Reducing the Rate of HIV Transmission in KwaZulu-Natal

Reducing the Rate of HIV Transmission in KwaZulu-Natal, South Africa

Summary
South Africa estimates that there are 7.06 million people living with HIV according to their mid-year population estimate from 2017 (Statistics of South Africa, 2017), making it home to the biggest epidemic of HIV worldwide (UNAIDS). HIV transmission is an issue that needs to be addressed in the province of KwaZulu-Natal (KZN), South Africa. This policy brief will present and discuss a variety of strategies to do this. According to Dr. Jeffrey Koplan, global health is “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care”(Jeffrey P. Koplan et al., 2009). While this intervention is focused on one province within South Africa, the framework can be adapted for use trans-nationally, making this a global health concern. The head of The Healthy Promotion Component of the Department of Health in KZN has the power to implement a program working to reduce the spread of HIV. This department is charged with distributing health messages, including safe sex practices and sexual health messages, as well as health promotion, and providing people with guidelines for healthy living (Health Department: Province of KwaZulu-Natal, 2001). The leader of this department has the ability to put programs in place to reduce the risk of HIV. If the program is found to be successful here, they can collaborate and share the framework with other local health departments in both South Africa, and other countries. In order to reduce the risk of HIV transmission the head of The Healthy Promotion Component of the Department of Health in the Province of KwaZulu-Natal (KZN) in South Africa should implement a program encouraging voluntary male circumcision in young men and men as part of a comprehensive HIV prevention program over the next three years, and this framework can serve as a pilot and blueprint for other countries with low male circumcision rates and higher rates of HIV.

Significance of Problem
According to UNAIDS there are approximately 2.46 million males aged 15 and older living in South Africa with HIV (UNAIDS, 2017). While a high burden of HIV is placed on young women, men are a key factor in this cycle of transmission. Older HIV+ men are having sex with younger women, potentially infecting them with HIV, who then infect their future male partners as they age (UNAIDS, 2017). Additionally, of men who are between the ages of 15 and 49, 17% had at least two sexual partners in the previous year, which is nearly 4x the amount of women in the same age group who had at least two sexual partners (UNAIDS, 2017). Being HIV+ puts people at risk for opportunistic infections that take advantage of weakened immune systems, such as Tuberculosis (TB), recurrent pneumonia, and candidiasis in the bronchi in the lungs (Centers for Disease Control and Prevention, 2018) to name a few. Opportunistic infections increase the cost of healthcare for a person with HIV and can significantly decrease the quality of life for those living with them. In addition to the increase in healthcare experienced by the infected person, they may not be able to work, and may also require a family member to stay home and care for them. This puts a significant financial burden on the family and on the infected person, as well as taking a toll on the local economy. If the rates of HIV transmission can be lowered, more people will be healthy enough to work, and family members will also be free to work, improving their economic situation.

HIV transmission is a complex issue with a variety of contributing factors, a Problem Tree created by the author identified several of them, a few of which will be highlighted here. Some of these factors are unprotected sex, high viral loads, and having multiple sexual partners. Some of the root causes of HIV transmission are poverty (Noel Dzimnenani Mbirimtengerenji, 2007), power structures within sexual relationships (Tabitha T. Langen, 2005), and education level (Bc. Tade´a?s Kopeck, 2017), although poverty plays a role in this factor. Poverty contributes to multiple causes of HIV transmission including, access to treatment, quality sex education, and access to condoms. Low quality sex education contributes to low rates of condom usage, and lower rates of voluntary male circumcision. The power imbalances often seen in sexual relationships contribute to the spread of HIV. Many times, it is not up to women whether or not a condom is used when they have sex, even when the sex is consensual, and power structures contribute to gender-based violence including sexual assault and rape. The stigma surrounding HIV may prevent people from getting tested and knowing their status, allowing them to pass the infection along to other people.

This issue is of significance to The Healthy Promotion Component of the Department of Health in KZN for a variety of reasons. Not only does HIV impact the health of its citizens, as KZN has the highest HIV prevalence of the provinces in South Africa (UNAIDS, 2015), but successfully rolling out a program that would reduce the transmission of HIV could bring the component more money from the government. This increase in funding would allow them to tackle other issues of importance as well as continue to work on lowering the risk of HIV transmission. Additionally, reducing the rates of HIV transmission would boost the component’s image, and could lead to recognition both nationally and internationally. This would allow the department to share the framework with other countries, contributing to a global reduction in HIV transmission. The increase in recognition could also help the department receive more grant funding. In addition to bringing in more funding, reducing the rate of HIV transmission would also cut the overall cost of healthcare in KZN, and cut down on the number of sick days people have. This reduction in cost of healthcare coupled with fewer sick days would boost the economy. The boost in economy could be tied back to this component of the health department, contributing to a boost in image and recognition.

Existing Approaches
An Intervention focused on Gender-Based Violence and HIV Risk Reduction
An article published in Prevention Science in 2009 titled “Integrated Gender-Based Violence and HIV Risk Reduction Intervention for South African men: Results of a Quasi-Experimental Field Trial” discussed a field trial in which two different communities in South Africa either had one session on reducing the risk of HIV and alcohol that lasted three hours long, or a series of five sessions that worked to address gender-based violence and behaviors associated with HIV risk (Seth C. Kalichman et al., 2009). The men were then tracked for up to six months post intervention. For this field trial 475 men with an average age of 30.2 years old in Cape Town South Africa participated (Seth C. Kalichman et al., 2009). The intervention focused on building skills and having the men set personal goals in order to reduce the risk of HIV and gender-based violence (Seth C. Kalichman et al., 2009). The men came up with risky sexual behaviors and worked to create solutions to address the risks associated with the behaviors (Seth C. Kalichman et al., 2009). Additionally, the men watched clips from popular movies and television shows and identified the risky behaviors in them, as well as addressed the violence and attitudes toward women portrayed in the scenes ((Seth C. Kalichman et al., 2009). The men were able to use the clips to reflect on their own past history of attitudes and violence towards women (Seth C. Kalichman et al., 2009). Another aspect of this particular intervention was training the men to speak out against violence and risky sexual behavior within their communities (Seth C. Kalichman et al., 2009). The alternative intervention was the three-hour session on alcohol and risky sexual behavior. This group discussed the use of alcohol in risky sexual situations and the risks that are associated with the two (Seth C. Kalichman et al., 2009). The study found that the men in the gender-based violence group were more likely to be tested for HIV during follow up, and that they were more likely to discuss condom usage with their sexual partners (Seth C. Kalichman et al., 2009). The study did not find that there was an increase in condom usage among the men, or a reduction in the number of sexual partners or unprotected sex (Seth C. Kalichman et al., 2009). This intervention used a more holistic approach to address the transmission of HIV. The approach increased awareness of gender-based violence, and the risks of HIV transmission, while enabling the men who participated to increase awareness within their community. While the intervention seemed as though it would be effective on paper, it lacked results. In this situation the intervention did not do anything to reduce the risky behaviors associated with HIV transmission, and appeared to only increase awareness of such behaviors.

Condom Programs
Condoms are known to be an effective tool in reducing the spread of HIV, and other sexually transmitted infections, and when they are used consistently and properly, this effectiveness can reach 95% (Mary Jane Rotheram-Borus, Dallas Swendeman, ; Gary Chovnick, 2009). Condom programs have the potential to be effective, but there are still many barriers to their effectiveness. In South Africa there was a reduction in the incidence of HIV between 2000 and 2008 when condom use increased after they were more frequently distributed (UNAIDS, 2015). However, condom programs require that they be readily available, and are coupled with rigorous promotion and marketing (UNAIDS, 2015). Additionally, condoms need to be used consistently for them to be an effective intervention for HIV. Condom programs need to be scaled up in order to distribute enough of them and promote them intensely enough to see results (UNAIDS, 2015).

Voluntary Male Circumcision
Voluntary medical male circumcision (VMMC) is an effective strategy for reducing the transmission of HIV between males and females, and can do so by 60% (AVERT, 2018). The World Health Organization along with UNAIDS have suggested the use of VMMC to reduce the risk of HIV transmission as part of a holistic HIV prevention program (AVERT, 2018). Their goal was to have 20.8 million men circumcised, 80% coverage, by the year 2016 in 14 critical countries, including South Africa (AVERT, 2018). 2015 data showed that approximately 11.6 million men underwent VMMC, with rates decreasing in 2015 (AVERT, 2018). If 80% coverage with VMMC were to be reached, a maximum of 3.4 million incident HIV infections could be avoided, and it is estimated that there would be a savings of US $16.5 billion because of avoided treatment costs by the year 2025 (AVERT, 2018). It is clear that VMMC would have a substantial impact on reducing the risk of HIV transmission, however, VMMC needs to be part of a more comprehensive and holistic approach to preventing HIV infection, as it only addresses one aspect of transmission. Additionally, a pitfall of a program could be an increase in risk of infection following the procedure if it is not performed by a person with proper training and tools.

Selected Solution
Based on the potential success of VMMC, this brief suggests that the director of The Healthy Promotion Component of the Health Department in KZN implement a program that encourages VMMC as part of a comprehensive HIV prevention program. Programs featuring VMMC would contribute to reaching the 80% coverage suggested by the World Health Organization and UNAIDS, leading to a massive economic savings, and a 60% reduction in HIV transmission (AVERT, 2018). Given this, it makes sense to implement such a program, potentially leading to local, national and international recognition. This recognition would boost the image of the department, and could increase government funding. Additionally, the potential for international recognition would increase the ability for the component to receive grants funding. The success of such a program would make it a shareable framework, contributing to a global reduction in HIV incidence.

In order for such a program to be effective it would have to be done by medically trained professionals, who have access to sterile tools, and a sterile environment to prevent infection associated with the procedure. Additionally, the program should focus on reaching young men, ideally before they become sexually active. The intervention should have an educational aspect associated with it, to increase knowledge and awareness of the procedure, and reduce fear. In order to maximize effectiveness, along with promotion of VMMC, the Healthy Promotion Component should work to connect young men with people who perform the procedure. This could be done by providing contact information for people who are known to perform VMMC, or by offering clinics that travel to the men in KZN. Along with making it readily accessible location wise, the procedure should be offered at a low cost, or for free in order to make it the most accessible. To make the program more comprehensive, information about other ways to reduce the risk of HIV transmission should be reviewed with the men before and after the procedure.

This program can be implemented by the Healthy Promotion Component of the health department in KZN. This department is responsible for messages promoting overall health, as well as promoting safe sex practices(Health Department: Province of KwaZulu-Natal, 2001), making this intervention something that falls within their domain. In order to make the intervention more feasible they could potentially collaborate with the Communicable Disease Control component of the department. This would help reduce the amount of work required by the Healthy Promotion Component alone, and could make the intervention more effective by allowing for input from people with different backgrounds and expertise. This intervention is something that could be developed and implemented within three years.
References:
AVERT. (2018). Voluntary Medical Male Circumcision Retrieved from https://www.avert.org/professionals/hiv-programming/prevention/voluntary-medical-male-circumcision#Increasing%20uptake%20of%20VMMC%20programmes
Centers for Disease Control and Prevention. (2018). AIDS and Opportunistic Infections. Retrieved from https://www.cdc.gov/hiv/basics/livingwithhiv/opportunisticinfections.html
Dzimnenani Mbirimtengerenji, Noel. (2007). Is HIV/AIDS Epidemic Outcome of Poverty in Sub-Saharan Africa? Croatian medical journal, 48(5), 605-617.
Kalichman, Seth C., Simbayi, Leickness C., Cloete, Allanise, Clayford, Mario, Arnolds, Warda, Mxoli, Mpumi, . . . Kalichman, Moira O. (2009). Integrated Gender-Based Violence and HIV Risk Reduction Intervention for South African Men: Results of a Quasi-Experimental Field Trial. Prevention science : the official journal of the Society for Prevention Research, 10(3), 260-269. doi:10.1007/s11121-009-0129-x
Kopeck, Bc. Tade´a?s. (2017). Education and HIV: Evidence from
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Rotheram-Borus, Mary Jane, Swendeman, Dallas, ; Chovnick, Gary. (2009). The Past, Present, and Future of HIV Prevention: Integrating Behavioral, Biomedical, and Structural Intervention Strategies for the Next Generation of HIV Prevention. Annual review of clinical psychology, 5, 143-167. doi:10.1146/annurev.clinpsy.032408.153530
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