Policy Responses to HIV/AIDS In Sub-Saharan Africa

This book is for and about sub-Saharan Africa because that is where people have the biggest risk to get HIV from health care. An HIV infection in a baby with an HIV-negative mother cannot be explained by mother-to-child transmission. An infection in a spouse whose only lifetime sex partner is HIV-negative cannot be explained by sexual transmission. Each such infection likely came from HIV-contaminated blood through some skin-piercing procedure – injection, infusion, tattooing, dental care, or other – with reused and unsterilized instruments. But until someone finds the source, the infection is unexplained. And whatever facility and procedure caused it may continue to infect others.
The intended audience for this book includes teachers, reporters, clergy, local leaders, activists, lawyers and others in the general population. I hope the information here will help people who know about one or more unexplained HIV infections to mobilize community and government efforts to find and fix whatever caused the infections. Although I have not written for health professionals, I expect many will be interested in the issues discussed here and may be ready to support investigations.

BACKGROUND: Couple HIV Testing and Counseling (HTC) has proven to increase HIV/Aids, health care provider, testing coverage and expand HIV prevention perspectives opportunities amidst numerous challenges to its access in Nigeria. This study was carried out to INTRODUCTION
determine barriers to couple counseling of HIV HIV testing and counseling (HTC) from the experience of counselors at the- remains the entry point in the global efforts to  Anti Retroviral Therapy (ART) clinics in Osun State combat the spread of HIV and provide
South Western NigeriaMETHODS: This was a descriptive cross, However, access to HTC health facilities alone
sectional qualitative study of 32 counselors does not translate into the utilization of HTC
1
from four (ART) clinics in Osun State, service. As a result of unequal gender
Southwestern, Nigeria. The study instrument dynamics in relationships and societal roles
was a focal group guide. Four focus group definitions that placed the female gender as
discussions of eight eligible counselors each second fiddle; women are bearing more of the
was carried out during the study period. the burden of reproductive health problems
RESULTS: Mean age of respondents was 31.4 including HIV. There has been a recognition
± 2.1 years with 31(96.9%) belonging to the 21- that men need to be equally involved in matters
40 years age group. Seven (22.0%) were male, of safe reproductive health. There is a need to
29 (90.6%) had up to post-secondary school counsel couples together in order to circumvent
level education, 18 (56.1%) were married while many of the barriers associated with the
19 (59.4%) were social workers and 10 (31.3%) traditional one - on - one HTC. Couples' testing
were nurses. Twenty-six (81.3%) were trained has proven to increase testing coverage and
on HCT while 11(34.4%) had further training expands HIV prevention opportunities amidst
2
on couple counseling. Focus group discussants numerous challenges to its access.
highlighted counselors faced numerous It is estimated that half to three-quarters
challenges when counseling couples. of new HIV infections could be prevented by
CONCLUSION: Only few of the counselors voluntary HIV counseling and testing services
w 3
ere trained on couple HTC and this targeted toward cohabiting couples. Despite
underscored the need for formal training for an increase in the number of health facilities and
counselors in order to circumvent most of this improved access, there have been low utilization
challenges based on the experience of health care of such services in the West African sub4 providers in ART setting in Osun State,

By affecting the lives and survival of numerous people, global health initiatives deeply alter local landscapes of inequality. They tackle some conditions at the origin of ill health while leaving others untouched, and they inevitably generate new inequalities. Yet, despite their inherently conflictual nature, global health players often minimize the political dimension of their interventions. Taking international AIDS control efforts in Tanzania as an example, this contribution discusses some modalities — and political causes — of the structural neglect of conflict in global health discourse and practice. It analyses how African HIV epidemics continue to be framed and managed in ways that obscure both the health inequalities at their origin, and those that result from efforts to control them. AIDS policy makers conceal inequalities by framing the epidemic as a problem of individual sexual behaviour, and by implicitly rationing access to HIV-prevention and-treatment services. Furthermore, the imposition of disease hierarchies set by international fora excludes broader health-related allocation decisions from domestic democratic debate. Drawing on a theoretical consideration of depoliticization as artificial deconflictualization, the article concludes by calling for a more open acknowledgement of conflict in global health policy making, and explores some analytical and practical implications of such a re-politicization of public health.

The heart failure syndrome has been recognized as a significant contributor to cardiovascular disease burden in sub-Saharan African for many decades. Seminal knowledge regarding heart failure in the region came from case reports and case series of the early 20th century which identified infectious, nutritional and idiopathic causes as the most common. With increasing urbanization, changes in lifestyle habits, and ageing of the population, the spectrum of causes of HF has also expanded resulting in a significant burden of both communicable and non-communicable etiologies. Heart failure in sub-Saharan Africa is notable for the range of etiologies that concurrently exist as well as the healthcare environment marked by limited resources, weak national healthcare systems and a paucity of national level data on disease trends. With the recent publication of the first and largest multinational prospective registry of acute heart failure in sub-Saharan Africa, it is timely to review the state of knowledge to date and describe the myriad forms of heart failure in the region. This review discusses several forms of heart failure that are common in sub-Saharan Africa (e.g., rheumatic heart disease, hypertensive heart disease, pericardial disease, various dilated cardiomyopathies, HIV cardiomyopathy, hypertrophic cardiomyopathy, endomyocardial fibrosis, ischemic heart disease, cor pulmonale) and presents each form with regard to epidemiology, natural history, clinical characteristics, diagnostic considerations and therapies. Areas and approaches to fill the remaining gaps in knowledge are also offered herein highlighting the need for research that is driven by regional disease burden and needs.

This legal review of Zimbabwean law seeks to answer key contextual questions that would frame any pilot or projects that Zimbabwe might choose to take up to increase numbers of the population who know their HIV status.
Included were questions such as, “Is HIV self-testing legal and, if so, under what conditions?”, “What legislation governs the distribution of HIVST kits and what rules/conditions exist concerning this distribution?” and “What are the human rights issues surrounding HIVST?” The review, which was commissioned by the Southern African AIDS Trust (SAT) was part of a series of reviews that looked across SAT’s countries of operation but also went broader to explore the situation in the USA, France and the UK – all of which have now legalised self-testing after thorough national debates and scientific input.

This report would not have been possible without all the pregnant rst time antenatal care bookers who agreed to participate in the survey, a warm thank you. My sincere gratitude goes to all the nurses in the public health clinics for their continued dedication and professionalism over the past 23 years in the implementation of this survey. The National Department of Health's Directorate: Epidemiology plays a pivotal role in the coordination of this survey (conducted in 1 500 clinics, 52 districts and all nine provinces and provincial laboratories) and publication of this report. I would like to thank each of the staff members for their time, passion and enthusiasm in ensuring that the implementation of these annual surveys are a success. A special, thanks go to Dr. Thabang Mosala, for her key role in providing technical strategic and leadership at all stages of the survey implementation and for leading the technical discussions during data analysis, interpretation of the ndings and for writing of this report. Many thanks also go to Ms. Manti Maifadi and Mr. Lusizo Ratya for taking the lead in the overall operational and logistical coordination of the survey, for providing technical input in this report and compiling the tables and gures contained in this report. A warm thanks to Ms. Audrey Mbatha for preparing all the maps, Ms. Fulufedzhani Musehane and Mr. Paul Ndala for assisting with the technical support to the provinces, districts and clinics to ensure that the nurses adhere to the survey protocol. Thanks to Ms. Corrie Nagel, Ms. Tinyiko Maluleke and Ms. Norah Moakamedi for their administrative support. Our sincere gratitude also to the 9 provincial HIV antenatal sentinel survey coordinators for their time and commitment in coordinating the survey in their respective provinces and districts and providing technical support to participating clinics: Mr. Z. Merile and Ms. L. Mangesi (EC), Mr. A. Khajoane (FS), Dr. B. Ikalafeng (GA), Ms N.

English abstract

AIDS-control strategies in sub-Saharan Africa involve crucial national political compromises. Yet, they are frequently formulated in heteronomous settings dominated by Western donor agencies. Drawing on a case study of Tanzania, a country whose response to the epidemic is 97% donor-funded, this thesis develops a political economy of international AIDS control. It explores some of the specifically political aspects of the struggle against HIV/AIDS in Tanzania by analysing the formulation of national HIV-prevention and -treatment policies, and confronting these policies with a critical review of their biological and epidemiological foundations. The fieldwork combines a series of 92 in-depth interviews with key policymakers at the national level with the observation of AIDS-related decision processes in donor-government meetings. In this way, this thesis analyses the unequal political attention given to different causal stories of the spread of the virus, and their impact on the use of evidence in the formulation of HIV-prevention policies. Moreover, it describes how AIDS policymakers adopt non-decision strategies when faced with the intricate trade-offs imposed by the inescapable prioritization of HIV-prevention and -treatment interventions in a context of insufficient resources. Finally, developing upon an analysis of the controversy among players about the effects of international AIDS control on the overall coherence of national health policies, the thesis explores the contradictions of a vertical AIDS response in a context of dysfunctional health systems and poor general population health. On this basis, it examines the possibilities to elaborate an emancipatory critique.
 
Résumé français

Alors que les stratégies de lutte contre le sida en Afrique sub-saharienne mettent en jeu des compromis politiques nationaux fondamentaux, elles sont souvent formulées de manière hétéronome et dans un contexte marqué par la prédominance des bailleurs occidentaux. À partir de l’étude du cas tanzanien, cette thèse analyse différents aspects proprement politiques de la lutte contre le sida, à travers une double perspective : l’étude de l’élaboration des stratégies nationales de prévention et de traitement du VIH et l’analyse critique de leurs fondements biologiques et épidémiologiques. La recherche se fonde sur une enquête de terrain combinant des entretiens approfondis avec les principaux acteurs institutionnels au niveau national, et l’observation des processus décisionnels lors de réunions programmatiques. Cette thèse met ainsi en évidence l’attention politique inégale accordée aux différents récits causaux de la propagation du virus, et le rôle de ces histoires causales dans la formulation des politiques de prévention. Elle donne à voir les stratégies de non-décision ou de « contournement du politique » qu’adoptent les acteurs face aux arbitrages difficiles qu’impose la définition de priorités dans un contexte d’insuffisance des ressources. Enfin, à partir d’une analyse des controverses au sujet des effets de la réponse internationale au VIH/sida sur la cohérence des politiques de santé en Tanzanie, la thèse explore les contradictions d’une lutte verticale contre le sida dans un contexte marqué par un système de soins défaillant et une mauvaise santé générale de la population. Elle examine, sur cette base, les conditions d’élaboration d’une critique émancipatrice.

 

The global commitment to ending the AIDS epidemic by 2030 places HIV prevention at the centre of the response. With the disease continuing to disproportionately affect young populations in the Eastern and Southern African Region (ESAR), particularly adolescent girls and young women, reducing HIV infections in this group is integral to achieving this ambitious target. This paper examines epidemiological patterns of the HIV epidemic among adolescents and young people, indicating where HIV prevention efforts need to be focused (i.e., adolescent girls and young women, adolescent boys and young men and young key populations). Key innovations in the science of HIV prevention and strategies for dealing with programme implementation are reviewed. The paper also discusses the value of processes to mitigate HIV vulnerability and recommends actions needed to sustain the HIV prevention response. Stemming the tide of new HIV infections among young people in the ESAR requires an amplification of efforts across all sectors, which will safeguard past achievements and advance actions towards eliminating AIDS as a public health threat.

This study, commissioned by the ILO, was undertaken by McKay & Romm with the help of 14 research assistants/consultants. It started in August 2005 and was finalised in 2006. ( It was then created into a book by the ILO: https://www.worldcat.org/title/report-on-hivaids-in-relation-to-the-informal-sector-in-zambia/oclc/75564204.)
The research was aimed at investigating, and at the same time intervening in addressing, HIV/AIDS in relation to the informal sector in Zambia. The study was set in four geographical sites: Lusaka, Kafue, Mumbwa and Solwezi, and sampled informal workers from trades and services at those sites. The study was organised in relation to an ILO four-country study conducted in Uganda, Ghana, Tanzania and South Africa, which also examined HIV/AIDS in the informal economy in each of the four countries (McKay). From the studies that have been undertaken, it is clear that workers experience vulnerabilities that are specific to the sector, and that ways of intervening need to be tailored to this context. With this background in mind, the current Zambian ILO/UNDP study considered the way in which strategies in Zambia had thus far been directed at fighting the pandemic and whether sufficient attention has been directed at the informal sector. A four-stage methodology was used in the study (following the studies in the other four countries). The stages were:

• administration of a Knowledge, Attitude, Perception and Behaviour
questionnaire (KAPB) to a sample of 407 respondents in the informal sector from across four targeted sites, namely: Lusaka, Kafue, Mumbwa and Solwezi;
• rapid assessment workshops (with about 50 participants each) undertaken in the same areas;
• peer education, making use of a training brochure specifically developed for this purpose (by Prof McKay and Dr Morr);
• a National Workshop aimed at disseminating and discussing the research outcomes and recommendations while also specifically identifying agents/actors to carry them forward.

EXECUTIVE SUMMARY
Health challenges in the Southern African Development Community (SADC) continue to undermine the attainment of a SADC vision that includes healthy citizens in all its Member States. Among these health challenges are the communicable diseases, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), Tuberculosis (TB) and Malaria.
In order to help address these challenges, the SADC Protocol on Health was invoked to produce an agreement on the harmonisation of disease surveillance throughout the SADC region. To support such harmonisation, and in accordance with the e-SADC framework, the SADC Secretariat has undertaken a study to assess the status of Telehealth and its potential as a surveillance and information-sharing tool for HIV and AIDS, TB and Malaria. A further objective of the study was to propose a Telehealth system that could serve as a platform for strengthening all aspects of surveillance of these diseases, as well as national referral hospitals and reference laboratories in the region.
The assessment highlighted several challenges, including: policy and the regulatory environment for eHealth in Member States; health information systems; human and financial resources; and the current use of, and available equipment and infrastructure for Telehealth in Member States.
The study also identified several strengths, which could form the foundation for a regional Telehealth network for disease surveillance (TNDS) to meet the needs of Member States and the SADC Secretariat.
Informed by the findings, the TNDS thus aims to support the harmonised control of HIV and AIDS, TB, Malaria and other communicable and non-communicable diseases, and to mitigate the impact of these diseases in the SADC region. The objectives are to:
- Enable timely collection and reporting of data on the three diseases through Internet links between Ministries of Health in SADC Member States and the SADC Secretariat, as well as through links between the Ministry of Health, the national referral hospital and national reference laboratory in each Member State;
- Serve as an early warning system for disease outbreaks;
- Support programming and management of communicable diseases;
- Improve referrals for the three diseases within and across SADC Member States;
- Strengthen sharing of information and knowledge among reference laboratories for HIV and AIDS, TB and Malaria; and
- Network the databases, as well as individuals, in order to create communities of practice for disease surveillance in the SADC region.
In terms of their use of Telehealth to meet these objectives, Member States fit into three broad categories:
- Mauritius and South Africa are well advanced, with policies and systems, as well as the technical infrastructure to support ICT-mediated services;
- Nine Member States (Angola, Botswana, DRC, Lesotho, Malawi, Mozambique, Namibia, Seychelles and Tanzania) are at various stages of building technical and human capacity for eHealth, and are implementing projects and programmes to improve health services through the use of ICT; and 
- Swaziland, Zambia and Zimbabwe have ICT infrastructure in the health sector that is in its early stages and that needs to be strengthened to provide basic eHealth services.
The main service areas are disease surveillance and early warning; patient referrals among hospitals; and specialised testing and quality assurance in national and supranational reference laboratories.
Three levels of ICT use are shown for each service area: an entry level, a intermediate level and an advanced level.  For disease surveillance and early warning, the levels are:
- Data collection, storage and analysis, with periodic non-automated updating and reporting;
- Data collection, storage and analysis, with periodic non-automated updating and reporting, with much greater speed and reliability; and
- Data collection, storage and analysis, with automated updating and reporting (web-based full early-warning system).
Proposed Telehealth System for HIV and AIDS, TB and Malaria Surveillance
and Information Sharing in the SADC Region
9
- For referral hospitals, the levels are:
- Communication between referring and receiving hospitals without imaging;
- Communication between referring and receiving hospitals, supported by full imaging studies; and - Full videoconferencing for real-time Teleconsultations.
For national and supranational reference laboratories, the levels are:
- Telepathology with store and forward technology;
- Telepathology with remote reading of locally-prepared and -stored slides; and
- Real-time Telepathology with remote handling of slides from the reference laboratory.
In order to assist Member States to progress to the next level in each of the three service areas through the implementation of the TNDS, the equipment and connectivity requirements for each level of service have been determined.
Since the SADC Secretariat is expected to assist African Development Fund (ADF) Member States in their implementation of the TNDS, a gap analysis identifies the additional infrastructure, equipment and other needs (such as geographic information systems, or GIS) that are needed in each ADF Member State. In addition to these technology requirements, specific human resources (such as ICT experts and ICT-skilled health workers), financial resources and institutional structures are required to put the network into operation.
The TNDS is designed to connect SADC Secretariat and each national node to the Internet, and to have the national node serve the national referral hospital and reference laboratory through a local area network (LAN) or wide area network (WAN). There are four options for connectivity:
- A mobile monitoring and reporting system;
- Cloud-based services;
- Digital subscriber loop (DSL) connectivity from local providers; and
- The TNDS as a component of a SADC-wide satellite-based communication services.
A scoring system for the options assesses their respective:
- Cost considerations;
- Reliability and maintainability;
- Levels of integration of various programmes with differing needs into the network; and
- Other considerations, including the SADC Secretariat’s remit with regards to activities in Member States.
Based on these considerations, the satellite option is recommended for connectivity. However, Member States can also leverage fibre optic and other connectivity options for connectivity to the TNDS.
The TNDS will connect not only computers and equipment, but will link users of the computers and equipment into a disease surveillance network of health professionals. Three options for structuring this human network into an efficient mechanism for knowledge and information sharing are provided in the Annexes:
- A formal network that is endorsed at the highest levels of the SADC Secretariat and that has a governing structure;
- A semi-structured formal collaboration among the nodes that has an advisory body to serve as a governance mechanism; and
- An informal network that grows organically and is self-managed.
The success of the TNDS in fulfilling its purpose will depend on long-term political commitment, the establishment of real conditions for ownership of the process within Member States, continued availability of a critical mass of trained technical personnel, effective resource mobilisation, and adequate budget provision. It will also be necessary to set up an monitoring and evaluation (M&E) system for the TNDS.

This piece of work is a systematic review that critically appraises past research studies, not later than five years that is directed towards investigating the knowledge, awareness, behaviour, attitudes and perception of young people in Nigeria towards HIV/AIDS and its prevention. Young people’s knowledge, awareness and perceptions have been identified in different levels and categories. Young people’s preventive awareness level and risk perceptions have also been revealed. Conclusively, the findings from the different studies selected for the systematic review have shown varying degrees of HIV knowledge among young people. This is to address the perceptions of young Nigerian adults towards HIV/AIDS. Significantly, the systematic review undertaken confirms the original theme of the study identifying and exploring the knowledge, attitudes, behaviours and perceptions of young adults to address the aim of the study. The results have, therefore, indicated that those in the colleges and universities were more knowledgeable than those that were not. Understanding of the virus helped to influence young people in their attitude towards infected people. Furthermore, understanding of HIV/AIDS and its prevention also differed among young adults; those in the university had better understanding compared to those in the colleges and dropouts.

The global commitment to ending the AIDS epidemic by 2030 places HIV prevention at the centre of the response. With the disease continuing to disproportionately affect young populations in the Eastern and Southern African Region (ESAR), particularly adolescent girls and young women, reducing HIV infections in this group is integral to achieving this ambitious target. This paper examines epidemiological patterns of the HIV epidemic among adolescents and young people, indicating where HIV prevention efforts need to be focused (i.e., adolescent girls and young women, adolescent boys and young men and young key populations). Key innovations in the science of HIV prevention and strategies for dealing with programme implementation are reviewed. The paper also discusses the value of processes to mitigate HIV vulnerability and recommends actions needed to sustain the HIV prevention response. Stemming the tide of new HIV infections among young people in the ESAR requires an amplification of efforts across all sectors, which will safeguard past achievements and advance actions towards eliminating AIDS as a public health threat.

Background: The immunosuppresion in HIV patients makes them highly susceptible to microbial infections. The aim of the study was to establish whether HIV stage (as depicted by CD4+ T lymphocyte counts) could independently be associated with periodontal status (as revealed by the measurement of clinical indices). Methods: One hundred and twenty HIV-infected patients attending an infectious diseases clinic in the Western Cape, South Africa were included in the study. The periodontal clinical indices such as plaque index, gingival index, pocket probing depth and clinical attachment levels were measured on the mesial aspect of the six Ramfjord teeth. The CD4 + T cell counts were taken from the patients' medical records and patients' HIV stage determined and grouped according to their CD4+ T cell counts into A (<200 cells /mm 3), B (200-500 cells /mm 3) and C (>500 cells /mm 3). Results: The mean age of 120 HIV-positive patients was 33.25 years and the mean CD4 + T cell count was 293.43 cells/mm 3. The probing depth and clinical attachment loss were found to be significantly associated with the total CD4 + T cell counts but not with HIV stage. Significant correlations were found between age and all clinical indices except for clinical attachment loss. No correlation was found between age and HIV stage of the patients. The use of antiretroviral therapy was significantly associated with probing depth and clinical attachment loss, but not with plaque nor gingival index. Significant associations were observed between smoking and all of the clinical indices except for the gingival index. A significant association was observed between the use of interdental aids and all the clinical indices except for probing depth, while brushing was significantly associated with plaque index only. CD4 + T cell counts were significantly associated with brushing frequency (p = 0.0190) and the use of interdental aids (p = 0.0170). Conclusion: The findings of this study conclude that HIV stage, ART and age are not independent risk factors for changes in the periodontal status of HIV-positive subjects but rather that smoking and oral hygiene habits determine their susceptibility to disease.

EXECUTIVE SUMMARY
Globally, an estimated 35.3 million people were living with Human Immunodeficiency Virus (HIV) in 2012. An increase from previous years as more people are receiving the life-saving antiretroviral therapy. There were 2.3 million new HIV infections globally in 2012, showing a 33% decline in the number of new infections from 3.4 million in 2001. At the same time, the number of AIDS related deaths are also declining, with 1.6 million AIDS deaths in 2012, down from 2.3 million in 2005 (UNAIDS, 2013).
Sub-Saharan Africa remains the epicenter of the epidemic and accounted for nearly 70% of the world’s burden of HIV and AIDS. South Africa is the worst affected country with an estimated 6.3 million people living with HIV, which is the largest number of people living with HIV and AIDS
in the world. Since 1990, this generalised HIV epidemic trend is monitored annually through the national antenatal sentinel surveillance tool. Since 2006, the HIV prevalence trends are published and reported at national, provincial and in the 52 districts, and disaggregated by age.
The goal of the national antenatal sentinel HIV prevalence survey is to produce robust scientific evidence at national, provincial and district level in order to:

•Determine the HIV sero-prevalence amongst first time antenatal clinic attendees, seen as a particularly suitable “sentinel” group to represent most closely the HIV prevalence of the general adult sexually active part of the population
• Provide baseline empirical data for national, provincial and district level estimates and extrapolation of HIV infections for future projections of the epidemic

THE OBJECTIVES ARE:
• To estimate the national prevalence of HIV infection among pregnant women in South Africa
• To determine the geographical distribution pattern of HIV infection among pregnant women attending antenatal clinics at national and provincial level, by district and by age categories
• To monitor trends over time for both HIV prevalence at national, provincial and district level in South Africa
• To provide scientific evidence to monitor the country’s progress towards meeting the Millennium Development Goal 6, Target 7, Indicator 18 - HIV prevalence amongst 15–24 year old pregnant women
In 2013, a total of 33 077 first time antenatal care attendees participated in the survey. The sample was sufficiently representative to make conclusive inferences on HIV occurrence at national and provincial level and in all 52 health districts. Intravenous blood samples were
collected from the surveyed pregnant women in 1 497 public sector antenatal clinics during October 2013. These biological specimens were collected and sent to central laboratories in the various provinces for HIV analysis. The blood test used was the Enzyme Linked Immuno
Sorbent Assay (ELISA) for HIV antigen testing. Given that the sentinel sites were chosen on.
2. The 2013 National Antenatal Sentinel HIV Prevalence Survey, South Africa a probability proportional to size by districts, the sampling period was fixed and the districts’ samples were self-weighting, the provincial prevalence estimates were calculated as the total of the results from the districts in the provinces. The national prevalence was weighted
according to the total number of women aged 15-49 years in each province using the 2013 mid-year population size estimates. The sample population realisation rate in 2013 was 91.9% and exceeded the 70% compliance rate as outlined in the survey protocol.

THE 2013 NATIONAL HIV PREVALENCE
The national HIV prevalence for 2013 was 29.7% (95% CI: 28.9-30.2), a slight increase of 0.2% from the 29.5% in 2011 and 2012 which was not statistically significant. The epidemic curve is still plateauing and there is no statistical difference in the national HIV prevalence  estimates in the past six years. The cross sectional design of this point prevalence sentinel
surveillance does not provide the association between HIV prevalence and the number of
people on anti-retroviral therapy (ART) treatment, the design of the survey in its current form
is purely descriptive. However, there are significant differences in HIV prevalence among the nine provinces and among the 52 health districts. The HIV epidemic in South Africa has in the  past six years observed stabilisation at national level only. THE 2013 PROVINCIAL HIV PREVALENCE In the nine provinces, there is fluctuation and significant heterogeneity in HIV prevalence trends between districts over the years. In 2013, the highest provincial HIV prevalence was recorded in KwaZulu-Natal (KZN) which increased from 37.4% in 2012 to 40.1% in 2013. Provinces with ‘higher’ HIV prevalence estimates compared with 2012 are the Eastern Cape (from 29.1%  in 2012 to 31.4% in 2013), Mpumalanga (increased from 35.6% in 2012 to 37.5% in 2013). These small increases fell within the expected sampling variability. The provinces with ‘lower’
HIV prevalence estimates were: North West (from 29.7% in 2012 to 28.2% in 2013) and Free State (decreased from 32.0% in 2012 to 29.8% in 2013). Their estimates were also within the expected sampling variability.

THE 2013 HIV PREVALENCE BY DISTRICT
The district level HIV epidemic is significantly heterogeneous, with prevalence's ranging from a low of 2.3% in Namaqua in the Northern Cape to a high of 45.9% in iLembe, KwaZulu-Natal. When data is pooled over the last four years, this heterogeneity persists. The number of districts recording prevalence levels above 40% has increased from two out of 52 in 2011 to six out of the 52 districts in 2013, five in KZN and one in Mpumalanga. In 2013, there were six districts in the country (five in KwaZulu-Natal and one in Mpumalanga) recording HIV prevalence above 40%. The highest prevalence in the country was recorded in iLembe (45.9%). The other five districts recording HIV prevalence above 40.0% were: uMkhanyakude (44.1%), eThekwini (41.1%), uMgungundlovu (42.5%), Ugu (41.1%) and uThukela in KwaZulu-Natal viz. (40.0%) and Gert Sibande in Mpumalanga at 40.8%.
.
THE 2013 HIV PREVALENCE DISTRIBUTION BY AGE
From 2007 to 2013, the peak in HIV prevalence occurs in the 30-34 year olds. The HIV prevalence in this age group increased from 41.5% in 2009 to 42.5% in 2013. When comparing The 2013 National Antenatal Sentinel HIV Prevalence Survey, South Africa the HIV prevalence in the different age categories with previous years it has gone up slightly in all age groups. The higher prevalence in older age groups could be partly explained by the ART usage. The 2013 HIV prevalence among the 15-24 pregnant women is 19.9%. The baseline HIV prevalence in the 15-24 year- old pregnant in 2001 was 23.1% and it is expected to be reduced by 75% in 2015, which translates to 5.3%. It is very worrying that the trend among young people (15-24) is not showing a decline (this age group should not be affected much by ART). The UN MDG 6 baseline HIV prevalence for the 15-24 pregnant MDG group in 2001 was 23.1% and it is expected to be reduced by 75% in 2015, which translates to 5.3%. The 2013 HIV prevalence among the 15-24 pregnant women is 19.9%.The decrease in HIV prevalence in this age group is slow but not significant.
CONCLUSION
The national HIV prevalence of 29.7% among antenatal women is in line with the prevalence of 29% and 30% since 2004, which shows stabilisation at national level. It is noted that there are significant differences between the nine provinces and even more significant heterogeneity
in HIV prevalence among the 52 health districts. The high HIV prevalence amongst young ANC women (15–24 years) is a concern. Going forward, an analytical exercise is required to understand the potential hypothesis for this trend. The HIV prevalence for women aged 15-29 has fallen (declining incidence) while the prevalence of those above 30 years has risen (provision of ARVs keeping infected women alive) resulting in the combined prevalence (15-49years) remaining almost unchanged.
In conclusion, the Department will revise the current design of the protocol in the context of expanding coverage of HIV testing, prevention of mother to child transmission (PMTCT) and ART and transition to PMTCT Option B+ for HIV-positive pregnant women. The Department  will also consider the use of linked testing (confidential or anonymous) with informed consent for HIV sentinel surveillance. This will require informed consent from pregnant women who are HIV tested for surveillance, providing them and the clinic with their HIV test results, and referring them to available HIV care, treatment and prevention interventions, if the test results
are positive. Further research will be conducted to better understand what contributes to increases in HIV prevalence and the HIV prevalence levels in Mpumalanga, Western Cape and KwaZulu-Natal, and whether the increase in HIV prevalence predominantly observed among older women is needed. The interpretation of HIV prevalence trends in this age group is difficult without an in-depth analysis of HIV incidence and the impact of increasing access to ART .In the context of expanding coverage of HIV testing, PMTCT and ART and transition to PMTCT Option B+ for HIV-positive pregnant women, the Department will be conducting an
Unlinked Anonymous Testing (UAT) based sentinel surveillance which raises ethical concerns. It recommends the use of linked testing (confidential or anonymous) with informed consent for HIV sentinel surveillance. This will require informed consent from pregnant women who are HIV tested for this antenatal sentinel surveillance survey, providing them and the clinic with their HIV test results, and referring those to available HIV care, treatment and prevention

Tuberculosis is one of the major public health issues across the world and remains the leading cause of death worldwide. Tuberculosis is the commonest opportunistic infection in people with HIV/AIDS and the combination is lethal. According to WHO Report 2018, about 2,51,000 people died of HIV-associated TB (HIV-TB). In 2018, there were an estimated 8,62,000 new cases of TB amongst people who were HIV-positive [1]. India accounts for about 10% of the global burden of HIV-TB.

ItisacommonbeliefinNigeriathatthatpersonswithdisabilitiesaresexuallyinactive, so they cannot be infected with HIV/AIDS. They are therefore often neglected in HIV and reproductive health rights policies and never on the priority list regarding sex education that teaches safe sex practices. The letter discusses global legislation and policies that support the inclusiveness of persons with disabilities in HIV/AIDS and provides actionable recommendations.

Sub-Saharan Africa contains over 60% of the world's HIV infections and Zambia is among the most severely affected countries in the region. As antiretroviral programs have been rapidly expanding, the long-term success of these programs depends on a good understanding of the behavioral determinants of acceptance and adherence to antiretroviral therapy (ART). The study used qualitative methods to gain local insight into potentially important factors affecting HIV-infected women's decision to accept or continue with ART. Some of the barriers identified by this study are consistent with factors cited in the existing adherence literature from both developed and developing nations such as side effects, hunger and stigma; other factors have not been previously reported. One major theme was unfamiliarity with the implications of having a chronic, potentially deadly disease. Other emerging themes from this study include the complicated effect of ART on interpersonal relationship, particularly between husbands and wives, the presence of depression and hopelessness, and lack of accurate information. The results suggest that the reasons for non-uptake of treatment include issues related to local cultural frameworks (e.g., illness ideology), mental and behavioral health (e.g., depression and/or interpersonal challenges), stigma, and motivating factors (e.g., values of church or marriage) of different cultures that affect the ability and willingness to take life-saving medicine for a long period of time. Qualitative studies are critical to better understand why ART eligible individuals are choosing not to initiate or continue treatment to achieve needed adherence levels.

This study examined the effects of emotions on risk concerns and behavior change among sex workers in Zambia. The aim was to investigate which health communication ad campaigns elicit emotions that lead to behavior change. Two types of HIV/AIDS ads were used for the analysis: Those focusing on eradicating the scourge by evoking negative emotions versus those aimed at fighting stigma with positive messages. Findings suggest that participants exposed to negatively framed ad campaigns were more likely to quit their sex working profession at follow-up than those exposed to ads designed to fight social stigma. In other words, negatively framed ad campaigns that invoked fear about HIV/AIDS were more likely to encourage behavior change among female sex workers in Zambia. The study speaks to the issue of risk versus crisis communication as they relate to how the Global North and South respond to stigma.

Abstract: Transforming growth factor-beta (TGF-β) and bone
morphogenic protein (BMP) signaling pathways are involved in
the vast majority of cellular processes and are fundamentally
important during the entire life of all metazoans. TGF-βs and
BMPs transduce their signals via canonical Smad-dependent
pathways which involve TGF-β/BMP ligands, receptors and
Smad molecules. Also, non-canonical Smad-independent
signalling pathways are involved in TGF-β/BMP signal
transduction. Here we investigated signalling cross-talk between
the pathways downstream of TGF-β and BMP signalling in
endometrial and endometriotic cells. Treatment of endometrial
and endometriotic stromal and epithelial cells with TGF-β1 or
TGF-β2 increased secretion of plasminogen activator inhibitor
1 (PAI-1) dramatically in all cell lines. Of note, higher PAI-1
secretion was observed in endometriotic cells compared to
endometrial cells. Both a transforming growth factor-beta
receptor-1 (TβRI) and a Bone morphogenic protein receptor-
1(BMPR1) inhibitors completely blocked the TGF-β-induced
PAI-1 secretion in all cell lines while a specific inhibitor of
Smad3 (SiS3) had a partial effect on PAI-1 secretion in all cell
lines. Additionally, we showed that Activin Receptor-Like kinase
(ALK-2) is the main BMP receptor that is responsible for
complete blockage of TGF-β-induced PAI-1 secretion whereas,
ALK-3 and ALK-6 exhibited partial effects on PAI-1 secretion.
In summary, the complete inhibition of TGF-β-induced PAI-1
secretion by a general BMPR1 and ALK-2 inhibitors suggest a possible cross-talk between TGF-β and BMP pathways. Since
only ALK-2 had a complete decrease of TGF-β-induced PAI-1
secretion compared to ALK-3 and ALK-6 in all cells, then our
results demonstrate the importance of ALK-2 as a point of
cross-talk of TGF-β and BMP pathways. Furthermore, we
showed TGF-β-induced phosphorylation of Smad1 in all cells
upon TGF-beta treatment. Our result further confirms that the
Smads are the most important intracellular transducers of TGF-
β and BMP signals
Keywords: Endometriosis, Transforming growth factorbetas,
Bone morphogenic protein, Activin Receptor-Like
kinase