There must be a silver lining

By Lucy Stackpool-Moore

Any day is a sad day for the world when senseless violence takes the life of a kind, compassionate human being. Yesterday was no exception, when David Kato, the litigation and advocacy officer for SMUG (Sexual Minorities Uganda) was killed in his home in Kampala.

David was a friend, and worked closely with IPPF on a number of occasions over the last two years. He spoke about the law and human rights at the Vienna International AIDS Conference.  Just a few months ago, David, representing Africa, provided an important perspective at a meeting of the UK Consortium on AIDS and International Development about barriers to universal access of HIV care & support. He made sure that due attention was given to this issue for all people, including those from sexual minority groups.



David Kato speaking at IPPF satelitte session in Vienna. Placard he created read "AIDS 2010 demands withdraw of the Ugandan Anti-Homosexuality Bill in its entirety now!"



At times like this we must look for inspiration and compassion and hope, and we must find the silver lining hiding in even the darkest of thunderclouds. I was reminded of the great Archbishop Desmond Tutu’s humane and wise comment about homophobia in March 2010—which he called ‘a step backward on human rights’ in Africa:

“Hate has no place in the house of God. No one should be excluded from our love, our compassion or our concern because of race or gender, faith or ethnicity -- or because of their sexual orientation… It is time to stand up against another wrong.

Gay, lesbian, bisexual and transgendered people are part of so many families. They are part of the human family. They are part of God's family. And of course they are part of the African family. But a wave of hate is spreading across my beloved continent. People are again being denied their fundamental rights and freedoms…

These are terrible backward steps for human rights in Africa. Our lesbian and gay brothers and sisters across Africa are living in fear…The wave of hate must stop… Exclusion is never the way forward on our shared paths to freedom and justice.”

IPPF is deeply shocked and saddened by the news of David Kato’s murder. Our thoughts are with David’s family and friends and colleagues at SMUG (Sexual Minorities Uganda). We have lost a friend, a colleague, a committed human rights activist and a generous and compassionate human being.

Adherence: More than just about taking pills

By Ashraf Grimwood (Kheth'Impilo, South Africa)

“I can't even complete a full course of antibiotics, how am I going to remember to take my ART?”

Adherence is usually understood to mean ‘the taking of medication as prescribed’ at the correct time and with the correct association with meals. But managing HIV infection is more than just about taking pills – adherence is about sticking to positive lifestyle choices.

The impact of HIV starts from the time of infection and earlier treatment will go a long way in avoiding complications. But before starting treatment it is important to be mentally ready and prepared. I always recommend to my patients that soon after diagnosis, regardless of how they feel, counselling is vital. The usual response is, “What would I talk about? I know how I got infected and I know what I need to do!” I say, “Just go. Talk about anything, give time to connect with the why and the how, understand your feelings and see if you can use this positively.”

The best way of managing an HIV infection is about making the right lifestyle choices and, critically, adhering to these. Adherence is about following lifestyle choices - irrespective of what they may be - that ensure the best health outcomes. Regular monitoring, CD4 counting, STI testing, exercise and a good dietary plan are crucial for good health maintenance before even starting to take pills.

Combination antiretroviral treatment is the best known way of controlling the virus. Pills need to be taken as directed by a clinician. It is important that personal lifestyle is discussed with a health care worker to ensure there is no clash. “How do I take my pills when… I work shift work? I travel often? I take recreational drugs? I am addicted to heroin? I am on methadone? I am pregnant? My partner does not yet know I am HIV positive?” These all need to be discussed with a health care practitioner. It is important to talk through any life issues that might impact on treatment adherence. Open honest communication is always the best option to ensure better health outcomes.

When starting treatment it is important to know what is being prescribed – learn the names, understand what they do, how they work, what their side effects are and when to seek professional advice. Ensure treatment is taken at the times prescribed and know how much leeway is acceptable with regards to the timing so the margin of safety is known when travelling across time zones or working shifts.

Any day forgotten gives the virus an opportunity to rebound and any resistant strain to dominate. This can lead to multi-drug resistance and treatment failure. Treatment failure means new drugs need to be prescribed. All these treatments have different side effect profiles which need different management. It is best to remain on the initial prescribed regimen if there are no adverse effects.

There are many tools that can be used to act as reminders for taking pills on time. Using a daily treatment tick-sheet or diary, pill boxes, and cell phone reminders are a few techniques that people have found work for them. Some take their daily ART at night after brushing their teeth, so they are often kept where this is done. Some have spare pills at their workplace. Packing pill boxes once a week or getting blister pre-packs for the month are other strategies that have worked for some.

All people living with HIV today have the opportunity to lead as normal lives as possible with this infection – and adhering to medication and selected lifestyle choices is often the starting point. No doubt it’s hard to stick to these. But being honest with ourselves and with our clients is always a great start.

Article from IPPF HIV Update newsletter - Issue 24: http://www.ippf.org/en/Resources/Newsletters/HIV+Update+Issue+24.htm

Treatment 2.0: Therapeutic and prevention benefits of ART

By Reuben Granich, Marco Vitoria, and Craig McClure (HIV/AIDS Department, WHO, Geneva)

Despite considerable progress, the global HIV situation remains serious. By the end of 2009, 5.2 million people were on antiretroviral treatment (ART); approximately 36 per cent of those estimated to be in need as per the new WHO recommendations. This, combined with the international fiscal crisis, has led to a growing concern regarding a weakening of the international commitment to universal access and to reaching the related Millennium Development Goals (MDG) by 2015. However, there are a number of reasons to be optimistic about our future efforts to confront HIV.

The 5.2 million people on treatment are a remarkable testament to the many outstanding examples of programmes that are doing great work on a large scale. However, our current response to HIV is often fragmented and unnecessarily complicated. This complexity often means late initiation of treatment, lack of continuum of care and increased costs for both programmes and patients. Retention of patients on antiretroviral therapy, which can mean the difference between life and death, is often hindered by our current approach to delivering treatment. Patients, where there is access to treatment, are often asked to travel great distances, wait in long queues, join lengthy waiting lists and return frequently to evaluate eligibility for treatment.

When placed on treatment, patients are often asked to adhere to difficult regimens with little hope of second line treatment in the case of toxicity or a failure to respond. Drug stock outs are also a stumbling block for adhering to ART programmes. Prevention, treatment, care and social support programmes are often in different locations and could be better integrated in order to effectively use scarce resources. There is a need to re-examine our approach to delivering prevention and treatment services to ensure easier access for people living with HIV.

Two key opportunities have the potential to hasten and expand the twin goals of saving lives and preventing new HIV infections. Firstly, the ongoing efforts to develop drug regimens and treatment strategies that will render HIV treatment easier to administer, more efficient to manage, and have a longer lasting impact for individuals and public health programmes. Secondly, it is also increasingly clear that universal access to ART can have a significant impact on HIV transmission. The potential individual and public health prevention benefits of treatment enhance the value of the universal access pledge from a life-saving initiative to a strategic investment aimed at ending the HIV epidemic.

‘Treatment 2.0’ was recently launched by UNAIDS and WHO to accelerate the simplification of ART in order to achieve and sustain universal access to treatment for all who need it and realize the significant potential for HIV and TB preventive benefits. The agenda of Treatment 2.0 involves radically simplifying drug regimens and diagnostics and monitoring, decentralizing service delivery, reducing costs and mobilizing communities.

When combined, expanding access to ART using simpler, more effective approaches and the use of ART as part of combination prevention will be critical in reaching the goals of universal access and will, most likely, result in cost savings over the medium and long term. Patient-friendly regimens should allow for improved adherence and increased access and retention to treatment. Our challenge is to understand how best to use new information regarding the role of ART for a reinvigorated, more effective and sustainable global response to AIDS. A simplified, public health approach to treatment is nothing new. WHO advanced this approach in 2003 to kick-start ART access in developing countries. Since then, the number of people on treatment has increased from 50,000 to over 5 million. What is potentially new is a renewed and intensified focus on simplification with accelerated expansion and full integration of treatment as a key aspect of HIV prevention efforts.

Article from IPPF HIV Update newsletter - Issue 24: http://www.ippf.org/en/Resources/Newsletters/HIV+Update+Issue+24.htm

HIV Update: Adherence 4 Life

By Kevin Osborne (IPPF)

Taking any routine medication on a regular basis is challenging for us all. More so if the regimen is life-saving and adhering to it requires a life-long commitment. With antiretroviral treatment (ART) reaching more people than ever, many more are now facing this challenge. As the world recognizes both World AIDS Day (1 December) and International Human Rights Day (10 December), it is important to ensure that our programmes are improving and maintaining the health and well-being of people living with HIV, including support for treatment adherence.

As treatment reduces a person’s viral load, it also reduces the risk of onward HIV transmission. This evidence shows that treatment should be part of a combination prevention strategy or ‘treatment as prevention’ approach. Starting treatment earlier means that viral load can be reduced earlier and this, in turn, can help to avert a significant number of new HIV infections. This is one aspect of the new ‘Treatment 2.0’ platform introduced by WHO and UNAIDS.

In 2010, WHO introduced updated guidelines promoting the earlier initiation of treatment, adding an estimated five million people who are now eligible for treatment. With more people receiving treatment, there is growing emphasis on issues such as treatment retention and resistance. Once treatment is no longer effective, it may be necessary to move to second- or third-lines of treatment – a luxury still not widely available in many low- and middle-income countries.

However, reflections by Dr. Ashraf Grimwood – CEO of Kheth'Impilo and a leading HIV clinician in South Africa for many years – indicates that adherence is more than just about taking pills. While scientists develop new treatment options to improve the effectiveness and ease of use, IPPF needs to provide further support to people living with HIV – in ways big and small – to help increase overall treatment adherence rates. From supplying pill boxes and promoting individual adherence, to scaling-up community-based support services and providing adherence counselling and peer support – a variety of interventions will help to realize the promise of treatment and treatment-centred HIV prevention.

Article from IPPF HIV Update newsletter - Issue 24: http://www.ippf.org/en/Resources/Newsletters/HIV+Update+Issue+24.htm