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Can the UNAIDS modes of transmission model be improved? A comparison of the original and revised model projections using data from a setting in west Africa.
AIDS. 2013 Oct 23; 27(16):2623-35.OBJECTIVE: The UNAIDS modes of transmission model (MoT) is a user-friendly model, developed to predict the distribution of new HIV infections among different subgroups. The model has been used in 29 countries to guide interventions. However, there is the risk that the simplifications inherent in the MoT produce misleading findings. Using input data from Nigeria, we compare projections from the MoT with those from a revised model that incorporates additional heterogeneity. METHODS: We revised the MoT to explicitly incorporate brothel and street-based sex-work, transactional sex, and HIV-discordant couples. Both models were parameterized using behavioural and epidemiological data from Cross River State, Nigeria. Model projections were compared, and the robustness of the revised model projections to different model assumptions, was investigated. RESULTS: The original MoT predicts 21% of new infections occur in most-at-risk-populations (MARPs), compared with 45% (40-75%, 95% Crl) once additional heterogeneity and updated parameterization is incorporated. Discordant couples, a subgroup previously not explicitly modelled, are predicted to contribute a third of new HIV infections. In addition, the new findings suggest that women engaging in transactional sex may be an important but previously less recognized risk group, with 16% of infections occurring in this subgroup. CONCLUSION: The MoT is an accessible model that can inform intervention priorities. However, the current model may be potentially misleading, with our comparisons in Nigeria suggesting that the model lacks resolution, making it challenging for the user to correctly interpret the nature of the epidemic. Our findings highlight the need for a formal review of the MoT.
Journal of the European Economic Association. 2012 Oct; 10(5):1025-1058.This paper estimates whether exports affect the incidence of HIV in Africa. This relationship has implications for HIV prevention policy as well as for the consequences of trade increases in Africa. I estimate this impact using two sources of data on HIV incidence, one generated based on UNAIDS estimates and the other based on observed HIV mortality. These data are combined with data on export value and volume. I find a fairly consistent positive relationship between exports and new HIV infections: doubling exports leads to a 10%-70% increase in new HIV infections. Consistent with theory, this relationship is larger in areas with higher baseline HIV prevalence. I interpret the result as suggesting that increased exports increase the movement of people (trucking), which increases sexual contacts. Consistent with this interpretation, the effect is larger for export growth than for income growth per se and is larger in areas with more extensive road networks.
PLoS Medicine. 2007 Jan; 4(1):e44.The HIV/AIDS area has always been highly politically and emotionally charged, and we wrote a controversial and provocative piece. Most of the responses to it were unreasoned. The most cogent response came from UNAIDS (the Joint United Nations Programme on HIV/AIDS), and it generally restated an already well articulated position. We disagree with a number of the points for the reasons discussed in our original essay, and applaud one point. First, a brief restatement of our argument is warranted. There is good evidence that HIV-related stigma adversely affects the lives of people living with HIV/AIDS. There is little or no evidence, however, to support the notion that HIV-related stigma is one of the determinants of the global HIV epidemic. Furthermore, an argument could be made for why stigma might slow or contain the spread of infection in the general population. Given the very different effect the two positions would have on policy and the significance of the HIV epidemic, they deserve investigation. Among epidemiologists, two competing hypotheses, for which there is no strong evidence either way, would constitute a position of equipoise. (excerpt)
PLoS Medicine. 2007 Jan; 4(1):e51.In their essay "HIV, Stigma, and Rates of Infection: A Rumour without Evidence", Daniel Reidpath and Kit Yee Chan rightly underscore the insufficient body of research on the relationship between stigma and discrimination and HIV transmission . Increased scientific attention and effective programming against stigma and discrimination are both sorely needed. But the Joint United Nations Programme on HIV/AIDS (UNAIDS) does not accept a number of points made in the essay. Discrimination based on health status, including HIV, is a human rights violation, and stigma is the social form of this violation. HIV stigma and discrimination are wrong in and of themselves, and should be stopped for that reason alone. Reidpath and Chan suggest, as "an alternative hypothesis to the UNAIDS position", that stigma against certain groups, including people living with HIV, may have a public health value because it "could reduce opportunities for contact between high- and low-risk groups". UNAIDS cannot endorse a hypothesis that bases a public health goal on a human rights violation; nor do we believe it is either right, or necessary, to pit the public health against human rights. (excerpt)
Reaching regional consensus on improved behavioural and serosurveillance for HIV: report from a regional conference in East Africa.
Geneva, Switzerland, Joint United Nations Programme on HIV / AIDS [UNAIDS], 1998. 12 p. (UNAIDS Best Practice Collection. Key Material; UNAIDS/98.9)This report documents a regional workshop on surveillance systems for HIV held in Nairobi, Kenya, on 10.13 February 1997. The UNAIDS-funded workshop gathered government epidemiologists, AIDS programme managers, and social scientists from Kenya, Malawi, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe as well as specialists from UNAIDS and other partner institutions. The group aimed to present current data and to work together to suggest practical guidelines for improving HIV surveillance systems in a maturing epidemic. (excerpt)
Potential impact of antiretroviral therapy on HIV-1 transmission and AIDS mortality in resource-limited settings.
Journal of Acquired Immune Deficiency Syndromes. 2006 Apr 15; 41(5):632-641.The objective was to estimate the potential impact of antiretroviral therapy on the heterosexual spread of HIV-1 infection and AIDS mortality in resource-limited settings. A mathematic model of HIV-1 disease progression and transmission was used to assess epidemiologic outcomes under different scenarios of antiretroviral therapy, including implementation of World Health Organization guidelines. Implementing antiretroviral therapy at 5% HIV-1 prevalence and administering it to 100% of AIDS cases are predicted to decrease new HIV-1 infections and cumulative deaths from AIDS after 10 years by 11.2% (inter-quartile range [IQR]: 1.8%-21.4%) and 33.4% (IQR: 26%-42.8%), respectively. Later implementation of therapy at endemic equilibrium (40% prevalence) is predicted to be less effective, decreasing new HIV-1 infections and cumulative deaths from AIDS by 10.5% (IQR: 2.6%-19.3%) and 27.6% (IQR: 20.8%-36.8%), respectively. Therapy is predicted to benefit the infected individual and the uninfected community by decreasing transmission and AIDS deaths. The community benefit is greater than the individual benefit after 25 years of treatment and increases with the proportion of AIDS cases treated. Antiretroviral therapy is predicted to have individual and public health benefits that increase with time and the proportion of infected persons treated. The impact of therapy is greater when introduced earlier in an epidemic, but the benefit can be lost by residual infectivity or disease progression on treatment and by sexual disinhibition of the general population. (author's)
The impact of HIV / AIDS on Southern Africa's children: poverty of planning and planning of poverty.
Pretoria, South Africa, Human Sciences Research Council, Southern African Regional Poverty Network, 2002. , 26 p. (Save the Children UK: Southern Africa Scenario Planning Paper)In the initial discussion of this paper the terms of reference began: “Save the Children has not been adept at managing its programme planning processes in the region. Country based strategic planning has often been a tortuous business which has alienated our staff because of the abstract language used. It has been a time consuming and often disjointed process leaving most participants dissatisfied with the final planning document”. Save the Children (SCF) is not alone in this. HIV/AIDS is changing the environment in which we operate. It will have effects as serious as the plague in medieval Europe and we do not know how to deal with it. In effect there is a complete poverty in planning which will result in considerable impoverishment and misery in much of Southern Africa. One new way to assess the situation would be to through developing scenarios. HEARD has some experience in this having been part of a team working with Shell South Africa on developing scenarios for their Southern African region. We therefore agreed to prepare a draft paper, and this was discussed with SCF staff. We did not agree to follow the terms of reference exactly but rather to prepare the paper with scenarios. The first draft was completed and sent for comment on 21st June with a deadline for comment of 27th June (Alan Whiteside was away from 27th June). The first draft showed up one major problem. SCF must be part of the brainstorming. We know what HIV/AIDS means in broad terms, we have some ability at developing broad scenarios but we do not know what SCF does or what these will mean for them. In effect while HEARD’s work is nearly complete that of SCF is only just beginning. (excerpt)
Our families, our friends: an action guide. Mobilize your community for HIV / AIDS prevention and care.
[Bangkok, Thailand], United Nations Development Programme [UNDP], South East Asia HIV and Development Project, 2000. vi, 30 p. (Best Practice Documentation on Community Mobilization for HIV / AIDS: Case of Thailand)Community actions on the prevention and control of AIDS are initiated based on the community’s needs. The community hospital may play an important role in promoting and supporting care for people with HIV/AIDS (PWHA) within their area. In turn, the sustainability of controlling HIV problems in the community is based on the strength of that community. Therefore, building resources within the community should be promoted, so that those concerned understand the problems, provide acceptance to PWHA, and work together to reduce the impact of HIV/AIDS. Religious leaders can play a major role in providing support and encouraging social change towards the acceptance of PWHA. Self-help groups are very important community units, they provide care, psychosocial support and generate income for PWHA. The work plan of activities needs to be flexible, based on the needs of PWHA and their community. This action guide can help people in your community to understand how to help one another and work together for their mutual benefit, now and in the future. (excerpt)
[Alexandria, Egypt], World Health Organization [WHO], Regional Office for the Eastern Mediterranean, 1993. , 33 p. (WHO-EM/GPA/014/E/L/93)This booklet discusses the epidemiology of AIDS, which, with over 600,000 cases reported to WHO from 1981 to 1992, is a worldwide concern. The three basic modes of HIV (causative agent) transmission are 1) sexual intercourse, 2) transmission by contaminated blood, blood products, and contaminated skin-piercing instruments, and 3) mother-to-child and perinatal transmission. The period between infection to the appearance of definite signs and symptoms ranges from 6 months to several years. Mean incubation period is 1 year for children and more than 5 years in adults. The stages of infection are acute illness, a latency phase, persistent generalized lymphadenopathy, AIDS-related complex, and AIDS. Methods of diagnosis include 1) serologic testing for antibodies to HIV, 2) detection of viral antigens, and 3) isolation and characterization of the HIV virus. The three main therapeutic approaches are antiviral drugs, passive protection, and drugs that treat AIDS-related infections and malignancies. Presently, there are more than 10 vaccines in phase 1 testing for immunogenicity and safety. In the absence of an effective treatment, prevention and control strategies such as prevention of sexual and blood-borne transmission, public health education, and case management, are necessary. In addition, the WHO Global Programme on AIDS has organized and sponsored various scientific meetings and consultations on research and policy issues. Country-based programs are also supported by WHO, which allocates at least 70% of its AIDS budget to this field.