The fight to reduce HIV transmission in South Africa is shaped and constrained by complex, interc... more The fight to reduce HIV transmission in South Africa is shaped and constrained by complex, interconnected layers of factors ranging from the political to the psychological. The HIV epidemic reached South Africa a decade or so after central and East Africa providing a window of opportunity within which to implement appropriate prevention and management programmes. However, the apartheid government largely ignored HIV/ AIDS and the post-apartheid government has not risen to the challenge of the epidemic so that South Africa looks set to become the AIDS capital of the continent. Current estimates are that one in five adult South Africans are living with HIV or AIDS and 1,700 more are being infected every day. The highest rates of infection are among those aged 20 to 40 years, the most economically active and also the parents to a new generation of children. While the macro-economic impact of the epidemic will only be known with time, many of the social impacts are more easily predicted. By the year 2010 five million children will have lost at least one parent. Already there are households headed by children as young as nine years old acting as guardians to younger siblings, sometimes with no source of income. Having weathered the trauma of losing parents the high rates of mother-to-child transmission mean that they will now have to care for terminally ill siblings.
Journal of the International Association of Providers of AIDS Care, Jan 28, 2015
Achieving the 90-90-90 targets by 2020 requires increased focus, resources, and efficiency to pro... more Achieving the 90-90-90 targets by 2020 requires increased focus, resources, and efficiency to provide earlier access to antiretroviral therapy (ART). We used 2009 to 2013 National AIDS Spending Assessment data to assess HIV care and treatment spending in 38 high-burden, low- and middle-income countries (LMICs). In 2013, 23 of the 38 high-burden countries spent less than 50% of total HIV spending on care and treatment. HIV spending on ART per people living with HIV (PLHIV; adjusted) averaged US$299 (US$32-US$2463). During 2009 to 2013, a 10% increase in average spending on care and treatment per PLHIV was associated with an increase in ART coverage of 2.4% and a decrease in estimated AIDS-related death rate of 2.4 per 1000 PLHIV. HIV spending in high-burden LMICs does not consistently reflect the new science around the preventative and clinical benefits of earlier HIV diagnosis and ART initiation.
Antiretroviral therapy (ART) prevents human immunodeficiency virus (HIV) disease progression, mor... more Antiretroviral therapy (ART) prevents human immunodeficiency virus (HIV) disease progression, mortality and transmission. We assess the impact of expanded HIV treatment for the prevention of Acquired Immunodeficiency Syndrome (AIDS)-related deaths and simulate four treatment scenarios for Nigeria and South Africa. For 1990-2013, we used the Joint United Nations Programme on HIV/AIDS (UNAIDS) database to examine trends in AIDS deaths, HIV incidence and prevalence, ART coverage, annual AIDS death rate, AIDS death-to-treatment and HIV infections to treatment ratios for the top 30 countries with the highest AIDS mortality burden and compare them with data from high-income countries. We projected the 1990-2020 AIDS deaths for Nigeria and South Africa using four treatment scenarios: 1) no ART; 2) maintaining current ART coverage; 3) 90% ART coverage based on 2013 World Health Organization (WHO) ART guidelines by 2020; and 4) reaching the United Nations 90-90-90 Target by 2020. In 2013, th...
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2014
The global target of tuberculosis (TB) elimination by 2050 requires new approaches. Active case f... more The global target of tuberculosis (TB) elimination by 2050 requires new approaches. Active case finding plus mass prophylactic treatment has been disappointing. We consider mass full anti-tuberculosis treatment as an approach to TB elimination in Kiribati, a Pacific Island nation, with a persistent epidemic of high TB incidence. To construct a mathematical model to predict whether mass treatment with a full course of anti-tuberculosis drugs might eliminate TB from the defined population of the Republic of Kiribati. We constructed a seven-state compartmental model of the life cycle of Mycobacterium tuberculosis in which active TB disease arises from the progression of infection, reinfection, reactivation and relapse, while distinguishing infectious from non-infectious disease. We evaluated the effects of 5-yearly mass treatment using a range of parameter values to generate outcomes in uncertainty analysis. Assuming population-wide treatment effectiveness for latent tuberculous infect...
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2011
The human immunodeficiency virus (HIV) and HIV-associated tuberculosis (TB-HIV) epidemics remain ... more The human immunodeficiency virus (HIV) and HIV-associated tuberculosis (TB-HIV) epidemics remain uncontrolled in many resource-limited regions, especially in sub-Saharan Africa. The scale of these epidemics requires the consideration of innovative bold interventions and 'out-of-the-box' thinking. To this end, a symposium entitled 'Controversies in HIV' was held at the 40th Union World Conference on Lung Health in Cancun, Mexico, in December 2009. The first topic debated, entitled 'Annual HIV testing and immediate start of antiretroviral therapy for all HIV-infected persons', received much attention at international conferences and in the literature in 2009. The second topic forms the subject of this article. The rationale for the use of empirical TB treatment is premised on the hypothesis that in settings worst affected by the TB-HIV epidemic, a subset of HIV-infected patients have such a high risk of undiagnosed TB and of associated mortality that their prog...
The epidemic of HIV in Malawi started early and at its peak 15% of all adults were infected with ... more The epidemic of HIV in Malawi started early and at its peak 15% of all adults were infected with HIV. Malawi is a low-income country and the cost of putting all HIV-positive people in Malawi onto ART, expressed as a percentage of the gross domestic product, is the highest in the world. Nevertheless, Malawi has made great progress and the greatly reduced cost of potent anti-retroviral therapy (ART) makes it possible to contemplate ending the epidemic of HIV/AIDS. Here we consider what would have happened without ART, the No ART counterfactual, the impact if the current level of roll-out of ART is maintained, the Current Programme, and the likely impact if treatment is made available to everyone who is eligible under the 2013 guidelines of the World Health Organization reaching full coverage by 2020, the Expanded Programme. The Current Programme has substantially reduced the epidemic of HIV and the number of people dying of AIDS. The Expanded Programme has the potential to avert more ...
Background Three recent randomised controlled trials [1-3] in Kenya, South Africa, and Uganda hav... more Background Three recent randomised controlled trials [1-3] in Kenya, South Africa, and Uganda have confirmed previous observational studies [4] and ecological experience [5] and demonstrated beyond reasonable doubt that male circumcision performed by well-trained medical professionals reduces the risk of men acquiring HIV through female-to-male transmission by approximately 60% [5,6]. Furthermore, results from the Kenyan trial indicate that the protective effects of circumcision are sustained for at least 42 mo [7], which suggests that circumcision is likely to provide lifelong partial protection. Although the evidence from the randomised trials is compelling, the longer-term population-level impact of introducing or expanding safe male circumcision services within comprehensive HIV prevention programmes remains unknown. Consequently, although some countries with a high prevalence of HIV have held stakeholder meetings and are developing policies on male circumcision for HIV prevention, many have not done so. In addition, the introduction and/or expansion of male circumcision programmes for HIV prevention raises a host of ethical, legal, and human rights issues [8-10]. Furthermore, the introduction/expansion of these programmes could be hindered by weak health infrastructures, scarce human resources for health [11], cultural concerns, political barriers, and financial constraints. In the face of these challenges, some decision-makers in sub-Saharan Africa are asking whether the introduction or expansion of male circumcision services for the reduction of HIV incidence will be cost-effective over the short, medium, and long term. Estimating the long-term population impact and cost-effectiveness of male circumcision programmes requires mathematical modelling approaches. However, when different modelling approaches use different baseline assumptions and input variables, they sometimes produce conflicting results. The Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), and the South African Centre for Epidemiological Modelling and Analysis (SA-CEMA) recently convened three expert group meetings in Geneva (2005), Stellenbosch (2007), and London (2008) to review published and unpublished modelling The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies.
Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the So... more Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the Southern African mining industry Original citation: Campbell, Cathy and Williams, B. (1999) Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the Southern African mining industry. Social science & medicine, 48 (11). pp. 1625-1639.
Background: The Global Plan to Stop TB estimates funding required in low-and middle-income countr... more Background: The Global Plan to Stop TB estimates funding required in low-and middle-income countries to achieve TB control targets set by the Stop TB Partnership within the context of the Millennium Development Goals. We estimate the contribution and impact of Global Fund investments under various scenarios of allocations across interventions and regions. Methodology/Principal Findings: Using Global Plan assumptions on expected cases and mortality, we estimate treatment costs and mortality impact for diagnosis and treatment for drug-sensitive and multidrug-resistant TB (MDR-TB), including antiretroviral treatment (ART) during DOTS for HIV-co-infected patients, for four country groups, overall and for the Global Fund investments. In 2015, China and India account for 24% of funding need, Eastern Europe and Central Asia (EECA) for 33%, sub-Saharan Africa (SSA) for 20%, and other low-and middle-income countries for 24%. Scale-up of MDR-TB treatment, especially in EECA, drives an increasing global TB funding need-an essential investment to contain the mortality burden associated with MDR-TB and future disease costs. Funding needs rise fastest in SSA, reflecting increasing coverage need of improved TB/HIV management, which saves most lives per dollar spent in the short term. The Global Fund is expected to finance 8-12% of Global Plan implementation costs annually. Lives saved through Global Fund TB support within the available funding envelope could increase 37% if allocations shifted from current regional demand patterns to a prioritized scale-up of improved TB/HIV treatment and secondly DOTS, both mainly in Africa 2 with EECA region, which has disproportionately high per-patient costs, funded from alternative resources. Conclusions/Significance: These findings, alongside country funding gaps, domestic funding and implementation capacity and equity considerations, should inform strategies and policies for international donors, national governments and disease control programs to implement a more optimal investment approach focusing on highest-impact populations and interventions.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2011
Background-Tenofovir gel, an antiretroviral-based vaginal microbicide, reduced HIV acquisition by... more Background-Tenofovir gel, an antiretroviral-based vaginal microbicide, reduced HIV acquisition by 39% in women in a recent randomised controlled clinical trial in South Africa. Methods-To inform policy we used a dynamical model of HIV transmission, calibrated to the epidemic in South Africa, to determine the population-level impact of this microbicide on HIV incidence, prevalence and deaths and to evaluate its cost-effectiveness. Results-If women use Tenofovir-gel in 80% or more of sexual encounters (high coverage), it could avert 2.33 (0.12 to 4.63) million new infections and save 1.30 (0.07 to 2.42) million lives and if used in 25% of sexual encounters (low coverage), it could avert 0.50 (0.04 to 0.77) million new infections and save 0.29 (0.02 to 0.
We investigate the prevalence of, and risk factors for, HIV infection among women in an urban Sou... more We investigate the prevalence of, and risk factors for, HIV infection among women in an urban South African setting. A random sample of 834 women was recruited into a community-based cross-sectional study. HIV prevalence was 37.1% with higher prevalence among migrant women (46.0%) than non-migrant women (34.7%), (odds ratio [OR]=1.61, 95% confidence interval [CI]: 1.11-2.31). The highest HIV prevalence (50.9%) was between ages 26 and 35 years. Having two or more lifetime partners increased the risk of HIV infection (OR=4.88, 95% CI: 3.01-7.89). Migration, age, marital status, alcohol use, syphilis and gonorrhoea were independently associated with HIV infection. Migration increases the risk of HIV infection. Provision of services to treat sexually transmitted diseases and educational empowerment programmes that will promote safer sex among migrant women are urgently needed.
In October 1998, cohorts of circular migrant men and their non-migrant sexual partners, and non-m... more In October 1998, cohorts of circular migrant men and their non-migrant sexual partners, and non-migrant men and their non-migrant sexual partners from rural South Africa were recruited and followed-up every 4 months until October 2001. At each visit, information on socio-demographic, sexual behaviour, sexually transmitted infections (STIs) and HIV was collected. In total, 553 individuals aged between 18 and 69 years were recruited. A man and his sexual partner(s) form a sexual partnership. Migration status, age, marital status, age at sexual debut, recent sexual partners and HIV status were found to be important determinants of STI. The risk of STI varies (σ2=1·45, P<0·001) significantly across sexual partnerships even after controlling for important determinants. The variance implies substantial correlation (0·59) between members of the same sexual partnership. Ignoring this correlation leads to incorrect inference. Migration contributes significantly to the spread of STIs. Comm...
There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in p... more There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in prevention of human immunodeficiency virus (HIV) and tuberculosis (TB) infections. The complex nature of the HIV and TB prevention responses, resource constraints, remaining questions about cost and feasibility, and the need to use a solid evidence base to make policy decisions, and the implementation challenges to translating trial data to operational settings require a well-organised and coordinated response to research in this area. To this end, we aimed to catalogue the ongoing and planned research activities that evaluate the impact of ART plus other interventions on HIV-and/or TB-related morbidity, mortality, risk behaviour, HIV incidence and transmission. Using a limited search methodology, 50 projects were identified examining ART as prevention, representing 5 regions and 52 countries with a global distribution. There are 24 randomised controlled clinical trials with at least 12 large randomised individual or community cluster trials in resource-constrained settings that are in the planning or early implementation stages. There is considerable heterogeneity between studies in terms of methodology, interventions and geographical location. While the identified studies will undoubtedly advance our understanding of the efficacy and effectiveness of ART for prevention, some key questions may remain unanswered or only partially answered. The large number and wide variety of research projects emphasise the importance of this research issue and clearly demonstrate the potential for synergies, partnerships and coordination across funding agencies.
The fight to reduce HIV transmission in South Africa is shaped and constrained by complex, interc... more The fight to reduce HIV transmission in South Africa is shaped and constrained by complex, interconnected layers of factors ranging from the political to the psychological. The HIV epidemic reached South Africa a decade or so after central and East Africa providing a window of opportunity within which to implement appropriate prevention and management programmes. However, the apartheid government largely ignored HIV/ AIDS and the post-apartheid government has not risen to the challenge of the epidemic so that South Africa looks set to become the AIDS capital of the continent. Current estimates are that one in five adult South Africans are living with HIV or AIDS and 1,700 more are being infected every day. The highest rates of infection are among those aged 20 to 40 years, the most economically active and also the parents to a new generation of children. While the macro-economic impact of the epidemic will only be known with time, many of the social impacts are more easily predicted. By the year 2010 five million children will have lost at least one parent. Already there are households headed by children as young as nine years old acting as guardians to younger siblings, sometimes with no source of income. Having weathered the trauma of losing parents the high rates of mother-to-child transmission mean that they will now have to care for terminally ill siblings.
Journal of the International Association of Providers of AIDS Care, Jan 28, 2015
Achieving the 90-90-90 targets by 2020 requires increased focus, resources, and efficiency to pro... more Achieving the 90-90-90 targets by 2020 requires increased focus, resources, and efficiency to provide earlier access to antiretroviral therapy (ART). We used 2009 to 2013 National AIDS Spending Assessment data to assess HIV care and treatment spending in 38 high-burden, low- and middle-income countries (LMICs). In 2013, 23 of the 38 high-burden countries spent less than 50% of total HIV spending on care and treatment. HIV spending on ART per people living with HIV (PLHIV; adjusted) averaged US$299 (US$32-US$2463). During 2009 to 2013, a 10% increase in average spending on care and treatment per PLHIV was associated with an increase in ART coverage of 2.4% and a decrease in estimated AIDS-related death rate of 2.4 per 1000 PLHIV. HIV spending in high-burden LMICs does not consistently reflect the new science around the preventative and clinical benefits of earlier HIV diagnosis and ART initiation.
Antiretroviral therapy (ART) prevents human immunodeficiency virus (HIV) disease progression, mor... more Antiretroviral therapy (ART) prevents human immunodeficiency virus (HIV) disease progression, mortality and transmission. We assess the impact of expanded HIV treatment for the prevention of Acquired Immunodeficiency Syndrome (AIDS)-related deaths and simulate four treatment scenarios for Nigeria and South Africa. For 1990-2013, we used the Joint United Nations Programme on HIV/AIDS (UNAIDS) database to examine trends in AIDS deaths, HIV incidence and prevalence, ART coverage, annual AIDS death rate, AIDS death-to-treatment and HIV infections to treatment ratios for the top 30 countries with the highest AIDS mortality burden and compare them with data from high-income countries. We projected the 1990-2020 AIDS deaths for Nigeria and South Africa using four treatment scenarios: 1) no ART; 2) maintaining current ART coverage; 3) 90% ART coverage based on 2013 World Health Organization (WHO) ART guidelines by 2020; and 4) reaching the United Nations 90-90-90 Target by 2020. In 2013, th...
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2014
The global target of tuberculosis (TB) elimination by 2050 requires new approaches. Active case f... more The global target of tuberculosis (TB) elimination by 2050 requires new approaches. Active case finding plus mass prophylactic treatment has been disappointing. We consider mass full anti-tuberculosis treatment as an approach to TB elimination in Kiribati, a Pacific Island nation, with a persistent epidemic of high TB incidence. To construct a mathematical model to predict whether mass treatment with a full course of anti-tuberculosis drugs might eliminate TB from the defined population of the Republic of Kiribati. We constructed a seven-state compartmental model of the life cycle of Mycobacterium tuberculosis in which active TB disease arises from the progression of infection, reinfection, reactivation and relapse, while distinguishing infectious from non-infectious disease. We evaluated the effects of 5-yearly mass treatment using a range of parameter values to generate outcomes in uncertainty analysis. Assuming population-wide treatment effectiveness for latent tuberculous infect...
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2011
The human immunodeficiency virus (HIV) and HIV-associated tuberculosis (TB-HIV) epidemics remain ... more The human immunodeficiency virus (HIV) and HIV-associated tuberculosis (TB-HIV) epidemics remain uncontrolled in many resource-limited regions, especially in sub-Saharan Africa. The scale of these epidemics requires the consideration of innovative bold interventions and 'out-of-the-box' thinking. To this end, a symposium entitled 'Controversies in HIV' was held at the 40th Union World Conference on Lung Health in Cancun, Mexico, in December 2009. The first topic debated, entitled 'Annual HIV testing and immediate start of antiretroviral therapy for all HIV-infected persons', received much attention at international conferences and in the literature in 2009. The second topic forms the subject of this article. The rationale for the use of empirical TB treatment is premised on the hypothesis that in settings worst affected by the TB-HIV epidemic, a subset of HIV-infected patients have such a high risk of undiagnosed TB and of associated mortality that their prog...
The epidemic of HIV in Malawi started early and at its peak 15% of all adults were infected with ... more The epidemic of HIV in Malawi started early and at its peak 15% of all adults were infected with HIV. Malawi is a low-income country and the cost of putting all HIV-positive people in Malawi onto ART, expressed as a percentage of the gross domestic product, is the highest in the world. Nevertheless, Malawi has made great progress and the greatly reduced cost of potent anti-retroviral therapy (ART) makes it possible to contemplate ending the epidemic of HIV/AIDS. Here we consider what would have happened without ART, the No ART counterfactual, the impact if the current level of roll-out of ART is maintained, the Current Programme, and the likely impact if treatment is made available to everyone who is eligible under the 2013 guidelines of the World Health Organization reaching full coverage by 2020, the Expanded Programme. The Current Programme has substantially reduced the epidemic of HIV and the number of people dying of AIDS. The Expanded Programme has the potential to avert more ...
Background Three recent randomised controlled trials [1-3] in Kenya, South Africa, and Uganda hav... more Background Three recent randomised controlled trials [1-3] in Kenya, South Africa, and Uganda have confirmed previous observational studies [4] and ecological experience [5] and demonstrated beyond reasonable doubt that male circumcision performed by well-trained medical professionals reduces the risk of men acquiring HIV through female-to-male transmission by approximately 60% [5,6]. Furthermore, results from the Kenyan trial indicate that the protective effects of circumcision are sustained for at least 42 mo [7], which suggests that circumcision is likely to provide lifelong partial protection. Although the evidence from the randomised trials is compelling, the longer-term population-level impact of introducing or expanding safe male circumcision services within comprehensive HIV prevention programmes remains unknown. Consequently, although some countries with a high prevalence of HIV have held stakeholder meetings and are developing policies on male circumcision for HIV prevention, many have not done so. In addition, the introduction and/or expansion of male circumcision programmes for HIV prevention raises a host of ethical, legal, and human rights issues [8-10]. Furthermore, the introduction/expansion of these programmes could be hindered by weak health infrastructures, scarce human resources for health [11], cultural concerns, political barriers, and financial constraints. In the face of these challenges, some decision-makers in sub-Saharan Africa are asking whether the introduction or expansion of male circumcision services for the reduction of HIV incidence will be cost-effective over the short, medium, and long term. Estimating the long-term population impact and cost-effectiveness of male circumcision programmes requires mathematical modelling approaches. However, when different modelling approaches use different baseline assumptions and input variables, they sometimes produce conflicting results. The Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), and the South African Centre for Epidemiological Modelling and Analysis (SA-CEMA) recently convened three expert group meetings in Geneva (2005), Stellenbosch (2007), and London (2008) to review published and unpublished modelling The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies.
Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the So... more Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the Southern African mining industry Original citation: Campbell, Cathy and Williams, B. (1999) Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the Southern African mining industry. Social science & medicine, 48 (11). pp. 1625-1639.
Background: The Global Plan to Stop TB estimates funding required in low-and middle-income countr... more Background: The Global Plan to Stop TB estimates funding required in low-and middle-income countries to achieve TB control targets set by the Stop TB Partnership within the context of the Millennium Development Goals. We estimate the contribution and impact of Global Fund investments under various scenarios of allocations across interventions and regions. Methodology/Principal Findings: Using Global Plan assumptions on expected cases and mortality, we estimate treatment costs and mortality impact for diagnosis and treatment for drug-sensitive and multidrug-resistant TB (MDR-TB), including antiretroviral treatment (ART) during DOTS for HIV-co-infected patients, for four country groups, overall and for the Global Fund investments. In 2015, China and India account for 24% of funding need, Eastern Europe and Central Asia (EECA) for 33%, sub-Saharan Africa (SSA) for 20%, and other low-and middle-income countries for 24%. Scale-up of MDR-TB treatment, especially in EECA, drives an increasing global TB funding need-an essential investment to contain the mortality burden associated with MDR-TB and future disease costs. Funding needs rise fastest in SSA, reflecting increasing coverage need of improved TB/HIV management, which saves most lives per dollar spent in the short term. The Global Fund is expected to finance 8-12% of Global Plan implementation costs annually. Lives saved through Global Fund TB support within the available funding envelope could increase 37% if allocations shifted from current regional demand patterns to a prioritized scale-up of improved TB/HIV treatment and secondly DOTS, both mainly in Africa 2 with EECA region, which has disproportionately high per-patient costs, funded from alternative resources. Conclusions/Significance: These findings, alongside country funding gaps, domestic funding and implementation capacity and equity considerations, should inform strategies and policies for international donors, national governments and disease control programs to implement a more optimal investment approach focusing on highest-impact populations and interventions.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2011
Background-Tenofovir gel, an antiretroviral-based vaginal microbicide, reduced HIV acquisition by... more Background-Tenofovir gel, an antiretroviral-based vaginal microbicide, reduced HIV acquisition by 39% in women in a recent randomised controlled clinical trial in South Africa. Methods-To inform policy we used a dynamical model of HIV transmission, calibrated to the epidemic in South Africa, to determine the population-level impact of this microbicide on HIV incidence, prevalence and deaths and to evaluate its cost-effectiveness. Results-If women use Tenofovir-gel in 80% or more of sexual encounters (high coverage), it could avert 2.33 (0.12 to 4.63) million new infections and save 1.30 (0.07 to 2.42) million lives and if used in 25% of sexual encounters (low coverage), it could avert 0.50 (0.04 to 0.77) million new infections and save 0.29 (0.02 to 0.
We investigate the prevalence of, and risk factors for, HIV infection among women in an urban Sou... more We investigate the prevalence of, and risk factors for, HIV infection among women in an urban South African setting. A random sample of 834 women was recruited into a community-based cross-sectional study. HIV prevalence was 37.1% with higher prevalence among migrant women (46.0%) than non-migrant women (34.7%), (odds ratio [OR]=1.61, 95% confidence interval [CI]: 1.11-2.31). The highest HIV prevalence (50.9%) was between ages 26 and 35 years. Having two or more lifetime partners increased the risk of HIV infection (OR=4.88, 95% CI: 3.01-7.89). Migration, age, marital status, alcohol use, syphilis and gonorrhoea were independently associated with HIV infection. Migration increases the risk of HIV infection. Provision of services to treat sexually transmitted diseases and educational empowerment programmes that will promote safer sex among migrant women are urgently needed.
In October 1998, cohorts of circular migrant men and their non-migrant sexual partners, and non-m... more In October 1998, cohorts of circular migrant men and their non-migrant sexual partners, and non-migrant men and their non-migrant sexual partners from rural South Africa were recruited and followed-up every 4 months until October 2001. At each visit, information on socio-demographic, sexual behaviour, sexually transmitted infections (STIs) and HIV was collected. In total, 553 individuals aged between 18 and 69 years were recruited. A man and his sexual partner(s) form a sexual partnership. Migration status, age, marital status, age at sexual debut, recent sexual partners and HIV status were found to be important determinants of STI. The risk of STI varies (σ2=1·45, P<0·001) significantly across sexual partnerships even after controlling for important determinants. The variance implies substantial correlation (0·59) between members of the same sexual partnership. Ignoring this correlation leads to incorrect inference. Migration contributes significantly to the spread of STIs. Comm...
There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in p... more There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in prevention of human immunodeficiency virus (HIV) and tuberculosis (TB) infections. The complex nature of the HIV and TB prevention responses, resource constraints, remaining questions about cost and feasibility, and the need to use a solid evidence base to make policy decisions, and the implementation challenges to translating trial data to operational settings require a well-organised and coordinated response to research in this area. To this end, we aimed to catalogue the ongoing and planned research activities that evaluate the impact of ART plus other interventions on HIV-and/or TB-related morbidity, mortality, risk behaviour, HIV incidence and transmission. Using a limited search methodology, 50 projects were identified examining ART as prevention, representing 5 regions and 52 countries with a global distribution. There are 24 randomised controlled clinical trials with at least 12 large randomised individual or community cluster trials in resource-constrained settings that are in the planning or early implementation stages. There is considerable heterogeneity between studies in terms of methodology, interventions and geographical location. While the identified studies will undoubtedly advance our understanding of the efficacy and effectiveness of ART for prevention, some key questions may remain unanswered or only partially answered. The large number and wide variety of research projects emphasise the importance of this research issue and clearly demonstrate the potential for synergies, partnerships and coordination across funding agencies.
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Papers by Brian Williams