# data[].attributes.body
News article about HIV in children, and how COVID has hindered the process of treating the affected children with HIV. Children who live in Sub-Saharan Africa are at in increased risk because of malnutrition.

# data[].attributes.attachment_link.readable_text
Last year, only 53% of children and infants living with HIV across the globe were properly diagnosed and getting lifesaving treatment. But affordable, child-friendly HIV treatment recently became more accessible than ever, thanks to recent advances and cost negotiations involving a generic version of the HIV drug dolutegravir.

To get the word out, international HIV and health organizations have called for better access to HIV treatment for children and infants. A joint statement posted by the World Health Organization (WHO) urges a massive scale-up of access to treatment to end pediatric AIDS.

Global health partners call on countries to urgently expand access to optimal, child-friendly HIV treatment. #EndAIDS @UNAIDS @UNICEF @PEPFAR @WHO @EGPAF @UNITAID @CHAI_health https://t.co/1YUMxJcLKB
- The Global Fund (@GlobalFund) December 22, 2020

The WHO recommends a dolutegravir-based regimen as first-line treatment for children. The generic 10 milligram child-friendly tablets were speedily approved by the U.S. Food and Drug Administration as a result of a collaboration with Unitaid, ViiV Healthcare, the Clinton Health Action Initiative (CHAI) and generic suppliers. To improve access to the drug, Unitaid and CHAI negotiated a deal that lowers the medication's cost by 75% for children living with HIV in low- and middle-income countries.

"For the first time, children living with HIV in low- and middle-income countries will have access to the same first-line antiretroviral medication at the same time as those in high-income countries," said Iain Barton, CEO of CHAI, in the WHO joint call for action. "The partnership should serve as a model to remove barriers that hinder development of pediatric formulations to deliver top-line medications quickly and affordably."

"This has the potential to be a true game changer for children with HIV," added Meg Doherty, director of Global HIV, Hepatitis and STI Programmes at the WHO. "We must do all in our power to help countries get this new pediatric [dolutegravir formulation] to all the children who need it."

Also signing on to WHO's statement are the United Nations Children's Fund (UNICEF) and its AIDS program (UNAIDS), the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Elizabeth Glaser Pediatric AIDS Foundation, CHAI, Unitaid and The Global Fund to Fight AIDS, Tuberculosis and Malaria.

"Children are still getting infected at alarming rates, and they are still dying from AIDS. This was even before COVID-19 interrupted vital HIV treatment and prevention services"

New @UNICEF report reveals a child is infected with #HIV every 100 seconds https://t.co/7uxLW6SKZQ
- Avert (@Avert_org) December 7, 2020

Scaling up pediatric dolutegravir is vital. Not only is it highly effective and easier to take, thus likely to boost adherence, but it is also desperately needed. As the WHO reports, 95,000 children died of preventable AIDS-related illness in 2019. What's more, of the 1.8 million children ages 14 and younger estimated to be living with HIV, 850,000 are undiagnosed or not on treatment.

A recent report from UNICEF found that 320,000 children and adolescents contracted HIV in 2019. This translates to one every 100 seconds. That was before the COVID-19 pandemic, which has only made matters worse-notably by disrupting treatment and services, lowering HIV services by 10% or more in many countries compared to pre-pandemic data.

In related news, Charles Lyons, president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation, penned an opinion piece titled " Prioritizing Children in the COVID-19 Response," which urges us to learn from HIV. You can read more HIV content related to children and adolescents on the POZ.com hashtag #Pediatric. Sample articles include " Still Here," a look at the challenges young long-term survivors continue to face, and " Why This New Strawberry-Flavored HIV Med Is a Game Changer."

# data[].attributes.attachment_link.keywords[]
elizabeth glaser pediatric aids foundation

# data[].attributes.attachment_link.keywords[]
joint united nations programme on hiv/aids

# data[].attributes.attachment_link.title
Good and Bad News About HIV Treatment for Children

# data[].attributes.attachment_link.description
Last year, only 53% of children and infants living with HIV across the globe were properly diagnosed and getting lifesaving treatment. But affordable, child-friendly HIV treatment recently became more accessible than ever, thanks to recent advances and cost negotiations involving a generic version of the HIV drug dolutegravir.

# data[].attributes.body
News article discussing how drought and food shortages can increase a females chance of contracting HIV; and how there is an increased risk of contracting HIV in Sub-Saharan Africa.

# data[].attributes.attachment_link.readable_text
A modeling study suggests that females in developing nations are especially vulnerable to the effects of drought and food shortages. The social, economic, and medical consequences may disproportionately increase their risk of contracting HIV.

When HIV emerged in the 1980s and 90s, males were more likely than females to contract the virus. However, globally, the majority of adults living with HIV are now females, according to United Nations data.

The Joint United Nations Program on HIV/AIDS (UNAIDS) report that HIV is the leading cause of death in females aged 30-49 years and the third leading cause of females in females aged 15-29 years globally.

The relative rates of males and females contracting HIV vary widely between countries, but data from the World Bank suggest that in Sub-Saharan Africa, for example, more than 60% of all those living with HIV are females.

Females aged 15-24 in this region of Africa are more than twice as likely as males in the same age bracket to become HIV positive, according to UNAIDS.

What makes females in developing countries so much more vulnerable to contracting HIV than males?
Research by Kelly Austin, associate professor of sociology at Lehigh University in Bethlehem, PA, and her colleagues suggests that droughts are one contributory factor.
Their study, which appears in the journal Social Indicators Research, found that food insecurity resulting from droughts has a disproportionate effect on females' risk of contracting HIV.

They used a statistical technique called structural equation modeling to explore the relationship between HIV infection rates and socioeconomic and environmental factors - including drought and food insecurity - in 91 developing nations.

According to the researchers, females in these societies have little autonomy and are often responsible for raising children, growing and harvesting food, collecting firewood, and fetching water. This makes them uniquely vulnerable to droughts and the ensuing food shortages.

The researchers identified four ways in which food insecurity exposes females to a greater risk of contracting HIV:

Malnutrition, which weakens immune defenses to HIV, and increased vulnerability to other illnesses, such as malaria, may also indirectly increase susceptibility to HIV.

Exacerbation of gender inequalities in terms of access to education and healthcare, including birth control services, which could protect females against HIV.

Early marriage of daughters for financial reasons, resulting in exposure to sexually transmitted illnesses at a younger age.

Financial motivation to become sex workers.

"Women in less developed countries disproportionately bear the burden in terms of ill health when facing food insecurity or a shock or disaster like drought that impacts the ability to get food or harvest food," says Austin.

"This information would be useful for policymakers and people working in international development and disaster response."

The findings are particularly concerning in light of the climate emergency, say the authors. The Food and Agriculture Organization of the United Nations (FAO) predict that climate change will increase the frequency, severity, and duration of droughts in the coming years.

The authors conclude:

"[D]uring times of drought and hardship special attention should be made to ensuring the safety and participation of young women in schooling, medical care, and other activities that ensure their well-being [...] a holistic approach must be taken that not only emphasizes conventional approaches, [such as] expanding access to medical care, but also prioritizing women's empowerment and environmental resilience and sustainability."

A possible limitation of the research was that it relied on structural equation modeling. Some researchers have criticized this technique, which is popular in the social sciences, for creating models that oversimplify highly complex real-world situations.

# data[].attributes.attachment_link.title
Drought may increase females' HIV risk in developing nations

# data[].attributes.attachment_link.description
A modeling study suggests that females in developing nations are especially vulnerable to the effects of drought and food shortages. The social, economic, and medical consequences may disproportionately increase their risk of contracting HIV. When HIV emerged in the 1980s and 90s, males were more likely than females to contract the virus.

# data[].attributes.body
News article about how research for HIV has helped scientists find a vaccine for COVID.

# data[].attributes.attachment_link.readable_text
People are receiving Covid-19 vaccines less than a year after public health authorities discovered SARS-CoV-2, the deadly new coronavirus. How did it happen so quickly? In part, the world can thank decades of frustrating and often fruitless research to find a vaccine for Human Immunodeficiency Virus or HIV, the virus that causes AIDS. Many of the new technologies and approaches employed to create potent Covid-19 vaccines and therapies trace their origins to the desperate search, starting in the early 1980s, to slow the spread of HIV.

AIDS has claimed 33 million lives to date, and 38 million people are currently living with HIV. There is still no vaccine. But since 1982, the U.S. has invested more than $76 billion in lifesaving treatments, quietly revolutionizing the development of vaccines and therapies for other viruses, including the coronavirus.

"Everything we do with every other pathogen spins off of things we've learned with HIV," said Anthony Fauci, a leader in HIV research as director of the National Institute of Allergy and Infectious Diseases since 1984.

Scientists haven't yet been able to develop an effective AIDS vaccine, partly because HIV is one of the most cunning, complex pathogens ever encountered. Like the coronavirus, HIV has a spike or envelope protein that binds to receptors on the surface of cells, but in HIV it doesn't stay intact long enough to be efficiently attacked by the immune system.

Over decades of work, however, HIV researchers developed a better understanding of the complex workings of the immune system. They mapped out in detail how HIV invades cells and replicates, and identified weak spots in the virus that can be targeted by drugs. Using X-ray crystallography and later electron microscopy, combined with computer modeling, researchers created highly detailed three-dimensional images of proteins on the surface of HIV. The idea was to use the images to engineer antigens, molecules that generate an immune response and prompt the body to mount a defense against the virus.

# data[].attributes.attachment_link.title
How HIV Research Laid the Foundation For Covid Vaccines

# data[].attributes.attachment_link.description
People are receiving Covid-19 vaccines less than a year after public health authorities discovered SARS-CoV-2, the deadly new coronavirus. How did it happen so quickly? In part, the world can thank decades of frustrating and often fruitless research to find a vaccine for Human Immunodeficiency Virus or HIV, the virus that causes AIDS.

# data[].attributes.body
Annie Lennox speaks on why she is an activist for HIV/Aids.

# data[].attributes.attachment_link.title
Annie Lennox: Why I am an HIV/AIDS activist

# data[].attributes.attachment_link.description
For the last eight years, pop singer Annie Lennox has devoted the majority of her time to her SING campaign, raising awareness and money to combat HIV/AIDS. She shares the experiences that have inspired her, from working with Nelson Mandela to meeting a little African girl in a desperate situation.

# data[].attributes.body
A Harvard School faculty member discusses his opinion on what the 4 major misconceptions are about HIV/AIDs. Touches on the millions of people that need to be tested for HIV in Africa.

# data[].attributes.attachment_link.readable_text
The following is a guest post by Daniel Halperin, who is on the faculty of Harvard School of Public Health and is finishing a co-authored book on AIDS. The opinions expressed are his own.
During the biannual International AIDS Conference this week in Vienna, there will be a strong push to increase funding for HIV/AIDS, along with calls to focus more on prevention of it. Given the poor track record of technological advances in HIV prevention, there is eager anticipation about a possible new vaginal gel that could help protect women from getting the virus. While future possibilities, such as the gel, and rhetoric in Vienna are well-intentioned, some of the assertions about AIDS are quite flawed. Here are four key misconceptions about AIDS:

1) Providing AIDS medications to everyone is the best prevention method. A new buzz phrase in the AIDS world is the "test and treat" notion. Some mathematical models have suggested that if tens of millions of people across Africa were tested for HIV, and everyone who tested positive was immediately placed on life-long antiretroviral medications, it would eventually end the epidemic. Such assertions are financially unrealistic, and rely on extremely optimistic and flawed modeling.

Real world evidence, in places such as America and Europe, suggests that although widespread treatment probably helps to reduce the infection rate, it does not eliminate it. So, instead, we should provide life-saving drugs to the people who urgently need them, rather than diverting expensive drugs, which can often have serious side effects, to millions of otherwise healthy individuals for a mainly speculative prevention benefit.

Preliminary research about potential "antiretroviral vaginal gels" will be presented Tuesday in Vienna. Such approaches could eventually help protect some women but, like condoms, they would need to be applied each time prior to sex. The gels may also have long-term toxic side effects and carry the risk that people will stop using more effective methods, like condoms or mutual fidelity, on the assumption they are now "protected" against HIV.

2) Behavior change doesn't work. Some long-standing prevention approaches, such as condoms, are effective at reducing risk, though the actual impact of programs vary considerably depending on the nature of the local epidemic. In countries where the driving force of AIDS is sex work, such as in Thailand or Cambodia, "100% condom" promotion programs have often been quite successful at reducing the rate of new infections.

In the much more severely affected countries in southern Africa, however, there is less indication that the heavy investment in condom programs has slowed the epidemic. That's mainly because it is notoriously difficult to maintain consistent condom use in the more long-term - and often overlapping - sexual partnerships where most HIV transmission in Africa occurs. Thus, in such settings it is crucial to also promote having fewer sexual partners.

3) There are no magic bullets. While this statement is certainly true, it masks another important truth, which is that the international prevention community has generally done a dismal job of prioritizing the best way to prevent HIV. The new mantra in the HIV world is "combination prevention," which means let's keep doing what we've been doing. Sadly, while many of the standard approaches, such as HIV testing and counseling, have important public health benefits, they have not been shown to reduce HIV infections in any major way.

By shying away from prioritizing the most effective interventions, some newer and potentially powerful approaches may not receive the attention and resources required to help stem the flow of new infections. Male circumcision, for example, is not as effective as condoms in reducing risk for each sex act but it lowers lifetime risk by at least 60% and confers protection every time a man has sex.

On that front, there has been some good news lately. In the part of western Kenya, where President Obama's father was born and which has been the most severely affected by AIDS, more than 100,000 men were circumcised last year. President Zuma of South Africa has also recently endorsed the procedure, which his ethnic group, the Zulus, abandoned two centuries ago.

Moreover, and especially in the current global economic recession, there is an urgent need to pursue the most cost-effective strategies, such as male circumcision. There is not sufficient funding to "do everything" to prevent - and treat - the millions of new HIV cases continuing to occur each year.

4) HIV/AIDS is different from all other epidemics. At the end of the day our objective should be healthy people, and HIV is just one of many diseases. AIDS is not the overriding health problem in most poor countries, where more-mundane problems such as lack of access to clean water overshadow it. HIV/AIDS receives billions of dollars in foreign aid annually. Meanwhile, diarrhea and pneumonia kill many more people globally yet receive a tiny fraction of aid. Luckily, the Obama administration and others are increasingly realizing the importance of finding ways to leverage HIV/AIDS funding to improve overall health.

While we must continue to search for new technological approaches, let's not forget that millions of lives have already been saved through using basic prevention approaches and common-sense changes in behavior.

# data[].attributes.attachment_link.title
Four major misconceptions about the global HIV/AIDS epidemic

# data[].attributes.attachment_link.description
During the biannual International AIDS Conference this week in Vienna, there will be a strong push to increase funding for HIV/AIDS, along with calls to focus more on prevention of it. Given the poor track record of technological advances in HIV prevention, there is eager anticipation about a possible new vaginal gel that could help protect women from getting the virus.

# data[].attributes.body
Arthur Ammann, a veteran doctor of the HIV/AIDs epidemic, discusses the global health epidemic.

# data[].attributes.attachment_link.readable_text
Interview by Sophie Roell

You were involved with the HIV/Aids epidemic at a very early stage, and, since then, have given a lot of thought to epidemics in general. Why are you so keen to use the term 'plague' to describe it?

At the beginning, in 1981, Aids was not called an epidemic because there were only a handful of patients that were affected. At that time, the cause was not known. As I got involved more deeply with the patients and their families, it became clear it was not just young gay men who were affected but that there were also mothers who were transmitting the virus to their babies, women who were getting infected from men, and people in need of blood transfusions who might become infected with the Aids virus.

The word 'epidemic,' for me, is a scientific word unattached to the many other facets of the epidemic―sociologic behaviour; the politics; discrimination; the personal impact on multiple lives.

I think it was the first disease that some of us dealt with that affected everybody in the family, and the communities that people worked and lived in, to such a great extent. It may have had a lot to do with the time at which it appeared. Communication was better than it had been a century earlier. It allowed more interaction and more description of the extent of the involvement. It was not like the early epidemics, which were confined to more specific geographic areas-this was global.

The human suffering isn't captured in the word 'epidemic.' I think, from a historical point of view, 'plague' better describes the broad impact of Aids.

You're also talking about the emotional impact.

Yes, because for those who were intimately involved, you were dealing with patients that you knew well. You knew their names, you knew the families, you saw the mothers and the children, you saw the ramifications of the disease. For some of us, it was not sitting in an office analysing data, saying, 'This year we had so many more thousands of cases in men, women, and children. The epidemic is expanding.' This was being involved, this was seeing the compassionate aspect but also the prejudicial aspect, the discrimination. It was going deeper into the humanity of the suffering. The word 'plague' captures that.

"The human suffering isn't captured in the word 'epidemic.' I think, from a historical point of view, 'plague' better describes the broad impact of Aids"

Plagues have intrigued me ever since I was a child, reading about them in the Old Testament. In high school, I read books about diseases and the discovery of diseases. It never struck me that I was interested in it because of numbers but more about what it did to humanity.

The first book on your list - Albert Camus's The Plague (1947) - seems to encapsulate all this very well. Tell me a bit about why you've included the book and why you think it's so good at talking about epidemics.

It's an amazing book, considering Camus probably never personally experienced a plague. In his novel, Camus captured everything that we were dealing with in the Aids epidemic without Aids existing at that time. Without his knowing what the consequences of the HIV plague were going to be, he seems to have gotten all the actors in there and the myriad of things that you wrestle with. For example, there's the researcher, there's the research subject, there's even the opportunist who takes advantage of the terrible things happening. There's the journalist-which reminds me of a book we'll talk about later, And the Band Played On. Journalists were critical in calling attention to the Aids epidemic. Camus describes that in The Plague as well. Then there are the volunteers-the people who just happened to be there at the time of the plague. Instead of running away from it-as many people do-Camus goes into how a volunteer gets deeply involved in it and what they can do.

Camus seems to have understood the many other components of a plague-the fear, the discrimination, the hopefulness and the hopelessness-and he also wrestles with, 'What is the meaning of this?'

I have read that the book could be an allegory of war, especially his dealing with what happened in France with the Nazis. That's not quite the same as a plague that comes on you from an infectious source. Even though there's suffering and death there, it's psychologically and emotionally dealing with the question of human evil. Plagues are not inherently evil, although they create profound and extensive pain and suffering.

How did Camus know all of this? Did he live through a plague? Not that I or anyone else knows of. But he did live through a terrible time with war, and war is integral to the spread of disease. Somehow he managed to put all that together in this very well-written book.

You use direct quotes from The Plague to begin each section of your own book, Lethal Decisions. Can you give an example of a quote that was particularly apt?

The one that hit me first was where he writes that, "...the plague had lost its fleshy substance." It's such a simple phrase. At the beginning, the people we saw had names. We knew them personally and we saw them getting sicker and we saw some of them dying.

Then, as the HIV epidemic continued, we started getting into confidentiality and reporting HIV infected patients anonymously. You didn't use the names because of the fear of discrimination. So, what was reported was that the epidemic had so many thousands of cases. In the process, people forgot the suffering of individuals. It didn't seem real anymore. People were overwhelmed by the numbers and began talking about, for example, 500,000 plus or minus 30,000 individuals. They didn't want to think about the real numbers. We got used to things.

That's very true of the Aids epidemic now. I started writing my book about the time there seemed to be a mounting indifference to HIV. The report last year was that there were 1.5 million new infections in women and children, and another million in men. Then we wait for the next year's report. We get shaken by the Ebola virus because it has caused 8,000 deaths in one year. In that same year, HIV caused a million deaths.

"In his novel, Camus captured everything that we were dealing with in the Aids epidemic without Aids existing at that time"

One of the reasons I wrote my book was because I did think the epidemic was losing its "fleshy substance." People were forgetting-especially about the women and children in poor countries. They were being talked about in terms of how bad the epidemic had become but very little was being done to help them.

I end my book with Camus's conclusion, where he reveals who wrote the book. He says, "the chronicle is drawing to an end and it seems to be the moment for Dr. Bernard Rieux to confess that he is the narrator". Then he goes on to say, "he was well placed for giving a true account of all that he saw and heard" and "following the dictates of his heart, he has deliberately taken the victim's side and tried to share with his fellow citizens the only certitudes they had in common-love, exile, and suffering. Thus he can truly say there was not one of these anxieties in which he did not share, no predicament of theirs that was not his." I wanted to end my book that way because he captured it in his novel.

I'm deliberately taking the side of the women and children, as if they're people that I know personally. I want to defend them. I don't want them to lose their dignity by being diminished or becoming less valuable. They have a right to health, they have a right not to remain in poverty, they have a right to the same medicines that we have and that have changed this epidemic in wealthy countries.

At the beginning of The Plague, people couldn't really believe it was happening. They just wanted to carry on as normal. Is that quite common in epidemics that people just aren't prepared to have something come along and disturb their lives?

It's absolutely characteristic. I refer to it as 'denialism'. The most well-known denialist in the Aids epidemic is Peter Duesberg, a tenured professor at the University of California, Berkeley, who says that HIV is not the cause of Aids.

Other, more subtle, forms of denialism exist. In 1981/82, we would go to meetings, present to the Red Cross and the National Institutes of Health, submit articles to journals. People said we were exaggerating, that this was not going to be a major epidemic, that this was confined to a small group of gay men who were having multiple sexual partners.

Get the weekly Five Books newsletter

Even as we were talking about it, the epidemic was affecting hundreds of thousands of people. It certainly existed before 1981. Nobody was aware of it because there was nobody to diagnose it early on. Individuals with Aids were misdiagnosed as having advanced tuberculosis or malnutrition.

"If you look through the history of medicine, and discovery, there's always a period of denialism where people and scientists say, 'That's not true!'"

People think that scientists look at the data, and then make conclusions that are evidence-based. But scientists can also be denialists. If you look through the history of medicine, and discovery, there's always a period of denialism where people and scientists say, 'That's not true!' Often they don't change their mind until it becomes so obvious and by that time it has caused irreversible damage. In the HIV epidemic, denialism led to irreversible damage in the form of advanced disease and death.

So, yes, denialism is a serious problem.

What about the moralistic element that comes up in The Plague: the priest telling the congregation that this has been brought upon them because they've done wrong. That was a feature early on in the HIV/Aids crisis wasn't it?

That was prominent early on and I don't think it's gone away. I still find people placing blame on those that suffer from HIV for what has happened. Part of it has to do with not understanding that we all have behaviours that can be damaging. It's a repeat of history, just like the spread of syphilis was blamed on prostitutes and not on the clients.

I had to deal with it early in the epidemic. As Camus describes in the book, there's a physician who is thrown into this plague and reasons, 'I'm a doctor-I have to respond to this. I can't and won't make a moral judgement.'

I used to tell people that if someone came in after a terrible automobile accident and it was because they were intoxicated, I would not place blame on them. As a physician, my duty, my moral obligation, is to treat the person no matter what.

The next book you've chosen is The Coming Plague (1994) by Laurie Garrett. Why is this on the list?

I met Laurie during the Aids epidemic because she used to come to all the major HIV/Aids meetings. I remember her sitting and listening to the scientists debate and argue about different aspects of HIV and Aids. She comes at the issue of plagues more from a historical viewpoint, coupled with scientific discoveries that provide us with a warning that things may get worse.

She goes through the past epidemics-Lassa fever, Ebola, HIV, malaria. She then points out that there are a lot of plagues that are still around us. Not only have we not solved them but, if we look at what's happening within those plagues, things could get worse. She talks about antibiotic resistance and changes in tuberculosis and malaria that make them more difficult to treat. Recently Garrett wrote a book about the Ebola virus epidemic, one of the coming plagues she had talked about in her earlier book.

"What if HIV mutated into a virus that was resistant to all of the drugs? That's a possibility"

We now have more than 25 drugs to prevent and treat HIV infection and yet HIV still persists. Do we now believe that even if someone gets infected, they can be treated or even cured? There is an open discussion in the scientific community about curing HIV-even as we still see millions of new infections and deaths each year. Many believe that with widespread use, the current drugs to treat HIV infection will soon get drug resistance and the epidemic will once again take off at an accelerated rate. You have to ask, 'Was Laurie Garrett correct when she talked about The Coming Plague?'

I think what she is saying is that we've gotten too complacent. Science has given us a great deal of confidence that we can solve these problems, but, even as those discoveries are made, we have to confront the fact that infectious agents mutate and that they can mutate into resistant organisms or even new organisms. There are now strains of tuberculosis that are resistant to every known treatment combination.

What if HIV mutated into a virus that was resistant to all of the drugs? That's a possibility. What if that new virus was going to keep spreading and keep the epidemic going? Or what if HIV recombines with another more infectious virus? Garrett is like a prophet saying, 'Okay, let's look at these diseases that existed in the past and what could happen if the infectious disease mutated or recombined with another virus to become an entirely new agent. Wouldn't we have a new plague threatening us?' And, just as in the Old Testament, I don't think people always want to hear the message of a prophet.

I partially experienced this overconfidence early in my training. I was a paediatrics resident in San Francisco, and one of the professors that I really liked-a fantastic teacher called Moses Grossman-was an infectious diseases specialist. I asked my fellow residents why they weren't going into the field of infectious diseases. They said, 'It's a dying field. We've got vaccines and antibiotics and everything is under control.' That was 1967.

Think about what has happened between 1967 and now. We're dealing with new infectious diseases and a threat of bacteria that are increasingly resistant to multiple antibiotics. There are issues of antibiotic resistance that we didn't think were possible. We have infectious diseases for which we have no vaccines.

In that book, Laurie is not only compiling the history of plagues but also talking about science and its ability to answer or not answer the new threats that we are likely to encounter.

There's quite a lot of talk in the media now, about the resurgence of tuberculosis.

This is another example of how if you neglect one disease, another disease that's been around a long time-and is partially contained-such as tuberculosis, can re-emerge as a major threat. When HIV isn't diagnosed or is treated late, the immune system is deficient and tuberculosis-which is contagious not through sexual activity but through physical contact-spreads in people with HIV. Standard drugs that were used to treat tuberculosis don't work now because you don't have the synergy between the immune system and the drugs. You have, in many areas of the world- including the US-multiple drug-resistant tuberculosis and a type of tuberculosis, emerging now, which is resistant to all drugs.

And it's occurring not just in patients with Aids but is being transmitted to healthcare workers through physical contact and through aerosolization. Unlike HIV, tuberculosis is much more contagious when taking care of patients.

So you've got this serious problem emerging, a secondary epidemic, which was totally unanticipated because of HIV and not paying attention to it. Then you have people saying they're not going to worry about it because it's occurring in countries where there's a high rate of HIV infection. But there have been instances where people have travelled on an airplane and were exposed to tuberculosis by an infected passenger. Again, that's part of Laurie's book.

Because of scientific advances, because of technology, because of people being able to travel, we are at much greater risk of some new plague emerging or a worsening of an existing plague.

Is there anything to be done, in your view?

Yes. We can't forget about public health. We have got to adhere to fundamental and historically sound public health principles. Most importantly, you have to respect these infectious diseases and not feel that we can control them simply by creating a new antibiotic.

The dangerous side-which I think has to be raised-as in historical times (and this has remained relevant for HIV), is that when diseases are contagious and you want to protect yourself from them you may think that the best way to do that is to ostracise the people with the infectious disease. That is the risk you run when you become adamant about controlling disease using isolation.

You don't have to go that far. We should be intervening at early phases of infection and doing simple things because complex science usually answers the issues of diseases when they are advanced. I call that downstream. To me, upstream is prevention. With the Ebola epidemic-which is repeatedly mentioned in some of these books-one of the solutions to keeping that from spreading is teaching people early on to recognise what Ebola is and then providing inexpensive interventions such as soap and water and latex gloves. It's that simple. That virus probably would not have spread as far as it did in a recent epidemic, had those simple public health principles been available.

There are measures that can be taken that are already available and don't require new discovery. We see that in some of the historical examples. Some of these diseases disappeared at the time people realised that you had to have sanitation-that the diseases were coming from contaminated water. Then you forget about that, and you have a cholera epidemic in Haiti in 2010 and again in 2016-because, in spite of all the money that was put into Haiti after the earthquake, they didn't provide basic sanitation and clean water for the people. The cholera epidemic came from the UN troops that were there to keep the peace. The real solution to preventing that from happening would have been to pay attention to basic public health principles of sanitation.

Let's talk about your next book. This is Randy Shilts's And The Band Played On (1987), about the early Aids epidemic.

Randy was a San Francisco Chronicle newspaper reporter and knew the gay community well. He saw the Aids epidemic evolving. He was concerned because his friends were infected and some of them were dying. He would come to my office at the university once a week and ask, 'What's new?' He did that not just with me but also with Dr Volberding, a hematolgist, Dr Conant, a dermatologist, Dr Greenspan, an oral surgeon, and dozens of others who were immersed in the new epidemic.

He was writing and documenting how this epidemic was expanding and taking the lives of more and more young gay men. Randy was also wrestling with the contribution of behaviour to this epidemic. Why this epidemic? Why this population? We have to remember that when he started writing the book, the virus wasn't known. It wasn't discovered until 1983-and a test for it wasn't approved until 1985, when the epidemic was in full force.

The book is not an easy read because it's not written in a narrative form, it's written in a journalistic form. But it's the first book that really documented the details of the spread of the virus, primarily among young gay men. When he spoke to me, we were dealing with the other ways that HIV was transmitted-from infected mothers to their babies and through blood transfusion. He writes about that in the book but it's not a major part of it.

"There was this incredible discrimination against gays because it was portrayed as being a gay disease. One of the early names for Aids was Gay Syndrome"

He documents the spread of the virus from very small communities of people to countrywide-and how that happened. I think he was fair in the way he wrote, although he's been criticised by a number of people for being too personal.

Randy pointed out how opposition to the emerging epidemic came initially from denialism: 'It's not going to affect other people, it's confined to a small group of gay men who are very sexually active.' And Randy documents that, yes, that's how it spread in the gay community. But that is not where it remained.

The people who didn't believe ranged from politicians as high as the president of the US-Ronald Reagan never acknowledged that Aids was a problem until the end of his second term. And the NIH [the National Institutes of Health]-which prides itself on early recognition of disease and doing research on it-denied that it was serious. Journal editors didn't want to publish some of the articles written about Aids. There was this incredible discrimination against gays because it was portrayed as being primarily a gay disease. One of the early names of the disease was Gay Syndrome.

Randy, in putting all of this together, shows how what became a global epidemic was resisted at the early phases-with dreadful consequences. He does it by putting names in the narrative. Randy does the best job-out of these five books-of really outlining opposition to a plague and where it comes from and identifying the obstacles to acknowledging that there is a new infectious disease that is going to threaten the world that we have got to take seriously. Maybe the evidence isn't complete yet but it's enough to act and we have to react quickly.

Your book, Lethal Decisions, is about mistakes that were made. Is it looking at this same period?

It starts where Randy ends. Randy died in 1994, just as these potent new drugs were being developed. As the epidemic Randy was documenting progressed, he got into the delays in treatment. Here in the US, the first drug that was available, AZT, could have been developed and gotten to HIV-infected individuals more quickly.

New drugs followed so that by 1996 there were some twenty drugs that could be used to treat HIV―in combination. They were potent and could halt disease progression. When the data came in on treatment with the new drugs it showed that there had been a major change in the epidemic. People who were infected were living longer, they weren't having to go to the doctor as frequently, and they weren't hospitalised as frequently. There was even data that people who were on treatment did not transmit the virus as easily as people who were not on treatment.

I start the book back in Randy's time, 1981, but take it past when Randy was no longer alive and show how here, at last, were all of these discoveries which were changing the face of HIV/Aids in wealthy countries.

We had the International HIV/Aids Conference in Vancouver in 1996. There were some 8,000 HIV/Aids specialists there. People like David Ho and Luc Montagnier were saying that we have to treat everybody who is HIV-infected, regardless of their clinical condition or immunologic status. That was the consensus among the majority of the scientific community.

But some clinicians felt that the recommendation did not apply to certain populations, especially women and children in poor countries. This was really difficult to understand. I had a suspicion that they reached this conclusion because they had a true conflict of interest-that their research studies and funding depended on answering a question which had, in fact, already been answered. That's where my Lethal Decisions comes in. How did decisions to withhold treatment and continue research to prove what had already been proven happen? What were people thinking-scientifically, ethically, public-health-wise? Did they know they were making decisions that would continue the epidemic?

I had to continue the story of the battles that Randy had pointed out, showing they didn't go away. They just took a different form with equal or much more serious consequences because the epidemic was now not 10,000 new cases in a year, it was a million new infections in a year. It should never have happened. It was a blot on US government-funded clinical research, the integrity of clinical researchers, and a failure of public health to do what could have saved millions of lives. That's why I wrote the book.

It could have been avoided?

Yes. Let me give you two examples. At the Vancouver meeting in 1996, HIV experts said everybody should be treated. The World Health Organisation is at the meeting and the head of it says that we've got to develop guidelines for treatment based on these new clinical research findings. But only in 2002 does WHO publish their first guidelines. That's a six-year gap between what the scientific community is saying―everybody should be treated-and WHO writing their guidelines for the world.

Then you pick up the guidelines and WHO says that they don't believe-here's the denialism-that the evidence is strong enough to treat everybody. They recommend that only the sickest of the HIV-infected individuals be treated. i.e. with people that were infected, you should withhold treatment until they get sicker. That was unprecedented. The tables should have been immediately turned and WHO asked, 'What evidence do you have that delaying a known, effective treatment is of any benefit?'

"WHO recommended that only the sickest of HIV-infected individuals be treated-that's like a doctor withholding cancer treatment until cancer goes to the brain"

I couldn't believe it. As a doctor, you use what treatment is available and what you know works. It would be unconscionable and malpractice to withhold treatment from someone and wait until they got sicker. If you had cancer and the doctor told you that we have a drug to treat your cancer but we're going to wait until it goes to the brain or the lung before we treat it, there would be a massive outcry.

What do you think was going on?

Not everyone is going to agree, but I think there were two reasons. Normally when people say they don't believe some information, it's because there's some sort of ramification for themselves.

In the case of HIV, with WHO, one reason was that they wanted to look good in the world of public health. They had been criticised repeatedly in the scientific and academic world and the media for not responding quickly enough to other epidimics. So they put spin on what they were doing. Say you need to treat everybody who is HIV infected-let's say that's 30 million people. Then you've got to treat all of them or you don't look so good.

But if you say, 'Well we don't believe the data is strong enough that everybody should be treated, we think you should only treat the sickest patients.' If you treated only 3 million and say that they are the ones who needed treatment (and not all 30 million) then you might look good in the world's eye. Maybe they just couldn't acknowledge that they were failing by treating only 10% of those who really needed it.

Another reason that people tell me was that WHO used an economic argument that was short-sighted and incorrect, postulating that there wasn't enough money to treat all individuals using these expensive drugs. I don't accept that because when the cost of the anti-retroviral drugs came down from $5,000-6,000 a year to $100 a year they didn't change their guidelines on who should be treated. Also, the true cost of the Aids epidemic includes clinic visits and hospitalizations. Had all HIV-infected individuals been treated these costs would have plummeted. Three years ago they finally capitulated and said everybody should be treated, but never acknowledged that they were incorrect in 2002.

So, it's an enigma. In other epidemics, is there any example where effective treatment for an infectious disease was withheld? I can't find any documentation, including published medical literature. So, in the Aids epidemic, the decision to allow the epidemic to continue by not treating the majority of those who were infected clearly set a new precedent. Life-saving treatment was withheld from people who were infected until the disease progressed and they died.

Let's talk about your next book, the

epidemiological history Plagues and Peoples (1976) by William McNeill. This was written before the Aids crisis, but there is a second edition (1988) which includes it.

Other than Camus, this is one of the first books I read, as I was trying to understand where HIV came from, why it was spreading and what might happen if it spread worldwide. How did people respond historically to other epidemics? In describing why epidemics happen, McNeill emphasises ecology-community, sociology, travel, climate-and how this affects the spread of different infectious agents. It seems logical that the spread of infectious agents would not only depend on their infectivity but also the environment where the infectious agent first exerts its influence. He comes to the conclusion that these epidemics happen primarily because of ecological influences.

McNeill wrote the original edition before HIV was discovered and I don't think he modified the book a lot in the second edition, in which he talked about the HIV epidemic. When he addresses some of the influences that resulted in the spread of HIV, I don't think he emphasises the influence of behaviour enough, although he does mention it. He looks upon HIV as originating from changes in ecology, that the virus could have been a recombination-which could be true-two viruses that recombine to finally become HIV. That's one of the theories. In fact it is a worrisome theory because it would mean the HIV might recombine or mutate again to become an even more contagious or lethal virus.

"McNeill's is a worrisome theory because it could mean HIV might recombine or mutate again to become an even more contagious or lethal virus"

Where the emergence and spread of HIV fits with McNeill's theories is that it is felt that the virus originated in monkeys and spread to bush hunters in areas of Western Africa. As the bush hunters travelled and went back to their villages, they spread the new virus through sexual intercourse. They had acquired, it in all likelihood, through accidental inoculations as they used machetes to kill and skin animals. The change in ecology would be the transfer of the virus from monkeys to humans followed by the ability to move from forest village to multiple villages and eventually internationally, the virus spreading by human sexual intercourse rather than by monkeys.

His book is instructive because it goes so far back. He's done a lot of research and it really says, in a different way, that these plagues are going to be with us because the world is changing. You've got globalisation-so now we have travel not by horseback or by military people in war but we've got airplanes where people travel and can spread new infectious agents. And we have massive populations of migrating people such as in the current refuge crises where an infections agent may be carried into a susceptible population with migration.

Then he goes into many of the issues that Laurie Garrett points out. Looking at all of this historically, what are the things that we have to worry about? The issue of drug resistance for example. WHO has recently provided a list of over 20 bacteria that are a threat to global health because we either lack appropriate antibiotics or there is antibiotic resistance. The virus that he highlights in his book is the influenza virus: the big epidemic in 1918 that killed more than 20 million people in two years. We have not seen an influenza virus epidemic that large again but we do know that each year we have to deal with how the virus mutated and whether or not the vaccine that was developed for that year will be effective or whether a new mutation will occur for which we don't have a vaccine. McNeill also goes into what has been attempted repeatedly but has fortunately never been successful on a large-scale―the use of infectious agents for biological warfare. That is still something people are talking about and there have been attempts to use it. In his book, McNeill doesn't mention the use of HIV as a war weapon, but it has happened. Women in rebel-held areas of Africa have been deliberately raped by HIV-infected men who know they will leave behind a virus that will eventually, without treatment, kill the woman, perhaps infect male sexual partners and also infect future infants should she become pregnant What these rebels leave behind is the equivalent of a viral landmine. It's a form of trying to immobilise the opposition long after rebel activity has ceased. There is documentation that this was included in the Rwandan massacre in 1994.

"McNeill also goes into what has been attempted repeatedly but has so far never been successful on a large-scale―the use of infectious agents for biological warfare"

McNeill's book is looking back at history and asking what we can learn from it. And, in my opinion, what we learn is that we've got to relearn what has happened before―that infectious disease epidemics may disappear but reappear in a different guise and may be as threatening today as they were 100 or even 500 years ago.

The last book on your list is Helen Epstein's The Invisible Cure: Why We Are Losing the Fight Against Aids in Africa (2007).

I found this book fascinating because, in her book, she addresses part of what I address in my book but she is coming at it from a slightly different perspective. She was a PhD scientist who was working in Africa on the Aids epidemic and now has turned to journalism to describe what her experience has been and what she thinks some of the solutions are. She's using two talents which is, I think, fantastic because a lot of scientists are not very good at writing for the public.

Interestingly, her observations, in spite of having a scientific background, come not so much from a 'bio-scientific' view-that all of the answers are in more research and more science. She turns that around and says that there are some existing ways of combating this epidemic without resorting to advanced science.

When she says "invisible cure," what she means is that some of these communities affected by HIV have their own ways of dealing with problems and are prevented from doing so-in what are possibly very effective ways-because of what I would call 'academic colonialism.' She expands on the idea that, 'We in the developed country have the answers to the problems of a poor country and if you just follow what we say then that would be the end of your problems.'

Helen Epstein gives some specific examples. She points out, in the book, that there were some parts of Africa where syphilis was epidemic and the people in the community recognised it. They didn't stigmatise it and they brought it under control.

She also points out the success of the Uganda ABC programme. This campaign was generated by Ugandans and stood for: A-abstinence, B-be careful (meaning fewer sexual partners) and C-condoms. The data shows that there was a significant decline in new HIV infections. Now, there's debate as to whether or not that's still effective. But, initially, it seemed to work and was generated not by the 'academic colonialist' but by the people themselves.

"There were some parts of Africa where syphilis was epidemic and the people in the community recognised it, didn't stigmatise it, and brought it under control"

In her book, she tries to shake up the establishment, saying, 'You have got to think more about what you're doing because some of the interventions that you think are appropriate may actually be completely wrong.' One example she uses is that of stigma. She feels that stigma was introduced by western countries' academic communities. We had so much discrimination here in the US that we felt it must exist in poor countries. So you've got to have confidentiality, you've got to have separate clinics, conduct individual counselling in privacy which was really not possible in countries with a paucity of infrastructure. The message was that HIV/Aids is so confidential that nobody should talk about having it. Yet in order to educate people about HIV-Aids you have to know what it does and how it spreads.

What that did was remove community support from people that had the disease. It indicated there must be something wrong with people who have this disease because that is what we're taught by these westerners-we can't identify people who have Aids or talk about them so they must have done something really bad.

Her book is provocative. It's her way of saying we have to be careful in our interventions. We go into poor countries thinking that we're correct and that we can't do anything wrong because we know best. We have to think more carefully about our interventions because they may not be effective in a different culture or they may send the wrong message or they may actually create harm.

The term that I've started using recently is 'moral hazard'. International oganizations went into Africa with research dollars and set up research studies. The benefits the researchers brought back to the US was in the form of new drugs that can be used by people who are wealthy or who have health insurance. The researchers get their own benefits from the research study conducted in the form of salaries, retirement and health care benefits but almost always, the poor people in Africa get nothing for participating in research. They can't even get the drug, if the drug works. The researchers get all the benefits while the research participants get nothing.

How is that moral hazard?

Let's say there is a highly paid researcher who gets a hundred million dollars to do a research study. It involves thousands of research subjects. He states that he does not believe the data from other studies or standard of care guidelines that individuals with HIV should be treated immediately. So he sets up a research study of withholding treatment from half the individuals and starts the other half on immediate treatment.

The study continues until the number of individuals in the delayed treatment group who die reaches a statistically significant level. After 100 patients die in the delayed treatment group and only 20 in the immediate treatment group, the researcher acknowledges that his original hypothesis was wrong. The researcher suffers no repercussion. In fact, his funding for salaries and benefits continues for himself, his staff, the laboratory, and data mangers. He publishes his results in a prestigious journal and even though the research studies showed that there is no benefit in delaying treatment his academic standing and possibility of promotion increases. He continues to receive grants and conduct more studies. The families of the research subjects who died receive no benefits or compensation. The individuals who survived don't even get put on standard of care drugs.

The researcher has assumed no risk but receives great benefits. Whether he is successful or not in the study, his career is unaffected and may even be enhanced.

The research subjects participate in the research believing that they would receive some benefit. if they were in the delayed treatment group, they undertook all the risk and received no benefit for themselves or their families. They may have even lost their lives.

It would seem to me that moral hazard should be a consideration in conducting a clinical research study and the consequences of failure weighed. The purpose would be to put greater accountability, when conducting a study, on the researchers and shift greater benefit to the research participants.

Perhaps an even more poignant example is that of the WHO 2002 guidelines for treatment for resource poor countries. As I mentioned earlier, WHO stated that there was no evidence that treating all HIV-infected individuals was of benefit and so they recommended withholding treatment from HIV-infected individuals until the infection advanced and the immune system deteriorated. In many instances waiting this long to start treatment resulted in the death of the individual from advanced Aids. But it was WHO that lacked evidence that withholding treatment was of any benefit. Indeed why were hundreds of millions of dollars spent on doing research to discover how to treat HIV only to recommend that it be withheld by an international organization that was not directly involved in treatment and care of HIV-infected patients?

I know that through your charity, Global Strategies, you are very active in parts of Africa. What is the situation in terms of HIV/Aids in Africa or, indeed, in Europe?

In Europe and in the US there is progress. New HIV infections have decreased by 50% or more and most of those who are infected get treatment with combination antiretroviral drugs. Individuals who are HIV-infected are living indefinitely. The number of newly infected infants born to HIV-infected mothers in the US has decreased from approximately 2,000 each year to less than 100. In cities like San Francisco, once a centre for HIV, there have been no babies born with HIV for five years.

"In Europe and in the US there is progress. In cities like San Francisco, once a centre for HIV, there have been no babies born with HIV for five years"

But if you look at Africa, especially sub-Saharan Africa, there is still not the progress that should have occurred considering that we have had potent drugs to treat and prevent HIV infection since 1996. We are still observing more than 1.5 million new infections and deaths each year. And these are the countries where much of the research was done on the benefits of the drugs for treatment and prevention of HIV.

I was terribly taken back by an article that I read, that was published this year in one of the medical journals. It was a study conducted in South Africa which is one of the countries that receives the most research money for HIV/Aids and has some of the best medical infrastructure in Africa. The investigators evaluated 1,700 newly diagnosed HIV-infected individuals and looked at what had happened to these individuals a year after diagnosis.

I'm reading the article and I look at the CD4 count, which is a measure of the immune system. And the immune system of the people who were evaluated was around 200. That is unbelievably deficient. It's so late in the disease that there is a real question of whether the deterioration is reversible even when the best of treatment is used. We're talking about CD4 counts that were seen two decade ago. The investigators reported that one year after diagnosis 13% of the individuals had died from Aids.

We have to ask why, when potent antiretroviral drugs were available for treatment, people are still dying of Aids. It's difficult to understand. They have the drugs in South Africa, why are they getting them so late? I had to come to a very, very uncomfortable conclusion. Who benefits from health research? Who, in an epidemic, fares the best? Who does not fare well? You go through Randy's book or Camus's and it's the poor people who suffer the most. They're infected and can't get the treatment because of their inferior social, political, and economic circumstances. They can't get the life-saving treatment they need.

To turn that around, sickness is also be one of the reasons African countries remain poor. If you look at East Asia, forging ahead, and Africa limping along behind, it's partly because of malaria and HIV/Aids and its impact on the workforce. When I was 18, I saw Out of Africa and was very inspired by it. I spent that year-1989-teaching at a rural school in Zimbabwe. I remember trying to educate the kids in my class about HIV/Aids but they weren't having any of it. They treated it as if it were a joke. I was 18, I was trying my best. But, subsequently, so many of those people have died.

I went to Zimbabwe last year, I took my daughter and grandson. It was fascinating and has a lot of the components that we've talked about. Despite how bad the economy is, the health sector in Zimbabwe is highly educated and very forward-thinking. They are able to get a lot of resources together, given the political status of the country.

However, Zimbabwe was one of the countries that adopted the faulty and incorrect WHO 2002 guidelines that stated antiretroviral should be withheld from HIV-infected individuals until they got to advanced stages of the disease. For more than a decade WHO and the US conducted workshops that taught healthcare workers that treatment should be withheld until the CD4 count reaches a level that indicated severe immunodeficiency. That is absolutely wrong, but it was the WHO and US funding that had the power and the money. WHO only reversed their position in 2013, 11 years after their first guidelines and 17 years after Aids experts declared that all HIV-infected individuals should be treated.

Because of all the aid for healthcare going into Zimbabwe, we went into some of the clinics. Surprisingly, we saw the shelves full of drugs to treat HIV-infected pregnant women, men and children. It wasn't a matter of not having the drugs. The drugs were right there ready to use. But people weren't being treated because they were still using the old WHO guidelines that required a CD4 count. They had been trained to do the CD4 counts but the new guidelines said they were no longer necessary. There was no one that told them that they could treat everybody who was HIV-infected regardless of the CD4 count.

The WHO goes in and spends money and has workshops and teaches them to do something that is not clinically correct. It turns out to be all wrong. But then nobody goes back and says, 'No no no, that was all wrong, let's change the posters, let's change the guidelines, let's get rid of the CD4 machine.'

There was one clinic that I remember which had a CD4 machine-these machines cost $150,000. From the beginning of the epidemic, a small group of us said that you don't need to do a CD4 count. Only starting treatment at a certain CD4 level ends up denying treatment to those who need it. When you have a bacterial infection, you go to the doctor and he puts you on antibiotics, you don't wait for a laboratory test to tell you how bad the infection is before you treat.

This goes back to some of Epstein's comments in her book, The Invisible Cure where she suggests that "Western" influences on the HIV epidemic may have been well-meaning but were misguided and in the long run may have created more harm than benefit.

There is also quite a bit complacency in the West, that the problem of HIV/Aids has nearly been solved i.e. it's no longer a risk to them, personally.

"We're dealing with a pervasive attitude of not viewing people in Africa as having the same value as people in more developed countries"

Perhaps we have the same attitude towards poor and marginalized individuals in our own countries, but I believe we're dealing with a pervasive attitude of not viewing people in Africa as having the same value as people in more developed countries. This is especially true for disadvantaged women and children who are being exploited for research that benefits the researchers and HIV-infected individuals in the US but are denied treatment for themselves after the research studies are completed.

During the early years of the HIV epidemic Aids activists demonstrated at the FDA, at NIH meetings, and at pharmaceutical companies. They demanded that they receive the drugs that were being evaluated in research studies. In poor countries, we don't have the activists because HIV-infected people are not politically connected and are disenfranchised.

At an academic and public health level, we don't make the same effort to end the epidemic in poor countries as we did in this country. We don't have the demonstrations in the streets, we've lost the activism. President Kennedy said (paraphrasing) that, 'We have the ability, we have the science, what we lack is the will.' He was talking about hunger but it can be applied to the Aids epidemic. We have the science to do it, we have the drugs to do it, we know how to prevent it, and we know how to treat it. Why is it continuing in these poor countries at a rate of more than 1.5 million new infections and deaths each year?

These books address all these issues that people don't like to talk about or fail to acknowledge. There is denialism―the epidemic won't be as bad as predicted; the infection affects other people not us; I demand treatment for myself but am indifferent to treatment for others. And there is discrimination-not just because of the disease but because of who has the disease. At this time, 50% of those infected with HIV are women and children. When the epidemic was first recognized women and children were less than 5% of those affected. The shift occurred because poor women and children have great difficulty in accessing prevention and treatment and women have difficulty in protecting themselves against unwanted sex even if the individual is HIV-infected. What is not acknowledged in the epidemic today is that these differences are because women are not viewed with equal dignity and value.

Is there anything that we can do? To people reading this, what would you advise as an individual to help reverse that?

We know the answers and we actually know what needs to be done. The problem is getting access to the decision-makers. If you read Randy's book, And The Band Played On, you see how frustrated he was with the same things-the bureaucracies, the indecision, the indifference and the unending delays. But what changed that in the US was activism and advocates who defended vulnerable populations and said, 'You can't do this; we will not let you.' They confronted the government, public health institutions, the pharmaceutical companies, the government-supported researchers, and said,'We demand accountability.'

"What changed things in the US was activism and advocates who defended vulnerable populations and said, 'You can't do this; we will not let you' ....There's a lot that we can do"

Effective activism and advocacy is much more difficult to do in these poor countries so they need others to step into that role―and that means us. There's a lot that we can do. We can say, for example, that we are not going to provide anyone with research dollars unless they do a better job of diagnosing and treating people who are HIV-infected and provide the medicines that work to them when the research studies are completed.

People in poor countries who participate in research should also receive more benefits as a result of their participation-like some form of healthcare through a simple and inexpensive insurance. If the researchers get healthcare benefits that are paid for by the research grants because they're conducting research then why shouldn't the research participants also receive the same benefit? We can demand that.

I'm a strong believer in activism. I think one of the reasons that situations of injustice and inequity exist is that we can easily ignore poor people. Increasingly we participate in a form of voyeurism. We watch documentaries and read about atrocities, inhumanity, violence, and starvation but we can too easily walk away from those images and do nothing to change what is happening.

It's also about increasing the economic and educational status of women and children and teaching them - especially women-how to protect themselves, how to demand health, how to achieve equity and perhaps, in that process, help them to become their own activists.

I think those in political power underestimate the impact of suffering on the poor and politically marginalized until it reaches a crescendo of indifference and abuse. That's what we're seeing now in the US and elsewhere, as individuals rebel against political solutions that don't benefit them. They are asking the questions, and it's mostly women and minorities who are saying, 'You can't ignore us-we are equally important.'

When you get complacent or when you ignore the voices of those who are suffering, bad things happen. I think, from a compassionate humanity point of view, there's a morality issue. You just can't turn away from these injustices. You can't forget about them because these are things that people suffer every day.

I just can't understand why there isn't more concern about 1.5 million people becoming infected and dying from an infectious disease that is completely preventable and treatable. That question has got to be put very bluntly to the people who can make a difference.

# data[].attributes.attachment_link.title
The Best Books on HIV/Aids Plague | Five Books Expert Recommendations

# data[].attributes.attachment_link.description
Interview by Sophie Roell You were involved with the HIV/Aids epidemic at a very early stage, and, since then, have given a lot of thought to epidemics in general. Why are you so keen to use the term 'plague' to describe it?

# data[].attributes.body
Case study about a how monitoring and evaluating HIV is implemented in a country in Sub-Saharan Africa.

# data[].attributes.attachment_link.readable_text
Peer Review reports

Background

The purpose of monitoring and evaluation (M&E) is to produce reliable and timely health information and use it to evaluate policy, set priorities, plan, and monitor the effectiveness and impacts of interventions [ 1, 2]. In recent years, many low- and middle-income countries have established dedicated (or vertical) M&E systems for their HIV programmes [ 3, 4]. The anticipated aims of such M&E systems have however not been realised in many countries due to low financial investment in M&E infrastructure, weak or ill-defined systems for collection, analysis, and dissemination of HIV data, inadequately trained data collectors, and insufficient technical capacity to transform HIV data into usable indicators [ 3, 4]. The non-integration of HIV M&E systems with overall health information systems is another important factor. Vertical M&E systems are often coordinated as separate parallel systems, often in a bid to improve the availability of quality HIV information for decision-makers. However, this intended benefit is often not realised [ 3- 7].

South Africa has established a vertical HIV M&E system to monitor its national HIV programme [ 8]. In South Africa's decentralised health sector, the district (sub-national) level of the health system is well-placed to use information generated by this HIV M&E system to monitor the HIV programme. However, it has not been documented if and how the HIV M&E system interacts with the district health information system (DHIS) designed to monitor overall health system performance at district level, or whether it affects the availability of HIV programme information at district level. This paper addresses this gap.

Disease-specific programmes and health systems

The emergence of global health initiatives (GHI)-notably the Global Fund for AIDS, TB and Malaria (GFATM) and the Presidential Emergency Plan for AIDS Relief (PEPFAR)-as major funders of HIV/AIDS interventions in low- and middle-income countries-has raised questions about the sustainability of disease-specific (vertical or targeted) programmes [ 9, 10]. GHIs increase HIV funding and services [ 11], but also fragment coordination by establishing parallel planning, coordination and monitoring systems within recipient countries, and worsen already weak health systems by diverting resources from general health services [ 12, 13]. This has prompted calls to strengthen health systems and find ways of maximising positive synergies between disease-specific programmes and health systems [ 9, 14].

Integration of disease-specific programmes into health systems is one way of strengthening health systems and maximising programme-system synergies [ 15]. Integration is largely understood in relation to the service delivery function of health systems: e.g. combining two or more disease-specific services at one delivery point, incorporating disease-specific services into general care, continuity of care over time or across levels, or working across government sectors [ 16- 19]. Health system impacts of service integration are however inconclusive due to poor evidence because of weak or incomparable evaluation methodologies [ 18- 20]. There is even less evidence on how targeted programmes interact with health system functions other than service delivery, such as financing, M&E, or governance [ 13, 18]. In practice programmes lie along a continuum from integrated to fully vertical, and depending on the context, integrate with different health system functions to varying extents [ 10, 13]. In the absence of conclusive evidence on effects of integration, it is advised that countries adopt organisational arrangements that optimise benefits for both programmes and systems in their context-specific settings [ 9].

The high cost of maintaining parallel disease-specific programmes, and the potential benefits of integrated services with unified finance, management and M&E processes provide compelling reasons to adopt organisational arrangements that optimise programme integration, particularly in weak health system contexts [ 15]. Some even suggest there are very few instances when integration should not be the norm [ 21]. Countries however need guidance on when and how to integrate disease-specific programmes to strengthen health systems. For example, in South Africa health system strengthening is a stated HIV programme goal [ 22, 23] but how to achieve this is unclear. Documenting how the HIV programme interacts with and affects health system functions is a step towards clarity.

HIV programme and the health system in South Africa

South Africa's post-apartheid HIV programme was established in 1994, initially emphasising prevention. Public sector antiretroviral therapy (ART) services were introduced in 2004 with earmarked funding following the Operational Plan for Comprehensive HIV/AIDS Care Management and Treatment (comprehensive plan) [ 22, 24]. An HIV M&E system was established to monitor the comprehensive plan [ 8, 22], and after adoption of the multi-sectoral HIV & AIDS and STI Strategic Plan 2007-2011 (NSP), the M&E framework was expanded to include other sectors [ 23].

The National Treasury funds health largely through an annual unconditional block grant named the 'equitable share' (based on population numbers and needs) which is allocated to provincial governments, who then distribute this between various departments including health. In addition, the National Treasury allocates to each provincial government dedicated funding for HIV-this is termed the conditional grant for HIV and AIDS [ 27]. Reporting on expenditure for conditional grants is different to that required for equitable share funding. The Division of Revenue Act (DORA) provides the legislative and accountability framework for the HIV and AIDS conditional grant, requiring provinces to submit HIV data as well as narrative and financial reports to the National Treasury [ 28].

Health system decentralisation has also been a national priority since 1994. As such, responsibility for managing health service delivery is decentralised to the district (sub-national) level [ 29, 30]. A district health information system (DHIS) has been established to support district health management teams (DHMT) in this role [ 31, 32]. The DHIS-a critical component of the national health information system-collects public sector facility data to produce a set of district health service indicators. Ideally, the disease-specific HIV M&E system should be a sub-component of a system-wide information system like the DHIS [ 1]. As such, DHMTs would be well-placed to integrate HIV information into overall district health system management.

A national study however reports that programme information generated through disease-specific M&E systems is not necessarily made available to district managers [ 33]. Though that report did not specify the HIV M&E system, it highlights the need to understand how the HIV M&E interacts with the health system M&E function (the DHIS) to determine whether any negative synergies between them affect the availability and use of HIV information for district management. This paper thus uses a district in South Africa as a case study to determine the extent to which the HIV M&E is integrated with the DHIS, and assess effects of the HIV M&E on availability of HIV information at district level. The paper also discusses factors influencing HIV M&E integration, and proposes ideas for maximising HIV programme-system synergies.

Methods

This cross-sectional descriptive study was conducted during April to July 2009 in one of South Africa's nine provinces. This largely rural province is divided into 3 district municipalities (districts). Districts are further split into several local municipalities (sub-districts) and overseen by district and sub-district managers, respectively. Each sub-district has several service delivery local areas (clusters of clinics), each overseen by a local area manager (or clinic supervisor). A manager at provincial level oversees the HIV programme assisted by four deputies-one each for prevention, care and support, treatment, and M&E sub-programmes-supported by assistant managers at provincial level and HIV programme managers at district and sub-district levels.

The prevention sub-programme in the study site included condom distribution, life skills and behaviour change, VCT, PMTCT; and later post-exposure prophylaxis for rape survivors (PEP) and HIV/TB collaboration (management for HIV-TB co-infected people) were added. At the time of the study the PMTCT protocol had just changed from single dose nevirapine (NVP) to short-course NVP and zidovudine (AZT). Prevention services were largely funded through equitable share funding. The treatment sub-programme focused on ART services whereby accredited comprehensive care, management and treatment [CCMT] sites initiated patients on ART, and down-referral sites managed those already initiated and stabilized on ART. During the study, there were 32 CCMT sites in the province (23 at hospitals, 9 at community health centres, and none at clinics). CCMT services were funded through the HIV conditional grant. About 75% of the province's conditional grant was allocated to CCMT services.

We purposively selected one of the three district municipalities in the province (one of 46 district municipalities in the country) for practical reasons as we were already working in that site. Like other district municipalities, our study site used the national DHIS and was also required to report to national level on a set of nationally-defined HIV indicators. We identified the most functional of five sub-districts in our study district, and within this, selected both CCMT sites and both down-referral sites, and used stratified sampling to select one clinic from each of seven local areas (the strata) (Table 1). Only one of our selected health facilities (a CCMT site) was NGO supported and thus reported HIV data to its funders as well as government. All our other facilities were fully government-funded and did not report HIV data to external donors.

We interviewed four senior HIV programme managers at provincial level and the operational managers of all 11 facilities where we also reviewed M&E documents. Ethical approval was granted by the University of the Witwatersrand and the Provincial Department of Health. Interviews were in English, tape-recorded where consented, transcribed, and analysed thematically.

The variables we measured are outlined in Table 2. To describe the HIV M&E system design we assessed whether it possessed the organisational attributes required of a national M&E system including: a comprehensive M&E plan with clear goals, targets and resources for its implementation, clear plans for data collection and analysis of defined indicators, and an appropriately staffed M&E unit to coordinate activities [ 4, 34]. To examine integration we adopted the methodological approach of Atun et al., [ 35] which measures the extent to which governance, planning, service delivery, demand generation, financing and M&E functions of vertical programmes are integrated with those of the health system. We assessed only the M&E function and examined the following M&E activities: data collection, collation and reporting, and analysis. Guided by definitions of integration as shared resources and technologies [ 36] and shared or merged coordination responsibility [ 21, 35], we measured the extent of integration as "full integration" if M&E activities and resources and coordination were shared between the HIV M&E system and the DHIS, "partial" if there was some, and "no integration" if there was no sharing. We measured availability of HIV indicators as the outcome of interest. Although information use is the ultimate purpose of an M&E system [ 1, 7], availability can be a marker of M&E system performance [ 4].

Results

Design of the HIV M&E system

We found that the HIV M&E was designed at national level, in accord with the national HIV programme M&E framework. The national level defined what HIV data to collect and report (these changed as services were modified or added) and designed the data recording and collation forms. Respondents reported that conditional grant funding was used to establish an HIV M&E unit at provincial level and to appoint an M&E unit manager and a data clerk at each ART (CCMT) site to specifically coordinate the production of ART indicators. The production of HIV prevention information was coordinated by the provincial health information unit which managed the DHIS. This unit was staffed by an information manager and a health information officer, and supported by one information officer and one data clerk each at district and sub-district levels, respectively.

The production of HIV information

In total 201 HIV data elements were recorded, though some were duplicated-e.g. the same VCT data was recorded on two different forms (Table 5). A review of data forms for June 2009 revealed that while VCT registers at all clinics and down-referral sites and the ARV patient monitoring register at one CCMT site were complete, all other forms had missing fields or were not used at all. Facility managers attributed the incomplete recording and non-use of forms to their staff not being trained, particularly on newly-introduced data elements and registers.

Staff at clinics and down-referral sites designed and used their own additional HIV forms (Table 6). For example, some designed registers to track patients who were eligible for ART, which the nationally-defined forms did not appear to enable them to do. Neither CCMT site implemented additional facility-specific forms, but respondents reportedly observed this practice at other CCMT sites in the province:

"Initially when the program started, they sort of used note books before we could introduce this tool. So it is difficult for them to change from their note books to the tools; they think the [DORA] tools are a bit too complicated. They stick to their note books. But you will find one facility having more than five or eight note books-so they are still sticking to their note books, because initially they have been made to improvise to use note books, so is not easy for them to change".(programme manager)

HIV prevention data that were recorded on VCT and PMTCT registers were manually aggregated by senior nurses on a DHIS monthly collation form and submitted to the sub-district level where the information officer captured the data on DHIS software and transmitted it electronically to the district and then the provincial health information unit. Analysis at sub-district and district level generated DHIS and HIV prevention indicators. ART data were collated on a monthly ARV collation form by data clerks at both CCMT sites (the two DR sites sent their data to CCMTs site for collation) and submitted directly to the HIV M&E unit where the HIV M&E manager captured and aggregated the data as counts and no analyses were done (Figure 1).

flow of HIV and DHIS data through various levels of the health system. The flow of HIV data and DHIS data from the health facility level (where data are recorded) to the national level of the health system was described, based on the data obtained through key informant interviews and review of M&E documents at facility level. The figure indicates that the flow of HIV treatment data is separate from and parallel with the flow of DHIS data.

Availability of HIV indicators at district level

From the provincial level, HIV data were submitted to the National Health Department (prevention and ART data) and the National Treasury Department (ART data) (Figure 1). The latter was referred to as "DORA reporting". The HIV M&E manager compiled the DORA report which included ART data and a few VCT and PMTCT indicators (supplied by the provincial information unit). HIV prevention data were available at the district level (as they were incorporated into the DHIS) and included in the district quarterly review (DQR)-a process where district health managers use health service data to review district performance. CCMT data were shared amongst HIV programme managers at provincial and district level but were not incorporated in the DHIS and not included in the DQR process.

Integration of the HIV M&E with the health system M&E function

Overall, the prevention sub-programme was partially integrated with the DHIS-data collection activities were partially integrated while the rest were fully integrated-while the treatment (ART) sub-programme M&E was not integrated with the DHIS (Table 7).

Respondents reported that ART data were coordinated separately to ensure DORA reporting deadlines were met, and because there was little confidence in the DHIS, as illustrated below:

"Because the CCMT data has got this political pressure of saying that by the 10th we are supposed to report at the National Department of Health. That is why by the 3rd they are supposed to be faxing directly. If we say they should report at the sub-district level then data is going to take a month to be at the provincial office, of which it is unacceptable." (programme manager)

"And another thing with the data that we are getting from the CCMT sites, ideally one would be even more happy if we were getting that data through the normal health facility data reporting, through the district health system. But it is not falling in the district health system; it goes directly from the facility to the province. And the only reason for that ...it's because, it says we are not confident with the data flow system and if we were to follow that data flow system as we should, probably we would be having nothing." (programme manager)

Discussion

The HIV M&E system described in this study essentially meets the organisational requirements of a national M&E system, but has several limitations that affect its efficiency and utility and constrain the availability of HIV data. Below we discuss these limitations and factors that may influence HIV M&E integration in South Africa. Finally, we use our case study findings to propose some ideas about how integration can strengthen health systems and maximise programme-system synergies.

Limitations of the HIV M&E system

The M&E system is designed and implemented in a top-down uncoordinated manner. It is characterised by a massive data set, duplication of data collection, incomplete data recording, and non-use of nationally-defined forms. These features have been shown to limit the efficiency and accuracy of HIV M&E systems in other settings [ 4, 37]. Our findings indicate these problems exist because the HIV M&E was seemingly designed in an uncoordinated and top-down and manner-some data were collected but not collated and analysed, data forms were introduced without ensuring they did not duplicate existing ones or increase administrative burdens, and health workers' perceptions of the forms were not considered.

A further limitation of the HIV M&E system is that its vertical design contradicts the notion of integrated management. While M&E activities for the production of HIV prevention data are integrated with the DHIS, those for the production of HIV treatment data are not, which creates silos within a silo-i.e. within the vertical HIV programme, parallel M&E processes for prevention and treatment data. This silo approach is not unique to South Africa. In other settings distinct M&E systems for different components of the HIV programme exist, with health facilities reporting separately on each component [ 3]. In our study, the silo M&E approach could potentially promote divisions in the management of HIV sub-programmes, which contradicts stated goals of an integrated HIV/AIDS response [ 23]. The silo approach also limits the availability-and potential use-of ART information at district level because ART data by-pass the DHIS, and undermines national policy intents of integrated district management [ 29, 30].

Factors influencing integration of the HIV M&E system

A recent systematic review of the evidence on integration of disease-specific programmes into health systems reveals a dearth of analyses of the information (M&E) building block. That review also reveals a "highly heterogeneous picture" with programmes integrating with different health system functions to varying extents-though the dearth of cross-site comparable data precludes firm conclusions about which factors impede and promote integration [ 13]. The evidence however suggests that context-specific factors related to health system characteristics (e.g. fragility, absorptive capacity) and the politico-economic and socio-cultural context (e.g. commitment of national leadership, health personnel preferences) influence the extent of integration [ 13]. Based on our study, we propose that the following politico-economic and health system factors may influence integration of the HIV M&E system.

Politically-driven ART exceptionalism in a post-AIDS denialism era

Initially conceptualized as an integrated programme in line with national policies, the HIV programme was however introduction as a targeted intervention with special access to ear-marked funding [ 40, 41]. This AIDS exceptionalism-treating AIDS as different from other public health threats [ 42], was fuelled by fears of health system incapacity and pressure to quickly curb a growing HIV epidemic [ 40, 41]. At its inception the HIV programme however focussed only prevention activities, and HIV treatment was introduced much later, following pressure and legal action from civil society actors [ 43]. Government's delayed action on ART provision, largely attributed to the then-president Mbeki's AIDS denialism [ 43], resulted in a huge unmet need for ART in South Africa [ 44].

Ear-marked HIV funding

The desire for control over their funded programme often drives donors to continue supporting even inappropriate vertical systems [ 21]. Research shows GHI-supported systems often satisfy donor interests, and undermine recipient priorities, often contradicting donors' stated aims to harmonise in-country coordination [ 12, 48, 49]. Like many donors, National Treasury reporting requirements-reflecting a desire to closely monitor the conditional grant-facilitate an M&E system that does not primarily serve the interests of recipient provinces and is at odds with the notion of integrated M&E. While the conditional grant provides a legal mechanism for government to ensure provinces spend on national priorities [ 50], its reporting mechanisms are at odds with the DORA legislation through which it is administered. The DORA states that systems for monitoring the conditional grant should not impose an "undue administrative burden" on recipients and "should be compatible and integrated with" other systems [ 51].

Lack of confidence in the capacity of the national health information system

Proposals for integration to maximise positive programme-system synergies

Maximising positive synergies between programmes and health systems is about finding practical ways in which disease-specific and health system functions can positively interact for optimal health benefit [ 54]. Below we highlight some ideas of what this may mean at sub-national (district) level, using our South African case study as an example.

The vertical HIV M&E system observed in this case study promotes fragmented health system coordination and seemingly benefits neither the HIV programme nor the health system. For HIV M&E systems set up like this we propose integration with the overall health information system (HIS), while strengthening HIS capacity to absorb new roles. Integration should be coupled with re-design of the HIV M&E system to ensure only a small set of relevant HIV data are collected to address needs at different levels of the health system, and to rationalise data reporting such that health facilities report up the health system hierarchy less frequently and only on a select set of priorities. Most data could rather be incorporated into supervision systems so facility managers and district managers use them for continuous monitoring and service improvement [ 55]. Inculcating data use to support health management at these levels contributes to South Africa's re-engineering primary health care (PHC) strategy [ 56].

A few other issues would need to be considered. First, HIV M&E integration entails alignment of both operational and administrative (or managerial) integration [ 21]. Operational integration would mean integrating HIV data collection and collation forms, data analysis software and templates, and information dissemination mechanisms with those of the overall HIS; and absorbing all HIV M&E-specific personnel (clerks, information officers and managers) within the HIS. It has been shown that the success of any changes to operational processes requires also paying attention to management issues [ 57]. As such managerial integration would mean assigning responsibility for overseeing the production and use of disease-specific information to district managers (rather than programme managers) and building their M&E skills. Enabling managers at the district level in this manner is a way of promoting integrated health management, especially in decentralised health system settings [ 58, 59].

Second, HIV M&E integration should occur alongside overall HIS strengthening. This undoubtedly requires resources, but some costs may be offset by efficiency gains due to reduced duplication consequent on integration [ 60]. For HIV M&E integration to maximise programme-system synergies, ear-marked HIV resources could be leveraged and channelled to develop overall HIS capacity to produce more timely and reliable disease-specific and general service data. For example, HIV funding could be used to pay salaries of absorbed HIV M&E personnel, train staff, and improve HIS infrastructure. Lessons can be drawn from integration of HIV laboratory services in Nigeria, whereby using ear-marked HIV funding to train all laboratory personnel and rehabilitate general laboratory infrastructure improved the quality of laboratory performance and benefitted both HIV programme and health system goals [ 61].

Third, the process of integration should be considered. We propose a phased process guided by operational research, and a bottom-up approach including relevant role players to engender ownership and enhance acceptance of new ways of working [ 59]. This means recognizing actors at lower levels of the health system and enabling them to take a lead role in their respective jurisdictions without always having to await approval from 'the top'. The fact that health care providers at clinic level in our study developed their own systems suggests that there is problem-solving capacity at sub-district level and this should be tapped, encouraged and supported. It also means getting consensus on actions and timelines, building trust amongst actors, and anticipating and managing any resistance to the inevitable re-distribution of roles because, as experience shows, those who lose responsibilities may try to re-assert their positions by undermining the process [ 59].

It is well documented in the literature that it is often donor demands that drive vertical reporting of data in low and middle income countries, often placing a heavy data reporting burden on health services. Our study provides a less-documented situation in which national government (funder) demands on sub-national levels (recipients) drive duplicate reporting and undermine data availability and use at district level. Though we used one case study district we expect the findings documented here to be transferable to other district municipalities in South Africa, especially in provinces that operate HIV M&E systems in parallel to the DHIS.

Conclusions

We have highlighted some of the limitations of vertical HIV M&E systems, and some broad factors that my influence their non-integration with the health system. Using a South African case study, we propose integration of the HIV M&E system with the overall health information system (HIS), while concurrently addressing any HIS weaknesses and building programme M&E skills of health system personnel. We view M&E integration as being about more than just merging data recording forms and reporting and dissemination mechanisms. It is about breaking away from historical silo funding that promotes disease-specific M&E systems over strengthening overall health information systems and about building the capacity of HIS personnel and health system managers to take on programme-specific M&E coordination responsibilities. It is an incremental learning process that will require political commitment and investment of time and resources. Leveraging ear-marked HIV funding to provide the needed resources to build overall HIS capacity is a practical way of translating health system strengthening intents of national HIV policy into tangible action.

Acknowledgements

We thank the Medical Research Council, South Africa for their grant which funded data collection activities. We also thank the staff and managers of participating health facilities and all respondents for their participation in the study.

Author information

Affiliations

1. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, South Africa

Mary Kawonga & Sharon Fonn

2. Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, P.O Box 1038, Johannesburg, 2000, South Africa

Duane Blaauw

Corresponding author

Correspondence to Mary Kawonga.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

MK and SF designed the study methodology. MK carried out the data collection and analysed the data. MK, DB, and SF all contributed to data interpretation and writing, reviewing, and conceptually revising subsequent drafts of the manuscript. All authors read and approved the final manuscript.

Authors' original submitted files for images

Below are the links to the authors' original submitted files for images.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Reprints and Permissions

About this article

Download citation

# data[].attributes.attachment_link.title
Aligning vertical interventions to health systems: a case study of the HIV monitoring and evaluation system in South Africa

# data[].attributes.attachment_link.description
Like many low- and middle-income countries, South Africa established a dedicated HIV monitoring and evaluation (M&E) system to track the national response to HIV/AIDS. Its implementation in the public health sector has however not been assessed.

# data[].attributes.body
A health organization that discusses the statistics of HIV and AIDS, and how they plan to help this global threat. Mentions the high rate of new HIV infections in Sub-Saharan Africa.

# data[].attributes.attachment_link.readable_text
HIV remains one of the most serious global health threats of our time. In 2017, 1.8 million people were infected with HIV, and 940,000 died of AIDS-related causes.

We believe we can end the AIDS epidemic. Since 2010, deaths related to AIDS have dropped by 35% in the part of the world where we work. More people are getting treatment than ever before. By keeping the focus on the needs and rights of key populations, we have the power to prevent new HIV infections and ensure those living with AIDS are not left behind. This is what Pathfinder does.

# data[].attributes.attachment_link.description
HIV remains one of the most serious global health threats of our time. In 2017, 1.8 million people were infected with HIV, and 940,000 died of AIDS-related causes. We believe we can end the AIDS epidemic. Since 2010, deaths related to AIDS have dropped by 35% in the part of the world where we work.

# data[].attributes.headline
Centers for Disease Control and Prevention

# data[].attributes.subject
Centers for Disease Control and Prevention

# data[].attributes.body
Talks about the background of HIV, symptoms, and different stages of HIV.

# data[].attributes.attachment_link.readable_text
Learning the basics about HIV can keep you healthy and  prevent HIV transmission. You can also download materials to share or watch videos on basic information about HIV.

What is HIV?

HIV (human immunodeficiency virus) is a virus that attacks the body's immune system. If HIV is not treated, it can lead to AIDS (acquired immunodeficiency syndrome).

There is currently no effective cure. Once people get HIV, they have it for life.

But with proper medical care, HIV can be controlled. People with HIV who get effective HIV treatment can live long, healthy lives and protect their partners.

Where did HIV come from?

HIV infection in humans came from a type of chimpanzee in Central Africa. Studies show that HIV may have jumped from chimpanzees to humans as far back as the late 1800s.

The chimpanzee version of the virus is called simian immunodeficiency virus. It was probably passed to humans when humans hunted these chimpanzees for meat and came in contact with their infected blood.

Over decades, HIV slowly spread across Africa and later into other parts of the world. The virus has existed in the United States since at least the mid to late 1970s.

To learn more about the history of HIV in the United States and CDC's response to the epidemic, see CDC's HIV and AIDS Timeline.

How do I know if I have HIV?

The only way to know if you have HIV is to get tested. Knowing your HIV status helps you make healthy decisions to prevent getting or transmitting HIV.

Are there symptoms?

For many, yes. Most people have flu-like symptoms within 2 to 4 weeks after infection. Symptoms may last for a few days or several weeks.

Having these symptoms alone doesn't mean you have HIV. Other illnesses can cause similar symptoms.

Some people have no symptoms at all. The only way to know if you have HIV is to get tested.

What are the stages of HIV?

When people with HIV don't get treatment, they typically progress through three stages. But HIV treatment can slow or prevent progression of the disease. With advances in HIV treatment, progression to Stage 3 (AIDS) is less common today than in the early years of HIV.

People have a large amount of HIV in their blood and are very contagious.

Many people have flu-like symptoms.

If you have flu-like symptoms and think you may have been exposed to HIV, get tested.

This stage is also called asymptomatic HIV infection or clinical latency.

HIV is still active and continues to reproduce in the body.

People may not have any symptoms or get sick during this phase but can transmit HIV.

People who take HIV treatment as prescribed may never move into Stage 3 (AIDS).

Without HIV treatment, this stage may last a decade or longer, or may progress faster. At the end of this stage, the amount of HIV in the blood (viral load) goes up and the person may move into Stage 3 (AIDS).

The most severe stage of HIV infection.

People with AIDS can have a high viral load and may easily transmit HIV to others.

People with AIDS have badly damaged immune systems. They can get an increasing number of opportunistic infections or other serious illnesses.

Without HIV treatment, people with AIDS typically survive about three years.

Page last reviewed:

# data[].attributes.attachment_link.description
When people with HIV don't get treatment, they typically progress through three stages. Learn about the three stages of HIV.