Here I review a range of academic journals over the past two months on global health and HIV, mindful of the fact that many of these pieces will inform the upcoming International AIDS Conference. At Transcriptions, we’re trying to bring together activists, scholars, physicians and others into conversation, so when a scholarly article appears on civil society and a global health concern, we’re interested. Ray et al’s article in Reproductive Health Matters covers maternal health and activism across southern Africa, arguing that public activism is vital for mitigating avoidable deaths. (Also see Judy Auerbach’s recent keyword article on Activism)
On the other hand, the controversial use of “global health” for strategic and diplomatic purposes is coming into clearer focus. Collins et al unapologetically advertise PEPFAR as a “vital force in US Health Diplomacy Abroad”, which is interesting in light of a recent New York Times article on vaccine programmes as a cover for the CIA. (Recently the US Global Health Initiative was shifted from USAID to its own Office of Global Health Diplomacy – for the controversy about this reframing of health as a strategic and diplomatic tool, see The Huff’s favourable piece and Foreign Policy’s critical piece).
In the build-up to the International AIDS Conference in Washington DC this July, there have a number of significant articles published recently on HIV medication, the most controversial of which have to do with biomedical prevention, including Treatment as Prevention and PrEP (grouped in a second post).
Given the amount of population and epidemiological research based on findings from southern Africa, I thought it useful to mention Lesley Green’s article just published in the South African Journal of Science on “indigenous knowledge-science wars” in South Africa in order to frame one national social and political context in which trials for TasP are being conducted. To understand TasP and other global health programmes in southern Africa, it’s important to remember that the social and political currents in which these biomedical technologies are deployed are crucial to how they play out in “real life” (see Part II for articles on “natural experiments” and “ecological observations”).
On the theme of the costs of treatment, there’s the question of whether cash payments should be used for HIV prevention, which raises a number of interesting ethical questions (and reminds us that we need a more critical review of what we mean by ethics in such settings). The authors conclude, predictably, that “ongoing RCTs with HIV incidence endpoints will shed more light on the efficacy of cash payments as a strategy for HIV prevention”.
Provider-initiated HIV testing and counseling is now beginning to generate a body of evaluative research, whose methods and concepts we could usefully examine. Kennedy et al’s systematic review concludes that “[Provider Initiated Testing and Counseling’s] impact on other outcomes is mixed, but does not appear to be worse than voluntary counseling and testing. PITC should continue to be expanded and rigorously evaluated across settings and outcomes”.
New evidence on the incidence of “superinfection” has major clinical and pharmacological implications, as reported in a study in the Journal of Infectious Diseases. Redd et al suggest that superinfection may be as common as infection but we have inadequate methods for measuring this accurately. It raises the question of how estimates such as these are arrived at. A recent article on provision of ART in South Africa struggles with just this question: how accurate are these estimates of ART uptake and how serious are their margins of error? Johnson et al found that South Africa exceeded national targets for new patients starting antiretroviral treatment (ART) by around 50% between 2007 and 2011 – achieving treatment coverage of close to 80% of eligible adults.
As the debate about Treatment as Prevention really gets going, older concerns about the importance of “concurrent partnerships” to transmission remain, particularly in Southern Africa. Kretzschmar and Caraël explore apparent discrepancies between theoretical and empirical studies of concurrency, and conclude with an appeal to “social and behavioral studies on sexual partnerships” and a more rigorous definition for “when a factor is considered a driving force for HIV epidemic spread” – interesting in light of Robert Thornton’s recent ethnography of sexual networks in Africa and the problem of conceptualizing concurrency. (See also Mmbaga et al’s “first” report from Tanzania on sexual practices and perceived risk of HIV among Men who have Sex with Men (MSM), where they argue that HIV prevention in Tanzania has excluded MSM and thus needs to consider this group in HIV programming).
As budgets for HIV and other global health programmes shrink or come under threat, there’s a growing discourse around the economic rationality of providing treatment, whether for prevention or as a form of life-long patient care. Political and moral considerations are thus apparently discrete elements in the real politik of HIV funding. So evidence showing that treatment provides positive economic returns for donors is extremely important in the current climate of scarcity and American political conservatism. Thirumurthy et al argue that HIV Treatment produces economic returns through increased work and education, and therefore warrants continued US Support. In this regard, a recent article by Bor et al showing data from South Africa regarding recovery and employment of patients of ART is particularly important. They suggest that “for some patients, further gains could be obtained from initiating antiretroviral therapy earlier, prior to HIV-related job loss”. These findings chime with a slew of recent articles on Treatment as Prevention – dealing with the epidemiological modeling and costing – see the second part of July’s In the Journals.