The world’s most vulnerable people are suffering and dying from effects of the “shadow pandemic"

The international community's must recommit to the health of women, children, and adolescents, write Helen Clark, board chair of PMNCH and former prime minister of New Zealand, and Kersti Kaljulaid, president of Estonia and newly appointed United Nations’ Secretary-General’s global advocate for Every Woman Every Child.

The spillover effects of the covid-19 pandemic on women, children, and adolescents have been under-reported in the media, yet they are significant. While women, children, and adolescents are not more likely than other population groups to get ill or die from covid-19, they are experiencing interruptions to essential health and social services caused by lockdowns and by the diversion of resources to manage the virus. The impact of this amounts to a “shadow pandemic,” which is affecting many millions of people.

Surveys conducted over the past year have revealed the scale of the impact: 39% of 124 countries surveyed reported a drop in coverage of family planning services; 38% reported drops in the coverage of maternal health services (antenatal and postnatal); and up to 200 000 additional stillbirths could occur over 12 months in 117 low and middle income countries.

We should heed the words of a pregnant woman in Kenya who feared being left to give birth without expert care and support: “I am worried because I’m not sure if I will find the facility open or if I will find nurses during delivery”, she said. Sadly, she is far from alone. 

In India, an adolescent girl bears witness to the lack of even the most basic sanitary supplies, saying: “Girls in quarantine tore up and used their own clothes as they didn’t have access to sanitary pads.”

An 18 year old Colombian woman with polycystic ovarian syndrome reports being unable to get any kind of medical appointment during the pandemic: “I stopped getting my period, and I want to find out what’s going on, but I can’t.”

These are themes repeated by disadvantaged and vulnerable people the world over. They desperately need healthcare, services, and supplies, and are entitled to receive them, but the pandemic has torn away the fragile support structures they rely on.

More than one third of countries are still reporting disruptions to immunization services. This particularly puts children at risk. Our attempts to manage covid-19 must not compromise our campaigns against other killer diseases, such as measles and polio.

Act together, act swiftly

These disruptions to essential services cannot continue. The international community must come together swiftly to protect the most vulnerable from the indirect effects of covid-19, even as it urgently addresses the virus itself through mass vaccination and other public health measures.

It is not simply a matter of preventing suffering and hardship. Women, newborns, children, and adolescents are at risk of dying as a result of the covid-19 pandemic without ever catching the disease.

In our respective roles of board chair of Partnership for Maternal, Newborn and Child Health (PMNCH) and newly appointed United Nations global advocate for Every Woman Every Child, we call on world leaders to commit to bold, meaningful, and co-ordinated global action on women’s, children’s, and adolescents’ health.

In 2015, global leaders agreed on sustainable development goals (SDGs) for the next 15 years. Progress toward them, however, has stalled, or even reversed, as a result of the pandemic. The world urgently needs to get back on track to achieving them—including the targets of the health SDGs and of the Every Women Every Child Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016-2030).

All efforts to get back on track must be driven by the central principle of the SDGs: “leave no one behind.” At the moment, millions are slipping further and further behind, with those caught in the cross-currents of conflict, fragile situations, and migration bearing a disproportionate burden. Getting back on track will require an unprecedented global effort, co-ordinated and led at the highest level and resourced by massive fresh investment. Working in partnerships and through multilateral cooperation will be critical.

Progress on the health SDGs was already too slow before the pandemic began—with huge health inequities persisting between countries and regions. This is highlighted by regional disparities in maternal deaths. Globally, while the number of maternal deaths dropped 35% between 2000 and 2017, sub-Saharan Africa and South Asia accounted for 86% of all maternal deaths.

Vaccines, equity, and data

So, what should the world be doing to protect the most vulnerable? A high priority is to do everything possible to ensure the equitable distribution of covid-19 vaccines through the international COVAX initiative. Access to therapeutics and testing, and to other vital tools and commodities such as personal protective equipment (PPE) and medical oxygen, also needs to be massively scaled up.

PMNCH lists other urgent priorities in its Call to Action on COVID-19 campaign. This has seven key goals: protecting access to sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) services; improving gender equality and access to sexual reproductive health and rights; improving quality care; supporting and protecting frontline health workers; ensuring stronger social safety nets; clean water and sanitation; and prevention of violence.

An equity based approach is essential to ending the covid-19 pandemic, but this depends on first gaining a detailed understanding of where inequities exist and who is affected. In May, the World Health Organization presented the 194 member states of the World Health Assembly with stark evidence of how badly the pandemic is affecting women’s, children’s, and adolescents’ health. It highlighted weaknesses in data systems, and especially the inability to monitor disruptions to essential health services in real time. To improve the volume and quality of health data dramatically, we strongly recommend expanding access to and use of digital technologies in health. These can be transformative, as we’ve already seen in Estonia. With the right infrastructure in place, they are a great equalizer, serving and uniting a whole country and enabling the most disadvantaged to access and shape health services.

We urge countries and the international community at large to recommit to the health and wellbeing of women, children, and adolescents. The pandemic has set progress back, but we owe it to the most vulnerable people in our world to get back on track and build back better and fairer. 

Helen Clark is the PMNCH board chair. She was prime minister of New Zealand from 1999–2008. From April 2009 she was administrator of the UN Development Programme, serving two terms.

Competing interests: none declared.

Kersti Kaljulaid is president of Estonia. Recently appointed the first global advocate of the United Nations Secretary-General for Every Woman Every Child (EWEC). In 2018-2020, Mme Kaljulaid was the co-chair to the High-Level Steering Group for EWEC. 

Competing interests: none declared.

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Originally published: BANK

Young women and pregnant women can effectively use vaginal rings and oral PrEP for HIV prevention

 

https://www.aidsmap.com/news/jul-2021/young-women-and-pregnant-women-can-effectively-use-vaginal-rings-and-oral-prep-hiv

Liz Highleyman

28 July 2021

Adolescent girls and young women can consistently use the dapivirine vaginal ring and daily pills for HIV pre-exposure prophylaxis (PrEP) when they receive adherence support, according to a study presented last week at the 11th International AIDS Society Conference on HIV Science (IAS 2021). Encouragingly, adherence to both methods was higher in this study than rates seen in prior trials. Another study found that both the ring and oral PrEP were safe for pregnant women, which to date has been an understudied population for HIV prevention.

IAS 2021

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"In many ways, these results exceeded even our own expectations, yet at the same time, it's not surprising to find that these young women have the capacity and desire to protect themselves against HIV," Dr Gonasagrie 'Lulu' Nair of Stellenbosch University in Cape Town, South Africa, said in a statement from the Microbicides Trials Network. "They simply need to feel empowered and have the agency to make choices based on what they feel is right for them."

In January 2021, the World Health Organization recommended the vaginal ring, a silicone device that slowly releases the non-nucleoside reverse transcriptase inhibitor dapivirine, as an additional prevention option for women at substantial risk for HIV.

A pair of phase III randomised clinical trials in sub-Saharan Africa, the Ring Study and ASPIRE, found that the ring reduced the risk of HIV infection by about 30%. An open-label extension of ASPIRE, known as HOPE, found that effectiveness rose to 39% with longer use. Two studies of oral PrEP using tenofovir disoproxil fumarate/emtricitabine (TDF/FTC; Truvada or generic equivalents) for women in Africa, VOICE and FEM-PrEP, found that the daily pills did not reduce the risk of infection more than a placebo.

These results were disappointing, given that oral PrEP is highly effective for gay and bisexual men and heterosexual couples. Further analysis showed that both the ring and oral PrEP worked well for women when adherence was high, but many African women – especially young women – had difficulty using the methods consistently. In VOICE and FEM-PrEP, less than 25% of young women maintained good adherence. In ASPIRE, the ring was 61% effective for women older than 25, only 10% effective for those younger than 25 and showed no efficacy for those 18 to 21.

But interim results from the REACH trial point to a more hopeful conclusion. This Microbicides Trials Network study, launched in February 2019, enrolled 247 adolescent girls and young women aged from 16 to 21 in South Africa, Uganda and Zimbabwe. The average age was 18 and more than a third were 16 or 17. They were not pregnant and were using reliable contraception.

Most of the participants were unmarried and 40% had previously been pregnant. Three-quarters had a secondary school education, with 37% currently in school; about one in five earned an income. Most (89%) reported having a primary sexual partner, 75% were aware of their partner's HIV status and 24% thought their primary partner had other partners. The women had an average of 2.5 sexual partners during the last three months and 35% had one or more sexually transmitted infections at baseline, with chlamydia being most common. While 7% said they were very worried about getting HIV, 39% said they were not at all worried.

The study aimed to assess the safety, adherence, acceptability and preference for the dapivirine ring and oral TDF/FTC. Using a crossover design, one group was randomly assigned to use the ring for six months (one ring per month) then switched to oral PrEP for six months. The second group used the methods in the opposite order. During the final six months, the women used the method of their choice, or neither.

Participants were offered a menu of adherence support including daily text message reminders, weekly check-ins by text or phone, pairing up with another participant as an adherence buddy, support groups and adherence counselling.

Nair presented interim findings after the first two six-month periods; at that point, most of the women (94.4%) had attended all study visits.

Both methods were generally safe and well-tolerated. About a third of participants reported adverse events related to the ring and about half reported side effects related to oral TDF/FTC. However, there were no serious adverse events with either method and no one stopped using the ring or PrEP pills for this reason.

The researchers estimated adherence based on the amount of residual dapivirine left in the returned rings or tenofovir drug levels in dried blood spots. Non-use or minimal use during the first 12 months was very uncommon, Nair said. Half the ring users (50.2%) achieved high use, 45.4% showed evidence of some use and just 4.4% showed no evidence of use. For oral TDF/FTC, the corresponding figures were 58.6% (four or more doses per week), 39.9% (one to three doses per week) and 1.5% (no tenofovir detected).

More news from IAS 2021

In terms of full compliance, however, the ring fared better. Half left the ring in place for a full month compared with less than a quarter who took at least six doses per week of TDF/FTC.

Moreover, the women reported a clear preference for the ring: 88.5% said the ring was acceptable while 63.9% said the same about oral TDF/FTC.

Although the study was not designed to evaluate effectiveness, Nair noted that there was just one new HIV infection, for an incidence rate of 0.5 per 100 person-years.

"Adherence to the ring and oral PrEP was higher than anticipated among African adolescent girls and young women. Both were well-tolerated and highly acceptable," the researchers concluded. "Adherence to both products can be achieved with tailored adherence support."

"What strikes me most about REACH is that not only are we seeing high adherence, but persistence appears to be high as well," said REACH protocol co-chair Professor Connie Celum of the University of Washington in Seattle. "Clearly, the ongoing support and individual attention paid to participants seems to make a difference. To see this kind of high adherence – it's pretty remarkable, especially during this time of COVID-19."

PrEP for pregnant women

A second study by the Microbicides Trial Network, dubbed DELIVER, evaluated the safety of the dapivirine vaginal ring and oral TDF/FTC in pregnant women.

DELIVER enrolled 150 women aged 18 to 40 in Malawi, South Africa, Uganda and Zimbabwe. The median age was 25 and nearly a third had a prior pregnancy. Of these, 101 were randomly assigned to use the monthly ring and 49 to use daily oral PrEP. They started using the methods during late pregnancy (about 36 to 38 weeks of gestation) and continued until delivery. The mothers and infants were then followed-up for six additional weeks.

Professor Bonus Makanani of the Malawi College of Medicine-Johns Hopkins University Research Project presented pregnancy outcomes for 141 participants.

Both prevention methods were found to be safe. Only one severe adverse event (nausea) was deemed related to TDF/FTC. No infants had severe adverse events linked to the methods.

Pregnancy complications were rare, with hypertensive disorders being the most common. Three women in the vaginal ring group and two in the TDF/FTC group had gestational hypertension (high blood pressure), and two in the TDF/FTC arm developed pre-eclampsia. Two women in each group experienced haemorrhage. One woman in the ring group and two in the TDF/FTC group had pre-term deliveries. There was one stillbirth and one newborn death, both in the TDF/FTC arm. These were comparable to the rates seen in other pregnant women at the clinics taking part in the study.

"In this first study of a long-acting HIV prevention agent in pregnancy, adverse pregnancy outcomes and complications were uncommon when the dapivirine vaginal ring and TDF/FTC were used in late pregnancy and were generally similar to rates observed in the communities where the study is being conducted," the researchers concluded. "These data support plans for subsequent investigation of safety among pregnant women using [the] dapivirine vaginal ring earlier in pregnancy."

Subsequent cohorts in the study will include 150 women who will start using the prevention methods at 30 to 35 weeks of gestation and 250 women who will do so starting at 12 to 29 weeks.

References

Nair G et al. Adherence to the dapivirine vaginal ring and oral PrEP among adolescent girls and young women in Africa: interim results from the REACH study. 11th IAS Conference on HIV Science, abstract OALC01LB01, 2021.

Makanani B et al. Prioritizing the evaluation of HIV prevention interventions in pregnancy: Interim results from a randomized, open-label safety trial of dapivirine vaginal ring and oral tenofovir disoproxil fumarate/emtricitabine use in late pregnancy. 11th IAS Conference on HIV Science, abstract PECLB26, 2021.

HIV has changed, but public knowledge and attitudes lag behind

https://www.aidsmap.com/news/jul-2021/hiv-has-changed-public-knowledge-and-attitudes-lag-behind

Mercy Shibemba

30 July 2021

A new report reveals patchy knowledge of HIV, low awareness of key developments like U=U and PrEP, and stigmatising perceptions of people living with HIV. The findings reveal “confusing and contradictory” views about HIV among the general public in the UK.

“The findings were not surprising, a little bit reassuring, but the report has just highlighted what we’ve always known and continue to experience in our daily lives,” commented advocate Rebecca Mbewe at the launch of the report yesterday.

The data comes from a National AIDS Trust and BritainThinks report on public knowledge and attitudes on HIV, which highlights differences across a range of demographic groups in the UK. BritainThinks conducted community stakeholder groups, held exploratory focus groups, conducted a nationally representative online survey of 3000 people and held deep dive focus groups to explore the key themes from the survey responses. They identified six key findings.

1. Most of the public don’t think or hear much about HIV.

Most participants reported feeling that they only ‘occasionally’ heard about HIV. TV programmes and films were reported as the most common way to hear about HIV, although just 21% of the public could recall one. One of the focus group participants shared:

“A lot of the adverts on TV and radio are about mental health and cancer, and don’t really concentrate on this at all. There’s not much awareness or education.”

Around six in ten people reported not having heard anything about HIV in the last six months. The most prominent difference amongst key demographics was that around two-thirds of both south Asian and White people reported that they had not heard anything about HIV, in comparison to 40% of Black people.

2. Knowledge of HIV is patchy amongst the general public.

Awareness of high-risk modes of transmission such as unprotected sex or sharing a syringe is high amongst the general public. However, 57% of the general public have a ‘middling’ knowledge of HIV transmission, commonly identifying at least one mode of transmission that carried no risk at all. The most frequently selected ‘no risk’ modes selected by the public were: standing on a used needle (61%), a blood transfusion in the UK (59%) and biting (36%).

More news from United Kingdom

South Asian people were significantly more likely to have a ‘lower than average’ knowledge of HIV transmission at 56%. Similarly, younger people (35%) and Londoners (32%) were also more likely to be in this category.

Public awareness of U=U is low, with 57% believing it is false that effective treatment prevents transmission of HIV. Few people were aware that most people living with HIV in the UK are on effective treatment and that this reduces transmission risk. Many were worried that U=U relies on people living with HIV consistently taking their treatment. There was a strong sense that it is “too good to be true”, with specific doubts about its real-world efficacy.

“People are not aware whether they can catch it or not catch it. People are not fully experts about this, I don’t think anyone is.”

Only a quarter of the general public believe that there is medicine available that can stop someone acquiring HIV. Awareness of PrEP and U=U was highest among gay and bisexual men and those who know someone living with HIV.

3. HIV continues to be seen as a serious health condition by the public.

Around 48% of the general public think of HIV as a serious health condition. Those most likely to agree were Black men (69%) and south Asian people (56%). However, there was a strong sense among the general public that HIV is a less urgent issue now than it had previously been.

“HIV is not as much of an issue as it used to be for UK society.”

Participants explained feeling this way because of:

• rarely hearing about HIV in the media, particularly in comparison to previous decades
• personally knowing someone living with HIV in the 80s or 90s, but not knowing anyone now
• hearing about advances in treatment for HIV, which mean the condition is now more manageable.

Some focus group participants felt that a ‘new narrative’ around HIV has started to cut through. Participants mentioned recent examples of information and content about HIV (such as the TV drama It’s a Sin) as ways to improve education and address stigma. In particular, depictions in TV and film, and celebrities and influencers talking about HIV, are seen as particularly vivid and engaging formats.

4. Most of the public say they are empathetic towards those living with HIV. However, sympathy and support is often qualified.

Around 85% of the public agree that people living with HIV deserve the same support and respect given to those with other health conditions. Those most likely to agree with this were those who recognise barriers against LGBT people, those with a high or middling knowledge of transmission, and those with a high or medium awareness of PrEP.

There are also key differences in racial demographics, with White and Black people significantly more likely to agree (86% and 88%) than south Asian people (75%). However, only a third of the public say they have sympathy for all people living with HIV, regardless of how they acquired it. Around a quarter of the public agree that a family member telling them that they are living with HIV would negatively impact their relationship with them.

“I think there is a bit of a difference sadly… someone who is born with it, it is out of their control. Someone who has acquired it, is it sex without a condom, or an exchange of bodily fluid, it could be because they’re not protecting themselves.”

5. Stigma towards those living with HIV continues to exist and is felt to be deeply entrenched.

The majority of the public believe society is more positive towards people living with HIV than it has been in the past. However, LGBT people and those who personally know someone living with HIV were most likely to disagree with this statement.

“Everything you hear about HIV is negative. Until they change the narrative, that’s not going to change.”

In the focus groups, many were concerned that people living with HIV are still stigmatised. This belief was particularly strong in the focus groups with south Asian people. Over four fifths of the general public believe that people living with HIV still frequently face negative judgement from others.

Stigma centred around three main themes:

• acquiring HIV is often linked with ‘irresponsible’ behaviours
• low knowledge of transmission routes, treatment and outcomes, leading to negative misassumptions about HIV
• negative attitudes towards LGBT people, who are closely associated with HIV.  

However, many in the focus groups were hesitant to share their unfiltered views about people living with HIV. This indicated a strong element of social desirability.

6. Most of the public say they are uncomfortable with having a sexual relationship with someone living with HIV.

Only 3% of the public indicated that they would be comfortable having a sexual relationship with someone living with HIV. The concerns about this centred on two themes: risk of acquiring HIV, and stigma and judgement from others. A specific focus was the safety of future children, which participants assumed would also acquire HIV.

“People living with HIV should always tell any sexual partners, even if they definitely can’t pass it on because they are on effective treatment.”

A large majority of the public think that people living with HIV should always tell sexual partners their HIV status. Participants expressed that there is a risk to personal health and that people should be able to make an informed decision about whether or not to continue with the relationship or sexual encounter.

However, there was sympathy for people living with HIV and the complexities of having to navigate this. It was recognised that this could be a cause for stress and anxiety and that there could be situations in which personal safety is put at risk because of sharing. 

Knowing key information about HIV decreases some discomfort about relationships with people living with HIV. Some focus group participants felt that key messages such as U=U were important for reducing stigma and that they should be shared more widely. It was felt that that this would encourage people to want to find out more and be more open to the idea of a relationship with someone living with HIV.

“Knowing there’s something that almost eradicates it [makes a difference].”

Speaking at the report launch, Professor Jane Anderson of Fast-Track Cities London said, “This is only the start, we know much more know [now] about what we might need to challenge, which is an important head start.”

References

National AIDS Trust and Fast-Track Cities London. HIV: Public knowledge and attitudes, 
July 2021.