HIV This Week

Collins C, Coates TJ, Szekeres G. Accountability in the global response to HIV: measuring progress, driving change. AIDS. 2008 Suppl 2:S105-111.

Accountability implies that institutions and individuals are answerable for their commitments and responsibilities. The concept of accountability is highly relevant in the global response to HIV because governments, donors and other actors have often failed to keep their commitments to expand funding and service delivery levels. Many governments have not been held accountable for failing to address the HIV-related needs of their populations adequately. Accountability is about more than passing judgement. Effective accountability mechanisms can be powerful tools to improve service delivery by providing constructive assessments and motivating decision makers to avoid negative external critiques. An impressive variety of HIV-related accountability projects have emerged over the past few years, the most prominent being the ongoing monitoring of government compliance with the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment. Other accountability efforts are essential in order to capture perspectives and priorities outside of governments and aid agencies. Many civil society-based accountability projects are now tracking HIV policy, service delivery and funding levels. Collins and colleagues make several suggestions to increase the impact of accountability efforts, including connecting accountability to sustained advocacy, holding multiple actors accountable, continually assessing what measures of success will be most powerful in driving improved outcomes, and supporting and building the capacity of civil society monitoring efforts. They also suggest exploring how the International AIDS Conferences could serve as an expanded platform for accountability.

Editors’ note: Accountability means measuring progress toward goals, commitments, and responsibilities for action at all levels: Accountability is a powerful tool to improve the quality, accessibility, and equitable delivery of services. Thus, accountability is an important social justice issue in the response to HIV. More robust accountability efforts, which build capacity for and stimulate constructive dialogue between health consumers and policy makers while measuring the appropriateness of programme choices, require increased financial and technical support. They are well worth the investment.

Bernstein A. AIDS and the next 25 years. Science. 2008 ; 320(5877):717.

Since HIV was discovered as the cause of AIDS a quarter century ago, over 60 million people have been infected with the virus and over 25 million people have died. These numbers make the result of two “proof of concept” vaccine efficacy trials—the STEP and Phambili trials—extremely disappointing. These results reflect our still-limited knowledge of HIV, its interactions with the human immune system, and the formidable, unprecedented challenges that it poses. But evidence of immunological protection in certain experimental models of HIV in nonhuman primates, and the intriguing observation that a small proportion of HIV-infected individuals (“elite controllers”) can completely suppress the virus for years, suggest that a vaccine may be achievable. More, not less, basic and early-stage clinical research is needed. We need to understand the role of both the innate and adaptive immune responses during HIV infection. We need to make it much more attractive for young researchers, including those from other fields, to enter the HIV vaccine field. And the continued engagement of industry is essential if we are ever to have a vaccine. We know from experience with other pathogens that a vaccine is the best way to stop a virus. The only end for a journey that began 25 years ago should be the development of a safe and effective HIV vaccine.

Editors’ Notes: Disappointment can lead to sober reflection and taking stock of what should remain a firm foundation and what can and should be challenged and changed. HIV has a high degree of sequence diversity and is a phenomenal foe, striking the very cells needed for an effective immune response. The stakes are high- this is not the time to walk away.

A quarter century of scientific discovery has been applied to developing an AIDS vaccine, yet this goal remains elusive. Specific characteristics of the virus, including the extreme genetic variability in circulating viral isolates worldwide, biological properties of HIV that impede immune attack, and a high mutation rate that allows for rapid escape from adaptive immune responses, render this a huge challenge. However, evidence of protection against AIDS viruses in animal models and control of HIV in humans under certain circumstances, together with scientific advances in understanding disease pathogenesis, provide a strong rationale and objective paths to continue the pursuit of an effective AIDS vaccine to stem the global epidemic.

Editors’ Notes: This review explains how the vaccines that work do so, before address ing the unique challenges for the development of an HIV vaccine. These include failure thus far to generate an immunogen to elicit effective neutralising antibodies and to identify the nature of T cell responses that could best contribute to vaccine protection against HIV. Nine critical issues and recommendations for immediate attention are laid out along with a call to pursue an HIV vaccine with greater passion than ever.

Highly active antiretroviral therapy prolongs the life of HIV-infected individuals, but it requires lifelong treatment and results in cumulative toxicities and viral-escape mutants. Gene therapy offers the promise of preventing progressive HIV infection by sustained interference with viral replication in the absence of chronic chemotherapy. Gene-targeting strategies are being developed with RNA-based agents, such as ribozymes, antisense, RNA aptamers and small interfering RNA, and protein-based agents, such as the mutant HIV Rev protein M10, fusion inhibitors and zinc-finger nucleases. Recent advances in T-cell-based strategies include gene-modified HIV-resistant T cells, lentiviral gene delivery, CD8(+) T cells, T bodies and engineered T-cell receptors. HIV-resistant hematopoietic stem cells have the potential to protect all cell types susceptible to HIV infection. The emergence of viral resistance can be addressed by therapies that use combinations of genetic agents and that inhibit both viral and host targets. Many of these strategies are being tested in ongoing and planned clinical trials.

Editors’ note: The plot thickens! Gene therapy could be a stand-alone approach or an adjuvant to drug regimens. However, most people living with HIV today are in settings with insufficient infrastructure to support such technology and viral escape will confound even gene therapy approaches. Several clinical trials testing gene transfer strategies are underway, but don’t hold your breath- this will take some time.

Gorik Ooms, Wim Van Damme, Brook K Baker, Paul Zeitz, Ted Schrecker. The ‘diagonal’ approach to Global Fund financing: a cure for the broader malaise of health systems? Globalization and Health. 2008;4(1):6 [Epub ahead of print].

The potentially destructive polarisation between ‘vertical’ financing ( aiming for disease-specific results) and ‘horizontal’ financing ( aiming for improved health systems) of health services in developing countries has found its way to the pages of Foreign Affairs and the Financial Times. The opportunity offered by ‘diagonal’ financing ( aiming for disease-specific results through improved health systems) seems to be obscured in this polarisation. In April 2007, the board of the Global Fund to fight AIDS, Tuberculosis and Malaria agreed to consider comprehensive country health programmes for financing. The new International Health Partnership Plus, launched in September 2007, will help low-income countries to develop such programmes. The combination could lead the Global Fund to fight AIDS, Tuberculosis and Malaria to a much broader financing scope. This evolution might be critical for the future of AIDS treatment in low-income countries, yet it is proposed at a time when the Global Fund to fight AIDS, Tuberculosis and Malaria is starved for resources. It might be unable to meet the needs of much broader and more expensive proposals. Furthermore, it might lose some of its exceptional features in the process: its aim for international sustainability, rather than in-country sustainability, and its capacity to circumvent spending restrictions imposed by the International Monetary Fund. Ooms and colleagues believe that a transformation of the Global Fund to fight AIDS, Tuberculosis and Malaria into a Global Health Fund is feasible, but only if accompanied by a substantial increase of donor commitments to the Global Fund. The transformation of the Global Fund into a ‘diagonal’ and ultimately perhaps ‘horizontal’ financing approach should happen gradually and carefully, and be accompanied by measures to safeguard its exceptional features.

Editors’ note: The pendulum between vertical and horizontal financing has swung back and forth for decades. Diagonal financing proponents think funding for AIDS treatment and prevention could be the driving wedge for urgently needed increases in the overall level of resources available for health. Such a strategy could seriously affect sustainability of antiretroviral treatment programmes and undermine HIV prevention efforts unless accompanied by significantly increased long-term resource commitments. Otherwise, as the authors suggest, like the rabbit-in-a–hat track, without the rabbit this strategy will fail.

Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008 Mar;23(2):95-100.

Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV is displacing funding for their own concerns. Even organizations dedicated to HIV prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically. This paper attempts to do so by considering donor funding for four historically prominent health agendas - HIV, population, health sector development, and infectious disease control - over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development’s (OECD) Development Assistance Committee, supplemented by data from other sources. Several trends indicate possible displacement effects, including HIV’s rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV control receives in US funding, and HIV aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.

Editors’ note: Although this study considers only aggregate donor funding, does not evaluate national health funding in depth, and does not account for factors influencing funding for other health issues, such as disease burden and effectiveness of advocacy, it will definitely start you thinking. We can only imagine how funding flows might have evolved in a world without AIDS, the so-called ‘counterfactual’ of which economists speak. More in-depth studies are needed to examine the politics of aid provision in high-income countries, interactions among donors themselves, and dynamics in low- and middle-income countries in the context of donor harmonization initiatives and the Three Ones principles that place countries squarely in the driver’s seat.

Lejars M, Pitigoi D, Teleman M, Nicolaiciuc D, Reintjes R. Implementing a second-generation HIV surveillance system in Romania: Experiences and challenges. Wien Klin Wochenschr 2007;119(7-8):242-247.

Romania is a low prevalence country for HIV. Nevertheless, a special epidemiological situation is evolving because of the high percentage of children who were infected by nosocomial transmission between 1986 and 1991 and the consequent increasing number of sexually transmitted cases in adults, in addition to new cases among injecting drug users. In this particular context and with regard to Romania’s accession to EU membership, second-generation surveillance (SGS) systems were to be implemented. Following a SWOT analysis of the existing surveillance system, a National conference, monthly working groups and a workshop for training were organized with concerned people from central level and from six pilot districts. Specialists in epidemiology, infectious diseases, dermato-venerology and health promotion were involved in the process of developing the survey methodologies, which were based on standard protocols. Methods of testing and legal and ethical issues were discussed, especially for illegal or stigmatized behaviours. Based on the specific HIV epidemiology of each district and also for practical reasons, the surveys developed and implemented were: serological and behavioural surveillance at dermato-venerology clinics in two of the selected districts, serological surveillance among patients aged 15-24 admitted to general hospitals in four districts, and behavioural surveillance among high school pupils aged 15-19 in five districts. While implementing SGS, financial and human resource constraints encountered in the development and implementation of the surveys at each location need to be taken into account. One of the most important lessons learnt during this project was the importance of teamwork and co-operation between the epidemiologists and clinicians involved in HIV surveillance. The lessons learned in Romania could be valuable for many regions in Europe.

Editors’ note: Low HIV prevalence countries face a “know your epidemic” challenge which calls for tailoring second generation surveillance strategies. Romania’s approach included a national conference, working groups, and training workshops. Involving members of populations at higher risk of HIV exposure in programme design, implementation and monitoring will be key to ensuring not only that human rights are respected but also that appropriate strategies for reaching out to marginalised populations are designed and implemented.

Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet 2007 Jun 2;369(9576):1883-9.

WHO regulations, dating back to 1951, emphasise the role of expert opinion in the development of recommendations. However, the organisation’s guidelines, approved in 2003, emphasise the use of systematic reviews for evidence of effects, processes that allow for the explicit incorporation of other types of information (including values), and evidence-informed dissemination and implementation strategies. Oxman and colleagues examined the use of evidence, particularly evidence of effects, in recommendations developed by WHO departments. The authors interviewed department directors (or their delegates) at WHO headquarters in Geneva, Switzerland, and reviewed a sample of the recommendation-containing reports that were discussed in the interviews (as well as related background documentation). Two individuals independently analysed the interviews and reviewed key features of the reports and background documentation. The authors found that systematic reviews and concise summaries of findings are rarely used for developing recommendations. Instead, processes usually rely heavily on experts in a particular specialty, rather than representatives of those who will have to live with the recommendations or on experts in particular methodological areas. The authors interpreted in this that progress in the development, adaptation, dissemination, and implementation of recommendations for member states will need leadership, the resources necessary for WHO to undertake these processes in a transparent and defensible way, and close attention to the current and emerging research literature related to these processes.

Editors’ note: This article received a lot of attention in public health circles. Although there are often difficulties in trying to obtain international consensus, it is clear that guidelines from normative agencies such as WHO need to be adapted by countries to their own epidemiological circumstances. For the record, the recommendations from the WHO/UNAIDS convened consultation on male circumcision and HIV in March 2007 were definitely anchored in the results of the three randomised controlled trials in Orange Farm, South Africa; Kisumu, Kenya; and Rakai District, Uganda but other evidence and information also came into play and influenced the recommendations (please see the UNAIDS website or WHO website).

Lalonde B, Wolvaardt JE, Webb EM, Tournas-Hardt A. A process and outcomes evaluation of the international AIDS conference: who attends? Who benefits most? MedGenMed 2007;9:6.

The objective of the study was to conduct a process and outcomes evaluation of the International AIDS Conference (IAC). Reaction evaluation data are presented from a delegate survey distributed at the 2004 IAC held in Thailand. Input and output data from the Thailand IAC are compared to data from previous IACs to ascertain attendance and reaction trends, which delegates benefit most, and host country effects. Outcomes effectiveness data were collected via a survey and intercept interviews. Data suggest that the host country may significantly affect the number and quality of basic science IAC presentations, who attends, and who benefits most. Intended and executed HIV work-related behaviour change was assessed under 9 classifications. Delegates who attended 1 previous IAC were more likely to report behaviour changes than attendees who attended more than 1 previous IAC. The conference needs to be continually evaluated to elicit the required data to plan effective future IACs.

Editors’ note: For those of you who attended the Bangkok International AIDS Society Conference, were you a “behaviour changee”? Or were you just more used to being asked about your work-related HIV behaviour? If it takes three years to analyse the data then Mexico 2008 won’t benefit from the Toronto 2006 delegate survey. Find a way to channel your own views and advice for improvement while there is still time!

Kamau EM. Roll Back Malaria and the new partnership for Africa’s development: Is there potential for synergistic collaboration in partnerships? Afr J Health Sci 2006;13:22-7.

This synopsis seeks to highlight and promote the enormous potential that exists between these two initiatives that seek to address closely related issues and targeting the same populations at risk within a fairly well defined geographical setting. It also attempts to argue that malaria control, just like HIV control, be given high priority in the New Partnership for Africa’s Development (NEPAD) health agenda, as current statistics indicate that malaria is again on the rise. While much attention and billions of dollars have rightly been given to HIV research, treatment and prevention, malaria, and not HIV, is the region’s leading cause of morbidity and mortality for children under the age of five years. This is the bad news. The good news is that unlike HIV, malaria treatment and prevention are relatively cheap. In addition, there is a payback to fighting malaria; support aimed directly at improving health, rather than poverty reduction, may be a more effective way of helping Africa to thrive. Robust and sustained growth may come to Africa through a mosquito net, Artemisinin-based Combination Therapies (ACTs) or a malaria vaccine, rather that a donor’s cheque for economic development initiatives.  

Editors’ note: We need to get out of our silos, strengthen health systems and look holistically at how we can best address malaria, tuberculosis, and HIV to improve Africa’s development prospects.

Wang Y, Collins C, Vergis M, Gerein N, Macq J. HIV/AIDS and TB: contextual issues and policy choice in programme relationships. Trop Med Int Health 2007;12:183-94.

Tuberculosis (TB) and HIV affect each other closely. Given the rapid spread of the HIV-driven TB epidemic worldwide, the case for establishing some form of relationship between control activities for HIV and TB is clear. However, the question ‘how’ has not been resolved satisfactorily. TB and HIV programmes have traditionally maintained their own management, supervision, funding flows and specialist boundaries. This article explores opportunities and challenges for collaboration between the two, through drawing on the expertise in organization and management, policy analysis and disease control of both TB and HIV. Based on an extensive literature review, the article investigates how contextual issues affect the design of a collaboration; what the organizational options are; and what impact a collaboration would have. A universal model for organizational change is unlikely and changes may present as both solutions and contradictions. Careful planning and consultation are required before implementing the changes, in order to avoid jeopardizing the function and effectiveness of both disease control programmes and the health service system.

Editors’ note: The need for close collaboration rather than isolation or even competition in the public health arena has been highlighted in several issues of HIV This Week. March 24^th is World TB Day, a good opportunity to highlight collaborative actions at country, regional and global level!

Simon C, de Lemos G. [UNITAID: an innovative and collective financing system for the fight against malaria, AIDS and tuberculosis]. Med Trop (Mars) 2006;66:583-4.

Malaria, AIDS and tuberculosis cause more than 6 million deaths a year in developing countries. And yet medicines allowing effective treatment either exist already or could be designed in forms adapted to the populations most severely affected by these pandemics (e.g., pediatric antiretroviral formulations suitable for developing countries). Simon and de Lemos describe how by providing sustainable predictable revenues, UNITAID promises to be a powerful tool to respond to the specific needs of developing countries in terms not only of leveraging price reductions but also of developing appropriate drug forms and diagnostic techniques not currently on the market. Stable financing as well as negotiation of large-volume procurement programs for several countries will make it easier for manufacturers to predict requirements and avoid shortages. UNITAID is an independent structure that complements the existing organizations involved in the fight against these pandemics. It intervenes only at the request of beneficiary countries using local human resources and logistics and works to improve the infrastructure facilities whenever necessary.

Bor J. The political economy of AIDS leadership in developing countries: An exploratory analysis. Soc Sci Med 2007 Feb 2; [Epub ahead of print]

The commitment of high-level government leaders is widely recognized as a key factor in curbing national AIDS epidemics. But where does such leadership come from? Bor presents a quantitative analysis of the determinants of AIDS leadership in 54 developing countries, using the 2003 AIDS Program Effort Index “political support” score as an indicator of political commitment. Explanatory variables include measures of political institutions as well as economic development and integration. Models developed in the author’s analysis explain over half of the variation in commitment across the countries in the sample. In particular, the author concludes press freedoms, income equality, and HIV prevalence stand out as determinants of political commitment.

Slutsker L, Marston BJ. HIV and malaria: interactions and implications. Curr Opin Infect Dis 2007;20:3-10.

Slutsker and Marston summarise accumulating evidence of interactions between HIV and malaria and implications related to prevention and treatment of coinfection. HIV-infected persons are at increased risk for clinical malaria; the risk is greatest when immune suppression is advanced. Adults with advanced HIV may be at risk for failure of malaria treatment, especially with sulfa-based therapies. Malaria is associated with increases in HIV viral load that, while modest, may increase HIV progression or the risk of HIV transmission. Cotrimoxazole prophylaxis greatly reduces the risk of malaria in people with HIV; the risk can be further reduced with antiretroviral treatment and the use of insecticide treated mosquito nets. Increased numbers of doses of intermittent preventive (malaria) treatment during pregnancy can reduce the risk of placental malaria in women with HIV. The author concludes that interactions between malaria and HIV have important public health implications. People with HIV should use cotrimoxazole and insecticide treated mosquito nets. Malaria prevention is particularly important for pregnant women with HIV, although more information is needed about the best combination of strategies for prevention. In people with HIV, malaria diagnoses should be confirmed, highly effective drugs should be used for treatment, and possible drug interactions should be considered.

Editors’ note: Less attention has been focused on HIV and malaria than on HIV and tuberculosis but, as this article underscores, interactions can contribute to morbidity and mortality. Preventing malaria and effectively treating it in people living with HIV is important on both the individual and community levels.

Zachariah and colleagues analysed data on newly registered HIV-positive tuberculosis (TB) patients systematically offered ART in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between “cost of transport” and ART acceptance. The authors performed a retrospective cross-sectional analysis on routine programme data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient’s residence. Of 1290 newly registered TB patients, 1003 (78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (X² for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (OR 4.0, 95% CI 2.0-8.1, P<0.001). The authors conclude that ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centres that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.

Editors’ note: Even with antiretroviral treatment and laboratory testing free, out of pocket expenses can have a major impact in hindering uptake of life-prolonging therapies.

Corbett EL, Bandason T, Cheung YB, Munyati S, Godfrey-Faussett P, Hayes R, Churchyard G, Butterworth A, Mason P. Epidemiology of tuberculosis in a high HIV prevalence population provided with enhanced diagnosis of symptomatic disease. PLoS Med 2006;4(1):e22. 10.1371/journal.pmed.0040022

Directly observed treatment short course (DOTS), the global control strategy aimed at controlling tuberculosis transmission through prompt diagnosis of symptomatic smear-positive disease, has failed to prevent rising tuberculosis incidence rates in Africa brought about by the HIV epidemic. However, rising incidence does not necessarily imply failure to control tuberculosis transmission, which is primarily driven by prevalent infectious disease. Corbett and colleagues investigated the epidemiology of prevalent and incident tuberculosis in a high HIV prevalence population provided with enhanced primary health care. Twenty-two businesses in Harare, Zimbabwe, were provided with free smear- and culture-based investigation of tuberculosis symptoms through occupational clinics. Anonymous HIV tests were requested from all employees. After two years of follow-up for incident tuberculosis, a culture-based survey for undiagnosed prevalent tuberculosis was conducted. A total of 6440 of 7478 eligible employees participated. HIV prevalence was 19%. For HIV-positive and -negative participants, the incidence of culture-positive tuberculosis was 25.3 and 1.3 per 1,000 person-years, respectively (RR 18.8, 95% CI 10.3-34.5: population attributable fraction = 78%), and point prevalence after 2 years was 5.7 and 2.6 per 1,000 population (OR 1.7; 95% CI 0.5-6.8: population attributable fraction = 14%). Most patients with prevalent culture-positive tuberculosis had sub-clinical disease when first detected. The authors conclude that strategies based on prompt investigation of tuberculosis symptoms, such as DOTS, may be an effective way of controlling prevalent tuberculosis in high HIV prevalence populations. This may translate into effective control of tuberculosis transmission despite high tuberculosis incidence rates and a period of sub-clinical infectiousness in some patients.

Nu’man J, King W, Bhalakia A, Criss S. A Framework for building organizational capacity integrating planning, monitoring, and evaluation. J Public Health Manag Pract 2007;13(Suppl 1):S24-S32.

HIV prevention organisations are increasingly adopting more intensive and evidence-based strategies with the goal of protecting targeted populations from HIV infection or transmission. Thus, capacity building has moved to the forefront as a set of activities necessary to enable HIV prevention organizations to plan, implement, monitor, and evaluate prevention programs and services. Cost-effective approaches to the provision of capacity building assistance traditionally use strategies that compromise efficaciousness and more intensive approaches can be cost prohibitive. In addition, traditional approaches treat programme planning and implementation and programme monitoring and evaluation as two separate entities, even though they are interdependent aspects of an efficient and effective service delivery system. Nu’man and colleagues describe a framework for building sustainable organisational capacity that combines high- and low-intensity approaches; integrates programme planning, monitoring, and evaluation; and focuses on building understanding of the value of appropriate organisational change. The authors used the described framework over a 3-year period with 52 community-based organisations funded by the Centers for Disease Control and Prevention (CDC) and organizations funded by CDC-funded health departments. The authors describe lessons learned and make recommendations for building long-term sustainability, organisational change at various levels, and the need to develop standardised indicators to measure changes in organisational capacity.

Bogart LM, Thorburn S. Relationship of African Americans’ sociodemographic characteristics to belief in conspiracies about HIV/AIDS and birth control. J Natl Med Assoc 2006;98:1144-50.

Although prior research shows that substantial proportions of African Americans hold conspiracy beliefs, little is known about the subgroups of African Americans most likely to endorse such beliefs. Bogart and Thorburn examined the relationship of African Americans’ socio-demographic characteristics to their conspiracy beliefs about HIV and birth control. Anonymous telephone surveys were conducted with a targeted random-digit-dial sample of 500 African Americans (15-44 years) in the contiguous United States. Respondents reported agreement with statements capturing beliefs in HIV conspiracies (one scale) and birth control conspiracies (two scales). Socio-demographic variables included gender, age, education, employment, income, number of people income supports, number of living children, marital status, religiosity, and black identity. Multivariate analyses indicated that stronger HIV conspiracy beliefs were significantly associated with male gender, black identity and lower income. Male gender and lower education were significantly related to black genocide conspiracy beliefs, and male gender and high religiosity were significantly related to contraceptive safety conspiracy beliefs. The set of socio-demographic characteristics explained a moderately small amount of the variance in conspiracy beliefs regarding HIV (R2 range=0.07-0.12) and birth control (R2 range=0.05-0.09). The authors conclude that findings suggest that conspiracy beliefs are not isolated to specific segments of the African-American population.

Laperriere H, Zuniga R. Sociopolitical determinants of an AIDS prevention program: multiple actors and vertical relationships of control and influence. Policy Polit Nurs Pract 2006;7:125-35

In every country, health and prevention “come down” from the authorities responsible for this mission by way of planners, local authorities, and peer educators until it reaches the target population. International and national systems function on the premise of a top-down transmission, with little room for integrating local information that might provide a better understanding of the implementation process. This analysis is based on an empirical evaluative research of HIV prevention projects with sex workers in a remote area of northern Brazil. It illustrates how nursing socio-political analysis can reveal how political interests can have perverse effects by contaminating the group’s internal relations and with established partnerships, thereby weakening the impact of prevention programmes. These effects can seriously affect community relations and social practices, far beyond the technical division of work and political hierarchies in the socio-sanitary network.