The Review of International HIV News
from HIVHope International
June 2013 - Vol. IV, No 2
Our God is so wonderful and shows His love to us in so many beautiful ways even when things in our lives are not the way we would wish. We praise His holy name and are thankful for the privilege of serving Him with you in HIV education and ministry.
What news is there from you and your ministry? We love to hear from you about how God is using you to impact people living with and impacted by HIV.
One such report came recently from the participants in one of our seminars five years ago in India. They recently held an event that included offering antibody testing and training for people in HIV education using the HIVHope International model. What a blessing to know that even after five years, they are still actively involved and impacting the lives of people in and beyond their community.
Please share with us what you are doing so that we can be encouraged and encourage others with your stories.
Duane Crumb for the HIVHope Team
Major Theme in HIV News
Those of you who have been participants in our seminars will remember me saying that I do not ever expect a cure for HIV disease but pray that some day i will be proven wrong. Well, that it appears that God is beginning to answer that prayer far sooner than I could ever have hoped.
The March 2013 issue of It's About People started with the breaking story about a baby in the state of Mississippi in the US who was born with HIV and was then cured. We shared the story with some hesitation and caution. Since then, the cure of the baby has been confirmed. That is wonderful news for that family and an amazing answer to prayer. However, it has also become increasingly clear that this case does not mean we can expect the end of HIV disease in the near future.
Most of the news stories in recent months have focused on hopes for a cure. We have selected two that we believe do a good job of summarizing what is being reported. The first article is long but does a good job of explaining the complex issues involved and provides valuable background.
Please read these articles carefully and use caution in any attempt to apply what is being said to people in your setting. As they make clear, we do not yet have a cure that will bring an end to the disease but there is more hope than I ever expected. God is good!
Three Types of HIV Cure
What do they mean, and where do we go from here?
Published Monday, April 15, 2013 by AmFAR, By Rowena Johnston, Ph.D. - If you've been following the news lately, you may be starting to wonder why anybody ever thought curing HIV was so challenging. On March 3 we heard the news that a child appeared to have been cured. Hard on the heels of that report came the news that 14 individuals in France had been functionally cured. So what do these cases mean? How are they similar, and how do they differ? And importantly for HIV research, where do we go from here?
Much depends on how a cure is defined. Researchers are used to thinking of a cure in two different ways. One type, a sterilizing cure, requires that HIV be eradicated from the body of the infected person. The second, a functional cure, is less stringent in that it requires that the patient is able to stop taking antiretroviral therapy without suffering any adverse consequences of the HIV that remains in their body.
The Berlin Patient
A decade ago, almost nobody spoke of curing HIV infection as a realistic goal, yet we find ourselves in early 2013 with not one, nor even two, but three different types of HIV cure. The first cure—the “Berlin patient,” who we now know as Timothy Brown—has been widely reported. Mr. Brown was living in Germany when he was diagnosed with HIV infection in the mid-1990s. His infection was well-controlled by antiretroviral therapy until he was diagnosed with acute myeloid leukemia about 10 years later. To treat the cancer, he received a stem-cell transplant, but his doctors took an extra step, finding a donor with a genetic mutation known as CCR5 delta-32. Naturally present in around 1–2 percent of Caucasians, this mutation renders people highly resistant to HIV infection. By transplanting cells from a donor with the mutation, doctors knew there was a good chance of curing Mr. Brown’s leukemia and hoped they might also eradicate—or at the very least bring under control—his HIV infection.
Since his transplant five years ago, standard clinical tests have failed to detect any HIV in Mr. Brown’s body, he hasn't taken any antiretroviral therapy, and he has certainly not manifested any signs or symptoms suggesting he is progressing to AIDS. Why do we think this means he is cured of HIV? In almost all cases, a person who stops taking antiretroviral therapy will experience a rebound in virus, a resurgence to levels that are both easily detected and that predict a progression to disease and ultimately death.
When this case was first reported at a conference in 2008, scientists were skeptical. To quell doubts, numerous more detailed tests have been performed, using the most powerful laboratory tools available today. The results collectively suggest that if there are any pieces of the virus left in his body, they are not capable of replicating. In other words, although many scientists are still not willing to go so far as to say HIV has been eradicated from Mr. Brown, it seems increasingly likely that any virus that may be left in his body will not rebound and cause health issues associated with HIV disease. This is as good a cure as exists for any disease.
The Mississippi Child
When doctors identified a child late last year who appeared to have been cured of HIV, they knew the case would require intensive documentation. The child had been born in Mississippi to a mother who tested HIV-positive during labor. Because this was the first point of contact between the mother and medical care, the doctors knew she had not taken antiretroviral therapy during pregnancy, an intervention that vastly reduces the chances of mother-to-child transmission of the virus. With this in mind, the pediatrician in charge of the case, Dr. Hannah Gay, decided to administer a treatment dose, rather than the usual prevention dose, of antiretroviral therapy to the infant just 31 hours after birth, to increase the chances that HIV infection could be prevented. She figured that if the infection occurred despite this therapy, at least the infant would be starting on therapy soon after birth. Infants are normally started on a treatment dose of antiretroviral therapy at six weeks or more, so there would be few other infants who had started antiretroviral treatment so soon after birth.
At roughly the same time that treatment was initiated, two tests were conducted to determine whether the infant was infected. Both tests involved PCR on blood samples. PCR detects nucleic acids, the components of both DNA and RNA. Both tests came back positive, indicating that the infant had HIV-infected cells, as well as virus in the blood. Because these tests were positive within the first 48 hours after birth, current guidelines suggest the infant was infected some time prior to birth. Over the ensuing weeks, close monitoring confirmed that the viral load dropped with successive tests, as expected when a patient is responding well to therapy.
Fast-forward over a year, and the mother and child stopped going to the doctor when the child was 18 months of age, returning to medical care at 23 months. At that time, the mother confirmed that her child had not been given antiretroviral therapy for at least five months. The doctors conducted a viral load test to determine an appropriate treatment regimen, and were very surprised when the test came back “undetectable,” meaning there were less than 48 copies of the virus in each milliliter of blood. In a child who has stopped antiretroviral therapy, the result would be expected to be as high as several million. Not trusting the result, the doctors ordered another test, which also came back undetectable.
Knowing that scientists are skeptical regarding any claims of a cure, doctors set up a collaboration to include scientists specializing in all the tests that had been done to confirm the cure in Timothy Brown. These highly sensitive tests collectively suggested that if there was any virus left in this child’s body, it was unlikely to be capable of multiplying and causing disease.
UNAIDS Global Report estimates that 1,000 HIV-infected infants are born each day; there are 330,000 HIV-infected children, living mostly in developing countries where expectant mothers are less likely to be tested and treated for HIV. For example, only three percent of HIV-infected pregnant women in North Africa and the Middle East and 23 percent of women in West and Central Africa received antiretroviral therapy.
Current World Health Organization (WHO) pediatric treatment guidance will remain in place pending results of future studies and clinical trials.
The French Cohort
Only a week or two after the child cure story broke, French researchers reported they were following 14 people who were “functionally” cured of HIV. The “Visconti cohort,” for Viro-Immunologic Sustained Control After Treatment Interruption, had been treated with antiretroviral therapy during acute infection, i.e., within the first several weeks after becoming infected. All had taken antiretroviral therapy for an average of three years and then stopped. They have now been off therapy for an average of more than seven years, and yet their CD4 cell counts are in the normal range and their viral loads are almost all below 50 copies per milliliter of blood, which is the goal for patients who are taking therapy. Although more sensitive laboratory tests have readily detected HIV in these patients, they appear to no longer need to take antiretroviral therapy to maintain their health, hence the designation “functionally cured.”
The French researchers have looked for explanations for these findings both in terms of the virus the patients were infected with, as well as genetic or other characteristics in the patients themselves. So far, there are no clear answers. In fact, the researchers note that only about 10–15 percent of patients who start therapy this early during infection can expect to similarly control their infection after they stop their medications, and so far we have no way of predicting which patients will fall into this category.
What Does It All Mean?
What do these three different types of HIV cure tell us? First, there is as yet no cure that can be applied broadly. Timothy Brown’s cure was a grueling and even life-threatening process that cannot be recommended for patients on a wider scale. Moreover, the stem-cell donor in his case had a rare mutation—finding a tissue match for every HIV patient from among these rare gene carriers would be impossible. Mr. Brown’s case has taught researchers which kinds of tests will be needed to satisfy the rightly skeptical scientific community that a cure has taken place.
The potential to apply the findings from the child cure case is intriguing. Each year around the world more than 330,000 infants are born HIV-positive. Although a regimen of antiretroviral therapy during pregnancy, sometimes with the addition of a brief regimen in infants after birth, can prevent around 98 percent of mother-to-child transmission of HIV, efforts to scale up this intervention have so far failed to reach all HIV-positive pregnant women. Even with universal coverage, some infants would still be born with HIV. What remains to be determined—and clinical research studies are currently being planned—is whether an early course of antiretroviral treatment in infants for a specific period of time can eliminate HIV infection after it has occurred.
The French cases described above are clearly examples of a functional cure—the patients all still have HIV, and yet have stopped taking their medication and have not progressed to HIV disease and AIDS. It is possible that such a cure might be effected more broadly, but the major challenge would be to identify HIV-infected people sufficiently early during the course of infection for the therapy to make this difference. Even so, it appears that only 10–15 percent of people are functionally curable this way.
It is less clear what type of cure Timothy Brown or the child have experienced. In both patients, trace amounts of the genetic material of the virus are sporadically detected. One challenge is knowing whether or not those results are “real.” In each case, the levels of virus are at the “limit of detection” of the assays being used. In other words, the virus hovers in the region in which the assays cannot definitively say whether or not the results are a false positive. Even if there really are traces of the virus left in these patients, what are the ramifications? In both cases, the patients have been off antiretroviral therapy for significant periods of time. If either had been harboring virus that was capable of replicating, in all likelihood that virus would have rebounded by now and would be readily detectable. It therefore seems most likely that any virus they still have is incapable of replicating either because it is defective or present only in fragments. If the only HIV present in either patient is not capable of replicating, and therefore cannot behave in the deleterious ways we care about, can we say they have a sterilizing cure?
Although most researchers might say no, one could argue that this may be as close to a sterilizing cure as we will ever come, and that such fragments may not be as concerning as they sound.
As promising as the recent reports of a cure have been, it is clear there is much work to be done to find a cure—or possibly different types of cure—that can be applied to the estimated 34 million people living with HIV today. That work will continue.
Dr. Johnston is amfAR’s vice president and director of research.
HIVHope - We include this lengthy review of the current status of "cure" research because it is a clear and thorough article that will help you explain to people the current status of the research and the meaning of stories they may see in the news. We pray it is helpful to you in your work.
The search for a cure
HIV Weekly, 5 June 2013 - What about a cure for HIV? Researchers recently gathered in Paris to discuss the future of HIV scientific research and the prospect of a cure. Delegates heard that there were some “lights at the end of the tunnel”. Studies suggest that a so-called 'functional cure' (control of HIV without the need for lifelong medication) may be possible – but only if treatment is started almost immediately after infection with HIV and then continues for a prolonged period of time. Only a very small number of people are diagnosed so promptly. The vast majority of people living with HIV are diagnosed later and usually only start treatment after they have had HIV for a number of years.
An obstacle to developing a cure appears to be the reservoir of cells with long-term HIV infection. These can’t be eradicated with current antiretroviral therapy.
There was a consensus among the researchers in Paris that there’s still a long way to go before a cure for HIV becomes a reality.
HIVHope - The last line of this article is very important. "There is still a long way to go before a cure for HIV becomes a reality." Please remember this and communicate it to people so that they do not fall victim to a false sense of security that say they can become infected without concern because a cure is only months away. Press reports like that are extremely misleading!
In Other News
Deaths are down, and the heroes of the story aren't who you think
By Jenny Trinitapoli and Alexander Weinreb, Wednesday, March 27, 2013 – The latest news on AIDS in sub-Saharan Africa, the epidemic’s epicenter, is good. New HIV infections have declined by 25 percent since 2001, AIDS-related deaths have decreased by 32 percent over the past 6 years, and there are expanded options for testing and treatment. After decades of doom-and-gloom news about AIDS in Africa, optimism is finally in the air.
What’s behind this positive turn? The standard narrative attributes these recent improvements to Western engagement. The heroes are the best-known acronyms in the world of AIDS (PEPFAR, UNAIDS, WHO), the Global Fund, and a host of NGOs. Together, these organizations have waged total war against AIDS in Africa—or what looks like total war if you compare it to efforts devoted to other diseases. They have spent tens of billions of dollars. They have mobilized legions of scientists, medical professionals, development workers, educators, TV programmers, marketing specialists, and volunteers. And they have shunned, silenced, and demonized those who oppose their good work. The good news about AIDS in Africa—so this standard narrative goes—is the result of their efforts.
This narrative contains some important elements of truth: Pharmacological treatments in particular are transforming HIV from a death sentence into a manageable, chronic condition, at least for those with access to antiretrovirals. But most of the measured improvements in AIDS in Africa are actually the result of cumulative, widespread behavior change that has led to a reduction in new HIV infections. In other words, the standard narrative is wrong.
The narrative is wrong because it ignores local African responses to AIDS and characterizes religion and religious leaders as part of the problem. We have systematically studied the role of religious leaders in sub-Saharan Africa for about a decade. As a single class of people, local religious leaders sit at the very top of our list of who should receive credit for the behavior changes that have curbed the spread of HIV in Africa.
This statement may surprise or even irritate people imagining fire-and-brimstone preachers who condemn the use of condoms, push conservative messages about sex and morality, and interpret AIDS as God’s wrath. That’s not what African religious leaders have been doing—quite the contrary. Yet their story remains untold.
Approximately 90 percent of Africans participate regularly in some religious congregation, and religious leaders have been preaching about sexual morality, in particular about abstinence and fidelity. But Africa’s religious leaders began doing this before PEPFAR and Western public health authorities told them to—long before the attention of the development world turned to AIDS in Africa. What prompted their efforts? Certainly not the fact that they were, or are, getting paid to do this by foreign NGOs. Ninety percent of congregation leaders in Malawi, for example, have never seen a penny from any international NGO or their programs. Rather, they started preaching and teaching and facilitating conversations about AIDS when they became overwhelmed with care-giving and burial responsibilities, and when their members—especially the women—began demanding that they do so.
Local religious messages about abstinence and faithfulness are, at their root, moral messages, but not exclusively so. For nearly two decades, religious leaders of various stripes in Malawi—a religiously diverse country with high HIV prevalence—have been offering practical messages about how to resist the temptation of beautiful women, how to prevent jealousies in polygamous households, how to discern whether a boyfriend or girlfriend will be a faithful spouse in the long run, and why withholding sex within marriage might be risky for both partners. These messages have mattered. In congregations where AIDS and sexual morality is discussed regularly, unmarried people are more likely to report being abstinent and married individuals faithful to their spouses.
At first, we worried that reporting bias (people wanting to appear good and consistent to interviewers asking invasive questions about religion, sexual behavior, etc.) could be driving this pattern. But when tested the responses against both more subjective and more objective criteria, the story checked out: Members of these congregations are less worried about AIDS (a good indicator that they aren't exposing themselves to much risk), and they’re less likely to test positive for HIV. Far from pushing fire-and-brimstone doctrine, religious messages about abstinence and faithfulness have been pragmatic and effective. They have reduced the spread of HIV in countless African communities that have been unreached by resources from the Global Fund and its counterparts.
On condoms—the public health buff’s favorite subject—religious leaders have been taking pragmatic positions. Most support the use of condoms to prevent HIV transmission. With the support of many religious leaders and organizations, including the Islamic Medical Association of Uganda, this balanced and pragmatic message quickly diffused throughout East Africa.
Of course, support for condoms doesn't mean that religious leaders are excitedly doling out condoms after communion. They are simply resigned to condoms as a lesser evil. At the same time, they criticize what they see as an obsessive focus on condom promotion on simple pragmatic grounds. First, condom-sex isn't sustainable in real relationships where there is a desire to procreate. A second factor is pleasure. This is why most of the more than 200 religious leaders we interviewed think that condoms are not a sustainable way for couples to live their lives, navigate their relationships, and fully enjoy sex.
On the world’s most religious continent, people use religious ideas, language, and organizations to address problems, big and small. This is the source of religion’s positive contribution to the recent improvements in Africa’s AIDS situation. Such stories need to be told.
HIVHope - What an interesting article! We all know that churches and church leaders have had and will continue to have a vital role in HIV. It is good to have this report to support that fact and share it with those who do not understand. We pray that this realization will draw many people to saving relationships with Jesus Christ.
Marriage Is a Risk Factor for HIV Infection in Malawi
AIDSMAP (04.08.13):: Roger Pebody - A researcher reports that cultural norms in the southeast African country of Malawi result in increased HIV risk for married women. Approximately 12 percent of Malawi adults are HIV-infected; women become infected at a younger age and more often than men in Malawi. The average annual income in Malawi is $200, and women are “substantially poorer” than men.
The study author conducted 12 focus groups comprised of 72 women, most of whom had been diagnosed with HIV during the last two years. The average age of participants was 33. Most participants had some primary education, but none were employed at the time of the focus groups. Although half of the participants were married during the study, almost all had been married—some two or three times. The women cited poverty and companionship as reasons for marriage.
The focus group participants reported several factors contributing to increased HIV risk for married women in Malawi: Polygamy is legal in Malawi; husbands are unfaithful; Malawi cultural norms dictate that couples abstain from sex for a year after childbirth;
Malawi men do not disclose their HIV status; and women are vulnerable to "nkhaza" (domestic abuse and violence, frequently with forced, unprotected sex).
Some study participants stated they have chosen poverty over marriage. The focus group participants suggested policy changes, including equal access to land and sustainable income-generating activity, and microfinancing to alleviate poverty among Malawi women.
The full report, “Marriage as a Risk Factor for HIV: Learning from the Experiences of HIV-Infected Women in Malawi,” was published online in the journal Global Public Health (2013; doi:10.1080/17441692.2012.761261).
HIVHope - The headline of this article is very disturbing. If people come to believe that being married puts them at risk of infection, they may decide to avoid marriage. They will not stop having sex, they will just turn their backs on the vital, biblical institution of marriage that is such an important factor in slowing the spread of the virus as it motivates people to be faithful to their partners.
Quality of health services is key in encouraging or discouraging people from HIV testing in Africa
Support of peers and family members also vital
Roger Pebody, Published: 26 March 2013 - The uptake of HIV testing in sub-Saharan Africa is influenced by the quality and manner in which health services are delivered, according to a review of 42 qualitative studies, published this month in BMC Public Health. Perceived problems with confidentiality, staff attitudes and long waiting times discouraged many people from testing, whereas trusted and more convenient facilities – and local availability of antiretroviral therapy – encouraged individuals to take an HIV test.
Moreover, the “availability and convenience of health care provider-initiated HIV testing provides that extra ‘push’ that enables individuals to overcome barriers,” the authors write. They call for stepping up provider-initiated HIV testing, especially when individuals are being screened for other, less stigmatising, conditions.
Their review also sheds light on numerous individual and relationship factors that encourage or discourage people from taking an HIV test.
On average, only four-in-ten African people living with HIV have been diagnosed. This study synthesised the results of 42 different qualitative studies conducted in 13 African countries, published between 2001 and 2012. The researchers were looking specifically for research on the factors influencing access to and uptake of HIV testing. They say that despite the diversity of settings in sub-Saharan Africa, their findings suggest that many of the barriers and facilitators of HIV testing are similar across the region
Health services – quality, trust and access
Numerous studies reported that uptake of testing was influenced by past experiences with health care and trust in providers. Problems with confidentiality, staff competence and staff attitudes discouraged people from testing. When services had staff who were not known in the local community, this enhanced perceptions of confidentiality.
When testing was provided at an HIV-specific health facility, this was often felt to be less confidential. Being seen at an HIV testing centre was often perceived to be synonymous with sexual promiscuity and being HIV positive.
When taking an HIV test had financial costs associated with it (user fees, travel expenses, loss of income), investing in health had to compete with other needs. Inconvenient testing hours and long waiting times exacerbated such problems. In some settings, some respondents believed that HIV testing technologies were unreliable.
Beliefs about risk of infection and health
Studies reported that individuals were motivated to test or decided it was unnecessary, based on their own assessment of their risk of infection. Having poor health oneself, or a sexual partner or child being in poor health, raised many people’s perception of risk. Sometimes having had multiple sexual partners or believing a partner to have been unfaithful also created a sense of vulnerability.
Such experiences motivated many to test, but paradoxically, some who assumed that they were infected did not feel the need to confirm this with a test.
A recurring theme of studies was individuals not testing for HIV because they perceived themselves to be at low risk of infection. This was sometimes motivated by low levels of sexual activity or a perception that HIV was primarily an issue for sex workers. Others did not feel the need to test because their partner was reported to be HIV-negative, because they trusted their partner, or because they did not have any symptoms of ill-health.
Nonetheless, numerous studies found that the increasing availability of antiretroviral treatment – with HIV no longer being seen as a death sentence – encouraged many people to test. Specifically, pregnant women were aware of having a means to prevent onward transmission should they be diagnosed with HIV.
Social relationships
Several studies reported that fears of being stigmatised discouraged people from testing. Individuals feared losing sexual partners and social support if they tested – divorce and domestic violence were seen as possible consequences. Single people were concerned that they would not be able to marry in the future.
Married women lacked autonomy in relation to HIV testing and their health more broadly. Women needed permission from husbands to test, but requesting it could raise suspicions of infidelity or accusations of having brought HIV into the couple. Frequently, HIV testing was shunned to avoid straining the marriage.
When people did choose to test, the support of peers and family members was key in the decision-making process.
Social expectations in relation to key life events could encourage HIV testing. Marriage and parenthood were, in many communities, highly valued events that linked an individual to the wider community. Several studies reported HIV testing being understood as a necessary step before marriage.
Similarly, HIV testing was accepted during antenatal care as it helped achieve the social obligation to give birth to a healthy child.
Reference
Musheke M et al. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa. BMC Public Health 13:220, 2013. (Full text freely available on line at http://www.biomedcentral.com/1471-2458/13/220/abstract.
HIVHope - We hope that sharing this article with you will give you some new ideas to help you motivate people to seek testing to learn whether they are living with HIV.
It's wrong to use your HIV status to get freebies
By ASUNTA WAGURA, Posted Wednesday, May 1 2013 - Depending on donor aid, our organisation gives food and other forms of support to people living with HIV who are in dire straits. This is an effort to help them regain their footing. Also, depending on the availability of funds, we give them seed money to start income-generating activities. We realised that many of our members, most of whom are women, become sole breadwinners due to a number of reasons.
Desperation
This required urgent attention because our members were becoming destitute and desperate by the day. Someone once said that the road to hell is paved with good intentions. With time and experience, we found that our good intention was, in some cases, creating a dependency of sorts and turning us into enablers.
When I tested HIV-positive, I could have done with some seed money. There were no employers out there — at least I never came across any — who were prepared to give a job to an HIV-positive single mother. We had to be creative and, like Hannibal said, "Find a way or make a way."
Positive change
The fact that I can now be called for a job, locally and internationally, because of my HIV status just goes to show that things can change. But this can only happen if we do our part. "It's up to you now," I always tell the members that we give seed money to, "because we can only support you to a certain extent." Trust me, teaching folks who were used to fish handouts how to fish is one tough assignment. I believe that one of the things that is robbing some PLWHs of their financial independence is AIDS. Nope, not that AIDS.
I am talking about Acquired Immune Dependency Syndrome. There are some who see their HIV sero-positive status as a meal ticket. They refuse to work and instead let the virus work for them. Our community health workers (CHWs) used to tell me of some PLWHs who were members of several HIV service organisations. "They are card-carrying members of all these NGOs and they know the days when each organisation gives food and will be there on time, every time."
Individuals like these give PLWHs a bad name. I have, multiple times, had to caution our CHWs to guard against giving seed money to the same members. There is only so much that we can do for one person.
What disheartened me was hearing reports from our nurses about people who were, literally, asking for it. "We've had cases of some people who are HIV-negative begging us to say they are HIV-positive just so they can be put in our food support programme."
"These people don't know what they're asking for," I said.
We have a choice
I am a firm believer that work is ordained by God and that it is a blessing. There are days that I drag myself to the office, even when I am feeling unwell, because I know that my line of work deals with human beings. It touches on matters of life and death.
Through saying and doing, I am trying to teach my children that work is honourable and rewarding. I know there is a sub-culture in our country of folks waiting for things to happen. Guys who wait for the government to do. Or, tragically, some lying that they are HIV-positive so they can be given things without sweating.
This is the diary of Asunta Wagura, a mother-of-five who tested HIV-positive 25 years ago. She is the executive director of the Kenya Network of Women with AIDS (KENWA).
HIVHope - There is a great deal of truth in this statement. Dependency is so destructive. It robs people of initiative, dignity, and the ability to make their lives better. It is very sad, but true, that so much of what is done by international NGOs and governments motivates people toward dependency.
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from HIVHope International
June 2013 - Vol. IV, No 2
Our God is so wonderful and shows His love to us in so many beautiful ways even when things in our lives are not the way we would wish. We praise His holy name and are thankful for the privilege of serving Him with you in HIV education and ministry.
What news is there from you and your ministry? We love to hear from you about how God is using you to impact people living with and impacted by HIV.
One such report came recently from the participants in one of our seminars five years ago in India. They recently held an event that included offering antibody testing and training for people in HIV education using the HIVHope International model. What a blessing to know that even after five years, they are still actively involved and impacting the lives of people in and beyond their community.
Please share with us what you are doing so that we can be encouraged and encourage others with your stories.
Duane Crumb for the HIVHope Team
Major Theme in HIV News
Those of you who have been participants in our seminars will remember me saying that I do not ever expect a cure for HIV disease but pray that some day i will be proven wrong. Well, that it appears that God is beginning to answer that prayer far sooner than I could ever have hoped.
The March 2013 issue of It's About People started with the breaking story about a baby in the state of Mississippi in the US who was born with HIV and was then cured. We shared the story with some hesitation and caution. Since then, the cure of the baby has been confirmed. That is wonderful news for that family and an amazing answer to prayer. However, it has also become increasingly clear that this case does not mean we can expect the end of HIV disease in the near future.
Most of the news stories in recent months have focused on hopes for a cure. We have selected two that we believe do a good job of summarizing what is being reported. The first article is long but does a good job of explaining the complex issues involved and provides valuable background.
Please read these articles carefully and use caution in any attempt to apply what is being said to people in your setting. As they make clear, we do not yet have a cure that will bring an end to the disease but there is more hope than I ever expected. God is good!
Three Types of HIV Cure
What do they mean, and where do we go from here?
Published Monday, April 15, 2013 by AmFAR, By Rowena Johnston, Ph.D. - If you've been following the news lately, you may be starting to wonder why anybody ever thought curing HIV was so challenging. On March 3 we heard the news that a child appeared to have been cured. Hard on the heels of that report came the news that 14 individuals in France had been functionally cured. So what do these cases mean? How are they similar, and how do they differ? And importantly for HIV research, where do we go from here?
Much depends on how a cure is defined. Researchers are used to thinking of a cure in two different ways. One type, a sterilizing cure, requires that HIV be eradicated from the body of the infected person. The second, a functional cure, is less stringent in that it requires that the patient is able to stop taking antiretroviral therapy without suffering any adverse consequences of the HIV that remains in their body.
The Berlin Patient
A decade ago, almost nobody spoke of curing HIV infection as a realistic goal, yet we find ourselves in early 2013 with not one, nor even two, but three different types of HIV cure. The first cure—the “Berlin patient,” who we now know as Timothy Brown—has been widely reported. Mr. Brown was living in Germany when he was diagnosed with HIV infection in the mid-1990s. His infection was well-controlled by antiretroviral therapy until he was diagnosed with acute myeloid leukemia about 10 years later. To treat the cancer, he received a stem-cell transplant, but his doctors took an extra step, finding a donor with a genetic mutation known as CCR5 delta-32. Naturally present in around 1–2 percent of Caucasians, this mutation renders people highly resistant to HIV infection. By transplanting cells from a donor with the mutation, doctors knew there was a good chance of curing Mr. Brown’s leukemia and hoped they might also eradicate—or at the very least bring under control—his HIV infection.
Since his transplant five years ago, standard clinical tests have failed to detect any HIV in Mr. Brown’s body, he hasn't taken any antiretroviral therapy, and he has certainly not manifested any signs or symptoms suggesting he is progressing to AIDS. Why do we think this means he is cured of HIV? In almost all cases, a person who stops taking antiretroviral therapy will experience a rebound in virus, a resurgence to levels that are both easily detected and that predict a progression to disease and ultimately death.
When this case was first reported at a conference in 2008, scientists were skeptical. To quell doubts, numerous more detailed tests have been performed, using the most powerful laboratory tools available today. The results collectively suggest that if there are any pieces of the virus left in his body, they are not capable of replicating. In other words, although many scientists are still not willing to go so far as to say HIV has been eradicated from Mr. Brown, it seems increasingly likely that any virus that may be left in his body will not rebound and cause health issues associated with HIV disease. This is as good a cure as exists for any disease.
The Mississippi Child
When doctors identified a child late last year who appeared to have been cured of HIV, they knew the case would require intensive documentation. The child had been born in Mississippi to a mother who tested HIV-positive during labor. Because this was the first point of contact between the mother and medical care, the doctors knew she had not taken antiretroviral therapy during pregnancy, an intervention that vastly reduces the chances of mother-to-child transmission of the virus. With this in mind, the pediatrician in charge of the case, Dr. Hannah Gay, decided to administer a treatment dose, rather than the usual prevention dose, of antiretroviral therapy to the infant just 31 hours after birth, to increase the chances that HIV infection could be prevented. She figured that if the infection occurred despite this therapy, at least the infant would be starting on therapy soon after birth. Infants are normally started on a treatment dose of antiretroviral therapy at six weeks or more, so there would be few other infants who had started antiretroviral treatment so soon after birth.
At roughly the same time that treatment was initiated, two tests were conducted to determine whether the infant was infected. Both tests involved PCR on blood samples. PCR detects nucleic acids, the components of both DNA and RNA. Both tests came back positive, indicating that the infant had HIV-infected cells, as well as virus in the blood. Because these tests were positive within the first 48 hours after birth, current guidelines suggest the infant was infected some time prior to birth. Over the ensuing weeks, close monitoring confirmed that the viral load dropped with successive tests, as expected when a patient is responding well to therapy.
Fast-forward over a year, and the mother and child stopped going to the doctor when the child was 18 months of age, returning to medical care at 23 months. At that time, the mother confirmed that her child had not been given antiretroviral therapy for at least five months. The doctors conducted a viral load test to determine an appropriate treatment regimen, and were very surprised when the test came back “undetectable,” meaning there were less than 48 copies of the virus in each milliliter of blood. In a child who has stopped antiretroviral therapy, the result would be expected to be as high as several million. Not trusting the result, the doctors ordered another test, which also came back undetectable.
Knowing that scientists are skeptical regarding any claims of a cure, doctors set up a collaboration to include scientists specializing in all the tests that had been done to confirm the cure in Timothy Brown. These highly sensitive tests collectively suggested that if there was any virus left in this child’s body, it was unlikely to be capable of multiplying and causing disease.
UNAIDS Global Report estimates that 1,000 HIV-infected infants are born each day; there are 330,000 HIV-infected children, living mostly in developing countries where expectant mothers are less likely to be tested and treated for HIV. For example, only three percent of HIV-infected pregnant women in North Africa and the Middle East and 23 percent of women in West and Central Africa received antiretroviral therapy.
Current World Health Organization (WHO) pediatric treatment guidance will remain in place pending results of future studies and clinical trials.
The French Cohort
Only a week or two after the child cure story broke, French researchers reported they were following 14 people who were “functionally” cured of HIV. The “Visconti cohort,” for Viro-Immunologic Sustained Control After Treatment Interruption, had been treated with antiretroviral therapy during acute infection, i.e., within the first several weeks after becoming infected. All had taken antiretroviral therapy for an average of three years and then stopped. They have now been off therapy for an average of more than seven years, and yet their CD4 cell counts are in the normal range and their viral loads are almost all below 50 copies per milliliter of blood, which is the goal for patients who are taking therapy. Although more sensitive laboratory tests have readily detected HIV in these patients, they appear to no longer need to take antiretroviral therapy to maintain their health, hence the designation “functionally cured.”
The French researchers have looked for explanations for these findings both in terms of the virus the patients were infected with, as well as genetic or other characteristics in the patients themselves. So far, there are no clear answers. In fact, the researchers note that only about 10–15 percent of patients who start therapy this early during infection can expect to similarly control their infection after they stop their medications, and so far we have no way of predicting which patients will fall into this category.
What Does It All Mean?
What do these three different types of HIV cure tell us? First, there is as yet no cure that can be applied broadly. Timothy Brown’s cure was a grueling and even life-threatening process that cannot be recommended for patients on a wider scale. Moreover, the stem-cell donor in his case had a rare mutation—finding a tissue match for every HIV patient from among these rare gene carriers would be impossible. Mr. Brown’s case has taught researchers which kinds of tests will be needed to satisfy the rightly skeptical scientific community that a cure has taken place.
The potential to apply the findings from the child cure case is intriguing. Each year around the world more than 330,000 infants are born HIV-positive. Although a regimen of antiretroviral therapy during pregnancy, sometimes with the addition of a brief regimen in infants after birth, can prevent around 98 percent of mother-to-child transmission of HIV, efforts to scale up this intervention have so far failed to reach all HIV-positive pregnant women. Even with universal coverage, some infants would still be born with HIV. What remains to be determined—and clinical research studies are currently being planned—is whether an early course of antiretroviral treatment in infants for a specific period of time can eliminate HIV infection after it has occurred.
The French cases described above are clearly examples of a functional cure—the patients all still have HIV, and yet have stopped taking their medication and have not progressed to HIV disease and AIDS. It is possible that such a cure might be effected more broadly, but the major challenge would be to identify HIV-infected people sufficiently early during the course of infection for the therapy to make this difference. Even so, it appears that only 10–15 percent of people are functionally curable this way.
It is less clear what type of cure Timothy Brown or the child have experienced. In both patients, trace amounts of the genetic material of the virus are sporadically detected. One challenge is knowing whether or not those results are “real.” In each case, the levels of virus are at the “limit of detection” of the assays being used. In other words, the virus hovers in the region in which the assays cannot definitively say whether or not the results are a false positive. Even if there really are traces of the virus left in these patients, what are the ramifications? In both cases, the patients have been off antiretroviral therapy for significant periods of time. If either had been harboring virus that was capable of replicating, in all likelihood that virus would have rebounded by now and would be readily detectable. It therefore seems most likely that any virus they still have is incapable of replicating either because it is defective or present only in fragments. If the only HIV present in either patient is not capable of replicating, and therefore cannot behave in the deleterious ways we care about, can we say they have a sterilizing cure?
Although most researchers might say no, one could argue that this may be as close to a sterilizing cure as we will ever come, and that such fragments may not be as concerning as they sound.
As promising as the recent reports of a cure have been, it is clear there is much work to be done to find a cure—or possibly different types of cure—that can be applied to the estimated 34 million people living with HIV today. That work will continue.
Dr. Johnston is amfAR’s vice president and director of research.
HIVHope - We include this lengthy review of the current status of "cure" research because it is a clear and thorough article that will help you explain to people the current status of the research and the meaning of stories they may see in the news. We pray it is helpful to you in your work.
The search for a cure
HIV Weekly, 5 June 2013 - What about a cure for HIV? Researchers recently gathered in Paris to discuss the future of HIV scientific research and the prospect of a cure. Delegates heard that there were some “lights at the end of the tunnel”. Studies suggest that a so-called 'functional cure' (control of HIV without the need for lifelong medication) may be possible – but only if treatment is started almost immediately after infection with HIV and then continues for a prolonged period of time. Only a very small number of people are diagnosed so promptly. The vast majority of people living with HIV are diagnosed later and usually only start treatment after they have had HIV for a number of years.
An obstacle to developing a cure appears to be the reservoir of cells with long-term HIV infection. These can’t be eradicated with current antiretroviral therapy.
There was a consensus among the researchers in Paris that there’s still a long way to go before a cure for HIV becomes a reality.
HIVHope - The last line of this article is very important. "There is still a long way to go before a cure for HIV becomes a reality." Please remember this and communicate it to people so that they do not fall victim to a false sense of security that say they can become infected without concern because a cure is only months away. Press reports like that are extremely misleading!
In Other News
Deaths are down, and the heroes of the story aren't who you think
By Jenny Trinitapoli and Alexander Weinreb, Wednesday, March 27, 2013 – The latest news on AIDS in sub-Saharan Africa, the epidemic’s epicenter, is good. New HIV infections have declined by 25 percent since 2001, AIDS-related deaths have decreased by 32 percent over the past 6 years, and there are expanded options for testing and treatment. After decades of doom-and-gloom news about AIDS in Africa, optimism is finally in the air.
What’s behind this positive turn? The standard narrative attributes these recent improvements to Western engagement. The heroes are the best-known acronyms in the world of AIDS (PEPFAR, UNAIDS, WHO), the Global Fund, and a host of NGOs. Together, these organizations have waged total war against AIDS in Africa—or what looks like total war if you compare it to efforts devoted to other diseases. They have spent tens of billions of dollars. They have mobilized legions of scientists, medical professionals, development workers, educators, TV programmers, marketing specialists, and volunteers. And they have shunned, silenced, and demonized those who oppose their good work. The good news about AIDS in Africa—so this standard narrative goes—is the result of their efforts.
This narrative contains some important elements of truth: Pharmacological treatments in particular are transforming HIV from a death sentence into a manageable, chronic condition, at least for those with access to antiretrovirals. But most of the measured improvements in AIDS in Africa are actually the result of cumulative, widespread behavior change that has led to a reduction in new HIV infections. In other words, the standard narrative is wrong.
The narrative is wrong because it ignores local African responses to AIDS and characterizes religion and religious leaders as part of the problem. We have systematically studied the role of religious leaders in sub-Saharan Africa for about a decade. As a single class of people, local religious leaders sit at the very top of our list of who should receive credit for the behavior changes that have curbed the spread of HIV in Africa.
This statement may surprise or even irritate people imagining fire-and-brimstone preachers who condemn the use of condoms, push conservative messages about sex and morality, and interpret AIDS as God’s wrath. That’s not what African religious leaders have been doing—quite the contrary. Yet their story remains untold.
Approximately 90 percent of Africans participate regularly in some religious congregation, and religious leaders have been preaching about sexual morality, in particular about abstinence and fidelity. But Africa’s religious leaders began doing this before PEPFAR and Western public health authorities told them to—long before the attention of the development world turned to AIDS in Africa. What prompted their efforts? Certainly not the fact that they were, or are, getting paid to do this by foreign NGOs. Ninety percent of congregation leaders in Malawi, for example, have never seen a penny from any international NGO or their programs. Rather, they started preaching and teaching and facilitating conversations about AIDS when they became overwhelmed with care-giving and burial responsibilities, and when their members—especially the women—began demanding that they do so.
Local religious messages about abstinence and faithfulness are, at their root, moral messages, but not exclusively so. For nearly two decades, religious leaders of various stripes in Malawi—a religiously diverse country with high HIV prevalence—have been offering practical messages about how to resist the temptation of beautiful women, how to prevent jealousies in polygamous households, how to discern whether a boyfriend or girlfriend will be a faithful spouse in the long run, and why withholding sex within marriage might be risky for both partners. These messages have mattered. In congregations where AIDS and sexual morality is discussed regularly, unmarried people are more likely to report being abstinent and married individuals faithful to their spouses.
At first, we worried that reporting bias (people wanting to appear good and consistent to interviewers asking invasive questions about religion, sexual behavior, etc.) could be driving this pattern. But when tested the responses against both more subjective and more objective criteria, the story checked out: Members of these congregations are less worried about AIDS (a good indicator that they aren't exposing themselves to much risk), and they’re less likely to test positive for HIV. Far from pushing fire-and-brimstone doctrine, religious messages about abstinence and faithfulness have been pragmatic and effective. They have reduced the spread of HIV in countless African communities that have been unreached by resources from the Global Fund and its counterparts.
On condoms—the public health buff’s favorite subject—religious leaders have been taking pragmatic positions. Most support the use of condoms to prevent HIV transmission. With the support of many religious leaders and organizations, including the Islamic Medical Association of Uganda, this balanced and pragmatic message quickly diffused throughout East Africa.
Of course, support for condoms doesn't mean that religious leaders are excitedly doling out condoms after communion. They are simply resigned to condoms as a lesser evil. At the same time, they criticize what they see as an obsessive focus on condom promotion on simple pragmatic grounds. First, condom-sex isn't sustainable in real relationships where there is a desire to procreate. A second factor is pleasure. This is why most of the more than 200 religious leaders we interviewed think that condoms are not a sustainable way for couples to live their lives, navigate their relationships, and fully enjoy sex.
On the world’s most religious continent, people use religious ideas, language, and organizations to address problems, big and small. This is the source of religion’s positive contribution to the recent improvements in Africa’s AIDS situation. Such stories need to be told.
HIVHope - What an interesting article! We all know that churches and church leaders have had and will continue to have a vital role in HIV. It is good to have this report to support that fact and share it with those who do not understand. We pray that this realization will draw many people to saving relationships with Jesus Christ.
Marriage Is a Risk Factor for HIV Infection in Malawi
AIDSMAP (04.08.13):: Roger Pebody - A researcher reports that cultural norms in the southeast African country of Malawi result in increased HIV risk for married women. Approximately 12 percent of Malawi adults are HIV-infected; women become infected at a younger age and more often than men in Malawi. The average annual income in Malawi is $200, and women are “substantially poorer” than men.
The study author conducted 12 focus groups comprised of 72 women, most of whom had been diagnosed with HIV during the last two years. The average age of participants was 33. Most participants had some primary education, but none were employed at the time of the focus groups. Although half of the participants were married during the study, almost all had been married—some two or three times. The women cited poverty and companionship as reasons for marriage.
The focus group participants reported several factors contributing to increased HIV risk for married women in Malawi: Polygamy is legal in Malawi; husbands are unfaithful; Malawi cultural norms dictate that couples abstain from sex for a year after childbirth;
Malawi men do not disclose their HIV status; and women are vulnerable to "nkhaza" (domestic abuse and violence, frequently with forced, unprotected sex).
Some study participants stated they have chosen poverty over marriage. The focus group participants suggested policy changes, including equal access to land and sustainable income-generating activity, and microfinancing to alleviate poverty among Malawi women.
The full report, “Marriage as a Risk Factor for HIV: Learning from the Experiences of HIV-Infected Women in Malawi,” was published online in the journal Global Public Health (2013; doi:10.1080/17441692.2012.761261).
HIVHope - The headline of this article is very disturbing. If people come to believe that being married puts them at risk of infection, they may decide to avoid marriage. They will not stop having sex, they will just turn their backs on the vital, biblical institution of marriage that is such an important factor in slowing the spread of the virus as it motivates people to be faithful to their partners.
Quality of health services is key in encouraging or discouraging people from HIV testing in Africa
Support of peers and family members also vital
Roger Pebody, Published: 26 March 2013 - The uptake of HIV testing in sub-Saharan Africa is influenced by the quality and manner in which health services are delivered, according to a review of 42 qualitative studies, published this month in BMC Public Health. Perceived problems with confidentiality, staff attitudes and long waiting times discouraged many people from testing, whereas trusted and more convenient facilities – and local availability of antiretroviral therapy – encouraged individuals to take an HIV test.
Moreover, the “availability and convenience of health care provider-initiated HIV testing provides that extra ‘push’ that enables individuals to overcome barriers,” the authors write. They call for stepping up provider-initiated HIV testing, especially when individuals are being screened for other, less stigmatising, conditions.
Their review also sheds light on numerous individual and relationship factors that encourage or discourage people from taking an HIV test.
On average, only four-in-ten African people living with HIV have been diagnosed. This study synthesised the results of 42 different qualitative studies conducted in 13 African countries, published between 2001 and 2012. The researchers were looking specifically for research on the factors influencing access to and uptake of HIV testing. They say that despite the diversity of settings in sub-Saharan Africa, their findings suggest that many of the barriers and facilitators of HIV testing are similar across the region
Health services – quality, trust and access
Numerous studies reported that uptake of testing was influenced by past experiences with health care and trust in providers. Problems with confidentiality, staff competence and staff attitudes discouraged people from testing. When services had staff who were not known in the local community, this enhanced perceptions of confidentiality.
When testing was provided at an HIV-specific health facility, this was often felt to be less confidential. Being seen at an HIV testing centre was often perceived to be synonymous with sexual promiscuity and being HIV positive.
When taking an HIV test had financial costs associated with it (user fees, travel expenses, loss of income), investing in health had to compete with other needs. Inconvenient testing hours and long waiting times exacerbated such problems. In some settings, some respondents believed that HIV testing technologies were unreliable.
Beliefs about risk of infection and health
Studies reported that individuals were motivated to test or decided it was unnecessary, based on their own assessment of their risk of infection. Having poor health oneself, or a sexual partner or child being in poor health, raised many people’s perception of risk. Sometimes having had multiple sexual partners or believing a partner to have been unfaithful also created a sense of vulnerability.
Such experiences motivated many to test, but paradoxically, some who assumed that they were infected did not feel the need to confirm this with a test.
A recurring theme of studies was individuals not testing for HIV because they perceived themselves to be at low risk of infection. This was sometimes motivated by low levels of sexual activity or a perception that HIV was primarily an issue for sex workers. Others did not feel the need to test because their partner was reported to be HIV-negative, because they trusted their partner, or because they did not have any symptoms of ill-health.
Nonetheless, numerous studies found that the increasing availability of antiretroviral treatment – with HIV no longer being seen as a death sentence – encouraged many people to test. Specifically, pregnant women were aware of having a means to prevent onward transmission should they be diagnosed with HIV.
Social relationships
Several studies reported that fears of being stigmatised discouraged people from testing. Individuals feared losing sexual partners and social support if they tested – divorce and domestic violence were seen as possible consequences. Single people were concerned that they would not be able to marry in the future.
Married women lacked autonomy in relation to HIV testing and their health more broadly. Women needed permission from husbands to test, but requesting it could raise suspicions of infidelity or accusations of having brought HIV into the couple. Frequently, HIV testing was shunned to avoid straining the marriage.
When people did choose to test, the support of peers and family members was key in the decision-making process.
Social expectations in relation to key life events could encourage HIV testing. Marriage and parenthood were, in many communities, highly valued events that linked an individual to the wider community. Several studies reported HIV testing being understood as a necessary step before marriage.
Similarly, HIV testing was accepted during antenatal care as it helped achieve the social obligation to give birth to a healthy child.
Reference
Musheke M et al. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa. BMC Public Health 13:220, 2013. (Full text freely available on line at http://www.biomedcentral.com/1471-2458/13/220/abstract.
HIVHope - We hope that sharing this article with you will give you some new ideas to help you motivate people to seek testing to learn whether they are living with HIV.
It's wrong to use your HIV status to get freebies
By ASUNTA WAGURA, Posted Wednesday, May 1 2013 - Depending on donor aid, our organisation gives food and other forms of support to people living with HIV who are in dire straits. This is an effort to help them regain their footing. Also, depending on the availability of funds, we give them seed money to start income-generating activities. We realised that many of our members, most of whom are women, become sole breadwinners due to a number of reasons.
Desperation
This required urgent attention because our members were becoming destitute and desperate by the day. Someone once said that the road to hell is paved with good intentions. With time and experience, we found that our good intention was, in some cases, creating a dependency of sorts and turning us into enablers.
When I tested HIV-positive, I could have done with some seed money. There were no employers out there — at least I never came across any — who were prepared to give a job to an HIV-positive single mother. We had to be creative and, like Hannibal said, "Find a way or make a way."
Positive change
The fact that I can now be called for a job, locally and internationally, because of my HIV status just goes to show that things can change. But this can only happen if we do our part. "It's up to you now," I always tell the members that we give seed money to, "because we can only support you to a certain extent." Trust me, teaching folks who were used to fish handouts how to fish is one tough assignment. I believe that one of the things that is robbing some PLWHs of their financial independence is AIDS. Nope, not that AIDS.
I am talking about Acquired Immune Dependency Syndrome. There are some who see their HIV sero-positive status as a meal ticket. They refuse to work and instead let the virus work for them. Our community health workers (CHWs) used to tell me of some PLWHs who were members of several HIV service organisations. "They are card-carrying members of all these NGOs and they know the days when each organisation gives food and will be there on time, every time."
Individuals like these give PLWHs a bad name. I have, multiple times, had to caution our CHWs to guard against giving seed money to the same members. There is only so much that we can do for one person.
What disheartened me was hearing reports from our nurses about people who were, literally, asking for it. "We've had cases of some people who are HIV-negative begging us to say they are HIV-positive just so they can be put in our food support programme."
"These people don't know what they're asking for," I said.
We have a choice
I am a firm believer that work is ordained by God and that it is a blessing. There are days that I drag myself to the office, even when I am feeling unwell, because I know that my line of work deals with human beings. It touches on matters of life and death.
Through saying and doing, I am trying to teach my children that work is honourable and rewarding. I know there is a sub-culture in our country of folks waiting for things to happen. Guys who wait for the government to do. Or, tragically, some lying that they are HIV-positive so they can be given things without sweating.
This is the diary of Asunta Wagura, a mother-of-five who tested HIV-positive 25 years ago. She is the executive director of the Kenya Network of Women with AIDS (KENWA).
HIVHope - There is a great deal of truth in this statement. Dependency is so destructive. It robs people of initiative, dignity, and the ability to make their lives better. It is very sad, but true, that so much of what is done by international NGOs and governments motivates people toward dependency.
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