidence for the past few years. In many studies, perhaps especially with HIV, there are always various doubts surrounding the conclusion drawn from the data collected and the accuracy of the data itself, for example whether the sampled group is representative of the population itself. This article is interesting in that it takes another set of data from Zimbabwe that shows a direct correlation between a change in risky sexual behavior and a decline in HIV incidence to demonstrate that there is indeed a correlation. Hence, from the data in Zimbabwe, we can conclude that there is actually a relationship between the two and that our current health policies do not need to be revised. At the same time, instead of directly confronting the controversies surrounding the data collected from Uganda, Simon Gregson uses data collected from Zimbabwe to show that there is indeed a connection between HIV incidence and behavioral change. Therefore, the controversies surrounding the Uganda studies are trivial in that the conclusions drawn from the Uganda studies are accurate even though the studies may not have been perfectly designed to study and draw a conclusion from HIV prevalence in Uganda. I found this approach to the controversies very intriguing.

HIV Decline Associated with Behavior Change Response

This past reading was interesting for two reasons. The first was the actual tangible information they found. In essence it was a reiteration of what had been stated before, that condom use, fewer sexual partners, and a later sexual initiation was crucial to lowering the spread of HIV AIDS. Although this was no new news, it was excellent to see a different perspective of charts and graphs. This part of the data then brings us to my second intriguing factor: how these positive traits stem from different behavior. What are these behaviors and are they applicable to the spread to different regions.

However what was far more interesting to me was the ability for members of a community to challenge (in such a critical yet constructive way) each other and their findings. This came at the very beginning and stayed throughout the article.

Although much of the information listed above was and is perceived as good, it was relieving to find that people don’t just take the good information at face value. Instead, they critically examined how this data came to be in hopes of finding the cause as well as to see whether or not it’s applicable to the general hypothesis. This is crucial when remembering that correlation does not necessarily equal causation. As demonstrated above this became very important in examining this specific set of data. We can only hope that this form of critic can be converted to all types of research in all areas of science.

Behavior and the Decline of HIV/AIDS in Zimbabwe

Change in sexual behavior has led to a decline in HIV prevalence. When it comes to epidemiology of a disease it is important to first define the words that are used because they sometimes have different meanings depending on the topic. In this case, the prevalence of a disease is the measurement of all individuals who are infected at a given time. And the incidence of a disease is the rate at which people are newly infected. Although the authors use both words in their essay, it is more appropriate to use prevalence. It is a statement to claim that the prevalence of HIV has been due in part to a change in sexual behavior because it is a very difficult variable to calculate. Whereas statistical information on the number of drugs that have been distributed or the amount of condoms that have been bought is can be accessible, it is hard to collect data on sexual behavior. A critic would say that there are several reasons why the study results could be inaccurate or inconclusive, some of which Gregson et al listed: migration out of a certain community of study in search of employment and HIV induced death. There could have been false information reported from some individuals and some clinics. However, this is difficult point to prove when as Gregson said, 10 out of 12 sites studied reported the same change over an average of 3 years. Not only that but, the trends seen in eastern Zmbabwe matched those that have been seen on the national level. Therefore, as difficult as the data collection for such an abstract finding might be, the data that has been collected can't not be at least telling of a bigger and bigger leaning toward behavior change as the only definite way of avoiding the disease as an adult. Therefore, change in social behavior is not necessarily the main reason for a the decline of HIV prevalence but that it could be starting to play a larger role in prevention.

Zimbabwe and Uganda changes in HIV/AIDS prevalence are NOT analogous!

Kesaobaka Modukanele

Response to HIV Decline Associated with Behavior Change in Eastern Zimbabwe article

Blog post for Tuesday October 20^th, 2009

The article HIV Decline Associated with Behavior Change in Eastern Zimbabwe delves into the main reasons for HIV prevalence decline in Zimbabwe. Among other factors like AIDS mortality, and reduced fertility in HIV positive women, the study “report[ed] a decline in HIV prevalence in eastern Zimbabwe between 1998 and 2003 associated with sexual behavior change in four distinct socioeconomic strata. (2)” Furthermore, this decline in prevalence rate was observed in more educated groups. The study then mentions briefly that despite the fact that high numbers of young adults migrated in pursuit of employment, there were “no differences in HIV prevalence or sexual risk behavior between migrants and residents at baseline”. It amazes me that the study immediately compares Zimbabwe’s case to that of Uganda – attributing all of the changes in HIV/AIDS prevalence to an overall change in risky sexual behavior. I do think there are variables that are not being taken into consideration. During the time of this study, Zimbabwe was going through intense political turmoil. My inclination was that any decline in HIV/AIDS prevalence rate would be because of the heavy migration patterns in Zimbabwe. According to an article I read in The Zimbabwe Independent, Zimbabwe’s leading business weekly newspaper, as of 2006, and population in Zimbabwe declined by 4 Million people! This decline is definitely not due to immediate migration but rather, many Zimbabwean residents had gradually left the country, fleeing harsh political and socio-economic condition, to neighboring countries like Botswana and South Africa. Therefore, my impression was that this study, although it did observe changes in sexual behavior patterns among the middle aged Zimbabwean population, did not do enough investigation on other factors that might have actually led to the decline in prevalence rate. In other words, the study convinces me that sexual behavior patterns in Zimbabwe did change between 1998 and 2003, but it does not sufficiently convince me that the decline in HIV prevalence rate was predominantly due to this change in behavior. To me, this article vaguely touches on other factors that may have contributed, such as migration patterns in Zimbabwe.

Is Zimbabwe's HIV Incidence Really Declining?

10/20 Post
Katie Nelson
When I first read this article, which stated that behavior change, such as wearing condoms, later sexual debuts, and fewer sexual partners, caused declining HIV prevalence in Zimbabwe, I was excited. Then I read the final paragraph, where Gregson talks about Zimbabwe's "well-educated population...good communications...and health service infrastructure", and saw that this article was published in 2006. Zimbabwe's political and economic situation has been in decline since the 1990s, but has only reached crisis proportions in the last five years. I worry that the results published in this paper are no longer accurate in the context of current events in Zimbabwe. In late 2005, President Robert Mugabe initiated a crackdown on illegal trade and slums, forcibly removing people from their homes and leaving much of Zimbabwe's urban poor homeless. A subset of the population already predisposed to a high incidence of HIV infection, removing them from the political and social infrastructure has contributed to current health crises, as well as disrupting the ARV treatment of some already living with AIDS. Additionally, more displaced women are now turning towards work in the sex trade in order to make a living. Additionally, can figures stating that HIV prevalence is on the decline in Zimbabwe now be trusted, now that it many people are now homeless, and no longer able to be surveyed, or have now died due to lack of treatment?

2008 saw a massive cholera epidemic affecting nearly a hundred thousand people, due to the near-collapse of Zimbabwe's health and sanitation systems. Because of severe inflation and a lack of government support, there is a dangerous shortage of healthcare professionals in Zimbabwe. Hyperinflation has caused four major hospitals to shut down and intense shortages in necessary drugs and supplies. Additionally, chronic food shortages mean that people already suffering from AIDS are more vulnerable to opportunistic infections in their malnourished states, and some studies suggest that ARV treatment is less effective in under-nourished people.

Education and Behavior Change

Rachel Kelley
Blog for 10/21 class

To prepare for our class/guest speaker tomorrow, I checked out the TeachAIDS website and watched some of their animated videos about HIV/AIDS. I was impressed! The videos used several techniques to deliver the message effectively - repetition (or phrases and images), symbols/analogy (related the immune system to a defensive army with army commanders being the CD4 cells), an interactive format (a quiz was included), and colorful and engaging animation, just to name a few. The doctor/teacher figure in the video is authoritative, but by asking questions and praising the patient for wanting to learn, he/she also seems approachable and caring. The progression of the video also makes a lot of sense. It starts with a doctor-patient scenario, then progresses to explain why it is important learn about HIV/AIDS, how someone gets infected, how to know (or not know) if one is infected, how to protect against infections, why testing is important, and what people can do to help. I'm interested to learn more about the development of this project in class tomorrow!

These videos seem like a great tool, but as the Gregson article suggests, behavior change can be a long process that involves entire communities. The article discusses the ambiguity of the causes of HIV decline in Zimbabwe; it seems to be neither optimistic nor pessimistic about the future of the epidemic there. We have been discussing behavior change as it relates to health education in local clinics in another one of my classes, so it was interesting to read about behavior change in a related but different context. Measuring the impact of "behavior change" is even difficult here in the US because of the interpersonal/social factors that are nearly impossible to control. Also, people have different stages of willingness and ability to change, so behavior change is often a scaled rather than an either/or response.

The Gregson article concludes by listing some of the factors that might have contributed to behavior change. I'm curious to know more about the various measures, particularly which one is estimated to have had the greatest effect. Given the ambiguity of the data, however, perhaps it is difficult to make such an estimation. Also a random question - why are the discussed age groups of women (15-24)and men (17-29) different? Wouldn't this inconsistency make it harder to easily compare the two groups?

20/10 - Behavior change - Vanessa Dang

Since I spent much of this past summer providing education and encouraging behavior change, I was excited to read this report on how effective it actually is. From the start, Gregson lists many of the reasons why some people believe that behavior change is not effective, or at least why we lack data that fully correlates a decline in HIV prevalence with behavior change. While I expected Gregson to provide sufficient evidence to override these claims, it seemed like he served more to support than to refute them. For example, after reporting the changes in behavior, Gregson finishes the article by discussing the impact of selective migration on HIV prevalence and then stating that ‘HIV prevalence reflects the accumulation of infections over a period of more than 10 years and is insensitive to behavior change.’ Based on these statements/reports, I didn’t feel fully convinced that the decline in HIV prevalence was due to behavior change.

At the same time, the 49% decline in HIV prevalence in women aged 15-24 years impressed me, however, it remains unconvincing that Gregson could use this drastic change with other statistics to indicate that behavior changes are the underlying reason for the decline. While I would have been more convinced if Gregson had refuted the various controversies behind the association of HIV prevalence decline with behavior change, I am still pleased with the report on the new, safer sexual practices in Zimbabwe. These changes really are impressive, especially considering a window of only 3 years, and are perhaps a good reason for continued education and behavior change/life skills education as a means of prevention.

Unrelated note: I was surprised to learn the reasons behind why HIV-infected men have a higher mortality rate than HIV-infected women. Gregson explains that men are generally older when they are first infected, due to engaging less often in risky sexual behaviors. I am curious what ages he is referring to, because it makes a difference in terms of how/why/when this change from safer to riskier behaviors occurs: when Gregson refers to ‘early-age,’ is he referring to teenagers who have not yet engaged in sexual activities, or is he referring to twenty year-olds who are practicing safe sex?

Response to HIV Decline in Zimbabwe: 10/19

While this was not the primary topic of the article on HIV decline in Zimbabwe, I was struck by the fact that HIV infection reduces fertility in women and chose to explore why that is the case. According to infoforhealth.org, studies show that the impact of HIV infection on female fertility is greatest in women at later stages of HIV infection and in women with high viral loads. However, pregnancy itself has not been shown to increase the rate of progression of HIV/AIDS. According to a United Nations report on HIV/AIDS and fertility in Sub-Saharan Africa, fertility rates in infected women are 25-40% lower than in uninfected women. The report also states that this lower fertility rate is largely due to biological mechanisms, rather than behavioral mechanisms. Biological mechanisms affecting fertility in HIV infected women include decreased sperm count in men, effects of co-infection with other sexually transmitted infections, and higher rates of both early and late fetal loss in infected women. While it is not surprising that HIV, which so dramatically affects the immune system and is tied to the reproductive system, would impact fertility in a biological manner, the United Nations report analyzes several behavioral factors in reduced fertility as well, which I found interesting. The ways in which HIV infection changes sexual behavior and fertility desires are numerous and complex, adding yet another element to the factors affecting the spread of the disease.

I also found it very interesting that the article on HIV decline asserted that HIV prevalence rates are “insensitive to behavior change” due to the lengthy incubation period of HIV infection. Thus the goal of attaining accurate data concerning the affect of behavioral interventions on HIV prevalence is very difficult to achieve, for prevalence rates and positive behavioral changes do not necessarily correlate.

Reading for 10/14

After reading the three articles, I thought the one that compared the Mwanza and Rakai trials was the most interesting of the three. Without that article, I would have concluded that the two trials have contradicted each other and that intervention in sexually transmitted diseases may not actually be a major factor in reducing HIV incidence and prevalence. The data collected from the Mwanza trials may have been a coincidence in that STD prevention works particularly well in that region, but may not be as effective elsewhere. However, after reading the comparison article, I realized that a conclusion can be drawn from the two seemingly contradictory trials, since the trials were conducted so differently. The article explained that the two regions were in different stages of the AIDS epidemic in that HIV prevalence was much higher and more stable in Rakai compared to Mwanza. Thus, STDs will have less of an effect on HIV incidence in Rakai compared to Mwanza and it will be inherently more difficult to reduce HIV incidence by STD prevention. In addition, herpes simplex virus type 2 (HSV-2) was much more common (45%) in Rakai than in Mwanza (<10%). This disease is untreatable, accounting for the fact that STD treatment in Rakai was much less influential to begin with so that it had almost no effect on HIV prevalence. I thought the most striking conclusion from this article is that it shows how STD prevention should be implemented into HIV prevention strategies and that the differences in STD intervention methods used in the two regions was the determining factor for whether HIV prevalence was reduced significantly. This has the most impact on HIV prevention policies in the world today. Instead of using mass treatment like in Rakai, we should instead use the Mwanza trial’s method of intervention, because the article shows that the method of intervention was the key determining factor that changed how effective the intervention was in decreasing the prevalence of HIV.

Mwanza v. Rakai

The most striking point to me in the Grosskurth article comparing the results of the Mwanza and Rakai trials was the difference in treatment in the two trials between treatment of symptomatic STDs. In the Rakai trial, which showed a lesser correlation between treatment of STDs and decreased prevalence of HIV, treatment of both symptomatic and asymptomatic STDs was provided periodically, not regularly. In Mwanza, in contrast, treatment of symptomatic STDs only was provided regularly, and a stronger correlation between treatment and decreased prevalence was observed.

This distinction seems fairly obvious--- symptomatic diseases means that they are more likely to cause inflamed lesions, which naturally would be more likely to prompt the spread of HIV. I understand that for the sake of the integrity of the experiment it was probably necessary to be more general in the course of treatment, if solely to get a more broad set of results. But, as in the Rakai trial, if the end result of the experiment is a more generalized trend that shows a lesser correlation than a more specific experimental design would show, I feel that it has not served its purpose. The results of the Mwanza trial are more helpful-- they indicate that STD intervention CAN be helpful to prevent the spread of HIV. The Mwanza trial also indicated another principle of medical care that I thought was fairly self-explanatory-- long-term, regular treatments are more beneficial than sporadic mass treatment campaigns, as in the case of the Rakai trial.

13-10 Vanessa Dang HIV Prevention

Malcolm Potts’ article presented shortcomings of some current HIV prevention methods; his criticism of these methods surprised me, because he identifies three methods as inadequate that are related to the ABC’s – which are the only three guaranteed ways to prevent HIV transmission. He discredits condom advocacy/education, HIV testing (which is crucial to practicing faithfulness), and abstinence. He presents statistics that show that these three prevention methods, in addition to the others he identifies, do not make vast contributions to decreased transmission rates. However, I still believe that these methods are worthwhile investments – especially those that involve behavior change. I agree that in light of his evidence for effective HIV prevention methods we should re-evaluate the distribution of funding; perhaps focusing on providing circumcisions for men. Potts does acknowledge that implementation of safe sexual behaviors is a necessary component of circumcision, which also makes me wonder if there is any evidence that circumcision has resulted in an increase of risky sexual behaviors, resulting from the fact that it alone greatly reduces the chance of HIV transmission in males. The other three articles regarding STI treatment and HIV transmission were also interesting, especially because of the different results. However, I agree with the article comparing the two studies that STI treatment is vitally important to general public health and that it most likely does coincide with reduced HIV transmission. In all, our readings from this week show that we still have much to do in maximizing the effectiveness of HIV prevention. At this point, I think that all of the methods that Potts identified should continue, even if they are not as effective as others. In general, behavior change is important for all around good health and safety, STI treatment is a necessary component for public health as well, and finally, I believe that research in various areas of HIV treatment could yield good results in the future. I suppose what I am trying to express is that the complexity of the HIV/AIDS epidemic requires the use of as many prevention methods as possible in order to target the widespread contributing factors that propagate spread of HIV/AIDS.

10/14 Reading

The Mwanza, Tanzania and Rakai, Uganda trials were interesting to examine in the scope of the high HIV-1 incidence in Sub-Saharan Africa. Even though some people may see the results of these trials to be contradictory of each other, I strongly agree with Grosskurth et al in that the different results reflect the many different factors surrounding the disease in each of the tested areas. Some of the important baseline factors that might have given rise to the differences such as disease maturity are very significant because the results, might point to the fact that different control and treatment measures need to be used when dealing with HIV-1 in relation to STDs. I believe the important message of these trials and of Grosskurth is that we cannot generalize: what applies to STDs and their influence on HIV-1 transmission and vice versa in one area does not have to necessarily apply to another place because there are several epidemiological, virological, behavioral and environmental differences. Another important point was that policy makers should not necessarily depend on one study to implement action; they must explore many and understand that differences and contradictory information is inevitable. With this insight, they can be more aware and conscious of the decisions they make. One issue I had with these experiments is with the comparison communities. Granted, it is already difficult as it is to do research on humans without breaching ethical and moral decorum. With that in mind, I would still question the ethics in maintaining a certain group without treatment intervention just for the sake of having a control group to compare against a variable group. Even though, as the authors informed us, the comparison communities were eventually given treatment at the end of the 2 years or the 10 months, in that duration several hundred people might have died or gotten infected who might have otherwise not have gotten infected. I realize that control groups are paramount to scientific research but I guess I only point this out to open discussion on what exactly can be done or not done as in this case and still be called ethical.
The Illife reading was very interesting to me because it basically disected national and international involvement in the AIDS epidemic in Africa in a different light. A point I thought was very interesting that he brought it is the idea of how the methods used to approach the epidemic in Europe and the US should have not been used to approach it in Sub-Saharan African because it was not concentrated in certain minorities like homosexuals and iv drug users. This point kind of recalls, the key point that Grosskurth was portraying when saying that the two studies did not contradict each other: there is no one general method of approach. The key is to take into consideration what is going on in a specific place and deal with it in a manner specific only to the area, obviously drawing in relevant information from other approaches. In this light, in the West and the WHO's efforts to fight the epidemic, there is a chance that it might have been propagated to spread even more. Interesting...

10/13 Response to Readings

The primary idea in the Iliffe reading that I found very intriguing revolved around the concept of discrimination and individual patient rights in Western AIDS policy versus African AIDS policy. I had previously viewed the prevention of stigma and discrimination against HIV/AIDS patients as a key component of HIV/AIDS prevention and treatment. However, I was unaware that much of the focus on avoiding discrimination eminated from the work of American AIDS activists and their influence on the WHO. Discrimination should obviously be combatted vigorously in infected communities. Yet I think it is crucial to recognize, as Iliffe suggests, the distinction between discrimination in HIV/AIDS communities where high-risk minority groups define the epidemic versus communities where the epidemic is widespread among the general population. Perhaps the spread of the epidemic in Africa could have been limited somewhat more successfully if Mann's focus on individual rights had not been quite so stridently pursued, and instead had been balanced by concern for the uninfected public.
Iliffe's chapter on "NGO's and the Evolution of Care" also struck me as interesting. As Iliffe discusses, the world had not yet experienced an epidemic in which non-governmental organizations played such a large role before the HIV/AIDS epidemic. Yet, as was the case in South Africa, the role of NGO's was often dictated by the relationship between the NGO sector and the government in any given country. In South Africa, tensions concerning the delayed rollout of ARV's and MTCT regimens under the Mbeki government caused severe rifts between NGO's and the South African government, limiting the ability of the two sectors to work together in fighting the epidemic. The evolution of the home-based care system under various NGO's is just one example of the potential power of these organizations to support and supplement government HIV/AIDS policies. Home-based care seems to have arisen to support a need for care that many African health systems could not provide; however, this system did not provide the complete medical care that most patients needed, and this is where government health systems needed huge improvement.
The primary points that I took away from the Mwanza and Rakai trials were that first of all, sustained health care, or in this case consistent, long-term treatment of STD's, is more effective in combatting the spread of the epidemic than short, mass treatments, as was the case in the Rakai trial.
I was surprised by Pott's assertions that there is little evidence suggesting that condom use and HIV testing have played any significant role in halting the spread of the epidemic in sub-Saharan Africa. These two tenets of HIV/AIDS prevention are so well-established, that I assumed they were supported by significant data. Furthermore, I was stunned by the fact that modeling suggests that male circumcision "could avert up to 5.7 million new HIV infections and 3 million deaths over the next 20 years in sub-Saharan Africa," and found Pott's point that donor funding needs to be redirected towards proven prevention strategies to be very valid. Many other strategies, such as increased condom use, may prove very effective in the future, but international focus should remain on prevention strategies that are backed by significant data.

STDs and HIV

Rachel Kelley
Post for 10/14

Reading about these two studies made me think a lot about experimental design. I knew before that there is a lot to consider when designing an experiment (i.e. controls, privacy issues, sample composition, etc.), but I had not thought about what a logistical feat that these large studies truly are! I can't imagine what kind of organization and planning it must have required to implement the mass testing and treatments of the Rakai study or the concerted follow-up and continuous treatment of the Mwanza study. On top of that, all of the resources (testing materials, antibiotics, etc) needed to be paid for and distributed.

I was a little disturbed by the policy in the Rakai study that failed to treat syphilis-infected individuals. It is true that such individuals were referred to another clinic, but it seems to me that it would have been more ethical for the study to treat them. Certainly the decision is complex because of finite resources of the study as well as their desire not to intervene in the control group. That being said, the study DID have the ability to treat syphilis infections, and the referrals were not as effective at treating infection. I think it is an injustice to allow people to suffer when there is an available means to alleviate that suffering. I much prefer the methods of the Mwanza study because they preserve and even strengthen the healthcare provider - patient relationship and justly treat all who are found to be sick. It also seems that the continuous support of the health care providers is a more effective intervention anyway.

The article that compared the two studies posed some interesting questions and recommendations in its concluding paragraphs. I would be curious to know if any of those questions/recommendations have been addressed in the nine years since it was published. Is there now a better way to treat HSV-2? Is there a better way to screen symptomless women for STDs?

Reassessing HIV Prevention Response

This weeks reading was very interesting to me, as it addressed the very practical part of HIV AIDS: how to deal with it. I personally, was surprised by Malcolm Potts’ (et al) research results. Some of the fundamental HIV AIDS remedies that seem to be the most commercialized and discussed seemed to be the least effective, while others that are rarely discussed were shown as the most effective.

HIV AIDS testing has been a hot topic since the beginning of the research within the epidemic. Even just weeks ago, a new development surfaced about better HIV AIDS testing, both faster and more accurate. However, as described in the article, HIV AIDS testing will be “unlikely to substantially alter the epidemic’s course.” This was surprising to me; as such an emphasis has been placed in funding for better testing. If the article holds true, perhaps resources going into testing should be redirected to more effective remedies.

In contrast, male circumcision, an area talked very little about, was listed as a leader in helping reduce the high infection rate. In fact, the article listed it first in the “what works category.” Other remedies in this category seemed more discussed, like reductions of sexual partners and abstinence. Still, attention should be drawn, even in academic circles, of how these other areas can help reduce infection.

In addition to these observations, I found two other areas interesting, both linked. I was rather shocked that the article made such large claims merely by correlation. As we know from statistics or any experimental based research, correlation does not equal causation. However, perhaps it was just the writing, it seemed as if the authors were inferring that in many situations, the correlations they saw were proof enough to infer causation.

That being said, I though that it was interesting how they went about refuting the natural concepts of HIV AIDS that most people think, including how poverty and other social concepts have a large stake in the diseases course.