adminWhile HIV programmes focus heavily on reducing externalised stigma and ill-treatment of HIV patients by society, little is done to deal with a patient’s self-perception and how that might deteriorate following an HIV diagnosis, speakers said at a session on stigma at the 16th International Conference on Aids and Sexually transmitted infections in Africa in Addis Ababa.
Studies show that depression is the most common psychiatric disorder among people living with HIV, and is more prevalent among HIV-positive people than the general population.
“Operational research carried out in Zambia has found a positive correlation between patients who self-stigmatised and failure to adhere to treatment,” said Sikazwe Izukanyi from Zambia’s Ministry of Health. “Self-stigma was often found in patients who did not disclose their status to partners or family members — making it difficult to maintain strict adherence to regimens while trying to hide the drugs.”
Izukanyi noted that while counselling was a standard part of HIV care in Zambia, counsellors needed to be made aware of the prevalence of self-stigma and how to deal with it.
A 2010 Ugandan study by Makerere University found that HIV-positive patients were more critical of themselves, had significantly greater problems making decisions, poorer sleep, tired more easily, experienced more appetite changes and had more cognitive impairment.
According to a study by Yordanos Tiruneh, an Ethiopian academic with US-based Northwestern University, antiretroviral (ARV) therapy has been key to reducing external stigma by minimising the visibility of physical imperfections and restoring functional daily activities such as the ability to work. The study, which used 105 interviews with Ethiopian men and women on ARVs, also found that the support networks formed by people living with HIV gave them much-needed social capital.
However, according to Yordanos, while ARVs were linked to a reduction in external stigma, the study found that they tended to increase internalised stigma, sometimes resulting in failure to properly adhere to ARVs.
“When I think of the two tablets that keep me alive, I hate myself and I feel that I am dead,” one of the study’s interviewees is quoted as saying. “Sometimes I get furious to see myself like a walking corpse, and other times I see myself as a doll that functions with a battery. I would say, without these batteries [pills], I am nothing.”
According to a US study, adherence to ARVs was higher in patients for whom anti-depressants were prescribed.
A severe shortage of mental health professionals in Africa means that HIV-associated depression is largely ignored. For instance, according to the UN World Health Organisation, Burundi has just one psychosocial care provider per 100 000, against a target of at least eight, while Ethiopia has less than one, against a similar target.
“The problem is largely a human resources one; while strengthening health systems, governments should remember to focus on mental-health issues,” said Izukanyi. “As it is, we have no systems for screening, diagnosing and treating patients with mental-health issues.”
Among other things, experts recommend integrating mental-health services into primary healthcare activities, developing mechanisms to ensure a good supply of psychotropic medication and more research into mental-health issues in Africa.
Meanwhile, UNAids and the US President’s Emergency Plan for Aids Relief (PEPFAR) have launched a five-year plan to have more than 20 million men in 14 eastern and southern African countries undergo medical male circumcision by 2015 as part of HIV prevention efforts.
According to mathematical modelling by the two organisations, achieving 80 percent coverage among males aged between 15 and 49 by 2015 — an estimated 20.3 million circumcisions — would avert some 3.4 million new HIV infections by 2025. The plan also aims to have established a sustainable national programme for infant circumcision of all boys up to two months old, and at least 80 percent of male adolescents.
“Voluntary medical male circumcision is a high-impact, cost-effective prevention tool that will bring us one step closer to our goal of an HIV-free generation,” said Michel Sidibe, executive director of UNAids. “Each HIV infection averted is money in the bank and fiscal space for the future.”
The plan was launched at the 16th International Conference on Aids and Sexually Transmitted Infections in Africa, in Addis Ababa, Ethiopia. Achieving the targets set will cost an estimated US$1.5 billion, and save some $16.5 billion in HIV treatment and care costs by 2025.
The UN World Health Organisation (WHO) and UNAids have provided operational guidance for the scale-up of medical male circumcision, but to date few countries have rolled out large-scale programmes. At the end of 2010, just 550 000 men had been circumcised in the 14 priority countries.
“Science has shown us the way, and it is time we closed the gap between scientific evidence and implementation . . . we have a real implementation deficit,” said Sidibe. “This one-time surgical procedure provides partial life-long protection against HIV . . . it has benefits not just for men but for women too, who will be less likely to be exposed to HIV in future.”
Medical male circumcision has also been shown to reduce urinary tract infections in infants and children; human papillomavirus, which causes cervical cancer in women; bacterial vaginosis in partners of circumcised men; and ulcerative sexually transmitted infections.
Speaking at the launch, US Global Aids Co-ordinator Eric Goosby reiterated US President Barack Obama’s pledge of 4.7 million PEPFAR-supported male circumcisions in eastern and southern Africa over the next two years.
Goosby noted that while the initial “catch-up” phase of the plan would be largely donor-funded, it was hoped that the second component of the plan, which involves sustaining the benefits of male circumcision through infant male circumcision, will largely be part of national medical funds.
Kenya has so far had the greatest success in scaling-up male circumcision — some 350 000 circumcisions over the past three years. Government officials said the key to the programme’s achievements was advocacy and quality of care.
Dr Nicholas Muraguri, head of Kenya’s National Aids and Sexually Transmitted Infections Control Programme, said, “People must believe in the benefits of the service you are providing, and getting leaders on board is critical; secondly, if you are offering a quality service, the queues will be endless.” — PlusNews.
derick.khumalo