African Journal of Reproductive Health

Transcription

Friday Okonofua, Editor
ISSN: 1118-4841
www.ajrh.info
AJRH Editorial Office:
[email protected]
[email protected]
BrownWalker Press
Boca Raton, Florida, USA • 2014
ISBN-10: 1-62734-522-1\ ISBN-13: 978-1-62734-522-4
www.brownwalker.com
WHARC receives core funding and support from the Ford
Foundation and technical cooperation and mentorship
from International Perspectives on Sexual and
Reproductive Health and Studies in Family Planning
AJRH is a member of the committee on Publication
Ethics
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HIV Prevention Research and Development
African Journal of Reproductive Health
Editor: Friday Okonofua
VOLUME 18 NUMBER 3
September 2014
CONTENTS
Editorial
Editorial: Biomedical HIV Prevention Research and Development in Africa
O A Dada
9-13
Commentary
Some Ethical Issues in HIV/AIDS Care
Peter F. Omonzejele
14-16
Original Articles
HIV Prevention and Research Considerations for Women in Sub-Saharan Africa: 17-24
Moving Toward Biobehavioral Prevention Strategies
Abigail Harrison
Medicalization of HIV and the African Response
25-33
Serah Gitome, Stella Njuguna, Zachary Kwena, Everlyne Ombati, Betty Njoroge and
Elizabeth A. Bukusi
The Abuja +12 Declaration: Implications for Investment in HIV Prevention Research 34-46
Africa
Rosemary Mburu, Morenike Oluwatoyin Folayan and Olayide Akanni
From Addiction to Infection: Managing Drug Abuse in the Context of HIV/AIDS in 47-54
Africa
Taiwo Akindipe, Lolade Abiodun, Sylvia Adebajo, Rahman Lawal and Solomon
Rataemane
Standards and Guidelines for HIV Prevention Research: Considerations for Local 55-65
Context in the Interpretation of Global Ethical Standards Using a Nigerian Case Study
Bridget Haire, Morenike Oluwatoyin Folayan and Brandon Brown
Development of Guidelines for the Conduct of HIV Research Monitoring by Ethics 66-73
Committees in Nigeria
Bridget Haire, Morenike Oluwatoyin Folayan and Jennifer Fleming
African Journal of Reproductive Health September 2014 (Special Edition); 18(3):
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The Promise and Peril of Pre-Exposure Prophylaxis (PrEP): Using Social Science to 74-83
Inform PrEP Interventions Among Female Sex Workers
Jennifer L. Syvertsen, Angela M Robertson, Andrew Scheibe, Sylvia Adebajo,
Steffanie A. Strathdee and Wendee M. Wechsberg
Money, Power and HIV: Economic Influences and HIV Among Men who have Sex 84-92
with Men in sub-Saharan Africa.
Andrew Scheibe, Brian Kanyemba, Jennifer Syvertsen, Sylvia Adebajo and Stefan
Baral
Addressing the Socio-Development Needs of Adolescents Living with HIV/AIDS in 93-101
Nigeria: A Call for Action
Morenike O Folayan, Morolake Odetoyinbo, Brandon Brown and Abigail Harrison
Tackling the Sexual and Reproductive Health and Rights of Adolescents Living with 102-108
HIV/AIDS: A Priority Need in Nigeria.
Morenike Oluwatoyin Folayan, Abigail Harrison, Morolake Odetoyinbo and Brandon
Brown
Changes in Sexual Risk Behaviour Among Adolescents: - Is the HIV Prevention 109-117
Programme in Nigeria Yielding Results?
Hafsatu Aboki, Morenike Oluwatoyin Folayan, Uduak Daniel and Munirat Ogunlayi
Beyond Informed Consent: Other Ethical Considerations in the Design and 118-126
Implementation of Sexual and Reproductive Health Research Among Adolescents
Morenike Oluwatoyin Folayan, Bridget Haire, Abigail Harrison, Olawunmi Fatusi
and Brandon Brown
The Use of Antiretroviral Therapy for the Prevention of New HIV Infection in 127-134
Populations at High Risk for HIV Sero-conversion in Nigeria
John Idoko and Morenike O. Folayan
Ethics of Ancillary Care in Clinical Trials in Low Income Countries: A Nigerian Case 135-142
Study.
Bridget G. Haire and Olusegun Ogundokun
Information for Authors
143-148
Subscription Information and Advert Rate
149-150
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ABOUT AJRH
African Journal of Reproductive Health (AJRH) is published by the Women’s Health and Action
Research Centre (WHARC). It is a multidisciplinary and international journal that publishes
original research, comprehensive review articles, short reports and commentaries on reproductive
health in Africa. The journal strives to provide a forum for African authors, as well as others
working in Africa, to share findings on all aspects of reproductive health, and to disseminate
innovative, relevant and useful information on reproductive health throughout the continent.
AJRH is indexed and included in Index Medicus/MEDLINE. The abstracts and tables of
contents are published online by INASP at http://www.ajol.info/ajol/ while full text is published
at http://www.ajrh.info and by Bioline International at http://www.bioline .org.br/. It is also
abstracted in Ulrich’s Periodical, Feminist Periodicals African Books Publishing Records.
Women’s Health and Action Research Centre
Km 11, Benin-Lagos Express Way
Igue-Iheya
P.O. Box 10231, Ugbowo
Benin City, Edo State, Nigeria
Email: [email protected] or [email protected]
WHARC website: http://www.wharc-online.org
AJRH website: http://www.ajrh.info
The Women’s Health and Action Research Centre (WHARC) is a registered non-profit
organization, committed to the promotion of women’s reproductive health in sub-Saharan Africa.
Founded in 1995, the centre’s primary mission is to conduct multidisciplinary and collaborative
research, advocacy and training on issues relating to the reproductive health of women. The
centre pursues its work principally through multidisciplinary groups of national and international
medical and social science researchers and advocates in reproductive health.
WHARC receives core funding and support from the Ford Foundation and technical
cooperation and mentorship from International Perspectives on Sexual and Reproductive Health
and Studies in Family Planning. Principal funding for the journal comes from the Consortium on
Unsafe Abortion in Africa. The goal of the centre is to improve the knowledge of women’s
reproductive health in Nigeria and other parts of Africa through collaborative research,
advocacy, workshops and seminars and through its series of publications – the African journal of
Reproductive Health, the Women’s Health Forum and occasional working papers.
ISSN: 1118-4841
Women’s Health and Action Research Centre @2013
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Revue Africaine de Santé de la Reproduction
Editor: Friday Okonofua
VOLUME 18 NUMÉRO 3
September 2014
SOMMAIRE
Editoriaux
Recherche sur la prévention biomédicale du VIH et le développement en Afrique
O A Dada
9-13
Commentaire et Arcticles
Quelques questions éthiques dans le traitement du VIH / SIDA
Peter F. Omonzejele
14-16
Prévention du VIH et considérations de la recherche au profit des femmes en Afrique 17-24
sub-saharienne: Vers les stratégies de la prévention bio-comportementale
Abigail Harrison
Médicalisation du VIH et la réponse africaine
Serah Gitome, Stella Njuguna, Zachary Kwena, Everlyne Ombati, Betty
Njoroge et Elizabeth A. Bukusi
25-33
Les +12 Déclaration d’Abuja: Conséquences pour les investissements dans la 34-46
recherche sur la prévention du VIH en Afrique
Rosemary Mburu, Morenike Oluwatoyin Folayan et Olayide Akanni
De la toxicomanie à l'infection: Le traitement de l'Abus de drogues dans le contexte 47-54
du VIH / SIDA en Afrique
Taiwo Akindipe, Lolade Abiodun, Sylvia Adebajo, Rahman Lawal et Salomon
Rataemane
Normes et lignes directrices pour la recherche sur la prévention du VIH:
Considérations relatives au contexte local dans l'interprétation des normes éthiques
globales à l'aide d'une étude de cas du Nigeria
Bridget Haire et Brandon Brown
55-65
Elaboration des lignes directrices pour la conduite de la surveillance de la recherche
sur le VIH par les comités d'éthique au Nigeria
Bridget Haire, Morenike Oluwatoyin Folayan et Jennifer Fleming
66-73
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Promesse et danger de la prophylaxie de la pré-exposition (PPrE): Utilisation 74-83
de sciences sociales pour éclairer les interventions de la PPrE chez les prostituées
Jennifer L. Syvertsen, Angela M Robertson, Andrew Scheibe, Sylvia Adebajo, Steffanie
A. Strathdee et Wendee M. Wechsberg
Argent, pouvoir et le VIH: Influences économiques et le VIH chez les hommes qui 84-92
ont des rapports sexuels avec des hommes en Afrique sub-saharienne.
Andrew Scheibe, Brian Kanyemba, Jennifer Syvertsen, Sylvia Adebajo et Stefan Baral
Répondre aux besoins du développement social des adolescents vivant avec le 93-101
VIH /SIDA au Nigeria: un appel à l'action
Morenike O Folayan, Morolake Odetoyinbo, Abigail Harrison et Brandon
Brown
S'attaquer à la santé sexuelle et les droits de la reproduction des adolescents 102-108
vivant avec le VIH / SIDA: Un besoin prioritaire au Nigeria.
Morenike Oluwatoyin Folayan, Morolake Odetoyinbo, Abigail Harrison et Brandon
Brown
Modifications dans le comportement sexuel à risque du VIH chez les adolescents: - 109-117
Est-ce que le programme de la prévention du VIH au Nigeria donne des résultats?
Hafsatu Aboki, Morenike Oluwatoyin Folayan, Uduak Daniel et Munirat Ogunlayi
Au-delà du consentement éclairé: Autres considérations éthiques dans la conception et 118-126
de la mise en œuvre de la recherche portant sur la santé sexuelle et de la reproduction
chez les adolescents
Morenike Oluwatoyin Folayan, Bridget Haire, Abigail Harrison, Olawunmi Fatusi et
Brandon Brown
L'utilisation du traitement antirétroviral pour la prévention des infections du 127-134
VIH auprès des populations à risque élevé de la conversion du VIH au Nigeria
John Idoko et Morenike O. Folayan
Ethique de soin auxiliaire par rapport aux essais cliniques dans les pays à faible 135-142
revenu: Une étude de cas du Nigeria.
Bridget G. Haire and Olusegun Ogundokun
Information Pour Les Auteurs
143-148
Subscription Information et frais d 'annonce
149-150
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APROPOS AJRH
La Revue Africaine de santé de la Reproduction (RASR) est publiée par le Women’s Health and
Action Research Centre (WHARC). C’est une revue à la fois pluridisciplinaire et internationale
qui publie des articles de recherche originaux, des articles de revue détaillés, de brefs rapports et
des commentaires sur la santé de la reproduction en Afrique. La Revue s’efforce de fournir un
forum aussi bien à des auteurs africains qu'a des professionels qui travaillent en Afrique, afin
qu'ils puissent partager leurs découvertes dans tous les aspects de la santé de reproduction et
diffuser à travers le continent, des informations innovatrices, pertinentes et utiles dans ce
domaine de santé de la reproduction.
La RASR est indexée et figure sur I’Index Medicus/MEDLINE. Les résumés et les tables des
matières sont publiés en ligne par INASP sur le site web http://www.ajol.info/ajol tandis que le
texte est publié à http://www.ajrh.info par Bioline International sur le site web
http://www.bioline.org.br/. Il est également résumé dans Ulrich Periodical, feminist Periodical
et African Books Publishing Records
Women’s Health and Action Research Centre
Km11, Benin-Lagos Express Way
P.O Box 10231, Igue-Iheya
Benin City, Edo State, Nigeria
http://www.wharc-online.org
http://www.ajrh.info
Le WHARC est une organization non gouvernementale à but non-lucratif s’engageé dans la
promotion de santé de la reproduction chez la femme en Afrique sub-saharéenne. Fondé en
1995, le Centre a pour objectif principal de mener des recherches pluridisciplinaires et en
collaboration, de promouvoir et de former des cadres en matières relatives à la santé de la
reproduction chez la femme. Le Centre travaille surtout à travers des groupes mutidisciplinaires
de chercheurs aussi bien nationaux qu’internationaux en sciences médicales et en sciences
économiques dans le domaine de santé de la reproduction.
Le WHARC recoit une aide financière pricinpale de la Fondation Ford et bénéficie de la
coopération technique de l’International Perspectives on Sexual and Reproductive Health et de
Studies in Family Planning. Le financencement principale pour la revue vient de la part du
Consortium on Unsafe Abortion in Africa. L’objectif du Centre est d’ameliorer la connaissance
en matière de santé de la reproduction chez la femme au Nigeria et dans d’autres régions
d’Afrique à travers la recherche en collaboration, le paidoyer, des ateliers et des séminaires à
travers des séries de publication - La Revue africaine de santé de la reproduction, Le Women’s
Health Forum et des rapports des recherches de circonstance.
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STAFF AND EDITORIAL BOARD MEMBERS
Editor
Friday Okonofua
Nigeria
Editor (French)
Cyril Mokwenye
Nigeria
Assistant Editors
Clifford Odimegwu
Michael Okobia
Patrick Erah
Babatunde Ahonsi
Nigeria
Nigeria
Nigeria
Nigeria
Managing Editor
Theresa I. Ezeoma
Nigeria
Assistant Managing Editor
Computer Typesetter
Ernest Godfrey
Nigeria
Subscription Officer
Cover Design
Shereen Siddiqui
New York, USA
Editorial Advisory Board
Rachel Snow
Alayne Adams
Adetunji Adewuyi
Lawrence Adeokun
Simi Afonja
Wole Akande
Nimi Briggs
Pitt Reitmaier
Lincoln Chen
John Cleland
Sylvia Deganus
Michel Garnet
Olufemi Olatunbosun
USA
USA
Nigeria
Nigeria
Nigeria
Nigeria
Nigeria
Germany
USA
United Kingdom
Ghana
France
Canada
Allan Hill
Margaret Hoffman
USA
South Africa
Albrecht Jahn
Phyllis Kanki
Annette Kapaun
Saidi Kapiga
Joan Kaufman
Peju Olukoya
Mere Kissekka
O.A Ladipo
Ulla Larsen
Adetokunbo Lucas
Florence Manguyu
Gernard Msamanga
Osato Giwa Osagie
Michael Mbizo
Ester Mwaikambo
Fredrick Naftolin
Carla Obermeyer
Grace Wyshak
Michael Reich
Khama Rogo
A. Orubuloye
Jenni Smit
Frank Van Balen
Kesley Harrison
Joseph Otubu
William Pick
Helen Rees
John Caldwell
Sarah Castle
Mandou Shabot
Iqbal Shah
Richard Turkson
Kim Dickson-Tetteh
Staffan Bergstrom
Mags Beksinska
Lindsay Edouard
Dozie Ikedife
Kunle Odunsi
Germany
USA
Germany
Tanzania
China
Switzerland
Ethiopia
UK
USA
Nigeria
Kenya
Tanzania
Nigeria
Switzerland
Tanzania
USA
USA
USA
USA
Kenya
Nigeria
South Africa
Netherlands
Finland
Nigeria
South Africa
South Africa
Australia
USA
Egypt
Switzerland
Ghana
South Africa
Sweden
South Africa
USA
Nigeria
USA
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EDITORIAL
Biomedical HIV Prevention Research and Development in Africa
Olukayode A. Dada
*For Correspondence: E-mail: [email protected]; Phone: +2348033237348
Chairman, Board of Trustees, New HIV Vaccine and Microbicide Advocacy Society (NHVMAS)
The research and development process for new
HIV prevention technologies is a global enterprise
and most parts of Africa, have been actively
involved in the identification and development of
effective methods. The new tools for HIV
prevention currently under development include
vaccines, topical microbicides such as gels, creams
and foams that can be applied to the vagina or
rectum prior to sexual intercourse. Male medical
circumcision, the use of antiretroviral drugs to
prevent acquisition of HIV infection (pre-exposure
prophylaxis - PrEP), and the use of antiretroviral
drugs to reduce transmission of HIV infection
(Treatment as prevention – TasP) have also proven
to be effective1.
In November 2013, the New HIV Vaccine and
Microbicide Advocacy Society (NHVMAS) of
Nigeria, in collaboration with the World AIDS
Campaign (WAC) and the Institute of Public
Health, Obafemi Awolowo University, Ile-Ife
Nigeria, convened an international gathering of
community activists and advocacy groups,
scientific investigators and donors to review the
progress as well as the obstacles to progress, in the
global endeavour to achieving biomedical HIV
prevention. The 2013 Biomedical HIV Prevention
Forum (BHPF), the first of a series of conferences
on biomedical HIV prevention research and
development in Africa, took place in Abuja, from
November 18 – 20, 2013. It provided a much
valued forum for international and regional
researchers, programme managers, policy makers,
advocates and stakeholders to share insights on the
current biomedical prevention research agenda and
recent findings, policy and programme
implications which it is hoped, will inform policy
formulation, policy review and programme
implementation globally.
NHVMAS is committed to advocacy for the
ethical conduct of research and the roll-out of
scientifically proven HIV prevention strategies and
methods that are acceptable for use by different
populations around the world to combat the
HIV/AIDS epidemic.
Currently available research-based prevention
strategies have already contributed to the
maintenance of low infection rates in a number of
settings and to declining HIV epidemics in specific
populations around the world. However, in
resource-constrained countries, particularly in
Africa, novel prevention strategies are needed for
reducing new infections where there is limited
access to health care and affordable antiretroviral
drugs. These must be based on ethical conduct of
research, clinical trials and programmatic
interventions, to ensure that the most infected and
affected populations are served in the most
humane and equitable ways possible.
This special edition of the African Journal of
Reproductive Health includes 14 publications from
the presentations at the meeting. These cover a
comprehensive range of issues including
discussions on promising biomedical and
behavioural HIV prevention interventions in
clinical trials and effective ways to translate new
knowledge into practice. The necessity for
concerted efforts to end the HIV epidemic was
echoed at the end of the meeting with a call by the
Civil Society coalition made to African
governments to prioritize HIV prevention and
development in the post 2015 health agenda for
the region.
Civil Society Call to African Governments at the
1st Biomedical HIV Prevention Forum, 18-19
November 2013. Abuja, Nigeria:
Conference
Communique
We are a coalition of civil society organisations
delivering programmes and advocacy in Africa on
HIV, health, and broader development agenda, and
we have come together around the 2013
Biomedical HIV Prevention Forum (BHPF) to
demand that HIV prevention research and
development be prioritized.
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There have been exciting developments in HIV
prevention research and treatment in the last 3
years. For the first time clinical trials of AIDS
vaccine,
microbicides
and
pre-exposure
prophylaxes showed encouraging levels of
efficacy in clinical trials. With the striking success
of the HPTN 052 trial, early initiation of
antiretroviral (ARV) treatment seems poised to
join condoms, partner reduction, clean needles and
voluntary medical male circumcision in the
toolbox of comprehensive combination prevention.
However, there have been challenges as well.
In 2011, for example, the VOICE trial was unable
to confirm the CAPRISA finding that a tenofovirbased vaginal microbicide gel could protect
women from infection. The Fem-PrEP trial results
were also disappointing: the study found that preexposure oral ARV prophylaxis (PrEP) that
worked very well in MSM appeared ineffective for
heterosexual women.
The successes and setbacks of the last three
years will inevitably lead to more, and more
complicated, HIV prevention research and
demonstration projects taking place in Africa. It
will also prompt increased national and regional
dialogue about the potential benefits and risks of
new prevention modalities and how they might
best be deployed in country-specific settings.
‘Getting to Zero’ will depend on expanding
antiretroviral treatment and proven HIV/AIDSprevention tools to all people that need them. In
this regard investing in research and development
of prevention tools that are appropriate for
populations at high risk of HIV infection such as
sex workers and men who have sex with men is of
great importance.
Now more than ever, political will and
commitment, illustrated through allocation of
adequate resources and bold action, is needed to
‘Get to Zero’ in Africa.
Therefore, at the 1st Biomedical HIV
Prevention Research Forum we call on African
governments to accelerate the realization of health
MDGs and the achievement of an AIDS-free
generation in Africa by ensuring the following:
1. Allocate at least 15% of national budgets to
health/step up domestic resource mobilization.
2. Increase funding for R&D; allocate at least 2%
of national health expenditure and at least 5%
of external aid for health projects to research
and research capacity building (as per Algiers
and Bamako declarations).
3. Accelerate R&D of HIV prevention tools such
as preventive vaccines, microbicides, drugs for
treatment and for prophylaxis; improve
delivery and regimens of proven tools such as
condoms, medical male circumcision, PreExposure Prophylaxis and Treatment as
Prevention (TasP).
4. Proactively develop policies and agreements
on intellectual property that will accelerate
access to and delivery of newly found
efficacious products for treatment and
prevention.
5. Create opportunities for sharing expertise and
lessons learned from research conducted
locally since countries in the region experience
similar social challenges that drive the
pandemic.
In return, African civil society organisations
involved in HIV prevention research and
development are committed to implementing the
following strategic actions:
1. Mobilising communities to access services and
contributing to the provision of prevention,
treatment, care and support services.
2. Promoting human rights and access to essential
medicines for all by advocating for rights and
evidence-based policies on health and for
mechanisms to strengthen health systems in
Africa.
3. Acting as a watchdog to ensure accountability,
good governance and more efficient
management of programmes and resources for
all stakeholders, including civil society
organisations; and
4. Encouraging
governments,
citizens,
development partners and the private sector to
contribute significantly to funding health and
research and development interventions.
References
1. Folayan MO, Gottemoeller M, Mburu R, Brown B.
Getting to zero the biomedical way in Africa:
outcomes of deliberation at the 2013 Biomedical HIV
prevention forum in Abuja, Nigeria. BMC
Proceedings 2014; 8(Suppl 3): 51 doi: 10.1186/17536561-8-S3-S1.
African Journal of Reproductive Health September 2014 (Special Edition); 18(3): 10
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EDITORIAUX
Recherche sur la prévention biomédicale du VIH et le
développement en Afrique
Olukayode A. Dada
Président du Conseil d'Administration, New HIV Vaccine and Microbicide Advocacy Society (NHVMAS)
Le processus de recherche et de développement de
nouvelles technologies de la prévention du VIH est
une entreprise mondiale et la plupart des régions
d'Afrique ont été activement impliqués dans
l'identification et le développement des méthodes
efficaces. Les nouveaux outils de prévention du
VIH en cours du développement comprennent les
vaccins, les microbicides topiques tels que les gels,
les crèmes et les mousses qui peuvent être
appliqués dans le vagin ou le rectum avant un
rapport sexuel. La circoncision médicale
masculine,
l'utilisation
des
médicaments
antirétroviraux pour prévenir l'acquisition de
l'infection du VIH (prophylaxie de la préexposition - PPrE), et l'utilisation des médicaments
antirétroviraux pour réduire la transmission de
l'infection du VIH (le traitement comme outil de la
prévention - TcP) ont également prouvé leur
efficacité.
En novembre 2013, le New HIV Vaccine and
Microbicide Advocacy Society (NHVMAS) du
Nigeria, en collaboration avec la Campagne
mondiale contre le sida (CMCS) et l'Institut de
santé publique de l'Université Obafemi Awolowo,
Ile-Ife au Nigeria, a organisé une rencontre
internationale de la communauté des militants et
des groupes de défense, des chercheurs
scientifiques et des donateurs pour examiner le
progrès ainsi que les obstacles au progrès, à l'effort
mondial en faveur de la prévention biomédicale du
VIH. Le Forum 2013 pour la prévention
biomédicale du VIH (FPBV), le premier d'une
série de conférences sur la recherche de la
prévention biomédicale du VIH et le
développement en Afrique, a eu lieu à Abuja, du
18 -20 novembre, 2013. Il fournit un forum très
apprécié pour des chercheurs internationaux et
régionaux, des gestionnaires de programmes, des
décideurs, des intervenants et des parties prenantes
de partager des idées sur l'ordre du jour actuel de
recherche biomédicale sur la prévention et des
découvertes récentes, les implications politiques et
des programmes qui, on l'espère, influenceront la
formulation des politiques, l'examen des politiques
et la mise en œuvre du programme sur le plan
mondial.
Le NHVMAS s'engage à la défense de l'éthique
de la recherche et de la mise en place des stratégies
de la prévention du VIH qui ont été
scientifiquement prouvées et les méthodes qui sont
acceptables pour une utilisation par des
populations différentes à travers le monde pour
lutter contre l'épidémie du VIH / SIDA.
A l’heure actuelle les stratégies de la
prévention qui sont fondées sur la recherche ont
déjà contribué au maintien de faibles taux
d'infection dans un certain nombre de paramètres
et de la baisse de l'épidémie du VIH dans des
populations spécifiques à travers le monde.
Cependant, dans les pays à ressources limitées,
surtout en Afrique, de nouvelles stratégies de
prévention sont nécessaires pour réduire les
nouvelles infections où il y a un accès limité aux
soins de santé et aux médicaments antirétroviraux
abordables. Ceux-ci doivent être fondées sur le
comportement éthique de la recherche, les essais
cliniques et les programmes d'intervention, afin de
s'assurer que les populations les plus infectées et
affectées sont servies dans les moyens les plus
humaines et équitables possibles.
Cette édition spéciale de la Revue Africaine de
Santé de la Reproduction publie 14 articles à
partir des présentations faites lors de la réunion.
Celles-ci couvrent une gamme complète de
questions, y compris des discussions sur les
interventions de la prévention biomédicale du VIH
et du comportement prometteurs dans les essais
cliniques et des moyens efficaces pour traduire les
nouvelles connaissances en pratique. La nécessité
d'efforts concertés pour mettre fin à l'épidémie du
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VIH a été reprise à la fin de la rencontre avec un
appel par la coalition de la société civile fait pour
les gouvernements africains pour privilégier la
prévention et le développement du VIH dans
l'agenda post 2015 de la santé pour la région.
Appel aux gouvernements africains par la
Sociétés civiles lors du 1er Forum sur la
prévention biomédicale du VIH, 18-19 novembre
2013, Abuja, Nigeria: Communiqué de la
Conférence
Nous sommes une coalition d'organisations de la
société civile qui offrent des programmes et le
plaidoyer en Afrique sur le VIH, la santé et le
programme de développement plus large, et nous
nous sommes réunis autour du Forum sur la
prévention biomédicale du VIH (FPBV) 2013 pour
exiger que la recherche sur la prévention du VIH
et le développement soit une priorité.
Il y a eu des développements passionnants dans
la recherche de la prévention du VIH et du
traitement au cours de 3 dernières années. Pour la
première fois les essais cliniques du vaccin contre
le sida, les microbicides et la prophylaxie de la
pré-exposition ont montré des niveaux d'efficacité
encourageants dans les essais cliniques. Etant
donné le succès frappant de l'essai HPTN 052,
l'initiation précoce de traitements antirétroviraux
(TAR) semble être prête à se joindre à des
préservatifs, la réduction des partenaires, des
aiguilles propres et la circoncision médicale
masculine volontaire dans la boîte à outils de la
prévention de la combinaison globale.
Cependant, il y a eu aussi des défis. En 2011,
par exemple, le procès VOICE n'a pas pu
confirmer la CAPRISA ayant découvert qu'un gel
vaginal microbicide à base de ténofovir pourrait
protéger les femmes contre l'infection. Les
résultats de l'essai Fem-PPrE ont également été
décevants: l'étude a révélé que la prophylaxie de
la pré-exposition par voie orale (PPrE) qui a très
bien fonctionné chez les HSH semblait inefficace
pour les femmes hétérosexuelles.
Les succès et les échecs de ces trois dernières
années vont inévitablement conduire à des
recherches de la prévention du VIH et des projets
de démonstration de plus en plus compliqués qui
auront lieu en Afrique. Il demandera également un
renforcement du dialogue national et régional sur
les avantages et les risques de nouvelles modalités
de prévention possibles et comment ils pourraient
mieux être déployés dans des contextes
spécifiques à chaque pays.
«Arriver à zéro» dépendra de l'extension du
traitement antirétroviral et des outils pour la
prévention du VIH / SIDA à toutes les personnes
qui en ont besoin. À cet égard, investir dans la
recherche et le développement d'outils de
prévention qui sont appropriés pour les
populations à risque élevé d'infection du VIH, tels
que les prostituées et les hommes qui ont des
rapports sexuels avec des hommes est d'une
grande importance.
Maintenant, plus que jamais, la volonté
politique et l'engagement, illustré par l'allocation
de ressources adéquates et des mesures
audacieuses, est nécessaire pour «Arriver à Zéro»
en Afrique.
Par conséquent, au 1er Forum de la recherche
sur la prévention biomédicale du VIH nous
lançons un appel aux gouvernements africains
pour qu’ils accélèrent la réalisation des OMD liés
à la santé et à la réalisation d'une génération sans
SIDA en Afrique tout en assurant la suivante:
1. Allouer au moins 15% des budgets
nationaux à la santé / intensifier la
mobilisation des ressources.
2. Augmenter le financement pour la R & D;
allouer au moins 2% des dépenses
nationales de santé et au moins 5% de l'aide
extérieure pour des projets de santé pour la
recherche et le renforcement des capacités
de recherche (suivant les Déclarations
d’Alger et de Bamako).
3. Accélérer la R & D d'outils de prévention
du VIH, tels que les vaccins préventifs, les
microbicides, des médicaments pour le
traitement et la prophylaxie; améliorer la
prestation et les schémas d'outils éprouvés
tels que les préservatifs, la circoncision
masculine médicale, prophylaxie de préexposition et le traitement comme outil de
la prévention (TcP).
4. Développer de façon proactive des
politiques et des accords sur la propriété
intellectuelle qui permettra d'accélérer
Dada
l'accès et la livraison des produits efficaces
nouvellement découverts pour le traitement
et la prévention.
5. Créer des occasions pour partager
l'expertise et les leçons tirées de la
recherche menée au niveau local depuis les
pays de l'expérience de la région des défis
sociaux semblables qui animent la
pandémie.
De leur part, les organisations de la société civile
africaine engagées dans la recherche de la
prévention du VIH et le développement se sont
engagées à mettre en œuvre les actions
stratégiques suivantes:
1. Mobiliser les communautés pour accéder aux
services et pour contribuer à la prestation de
services de prévention, de traitement, de soins
et de soutien.
2. Promouvoir les droits de l’homme et l'accès
aux médicaments essentiels pour tous par la
défense des droits et de politiques fondées sur
des données probantes sur la santé et des
mécanismes pour renforcer les systèmes de
santé en Afrique.
3. Agir comme un chien de garde pour assurer la
responsabilisation, la bonne gouvernance et une
gestion plus efficace des programmes et des
ressources pour toutes les parties prenantes, y
compris les organisations de la société civile; et
4. Encourager les gouvernements, les citoyens, les
partenaires au développement et le secteur
privé à contribuer de manière significative au
financement des interventions dans les
domaines de la santé, de la recherche et du
développement.
Références
1. Folayan MO, Gottemoeller M, Mburu R, Brown B.
Getting to zero the biomedical way in Africa:
outcomes of delibration at the 2013 Biomedical
HIV prevention forum in Abuja, Nigeria. BMC
Proceedings 2014; 8(Suppl 3): 51 doi:
10.1186/1753-6561-8-S3-S1.
Omonzejele
The Ethics of HIV/AIDS Care
COMMENTARY
Some Ethical Issues in HIV/AIDS Care
Peter F. Omonzejele
Associate Professor in Bioethics, Department of Philosophy, University of Benin, Benin City, Nigeria.
*For Correspondence: E-mail: [email protected]; Phone: +234 70 384 299 66
HIV (human immunodeficiency virus) causes
AIDS (Acquired Immune Deficiency Syndrome).
HIV can be transmitted through sex, needles,
clippers used by barbers, unsterilized instruments
used for the incision of tribal marks, tattoos, and
circumcisions, unscreened blood transfusions, etc.
HIV destroys the immune system which makes the
human body vulnerable and susceptible to
diseases. About 25 million people have died from
AIDS, while about 33 million people are presently
living with HIV. Sub-Saharan Africa has the
highest burden of people living with HIV/AIDS.
Beyond the issue of HIV/AIDS being a medical
issue, it also holds serious and important ethical
issues for humans. Some of those moral issues are:
HIV testing and the problems surrounding HIVinfected health-care professionals and the duty to
treat people with HIV and AIDS1. We would very
briefly discuss those moral concerns associated
with HIV/AIDS care.
HIV Testing/Screening
Medical laboratory investigation is a routine way
of getting to know, in a specific way, what could
be wrong with us when we consult our physicians.
The outcome of the laboratory investigations often
defines the line of care provided by our healthcare
providers. However, the decision to undertake
laboratory investigations for a patient requires the
patient to grant his/her informed consent.
The principle of informed consent is based on
the understanding that humans are autonomous
agents capable of decision-making with regards to
their health and indeed to other matters that
directly pertain to them. It is for that reason that a
medical procedure could not be performed on an
individual without that person’s consent or
agreement. At this point, we need to enquire on if
there are prima facie compelling ethical reasons
for mandatory HIV testing on persons. On the
other hand, are there any meaningful and ethically
sustaining benefits derivable from conducting
mandatory test for an incurable condition, such as
HIV/AIDS?
In the case of HIV test, some ethicists have
argued against mandatory HIV testing because
there is no cure for the condition2. The logical gap
is: if there is no cure then why go for HIV testing?
However, there is a general shift from this line of
thinking with the introduction of drugs (such as
Zidovudine and the use of other combined drugs)
which has proved effective in the management of
the condition though it does not provide cure. With
the small advancement in the management of the
HIV/AIDS pandemic, people were then
encouraged to undertake voluntary HIV testing.
Voluntary HIV testing would simply mean that
one could choose to know his/her HIV status or
not, and such a decision holds direct implication
for that individual. However, there are times where
the knowledge of one’s HIV status holds
implication for others, such as in the case of a
pregnant woman. This is because pregnant women
take responsibility for themselves and for their
fetuses as well. Morally speaking, it then implies
that an HIV positive woman must ensure (where it
is possible) that their unborn child is protected
from HIV vertical transmission. It is for that
reason must bioethicists would argue that it makes
moral sense for pregnant women to know their
HIV status.
The moral question then is: if there are drugs
that could significantly reduce vertical HIV
transmission (that is from mother to fetus), should
not all pregnant women be compelled to undertake
HIV test in the interest of the unborn child? But in
response, some feminists have argued against
African Journal of Reproductive Health September 2014 (Special Edition); 18(3):14
Omonzejele
compelling all pregnant women to undergo HIV
testing. In their thinking, mandatory testing
violates the rights of women. Anyway, the present
practice in most countries is directed towards
voluntary HIV testing for pregnant women as a
way of reducing HIV vertical transmission.
Healthcare Givers, Patients and HIV Infection
HIV/AIDS is a pandemic with horrendous
consequences. This means that everyone is
potentially at risk of contracting the disease except
we live carefully and responsibly. Healthcare
givers and patients are equally at risk. We have
some healthcare givers who are HIV positive in
the same way that there are some people (nonhealthcare givers) who are HIV positive. Let us
examine the relationship between both parties
against the background that it is universally
accepted, which is, that people living with
HIV/AIDS should not be discriminated against, be
it at the work place, in the healthcare setting and
indeed anywhere else.
This is because most people would agree that it
is morally wrong to turn down the sick from where
they wish to seek care. This implies that it would
be wrong for healthcare givers not to attend to
patients because of such patients’ HIV positive
status. But the sole reason why healthcare givers
are reluctant to care for HIV positive patients
(especially where such care is invasive) is the fear
of themselves getting infected. This is done on the
grounds of self-preservation. The inclination by
some healthcare givers not to provide care to HIV
positive patients has been generally condemned.
Healthcare givers like everyone else could be
HIV positive. It is generally agreed that people are
at liberty to decide on if they wish to be tested for
HIV antibodies or not. However, it has been
argued that unlike other people (who could be
potential patients) healthcare givers should
undertake mandatory HIV testing, this is because
in the course of providing care, there is a small
chance of infecting their patients. Schuklenk
highlights the debate as to “whether all health-care
personnel should be mandatorily tested for HIV
antibodies and, if so, whether those who test HIVpositive should be allowed to continue working as
health-care professionals”3. Gostin’s response is
that, all healthcare professionals should be made to
undertake HIV testing; however, the results should
be made available to their employers and not to
their patients; and that it beholds on their
employers to closely monitor infected healthcare
givers in the discharge of their duties4. But Gostin
was reluctant to engage with the debate as to
whether such healthcare professionals should be
allowed to provide invasive care. This raises a
moral question, which is: if HIV positive
healthcare givers are not allowed to undertake
invasive care, does it not amount to discrimination
against them? Should it not have been more
appropriate for them to be closely monitored while
they provide the so called invasive care or
procedure? But another pressing question is: Even
where such HIV positive healthcare providers are
closely monitored and if patients are aware of their
status, would patients accept to use their expertise
if they had an alternative?
It appears that most people make demands on
health professionals than they would on other
professions. May be, the reason for this state of
affairs is because healthcare providers have access
to the inner most parts of our bodies, in a way that
people in other professions do not. Despite that,
we must be careful not to treat people differently
merely on the grounds of their professions. I am
the first to admit that people ought to protect
themselves and remove themselves from harm’s
way, however, one must be cautious not to set
double standards. For instance, it would be
morally reprehensible if a gynaecologist refuses to
care for a pregnant woman who is HIV positive.
But there seems to be a logical problem here,
which is: If all humans have bodies and bodies can
be infected with the HIV virus, then why is there
discrimination between the body of the doctor and
that of a patient or a potential patient? It raises the
question of prejudice and bias which need to be
addressed social scientifically side by side the
pharmaceutical and medical improvements in
handling HIV/AIDS. This is my concern about
double standards, not only in the healthcare
setting, but in any setting for that matter. Double
standard defies rationality and logic; the use and
universality of principles of ethics. It also brings to
the fore human nature and the ethics of behaviour
among humans.
Omonzejele
Commentary.
Conclusion
The HIV/AIDS pandemic continues to raise
contentious ethical issues emanating from the
mode of transmission and to those emanating from
efforts at containing the medical condition. Ethical
issues discussed in this commentary range from
HIV testing to the relationship between healthcare
givers and patients within the HIV/AIDS context.
This commentary is by no means exhaustive as
there are other moral issues involved in the ethics
of HIV/AIDS care. For instance, the use of
experimental drugs and HIV/AIDS care within the
context of polygamous marital arrangements also
hold important moral concerns, but the discussion
of those issues is beyond the scope of this brief
References
1. Schuklenk, Udo. “AIDS: Individual and ‘Public’
Interest”. In: Kushe Helga and Peter Singer (eds).
2001. A Companion to Bioethics. Blackwell
Publishing. 2001; 343.
2. Bayer, R,, Levine, C. and Wolf, C. HIV Antibody
Screening: An Ethical Framework for Evaluating
Proposed Programs. Journal of American Medical
Association. 1986; (256): 1768-1774.
3. Schuklenk, Udo. “AIDS: Individual and ‘Public’
Interest”. In: Kushe Helga and Peter Singer (eds).
2001. A Companion to Bioethics. Blackwell
Publishing. 2001; 351.
4. Gostin, L. The HIV-infected Healthcare Professional:
Public Policy, Discrimination, and Patient Safety.
Law, Medicine and Health Care.1990; (18): 303-310
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Biobehavioral HIV Prevention Strategies for Women in Sub-saharan Africa
PERSPECTIVES PAPER
HIV Prevention and Research Considerations for Women in
Sub-Saharan Africa: Moving toward Biobehavioral Prevention
Strategies
Abigail Harrison
Brown University School of Public Health, 121 South Main St, Providence RI 02912 USA
*For Correspondence: E-mail: [email protected]; Phone: 014018636183
Abstract
This paper addresses current and emerging HIV prevention strategies for women in Sub-Saharan Africa, in light of recent trial
results and ongoing research. What are the major opportunities and challenges for widespread implementation of new and
emerging HIV prevention strategies? The paper discusses the major individual, social and structural factors that underpin
women’s disproportionate risk for HIV infection, with attention to gender, adolescents as a vulnerable population, and the need to
engage men. Also, the influence of these factors on the ultimate success of both behavioral and biomedical HIV prevention
technologies for women in sub-Saharan Africa is discussed. Finally, the paper examined how the new and emerging
biobehavioral prevention strategies served as tools to empower women to adopt healthy HIV preventive and reproductive health
behaviors. (Afr J Reprod Health 2014; 18[3]: 17-24)
Keywords: Sub-Saharan Africa, biobehavioral prevention, HIV, gender, adolescents
Résumé
Cet article traite des stratégies actuelles et émergentes de la prévention du VIH en faveur des femmes en Afrique sub-saharienne,
à la lumière des résultats des essais et des recherches récentes en cours. Quels sont les principaux défis et opportunités pour la
mise en œuvre généralisée des stratégies nouvelles et émergentes de la prévention du VIH? L’article examine les facteurs
individuels, sociaux et structurels majeurs qui sous-tendent un risque disproportionné des femmes pour l'infection du VIH, tout
en consacrant l’attention aux sexes, aux adolescents comme une population vulnérable, et la nécessité de faire participer les
hommes. En outre, l'influence de ces facteurs sur le succès ultime de ces deux technologies de la prévention comportementales et
biomédicales du VIH pour les femmes en Afrique sub-saharienne est discutée. Enfin, le document examine la façon dont les
stratégies nouvelles et émergentes de la prévention ont servi d'outils à l'autonomisation des femmes à adopter de bons
comportements de la prévention et de santé de la reproduction contre le VIH. (Afr J Reprod Health 2014; 18[3]: 17-24)
Mots-clés: Afrique sub-saharienne, prévention comportementale, VIH, sexe, adolescents
Introduction
Of the 34 million people globally living with
HIV/AIDS, approximately 50% are women1.
Further, women account for just over half (about
51%) of new infections each year. In sub-Saharan
Africa, that figure is higher, with women
accounting for approximately 60% of all
infections. It is common to say that women are
disproportionately affected by HIV/AIDS: this
results from the pronounced age differences in
patterns of HIV prevalence, in which younger
women are much more likely to be HIV-infected
than older women, and also from gender
differences, as younger women are more likely to
be HIV-infected than their same-age male peers2,3.
In the generalized HIV/AIDS epidemics found in
some parts of sub-Saharan Africa, these
differences are as much as two-three fold; in other
words, women are 2-3 times more likely than men
of the same age to be HIV-infected4,5. Strong
regional differences in HIV prevalence also exist
across the African continent, ranging from nearly
20% of the general population in the heavily HIVaffected countries of southern Africa, to less than
10% in most of West Africa1,6.
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More than a decade has passed since the first call
to action was issued regarding the need to reduce
high levels of HIV infection in sub-Saharan Africa
through addressing the prevention needs of young
African women7. While substantial research has
addressed this topic, particularly the area of gender
relations and inequalities, further research on the
links to broader social and health inequalities is
needed. This paper examines current knowledge
on the factors underlying women’s high rates of
HIV infection, and state-of-the-art approaches to
HIV prevention across the social, behavioral and
biomedical spectrum.
Behavioral, Biological and Structural Risk
Factors for HIV Infection in Women
Although risk profiles may differ according to
individual and contextual characteristics, wellknown behavioral risk factors for HIV infection in
women include unprotected sex, relationships with
older male partners (who may be more likely to be
HIV infected and whose greater power in a
relationship may limit a woman’s ability to
negotiate the terms of sexual activity or
prevention), and a history of sexual abuse or
violence2. The risk also increases in areas where
commercial sex is common, or other forms of
transactional sex8,9. Important biological risk
factors are greater susceptibility to HIV
transmission due to cervical ectopy, which is
particularly pronounced in younger women, the
presence of co-factors such as other sexually
transmitted diseases or other infections, and the
greater ease of transmission from men to women10.
There are important links between HIV/AIDS
and reproductive health. For many women,
HIV/AIDS is the most important reproductive
health issue they face, because of the genderspecific ways in which the disease affects them,
and because the majority of HIV infections
experienced by women are related to pregnancy,
childbearing, or breastfeeding. Also, pregnancy
and HIV infection are inextricably linked, and
younger women face a particularly high risk
through unintended pregnancy11. In part, this is
due to the common exposure – unprotected sex –
that places women at risk for both outcomes.
More broadly, pregnant women generally
experience higher rates of HIV infection than their
non-pregnant counterparts. For instance, 15-24
year old non-pregnant women in South Africa
have an HIV prevalence of 20%, compared to 39%
among pregnant women in the same age group.
HIV prevalence among pregnant women in South
Africa is 5.6% at ages 15-19, 17.4% at ages 20-24,
and rises to 31.7% among those aged 25-29
years12. Family planning, one of the most basic
interventions for women, is also an important HIV
prevention strategy13. For HIV positive women,
contraception can prevent mother-to-child
transmission of HIV infection, while for HIV
negative women, preventing unintended pregnancy
is an important opportunity for HIV prevention,
particularly through the use of condoms and other
barrier methods for dual protection.
Social factors that are well known to be
protective for women, in other words to lower
their HIV risk, include school attendance and
completion15. Further research is needed on the
structural drivers of HIV/AIDS, to obtain a better
understanding of sustained high HIV incidence,
particularly in the population of women under age
30. The links between economic factors, such as
poverty and household well-being, and multiple
health outcomes, including HIV/AIDS, are well
established15.
The Role of Gender Inequality
Gender inequality is an important structural factor
underlying many common risk factors associated
with women’s greater HIV risk, such as unequal
partner relations and their impact on HIV
prevention9. The World Health Organization
defines gender as’ the socially constructed roles,
behaviors, activities and attributes that a given
society considers appropriate for men and
women16. In its 2012 report on the state of the
global AIDS epidemic, UNAIDS stated that
‘gender inequality drives the HIV epidemic’ and
devoted the issue to discussion of the genderrelated risk factors that influence HIV infection
among women1. Epidemiological evidence from
multiple settings across sub-Saharan Africa
suggests several important ways in which gender
inequalities affect women’s disproportionate risk
for HIV infection, and many studies now
demonstrate the numerous ways in which gender
inequalities place women at risk for HIV. First,
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women’s unequal social, economic and political
status places women at an inherent disadvantage in
many aspects of life9,17. Second, within the
context of relationships, women’s unequal power –
which in many locations remains codified in law –
constraints women’s ability to negotiate at a
relationship, family and household level. Third,
there is a high prevalence of gender-based
violence, and women who experience trauma,
abuse, or other forms of sexual violence are at
increased risk for HIV18.
The Special Vulnerability of Adolescents and
Young Women
The period of adolescence, defined broadly as the
period between ages 10-19 that marks the
transition from childhood into adulthood, is a
unique phase of life, characterized by rapid
physical, emotional and developmental change19.
Adolescents may often be impulsive and inclined
toward higher risk-taking, sometimes related to
perceived invulnerability20. For higher risk
adolescents, mental health is particularly
important, and low self-esteem and other outcomes
may be particularly salient at this time21.
Adolescents are considered a vulnerable
population, which raises ethical considerations
regarding participation in HIV prevention or other
clinical trials22. As a uniquely vulnerable
population, adolescents and younger women have
special intervention needs.
Further, because of biological differences,
some biological prevention methods may be
unsafe for younger populations, concerns that have
been raised increasingly with the advent of new
biomedical prevention technologies and related
efficacy trials23. However, from a rights
perspective, it is important to note that young
people, like any other population, are entitled to
the most effective HIV prevention education and
methods available unless valid reasons exist for
their exclusion from trials or from product use22.
The Importance of Engaging Men
As previous studies have indicated, men are often
neglected in discussions of gender and sexual and
reproductive health, thus comprising the ‘forgotten
fifty percent’ of the population24. Recent
scholarship, including intervention studies,
suggests the importance of engaging men, for their
own improved health as well as better outcomes
for women25. The idea of ‘gender-transformative’
interventions by definition engages both men and
women in shifting toward more equitable gender
norms and values, with links to specific health
outcomes such as HIV prevention26,27. In some
gender-focused studies, intervention effects on
men have been stronger than those for women,
suggesting that changing men’s behaviors related
to gender attitudes, beliefs and behaviors is not
only important, but feasible28.
What are the Available Interventions?
Biomedical HIV Prevention: The advent of the
‘treatment as prevention’ era has major
implications for women’s HIV prevention in subSaharan Africa, as for other high-risk
populations29. Since 2000, great hope has been
placed in the development of microbicides and
other pre-exposure prophylaxis. Microbicides are
vaginal or rectal products applied topically to
prevent sexual transmission of HIV infection30.
Most of the microbicide trials have been
conducted in women. Prior to 2011, of the nine
microbicide trials conducted, only three were
completed, and the results were marked by low
efficacy of the products, limited acceptability, and
poor product adherence31. The newer products,
however, are ART-based, and have shown
promising results.
In 2010, the results of
CAPRISA 004, a trial of tenofovir gel use in South
African women, found 39% fewer incident HIV
infections in women who used the gel, as
compared to a placebo32. This positive finding
was supplemented by positive results from several
other trials of pre-exposure prophylaxis, including
a reduction in heterosexual transmission among
couples in Botswana, men who have sex with men
in the United States, and injection drug users in
Thailand30. Two other trials, however, Partners
PrEP in Uganda and Kenya and FemPrEP in
Kenya, Tanzania and South Africa, found only
partial effectiveness or no effectiveness30. Most
importantly to advancement of HIV prevention
research, the VOICE (vaginal and oral
interventions to control the epidemic) trial, a
confirmatory trial of more than 5,000 women in
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Uganda, South Africa and Zimbabwe, did not
demonstrate efficacy of the product, which was
both orally and topically administered tenofovir
gel33. A further trial, FACTS, is currently ongoing
in South Africa33.
These differential results are difficult to
interpret, and have led to widespread debate about
women’s use of the products and ability or desire
to adhere to product use, most specifically with
regard to daily, long-term use. In many of the
trials, adherence to the product has been low, in
the range of 50% or less31. There are many known
barriers to use of microbicides and other
prevention products by women34. Commonly cited
barriers include questions about the feasibility for
women to use a product daily or even at each
sexual intercourse, an important concern
underlying low adherence35. For many women,
there are also partner considerations, especially
negotiating use of a product. Above all, it may
simply be difficult to expect that any group of
people use a pill daily for prevention, as opposed
to treatment. While more data are needed to
understand these outcomes and women’s own
perspectives, the trial results do highlight women’s
different needs, motivations and barriers to use, as
well as shifting needs and preferences over their
life course, or even a much shorter window,
possibly a six month period. HIV prevention does
not occur in isolation, but rather in the context of
women’s daily lives, which may include a desire
for pregnancy, or a desire to prevent pregnancy.
To be successful in the long term, any daily use
product for women would likely need to take such
factors into consideration.
In response to such concerns, and drawing on
expertise from the family planning field, the idea
of multipurpose prevention technologies (MPTs)
has emerged36,37. MPTs generally provide
simultaneous protection against HIV and
pregnancy, with a range of products currently
under development38. These include vaginal gels
with HIV prevention and contraceptive properties,
long-acting intravaginal rings such as the
dapivirine ring or SILCS diaphragm, new and
improved barrier devices, and vaginal tablets and
films39,40. The development of these products
acknowledges the critical importance of the
ongoing search for female controlled technologies,
as well as the need to situate women’s HIV
prevention in a broader reproductive health
context.
Behavioral
Interventions:
Ideally,
biobehavioral intervention strategies should
combine elements of effective biomedical and
behavioral interventions. A wide range of
behavioral HIV prevention interventions for
women has been tested in sub-Saharan Africa41. In
this report, interventions with promise for
addressing women’s needs in relation to gender,
HIV prevention and pregnancy are discussed. One
of the largest studies, the MIRA trial in Zimbabwe
and South Africa, evaluated the efficacy of
diaphragm and condom use for preventing HIV
infection and pregnancy in high risk women42.
Although the study did not reduce incident HIV
infections, numerous important lessons were
obtained regarding women’s HIV preventive
behaviors and changes over time. In South Africa,
the Stepping Stones intervention was evaluated via
a community-level randomised controlled trial.
This study, which included both women and men,
had important effects on gender-related risk
factors, as well as on incidence of HSV-2, and on
lowering men’s sexual risk behaviors and
perpetration of violence toward women43.
Stepping Stones is one of several emerging
‘gender-transformative’ interventions, which are
focused on shifting gender norms and values in
pursuit of specific health outcomes such as HIV
prevention.
Focusing on women’s most pressing needs,
including pregnancy prevention, may have
secondary effects on HIV prevention44. Targeted
interventions could help to address the issue of
high HIV infection and pregnancy rates,
particularly among the highest risk group of young
adult women. Use of family planning by HIV
positive women has important implications for
preventing mother-child transmission of HIV
infection45, while use of dual protection among
uninfected women can prevent both HIV and
pregnancy.
Finally, starting early and addressing
adolescent HIV prevention needs is of critical
importance. Across a number of African settings,
HIV prevention interventions in both school and
non-school settings have been evaluated46,47.
Harrison
Implementing more effective sexuality education
in schools is an important first step, followed by
evidence-based HIV prevention strategies48,49.
Structural
Interventions:
Structural
interventions seek to influence the societal and
contextual factors underlying HIV risk50. Other
pressing needs for women may include financial
support, such as livelihoods and economic
opportunities51, or support to complete schooling,
or provision of safe spaces in communities where
young people can gather.
An important
intervention for women, the IMAGE project,
examined via a randomized controlled trial
whether participation in micro-credit lending and
sexual violence prevention education reduced
women’s HIV risk52. While no effect on HIV
incidence had such combined economicbehavioral approaches may hold promise for
African women.
Recommendations and Way Forward
Interventions aimed at reducing the high incidence
of HIV infection in African women do not come in
a ‘one size fits all’ package. Multiple, integrated
interventions will likely be needed to address the
diverse needs of women. Importantly, there is an
emerging consensus around the idea of
‘biobehavioral’53 HIV prevention strategies for
women, recognizing that the biomedical and the
behavioral need to work together, in mutually
reinforcing ways. With the advent of new ARTbased prevention strategies, a greatly expanded
toolkit to promote biobehavioral HIV prevention
for women exists.
In this regard, the idea of a ‘life course
approach to interventions’ may be relevant, in
which a series of interventions beginning in
childhood and continuing through to adulthood are
implemented. Ideally, these would include a focus
on gender equitable norms and values in
childhood, to lay the foundation for healthpromoting behaviors; age-appropriate sexuality
education in early adolescence, primarily focused
on life skills and a range of preventive behaviors;
and a focus on the more specific needs of the
teenage population to ensure a safe and healthy
transition to adulthood, followed by high quality
service and individual level interventions to
promote effective use of HIV prevention
strategies. The separate and integrated needs of
young women and men should also be considered.
Specific recommendations can be offered as
follows:
Integrate HIV prevention with women’s broader
reproductive health concerns
At different times in their lives, most women will
desire to prevent pregnancy, and also to bear
children.
Multi-purpose
interventions
or
technologies, and combined biomedical/behavioral
approaches, will likely work best to address
women’s shifting needs and desires over the life
course. Within high HIV prevalence settings like
southern Africa, such interventions should include
attention to safe reproductive decision-making and
planned pregnancy, including knowledge of HIV
status among couples, in order to reduce
unintended pregnancy and the likely transmission
of HIV infection. Integration of HIV/RH services
is also important in order to ensure better access to
care and prevention. Family planning remains one
of the most basic and cost-effective interventions
for women, and plays a critical role in reducing
mother-child HIV transmission.
Facilitating rapid integration of successful
results from intervention trials into policy
With important new results emerging for women,
particularly in the area of ART-based biomedical
prevention including PrEP, microbicides and
treatment-as-prevention, steps must be taken to
prepare health services as well as the general
population with women-centered strategies for the
advent of new and more effective interventions
and technologies. Given that adherence is one of
the
biggest
challenges
to
successful
implementation, education and communication
efforts are particularly important.
Engaging
women and communities in meaningful ways in
this research and policy development is important
to define these needs.
Addressing the special needs and vulnerabilities
of young, high-risk women
The risk for a range of adverse reproductive health
outcomes is compounded by young age and by
Harrison
being female. Services and interventions need to
address younger women’s high-risk status, as well
as the increased vulnerability related to
developmental factors, particularly increased life
instability during the transition to adulthood.
Adolescents and young adult women require
specialized services and interventions, and access
to comprehensive services including social,
psychological, and mental health. Preventing
unintended pregnancies along with HIV/STIs is a
top priority for this age group.
Situating HIV prevention in the context of
women’s daily lives
Perhaps most importantly, there is a need to situate
prevention efforts – whether biomedical or
behavioral or combined – in the context of
women’s daily lives and realities. Many African
women face family, social and economic
pressures, some of which may impede successful
HIV prevention. Women’s needs and desires shift
over time, as do those of their partners and
families.
Different products and prevention
methods will suit different women, making the
expanded toolkit even more important.
Committing sufficient resources to this area is a
necessary condition for success
The past decade has witnessed the unprecedented
commitment of resources to the global HIV/AIDS
epidemic. For the next decade, similar
commitment to women’s reproductive health and
HIV concerns is warranted. Efforts to revise the
Millennium Development Goals should take these
concerns into account, as well as global efforts to
renew and expand funding for family planning and
the prevention of unintended pregnancies. All of
these efforts can act synergistically to improve
women’s health and reduce HIV rates over time.
Together, these recommendations can help to
ensure that the policy and programmatic successes
and innovations of the past decade, along with
emerging scientific results, are translated into
effective action for women.
Acknowledgement
Funding is gratefully acknowledged from the
Eunice Kennedy Shriver National Institute of
Child’s Health and Human Development
(1R24HD077976-01), Partnership for the Next
Generation of HIV Social Science, and from
Brown University, BIARI Program and Population
Studies and Training Center.
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Gitome et al.
Medicalization of HIV
PERSPECTIVES PAPER
Medicalization of HIV and the African Response
Serah Gitome, Stella Njuguna, Zachary Kwena, Everlyne Ombati, Betty Njoroge and
Elizabeth A. Bukusi
Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
*For Correspondence: E-mail: [email protected]; Phone: +254721422355
Abstract
Since the discovery of HIV, the advent of anti-retrovirals in the late 80s heralded an era of medicalization of HIV and fostered
major advancements in the management of the disease. Africa, despite its high HIV burden, lagged behind in the adoption of
these advancements due to major resource and logistical constraints. Innovative responses such as family-centered models of
care, community systems strengthening, integration of HIV care with existing health services, and economic and mobile phonebased approaches have been critical in the successful roll-out of evidence-based HIV/AIDS treatment even in the most resourcelimited settings. (Afr J Reprod Health 2014; 18[3]: 25-33)
Keywords: medicalization, HIV, Africa
Résumé
Depuis la découverte du VIH, l'avènement des antirétroviraux à la fin des années 80 a marqué l'ère de la médicalisation du VIH et
a favorisé des progres majeurs dans la gestion de la maladie. En dépit de son lourd fardeau du VIH, l’Afrique traîne dans
l'adoption de ces progrès en raison des contraintes importants de ressources et des logistiques. Des réponses innovantes telles que
les modèles centrés sur les soins dans la famille, le renforcement des systèmes communautaires, l'intégration des soins du VIH
dans les services de santé existants, et les approches fondées sur l’économie et les téléphones portables ont joué un rôle crucial
dans le succès de la mise à disposition de traitements du VIH fondés sur des preuves, même dans la plupart des pays à ressources
limitées. (Afr J Reprod Health 2014; 18[3]: 25-33)
Mots-clés: Médicalisation, VIH, Afrique
Introduction
Medicalization, a process of defining and treating
non-medical problems as medical problems in
terms of illness and disorder, has been in existence
since the 19th century1-3.. Medicalization is based
on a biomedical model of disease that sees
behaviors, conditions or illnesses "as a direct result
of malfunctions within the human body”1,4.
Commercial and market interests are currently the
main drivers of medicalization due to recent
advances in biotechnology, genomic medicine,
consumer focus and managed care2.
Recognizing a condition as a disease or
disorder, and having it treated to improve the
experience and quality of life of the affected
individual, is a key benefit of medicalization.
Numerous examples exist where medicalization of
certain problems previously confined to socio-
cultural circles has helped in finding solutions. For
example, Alzheimer's, a previously neglected
disease often associated with senility, is now
classified as a mental illness treatable using
biomedical drugs5,6. What was largely considered
normal or aberrant child behavior in the past has
been medicalized, resulting in rising numbers of
children being diagnosed with attention deficit
hyperactivity disorder (ADHD)7. Male sexual
problems such as erectile dysfunction and
perceived undersized penises have also been
medicalized resulting in development of therapies
such as Viagra and penile enlargement8,9.
On the other hand, medicalization may connote
negative aspects such as unnecessary focus on
biomedical language, explanations, and solutions
to address what are often cultural, psychological,
relational, and social problems10. Opponents of
medicalization argue that construing non-medical

African Journal of Reproductive Health

Transcription

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