Articles tagged as "HIV This Month 2015 #12 - December 2015"

Can cryptococcal antigen screening and treatment improve outcomes?

Cryptococcal antigen screening in patients initiating ART in South Africa: a prospective cohort study.

Longley N, Jarvis JN, Meintjes G, Boulle A, Cross A, Kelly N, Govender NP, Bekker LG, Wood R, Harrison TS. Clin Infect Dis. 2015 Nov 12. pii: civ936. [Epub ahead of print]

Background: Retrospective data suggest that cryptococcal antigen (CrAg) screening in patients with late-stage HIV initiating antiretrovirals may reduce cryptococcal disease and deaths. Prospective data are limited.

Methods: CrAg was measured using lateral flow assays (LFA) and latex agglutination (LA) tests in 645 HIV-positive, ART-naive patients with CD4 counts ≤100 cells/µL in Cape Town, South Africa. CrAg-positive patients were offered lumbar puncture (LP) and treated with antifungals. Patients were started on ART between 2-4 weeks and followed up for 1 year.

Results: 4.3% (28/645) of patients were CrAg-positive in serum and plasma with LFA. These included 16 also positive by urine LFA (2.5% of total screened) and 7 by serum LA (1.1% of total). In 4 of 10 LFA-positive cases agreeing to LP, the cerebrospinal fluid (CSF) CrAg-LFA was positive. A positive CSF CrAg was associated with higher screening plasma/serum LFA titres. Among the 28 CrAg-positive patients, mortality was 14.3% at 10 weeks and 25% at 12 months. Only one CrAg-positive patient, who defaulted from care, died from cryptococcal meningitis (CM). Mortality in CrAg-negative patients was 11.5% at 1 year. Only 2 possible CM cases were identified in CrAg-negative patients.

Conclusions: Cryptococcal antigen screening of individuals initiating ART and pre-emptive fluconazole treatment of CrAg-positive patients resulted in markedly fewer cases of cryptococcal meningitis compared to historic unscreened cohorts. Studies are needed to refine management of CrAg positive patients, who have high mortality that does not appear to be wholly attributable to cryptococcal disease.

Abstract   Full-text [free] access

Editor’s notes: In sub-Saharan Africa, cryptococcal meningitis is the leading cause of adult meningitis. Even with current antifungal therapies, mortality remains high. Asymptomatic cryptococcal antigenemia precedes cryptococcal meningitis and independently predicts mortality in people initiating antiretroviral therapy (ART). Therefore, preventing disease in people found to be cryptococcal antigen (CrAg) positive at ART initiation has potential to reduce morbidity and mortality.

In this prospective study in Cape Town, South Africa, people initiating ART with low CD4 counts (≤100 cells/ μL) underwent CrAg screening. People without proven cryptocococcal meningitis but with a positive cryptococcal antigen test were pre-emptively treated with oral fluconazole, and were started on ART within two to four weeks. They were followed up for a year. This approach did not lead to delays in ART initiation, and resulted in fewer cryptococcal meningitis cases. However, despite pre-emptive antifungal therapy, mortality remained twice as high among people who were CrAg positive, even after adjustment for CD4 cell count. This high mortality appears not completely attributable to cryptococcal disease, and the authors hypothesize that cryptococcal antigen positivity in itself is a marker for severe immunosuppression.

Interestingly, the authors found a lower prevalence of asymptomatic antigenaemia than expected: about 4% in this study (2011-2014) compared to 6% in a similar population in 2002 to 2005. The authors suggest that earlier HIV diagnosis and improved access to care may be the main reasons for this, proposing that reducing the duration of severe immunosuppression may reduce the risk of cryptococcal disease, either due to reactivation or rapid progression of new infection.

The authors conclude that the optimal strategies for implementing screening and the optimal pre-emptive antifungal regimen remain to be defined. Screening may best be delivered as part of a combined opportunistic infection screening and treatment package for people presenting with low CD4 counts. 

Avoid TB deaths
Comorbidity, HIV Treatment
South Africa
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Expanding ART access: increasing costs

The HIV treatment gap: estimates of the financial resources needed versus available for scale-up of antiretroviral therapy in 97 countries from 2015 to 2020.

Dutta A, Barker C, Kallarakal A. PLoS Med. 2015 Nov 24;12(11):e1001907. doi: 10.1371/journal.pmed.1001907. eCollection 2015.

Background: The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available.

Methods and findings: Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead.

We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data.

Conclusions: The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.

Abstract Full-text [free] access

Editor’s notes: This is a complex and important paper that seeks to understand the financial requirements necessary to: a) continue countries’ current policies of eligibility for ART, b) roll out universal adoption of certain aspects of WHO 2013 eligibility guidelines, and c) expand eligibility as per WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS ‘90-90-90’ targets.

The authors estimated the number of adults and children eligible for and receiving HIV treatment, as well as the cost of providing ART in 97 countries across six regions, covering different income levels. They estimated that 25.7 million adults and 1.57 million children could receive ART by 2020 if countries maintain the current eligibility strategies. If countries adopted WHO 2013 eligibility guidelines, 26.5 million adults and 1.53 million children would be on ART by 2020, and if they adopted the 90-90-90 scenario, 30.4 million adults and 1.68 million children could receive treatment by then. The financial resources necessary for this scale up are estimated to be US$ 45.8 billion under current eligibility, US$ 48.7 billion under WHO 2013 scenario and US$ 52.5 billion under the 90-90-90 scenario. The estimated funding gap for the six year period ranges between US$ 20 and US$ 25 billion. In this study, the costs of commodities were taken directly from data collated by other organisations.  No empirical cost estimates of service delivery were made.  Nor was there an attempt to understand the cost implications of the development synergies and social and programme enablers that may be needed to increase the number of people living with HIV knowing their status.  The new WHO recommendations need to be actively pursued if we are to meet targets, rather than passively continuing with “business as usual”. 

Nonetheless, the findings of this study highlight the gap between guidelines written by WHO and very real programmatic obstacles on the ground. There is evidence to suggest that universal test-and-treat strategies could lead to substantially improved health outcomes at the population level, as well as potentially being cost-saving in the long-term. However, as the authors have illustrated, it would require increased levels of funding. What needs to be explored further now is how to overcome the logistical hurdles of rolling out such an initiative. Changing systems and practices is costly and takes time. Health workers will have to be retrained, data collection strategies will have to be revised. Expanding treatment may also mean increasing the number of health staff working on this initiative, which has an opportunity cost that may reverberate in other parts of the health system. Substantially altering health service provision, particularly in weak health systems, may have knock-on effects with unexpected and unintended consequences.

WHO guidelines serve a vital purpose of giving us a goal to aim for. But studies like this one help us know if and how we can get there. 

Africa, Asia, Europe, Latin America, Oceania
Algeria, Angola, Armenia, Azerbaijan, Bahamas, Bangladesh, Barbados, Belarus, Belize, Benin, Bhutan, Bolivia, Botswana, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Côte d'Ivoire, Cuba, Democratic Republic of the Congo, Djibouti, Dominican Republic, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Georgia, Ghana, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iran (Islamic Republic of), Jamaica, Kazakhstan, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Malaysia, Mali, Mauritania, Mauritius, Moldova, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Nicaragua, Niger, Nigeria, Pakistan, Papua New Guinea, Philippines, Republic of the Congo, Romania, Russia, Rwanda, Senegal, Serbia and Montenegro, Sierra Leone, Somalia, South Africa, Sri Lanka, Sudan, Suriname, Swaziland, Tajikistan, Thailand, Togo, Trinidad and Tobago, Tunisia, Uganda, Ukraine, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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More savings, more hope, and more HIV-preventive attitudes among vulnerable adolescent youth

Effect of savings-led economic empowerment on HIV preventive practices among orphaned adolescents in rural Uganda: results from the Suubi-Maka randomized experiment.

Jennings L, Ssewamala FM, Nabunya P. AIDS Care. 2015 Nov 7:1-10. [Epub ahead of print]

Improving economic resources of impoverished youth may alter intentions to engage in sexual risk behaviors by motivating positive future planning to avoid HIV risk and by altering economic contexts contributing to HIV risk. Yet, few studies have examined the effect of economic-strengthening on economic and sexual behaviors of orphaned youth, despite high poverty and high HIV infection in this population. Hierarchal longitudinal regressions were used to examine the effect of a savings-led economic empowerment intervention, the Suubi-Maka Project, on changes in orphaned adolescents' cash savings and attitudes toward savings and HIV-preventive practices over time. We randomized 346 Ugandan adolescents, aged 10-17 years, to either the control group receiving usual orphan care plus mentoring (n = 167) or the intervention group receiving usual orphan care plus mentoring, financial education, and matched savings accounts (n = 179). Assessments were conducted at baseline, 12, and 24 months. Results indicated that intervention adolescents significantly increased their cash savings over time (b = $US12.32, +/-1.12, p < .001) compared to adolescents in the control group. At 24 months post-baseline, 92% of intervention adolescents had accumulated savings compared to 43% in the control group (p < .001). The largest changes in savings goals were the proportion of intervention adolescents valuing saving for money to buy a home (DeltaT1-T0 = +14.9, p < .001), pursue vocational training (DeltaT1-T0 = +8.8, p < .01), and start a business (T1-T0 = +6.7, p < .01). Intervention adolescents also had a significant relative increase over time in HIV-preventive attitudinal scores (b = +0.19, +/-0.09, p < .05), most commonly toward perceived risk of HIV (95.8%, n = 159), sexual abstinence or postponement (91.6%, n = 152), and consistent condom use (93.4%, n = 144). In addition, intervention adolescents had 2.017 significantly greater odds of a maximum HIV-prevention score (OR = 2.017, 95%CI: 1.43-2.84). To minimize HIV risk throughout the adolescent and young adult periods, long-term strategies are needed to integrate youth economic development, including savings and income generation, with age-appropriate combination prevention interventions.

Abstract access 

Editor’s notes: This study contributes to the small but growing evidence on the effectiveness of economic strengthening activities for HIV prevention and treatment outcomes. It used a cluster randomised experimental design to evaluate the impact of a savings-led economic empowerment programme for orphaned adolescents on savings behaviour, as well as sexually protective attitudes. The authors report a significant and large impact on cash savings, as well as an increase in HIV-preventive attitudinal scores. This is particularly promising given the need to address the multiple needs of adolescent youth to promote their healthy transition to adulthood.

It is important to note that this study considered attitudinal outcomes, rather than biological or even reported behavioural ones. There are considerable limitations to such measures that often do not reflect actual sexual behaviours. Also, given the significant additional cost and economic benefits of the savings component in the programme arm, a key question remains, namely how incrementally cost-effective it is in achieving HIV and economic development goals. 

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Client violence against female sex workers in Mexico

Prevalence and correlates of client-perpetrated violence against female sex workers in 13 Mexican cities.

Semple SJ, Stockman JK, Pitpitan EV, Strathdee SA, Chavarin CV, Mendoza DV, Aarons GA, Patterson TL. PLoS One. 2015 Nov 23;10(11):e0143317. doi: 10.1371/journal.pone.0143317. eCollection 2015.

Background: Globally, client-perpetrated violence against female sex workers (FSWs) has been associated with multiple health-related harms, including high-risk sexual behavior and increased exposure to HIV/STIs. This study examined correlates of client-perpetrated sexual, physical, and economic violence (e.g., robbery) against FSWs in 13 cities throughout Mexico.

Methods: FSWs (N = 1089) who were enrolled in a brief, evidence-based, sexual risk reduction intervention for FSWs (Mujer Segura) were interviewed about their work context, including experiences of violence perpetrated by clients, sexual risk and substance use practices, financial need, and social supports. Three broad categories of factors (sociodemographic, work context, behavioral and social characteristics of FSWs) were examined as correlates of sexual, physical, and economic violence.

Results: The prevalence of different types of client-perpetrated violence against FSWs in the past 6 months was: sexual (11.7%), physical (11.8%), economic (16.9%), and any violence (22.6%). Greater financial need, self-identification as a street worker, and lower perceived emotional support were independently associated with all three types of violence. Alcohol use before or during sex with clients in the past month was associated with physical and sexual violence. Using drugs before or during sex with clients, injection drug use in the past month, and population size of city were associated with sexual violence only, and FSWs' alcohol use score (AUDIT-C) was associated with economic violence only.

Conclusions: Correlates of client-perpetrated violence encompassed sociodemographic, work context, and behavioral and social factors, suggesting that approaches to violence prevention for FSWs must be multi-dimensional. Prevention could involve teaching FSWs strategies for risk avoidance in the workplace (e.g., avoiding use of alcohol with clients), enhancement of FSWs' community-based supports, development of interventions that deliver an anti-violence curriculum to clients, and programs to address FSWs' financial need by increasing their economic opportunities outside of the sex trade.

Abstract Full-text [free] access

Editor’s notes: Violence against women who sell sex is receiving increasing attention. Perpetrators include clients, police, strangers, local thugs and husbands or intimate (non-paying) partners. This study from Mexico examined physical, sexual and emotional violence by clients among female sex workers in 13 cities in Mexico. Violence by clients was common (22.6% any violence, past six months) and similar to rates reported in other countries. Violence exposure was associated with greater financial need, street sex work, and lower perceived emotional support. Sexual and physical violence were also associated with alcohol use. Alcohol use, street sex work and debt have been associated with violence exposure among female sex workers in other low and middle income settings. This research supports a growing body of evidence which suggests that violence prevention should be a key element in services designed for and with female sex workers. Successful violence and HIV prevention programming will need to address the broader structural determinants of vulnerability such as poverty, sex work structure (typology), stigma and discrimination, and associated alcohol and drug use.  

Latin America
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Justification of PrEP use as protection from rape

Negotiating the use of female-initiated HIV prevention methods in a context of gender-based violence: the narrative of rape.

Hartmann M, Montgomery E, Stadler J, Laborde N, Magazi B, Mathebula F, van der Straten A. Cult Health Sex. 2015 Nov 9:1-14. [Epub ahead of print]

Female-initiated methods of HIV prevention are needed to address barriers to HIV prevention rooted in gender inequalities. Understanding the sociocultural context of pre-exposure prophylaxis (PrEP) trials, including gender-based violence, is thus critical. MTN-003C (VOICE-C), a qualitative sub-study of the larger MTN-003 (VOICE) trial, examined sociocultural barriers and facilitators to PrEP amongst women in Johannesburg. We conducted focus-group discussions, in-depth interviews and ethnographic interviews with 102 trial participants, 22 male partners, 17 community advisory board members and 23 community stakeholders. We analysed how discussions of rape are emblematic of the gendered context in which HIV risk occurs. Rape emerged spontaneously in half of discussions with community advisory board members, two-thirds with stakeholders and among one-fifth of interviews/discussions with trial participants. Rape was used to reframe HIV risk as external to women's or partner's behaviour and to justify the importance of PrEP. Our research illustrates how women, in contexts of high levels of sexual violence, may use existing gender inequalities to negotiate PrEP use. This suggests that future interventions should simultaneously address harmful gender attitudes, as well as equip women with alternative means to negotiate product use, in order to more effectively empower women to protect themselves from HIV.

Abstract access 

Editor’s notes: This paper presents qualitative research which explored the broader context of gender-based violence surrounding PrEP use. The study was an ancillary study alongside the VOICE trial at the South Africa site, which evaluated daily oral and vaginal PrEP. Participants in the ancillary study included women participants, male partners and community stakeholders. The authors found that the issue of rape was spontaneously mentioned by the majority of participants, with the exception of male partners. From these discussions of rape, issues of gender norms emerged, which revealed a continuum from what was called gender exploitative and gender accommodating. The context of gender exploitative was expressed as rape as a reflection of women’s vulnerability. In this context women’s vulnerability to rape and HIV provides a rationale for the use of PrEP. This includes protecting them against sexual violence victimisation. The study highlights that rape provides justification for the use of PrEP but reveals that such justification is complex in that women are seen as both vulnerable to rape but also blamed for rape through unacceptable behaviours including drinking alcohol. The authors conclude that the focus on rape by strangers hides women’s vulnerability to sexual violence from partners and argue that any move to legitimise PrEP for the threat of rape may undermine its use in consensual sex and reinforces negative gender norms about women’s vulnerability to strangers. They suggest that initiatives surrounding PrEP need to recognise and challenge harmful gender norms. This study has highlighted that while PrEP has not been imagined as a gendered HIV prevention tool, in contrast to microbicides, it does in fact emerge as a tool that will be gendered in potentially harmful ways. 

South Africa
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Can children recognise HIV-associated symptoms in their carers? Evaluation of a verbal assessment tool for children in South Africa.

Measuring child awareness for adult symptomatic HIV using a verbal assessment tool: concordance between adult-child dyads on adult HIV-associated symptoms and illnesses.

Becker E, Kuo C, Operario D, Moshabela M, Cluver L. Sex Transm Infect. 2015 Nov;91(7):528-33. doi: 10.1136/sextrans-2014-051728. Epub 2015 Jan 13.

Objectives: This study assessed children's awareness for adult HIV-associated symptoms and illnesses using a verbal assessment tool by analysing inter-rater reliability between adult-child dyads. This study also evaluated sociodemographic and household characteristics associated with child awareness of adult symptomatic HIV.

Methods: A cross-sectional survey using a representative community sample of adult-child dyads (N=2477 dyads) was conducted in KwaZulu-Natal, South Africa. Analyses focused on a subsample (n=673 adult-child dyads) who completed verbal assessment interviews for symptomatic HIV. We used an existing validated verbal autopsy approach, originally designed to determine AIDS-related deaths by adult proxy reporters. We adapted this approach for use by child proxy reporters for reporting on HIV-associated symptoms and illnesses among living adults. Analyses assessed whether children could reliably report on adult HIV-associated symptoms and illnesses and adult provisional HIV status.

Results: Adult-child pairs concurred above the 65th percentile for 9 of the 10 HIV-associated symptoms and illnesses with sensitivities ranging from 10% to 100% and specificities ranging from 20% to 100%. Concordant reporting between adult-child dyads for the adult's provisional HIV status was 72% (sensitivity=68%, specificity=73%). Children were more likely to reliably match adult's reports of provisional HIV status when they lived in households with more household members, and households with more robust socioeconomic indicators including access to potable water, food security and television.

Conclusions: Children demonstrate awareness of HIV-associated symptoms and illnesses experienced by adults in their household. Children in households with greater socioeconomic resources and more household members were more likely to reliably report on the adult's provisional HIV status.

Abstract Full-text [free] access

Editor’s notes: This study tested a new tool for assessing whether children who are caring for adults living with HIV in their household are able to recognise HIV-associated symptoms and illnesses. The study was conducted with households in one rural and one urban site in KwaZulu-Natal, South Africa. The authors report on the analysis of results from a sub-sample of 673 dyads, composed of one adult and one child living in the same household. With the help of researchers, children aged 10-17, completed a verbal tool that was adapted for this study from a previous ‘verbal autopsy’ tool used to assess AIDS-associated deaths. The adult in each of the dyads also completed an adult version of the study’s adapted tool. The tool contained questions on ten symptoms and illnesses associated with HIV. Some of these strongly indicate HIV presence when found in a combination of two or more (e.g. TB; oral candidiasis; diarrhoea; herpes). Children-adult responses were compared in each dyad and tested for concurrency and sensibility. Overall, children and adult responses matched for more than 65% for nine out of ten of the symptoms/illnesses listed. There were variations in reliable matching depending on symptoms/illnesses. Some symptoms may have been harder for children to report on behalf of the adult, for example, constant diarrhoea. The tool used with the children may be useful for improving our understanding of the issues faced by young carers in households where some members are living with HIV. The tool may also help to understand strategies put in place by young carers looking after an adult with HIV-associated illnesses.

South Africa
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Vulnerabilities of children living with HIV positive adults

Children living with HIV-infected adults: estimates for 23 countries in sub-Saharan Africa.

Short SE, Goldberg RE. PLoS One. 2015 Nov 17; 10(11): e0142580.

Background: In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children's health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children's health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods: Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results: The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion: Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

Abstract Full-text [free] access

Editor’s notes: This paper is an important contribution to the literature on the impact of the HIV epidemic. Using Demographic and Health Survey (DHS) data from 23 countries it highlights the considerable number of children living with HIV-positive adults in sub-Saharan Africa. However, notable exceptions from the analysis (no DHS data available) included South Africa. This, coupled with specific issues related to DHS data collection methods and response rates, means that the number of children living with HIV-positive adults is much higher. Reductions in mortality from HIV due to increased treatment availability and the addition of adults newly acquiring HIV means that population of children living with an HIV-positive adult will continue to increase in the near future.

Children living with HIV-positive adults are clearly vulnerable and like all vulnerable children should be focussed on in efforts to promote child wellbeing. The authors suggest, however, that children living with HIV-positive adults may have distinct vulnerabilities that need to be considered. These include direct exposure to opportunistic infections, social stigma and disrupted networks, as well as increases in poverty. The challenge for many countries is how to identify these children and ensure that focussed programmes are delivered effectively.

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