HIV This Week

The impact of HIV scale-up on health systems: A priority research agenda.

Rabkin M, El-Sadr WM, De Cock KM; Bellagio HIV/Health Systems Working Group1. J Acquir Immune Defic Syndr. 2009 Nov;52 Suppl 1:S6-11.

Collaborators: Abrams E, Cahn P, Coovadia H, De Cock KM, Dybul M, El-Sadr W, Freywhot S, Isbell M, Levine R, Melaku Z, Mermin J, Mugyenyi P, Mukherjee J, Perriens J, Rabkin M, Samb B, Sewankambo N, Sinkala M, Weil D, Zewdie D.

Although much has been learned about the implementation of HIV prevention, care, and treatment services in resource-limited settings, the broader impact of the rapid scale-up of HIV programs on fragile health systems has only recently been explored. A high-level working group identified priority research questions regarding the impact of HIV scale-up on key elements of health systems: service delivery; management; information, evidence, and strategic planning; medical products, vaccines, and technologies; health financing and payments; leadership and governance; and the behaviours of providers, consumers, and communities. Rigorous multisectoral studies are needed if HIV program expansion to the millions still needing care and treatment is to continue, and if the synergies between vertically funded HIV programs and the health systems of which they are a part are to be maximized to strengthen nations’ ability to meet all their health challenges.

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Editors’ note: Citing the paucity of rigorous evidence to support a negative or positive impact of HIV scale-up on health systems and the fact that opinion has dominated the debate thus far, this paper lays out 38 priority research questions in 7 categories in what is a forward-looking research agenda. The answers to these questions will guide efforts to maximize the synergies between vertical programmes and the health systems of which they are a part in a ‘diagonal approach’ that attends to both disease-specific and systemic priorities.  

The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.

Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. Health Policy Plan. 2009; 24:239-52.

This paper reviews country-level evidence about the impact of global health initiatives, which have had profound effects on recipient country health systems in middle- and low- income countries. Biesma and colleagues have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President’s Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries’ national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoringand evaluation systems. Sub-national and district studies are needed to assess the degree to which global health initiatives are learning to align with and build the capacities of countries to respond to HIV; whether marginalized populations access and benefit from global health initiatives-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV programmes funded by the global health initiatives. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.

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Editor’s note: Global health initiatives are defined as ‘ a blueprint for financing, resourcing, coordinating and/or implementing disease control across at least several countries in more than one region of the world’. They may be bilateral (e.g. US PEPFAR), multilateral (e.g. World Bank MAP), or public-private partnerships (Global Fund) aid mechanisms. This first systematic review of published and unpublished reports from 2002 to 2007 examines the effects of these three initiatives on national policy; coordination and planning; stakeholder involvement; disbursement, absorptive capacity, and management; monitoring and evaluation; and human resources. It suggests that these initiatives, each with different effects, initially often had negative effects, revealing country system weaknesses. As lessons were learned, the effects on health systems were more positive. The principal recommendations of this review are first, that global health initiatives, recipient donor countries, civil society organisations, and technical agencies alike should engage more fully with the Paris Principles for AIDS Effectiveness. Secondly, country and global policy makers and donors should demand and fund the acquisition of better evidence, including more analytical health policy and health systems evaluation. This article should be very high on your reading list!

Sanjana P, Torpey K, Schwarzwalder A, Simumba C, Kasonde P, Nyirenda L, Kapanda P, Kakungu-Simpungwe M, Kabaso M, Thompson C. Hum Resour Health. 2009 ;7:44.

The human resource shortage in Zambia is placing a heavy burden on the few health care workers available at health facilities. The Zambia Prevention, Care and Treatment Partnership began training and placing community volunteers as lay counsellors in order to complement the efforts of the health care workers in providing HIV counselling and testing services. These volunteers are trained using the standard national counselling and testing curriculum. This study was conducted to review the effectiveness of lay counsellors in addressing staff shortages and the provision of HIV counselling and testing services. Quantitative and qualitative data were collected by means of semistructured interviews from all active lay counsellors in each of the facilities and a facility manager or counselling supervisor overseeing counselling and testing services and clients. At each of the 10 selected facilities, all counselling and testing record books for the month of May 2007 were examined and any recordkeeping errors were tallied by cadre. Qualitative data were collected through focus group discussions with health care workers at each facility. Lay counsellors provide counselling and testing services of quality and relieve the workload of overstretched health care workers. Facility managers recognize and appreciate the services provided by lay counsellors. Lay counsellors provide up to 70% of counselling and testing services at health facilities. The data review revealed lower error rates for lay counsellors, compared to health care workers, in completing the counselling and testing registers. Community volunteers, with approved training and ongoing supervision, can play a major role at health facilities to provide counselling and testing services of quality, and relieve the burden on already overstretched health care workers.

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Editors’ note: Zambia is more than an order-of-magnitude (10 times) below the recommended staff-to-population ratios for nurses (1:700 versus 1:8064) and pharmacists (1:8000 versus 1:473,000), spurring it on to find solutions to this health care bottleneck. A two-week classroom component followed by a four-week supervised practicum and training in finger-prick HIV testing has created a cadre of lay counsellors providing quality services to satisfied clients. Some lay counsellors view reducing stigma and representing community role models as additional responsibilities. The fact that this is a voluntary programme (lay counsellors receive 25USD per month to defray travel costs but no other compensation) may jeopardise its sustainability. Continued supervision of the work of these lay counsellors, along with formalisation of their relationship with health facilities, could enhance both performance and retention. 

Price JE, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care. 2009;21(5):608-14.

With the intensive scale-up of care and treatment for HIV in developing countries, some fear that intensified attention to HIV programmes may overwhelm health care systems and lead to declines in delivery of other primary health care. Few data exist that confirm negative or positive synergies on health care provision generally resulting from HIV-dedicated programs. Using a retrospective observational design Price and colleagues compare aggregate service data in Rwandan health facilities before and after the introduction of HIV care on selected measures of primary health care. The study tests the hypothesis that non-HIV care does not decrease after the introduction of basic HIV care. Overall, no declines were observed in reproductive health services, services for children, laboratory tests, and curative care. Statistically significant increases were found in utilization and provision of some preventive services. Multivariate regression, including introduction of HIV care and two important health care financing initiatives in Rwanda, revealed positive associations of all with observed increases. Introduction of HIV services was especially associated with increases in reproductive health. While hospitalization rates increased for the whole sample, declines were observed at health facilities that offered basic HIV care plus highly active antiretroviral therapy. The authors indicate that their results partially counter fears that HIV programs are producing adverse effects in non-HIV service delivery. Rather than leading to declines in other primary health care delivery, they say their findings suggest that the integration of HIV clinical services may contribute to increases.

Editors’ note: This study of 30 primary health centres that had at least 6 months experience offering basic HIV care, defined as voluntary counselling and testing, prevention of mother-to-child transmission services, and preventive therapy with cotrimoxasole, found positive synergies between HIV care and the delivery of other primary care services, particularly antenatal care. This study would be strengthened by consideration of outcome indicators, such as maternal mortality and incidence of congenital syphilis, rather than solely service utilisation indicators. The changes documented here occurred against a backdrop of two important nationally coordinated health care financing programmes that the researchers did try to take into account– the mutuelle de santé, Rwanda’s nationwide primary health insurance system, and performance based financing of health centres. Both of these programmes would be expected to increase uptake and improve outcomes.

Hanefeld J, Musheke M. What impact do Global Health Initiatives have on human resources for antiretroviral treatment roll-out? A qualitative policy analysis of implementation processes in Zambia. Hum Resour Health. 2009 Feb 10;7(1):8. [Epub ahead of print]

Since the beginning of the 21st century, development assistance for AIDS has increasingly been provided through Global Health Initiatives (GHI), specifically the United States Presidential Emergency Plan for AIDS Relief, the Global Fund to Fight HIV, TB and Malaria and the World Bank Multi-country AIDS Programme. Zambia, like many of the countries heavily affected by HIV in southern Africa, also faces a shortage of human resources for health. The country receives significant amounts of funding from GHIs for the large-scale provision of antiretroviral treatment through the public and private sector. This paper examines the impact of GHIs on human resources for antiretroviral treatment roll-out in Zambia, at national level, in one province and two districts. Hanefeld and Musheke undertook a qualitative policy analysis relying on in-depth interviews with more than 90 policy-makers and implementers at all levels. Findings show that while GHIs do not provide significant funding for additional human resources, their interventions have significant impact on human resources for health at all levels. While GHIs successfully retrain a large number of health workers, evidence suggests that GHIs actively deplete the pool of skilled human resources for health by recruiting public sector staff to work for GHI-funded nongovernmental implementing agencies. The secondment of GHI staff into public sector facilities may help alleviate immediate staff shortages, but this practice risks undermining sustainability of programmes. GHI-supported programmes and initiatives add significantly to the workload of existing public sector staff at all levels, while incentives including salary top-ups and overtime payments mean that antiretroviral treatment programmes are more popular among staff than services for non-focal diseases. Research findings suggest that GHIs need to actively mediate against the potentially negative consequences of their funding on human resources for health. Evidence presented highlights the need for new strategies that integrate retraining of existing staff with longer-term staff development to ensure staff retention. The study results show that GHIs must provide significant new and longer-term funding for additional human resources to avoid negative consequences on the overall provision of health care services and to ensure sustainability and quality of programmes they support.

Editors’ note: Zambia faces a severe shortage in human resources for health with the greatest need being for laboratory technicians, followed by pharmacists, doctors, nurses, and data monitors. There is rapid turnover of staff, high staff absenteeism, and unequal urban-rural distribution. At the time this research was conducted, the only targeted human resource intervention receiving any donor support was the rural retention scheme. Countries should require Global Health Initiatives to conduct human resource impact assessments. It is time to think seriously about the wisdom of addressing public sector human resources needs, in the interest of the long-term sustainability of antiretroviral treatment programmes.

Kiggundu V, Watya S, Kigozi G, Serwadda D, Nalugoda F, Buwembo D, Settuba A, Anyokorit M, Nkale J, Kighoma N, Ssempijja V, Wawer M, Gray RH. The number of procedures required to achieve optimal competency with male circumcision: findings from a randomized trial in Rakai, Uganda. BJU Int. 2009 Apr 17. [Epub ahead of print]

Kiggundu and colleagues set out to assess the number of procedures required to achieve optimal competency (time required for surgery with minimal adverse events) in Rakai, Uganda, and thus facilitate the development of guidelines for training providers, as male circumcision reduces the acquisition of human immunodeficiency virus (HIV) in men and is recommended for HIV prevention. In a randomized trial, 3011 men were circumcised, using the sleeve method, by six physicians who had completed training, which included 15-20 supervised procedures. The duration of surgery from local anaesthesia to wound closure, moderate or severe surgery-related adverse events, and wound healing were assessed in relation to the number of procedures done by each physician. The median age of the patients was 24 years. The number of procedures per surgeon was 20-981. The mean time required to complete surgery was approximately 40 min for the first 100 procedures and declined to 25 min for the subsequent 100 circumcisions. After controlling for the number of procedures there was no significant difference in duration of the surgery by patient HIV status or age. The rate of moderate and severe adverse events was 8.8% (10/114) for the first 19 unsupervised procedures after training, 4.0% for the next 20-99 (13/328) and 2.0% for the last 100 (P for trend, 0.003). All adverse events resolved with management. The completion of more than 100 circumcisions was required before newly trained physicians achieved the optimum duration of surgery. Adverse events were higher immediately after training and additional supervision is needed for at least the first 20 procedures after completing training.

Editors’ note: This is the kind of operational research that will improve service outcomes if its results are now taken on board. They strongly suggest that time pressure should not be placed on newly trained surgeons, who will become more efficient with time in any case, and that they should be supervised for the first 20 circumcisions they perform after training, in addition to periodic supervision for the next 80. This surgical procedure, described in male circumcision circles as ‘minor surgery on a major organ’, warrants the strong emphasis being placed on safety and quality assurance.

Kline MW, Ferris MG, Jones DC, Calles NR, Mizwa MB, Schwarzwald HL, Wanless RS, Schutze GE. The Paeditric AIDS Corps: responding to the African HIV/AIDS health professional resource crisis. Paediatrics. 2009 Jan;123(1):134-6.

Health professional capacity for delivery of HIV care and treatment is severely constrained across sub-Saharan Africa. African health professional expertise in paediatrics is in particularly short supply. Here Kline et al describe a Paediatric AIDS Corps program that was designed to place paediatricians and other physicians in Africa on a long-term basis to expand existing health professional capacity for paediatric and family HIV care and treatment. In the first 2 years of this program, 76 physicians were placed in 5 African countries that have been hit hard by AIDS. Enrolment of HIV-infected children in care more than quadrupled over a 24-month period, to 26 590. The authors believe that this pilot program can serve as a model for larger-scale efforts to immediately expand access for African children and families to life-saving HIV care and treatment.

Editors’ notes: With health professional capacity for delivering HIV treatment and care severely constrained across sub-Saharan Africa, attention has turned to task-shifting to other health cadres, task-sharing which involves parts of procedures or tasks being taken on by different health care providers, recruiting and retaining new health caregivers, and hosting short-term volunteer projects. This programme, responding to the fact that children are underrepresented among patients on antiretroviral treatment in virtually every setting in sub-Saharan Africa, mobilised US graduates of residency training programmes in paediatrics, family medicine, and internal medicine for assignments of a year or longer in Botswana, Lesotho, Swaziland, Malawi, and Burkina Faso. They receive a living stipend, full benefits, a housing allowance, and student loan debt relief. The programme plans its own obsolescence by training local health professionals. Its success in improving paediatric treatment coverage while being locally acceptable will be of interest to many worldwide who would like to contribute in some way to improve the dire situation of the vast majority of the 2 million children living with HIV in Africa.

Kim JC, Askew I, Muvhango L, Dwane N, Abramsky T, Jan S, Ntlemo E, Chege J, Watts C. RADAR, School of Public Health, University of the Witwatersrand, Acornhoek, South Africa. Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study. BMJ. 2009 Mar 13;338:b515.

Although international guidelines specify the central role of the health sector in providing comprehensive care, including HIV post-exposure prophylaxis (PEP), after sexual assault, in both industrialised and developing countries there are many challenges to providing timely and comprehensive services. A nurse-driven model of post-rape care was integrated into existing hospital services; the before and after study design evaluated impacts on quality of care, reviewing 334 hospital charts and conducting interviews with 16 service providers and 109 patients in a 450-bed district hospital in rural South Africa. The key measures for improvement examined were quality of care after rape (forensic history and examination, provision of emergency contraception, prophylaxis for sexually transmitted infections, referrals); provision of HIV counselling and testing and provision and completion of full 28 day course of PEP; and service utilisation (number of service providers seen on first visit and number of rape cases presenting to hospital per month). After completing baseline research, Kim and colleagues introduced a five-part intervention model, consisting of a sexual violence advisory committee, hospital rape management policy, training workshop for service providers, designated examining room, and community awareness campaigns. Existing services had been fragmented and of poor quality. After the intervention, there were considerable improvements in clinical history and examination, pregnancy testing, emergency contraception, prophylaxis for sexually transmitted infections; HIV counselling and testing, PEP, trauma counselling, and referrals. Completion of the 28-day course of PEP drugs increased from 20% to 58%. The authors conclude that it is possible to improve the quality of care after sexual assault, including HIV prophylaxis, within a rural South African hospital at modest cost, using existing staff. With additional training, nurses can become the primary providers of this care.

Editors’ note: Refentse means ‘we shall overcome’ in Venda, the language of this rural South African area and that is exactly what these investigators aimed to do. Aside from immediate genital and bodily injuries, sexual violence brings risks of HIV and sexually transmitted disease, unwanted pregnancy, urinary tract infections, chronic pelvic pain, miscarriage, depression, substance abuse, post-traumatic stress disorder, and suicide. They used formative research to conduct a baseline assessment with providers and patients to define problems and design a strategy for change. The process and its positive findings are an example for managers and providers of sexual assault care, but also of other services, who are keen to embark on a transparent, participatory process to improve their programme outcomes.

Fritts M, Crawford CC, Quibell D, Gupta A, Jonas WB, Coulter ID, Andrade A. Traditional Indian medicine and homeopathy for HIV/AIDS: a review of the literature. AIDS Res Ther. 2008;5(1):25.

India ranks third in the world in absolute burden of HIV. While increasing numbers of Government-sponsored clinics are providing free antiretroviral therapy, its utility is limited by lack of affordability and acceptability and the requirement for lifelong administration. Allopathic practitioners in India are outnumbered by practitioners of traditional Indian medicine and homeopathy, which is used by two-thirds of its population in rural areas to help meet its primary health care needs. However, little is known about traditional Indian medicine and homeopathy use, safety or efficacy in HIV management. These data suggest that India’s community-based, culturally-relevant traditional Indian medicine and homeopathy system, which is one of the largest indigenous medical systems in the world, remains an untapped ally in the fight against its HIV epidemic. The purpose of this review was to assess the quality of peer-reviewed, published literature on traditional Indian medicine and homeopathy for HIV treatment and care. Of 160 original articles reviewed, 19 laboratory studies, 17 clinical studies and six previous reviews of the literature were identified that covered at least one system of traditional Indian medicine and homeopathy, which includes Ayurveda, yoga, naturopathy, Unani medicine, and Siddha medicine and homeopathy. Most studies examined either Ayurvedic or homeopathic treatments. Only four of these studies were randomized controlled trials, and only 10 were published in MEDLINE-indexed journals. Overall, the studies reported positive effects and even cure and reversal of HIV infection, but frequent design flaws call into question their internal and external validity. Common reasons for poor methodological quality included lack of details on products and their standardization, small sample sizes, selection of inappropriate or weak outcome measures, and incomplete reporting of study results. This review exposes a broad gap between the widespread use of traditional Indian medicine and homeopathy therapies for HIV, and the dearth of high-quality data supporting their effectiveness and safety. In light of the suboptimal effectiveness of vaccines, antiretroviral treatment, barrier methods, and behaviour change strategies for prevention and cure of HIV infection, it is both important and urgent to develop a rigorous research agenda that uses innovative methodologies to investigate, evaluate, and maximize the role of traditional Indian medicine and homeopathy in managing HIV and associated illnesses in India.

Editors’ note: This review presents an interesting overview of the history and principles of each system of traditional Indian medicine and homeopathy and highlights the current antiretroviral treatment gap, before summarising the results of in vitro, in vivo, and clinical studies of the impact of traditional Indian medicine and homeopathy on HIV. While yoga and healthy diet are considered beneficial by most people, the use of herbal preparations and homeopathic treatments for tuberculosis and HIV in the absence of data on effectiveness is concerning. Both the paucity of evidence and the use of these therapies by significant numbers of people living with HIV call for systematic assessment of the potential benefits and potential harms of traditional Indian medicine and homeopathy. Increased cross-training between traditional medicine and allopathic (modern) practitioners and development of a collaborative research agenda for studies using rigorous methodologies hold the promise of improved patient outcomes.

Tonwe-Gold and colleagues describe a family-focused approach to HIV care and treatment and report on the first 2 years experience of implementing the mother-to-child transmission (MTCT)-plus program in Abidjan, Côte d’Ivoire. The MTCT-plus initiative aims to enrol HIV-infected pregnant and postpartum women in comprehensive HIV care and treatment for themselves and their families. Between August 2003 and August 2005, 605 HIV-infected pregnant or postpartum women and 582 HIV-exposed infants enrolled. Of their 568 male partners reported alive, 52% were aware of their wife’s HIV status and 30% were tested for HIV; 53% of these tested partners were found to be HIV-infected and 78% enrolled into the program. Overall only 10% of the women enrolled together with their infected partner. On the other hand, the program involved half of the seronegative men who came for voluntary counselling and testing in the care of their families. Of 1624 children <15 years reported alive by their mothers (excluding the last newborn infants of the most recent pregnancy systematically screened for HIV), only 10.8% were brought in for HIV testing, of whom 12.3% were found to be HIV-infected. With respect to lessons learned and challenges, the authors conclude that this family-focused model of HIV care pays attention to the needs of families and household members. The program was successful in enrolling HIV women, their partners and infants in continuous follow-up. However engaging partners and family members of newly enrolled women into care involves numerous challenges such as disclosure of HIV status by women to their partners and family members. Further efforts are required to understand barriers for families accessing HIV services as strategies to improve partner involvement and provide access to care for other children in the households are needed in this West African urban setting.

Editors’ note: Nondisclosure was the major factor limiting this family-centred programme in two poor urban Abidjan slums experiencing multiple unfavourable social and political conditions. The cascade of effort deployed to engage partners resulted in 30% having HIV testing and counselling, however only 69 of the estimated 300 men likely to have HIV infection enrolled in the programme. Testing was also an entry point for seronegative men to participate in adherence support sessions for their family members and attend peer support groups. Recognizing that the immediate environment has a direct impact on an individual’s ability to promote his or her own health, the innovative MTCT-plus model of care starts with pregnant women as the entry point to HIV care and services for the whole family.

Zachariah R, Ford N, Philips M, S Lynch, Massaquoi M, Janssens V, Harries AD. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2008 Nov 5. [Epub ahead of print]

Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions, and low motivation. In particular, the burden of HIV has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières’ experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition; and international ‘brain drain’. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance; and preventing deaths of health workers from HIV. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.

Editors’ note: Given that an estimated 2.4 million doctors and nurses are needed to meet the Millennium Development Goals, it is no surprise that increasing attention has turned to task shifting, a concept dating back decades. This excellent review provides examples to highlight the opportunities and challenges of task shifting in HIV care in sub-Saharan Africa. It lays out the main operational research priorities (quality, safety, acceptability, cost, management, and impact) to obtain data for decision-making to improve task shifting outcomes iteratively.

The tenets of fuzzy trace theory are summarized with respect to their relevance to health and medical decision making. Illustrations are given for HIV prevention, cardiovascular disease, surgical risk, genetic risk, and cancer prevention and control. A core idea of fuzzy trace theory is that people rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decision making. This idea explains why precise information (e.g., about risk) is not necessarily effective in encouraging prevention behaviours or in supporting medical decision making. People can get the facts right, and still not derive the proper meaning, which is key to informed decision making. Getting the gist is not sufficient, however. Retrieval (e.g., of health-related values) and processing interference brought on by thinking about nested or overlapping classes (e.g., in ratio concepts, such as probability) are also important. Theory-based interventions that work (and why they work) are presented, ranging from specific techniques aimed at enhancing representation, retrieval, and processing to a comprehensive intervention that integrates these components.

Editors’ note: An interesting read, this paper presents fuzzy trace theory assumptions of how health information is mentally represented, retrieved, and processed in decision–making and subsequent behaviour. Verbatim facts (including graphs, numbers, pictures, literal information, etc.) are less likely to influence judgment and decision-making than are gist representations (subjective, qualitative interpretations of information based on emotion, education, culture, previous experience, worldview, and level of development). Risk reduction interventions based on fuzzy trace theory build capacity for automatic responses to contextual cues that signal risk (rather than deliberative thinking), retrieval of core values and principles relevant in risky contexts, and their application to make healthy decisions. Do you get the gist?

Rankin SH, Lindgren T, Kools SM, Schell E. The condom divide: disenfranchisement of Malawi women by church and state. J Obstet Gynecol Neonatal Nurs. 2008;37(5):596-604; quiz 604-6.

Rankin and colleagues examined the impact of 2 mitigating social institutions, religious organizations, and the state, on Malawi women’s vulnerability to HIV. In-depth interviews with a purposive sample of 40 central leaders from 5 faith-based organizations in Malawi were recorded and transcribed as part of an on-going larger study. Qualitative description was used to identify themes and categories. The study took place in primarily urban and periurban areas of south-central Malawi. A minimum of 6 leaders from each faith-based organization were interviewed; the mean age of the primarily male (68%) participants was 44 years (range 26-74). Analysis of religious leaders’ messages about HIV produced an overarching theme, the condom divide, which conceptualized the divergence between faith-based organizations and the state’s prevention messages related to HIV prevention strategies. The authors conclude that faith-based organizations have « demonized » state messages about condoms as promoting sin. The faith-based organizations’ insistence on abstinence and faithfulness leaves women with few options to protect themselves. As socially conscious citizens of the world, nurses can increase the responsiveness to the disparate levels of suffering and death in countries like Malawi.

Editors’ note: Whereas the Malawi government has broken the silence about sexual behaviours and their contributions to the HIV epidemic and is actively involved in HIV prevention, faith-based organisations in this country in which religion plays an important role are lagging behind. About 55% of the population is Protestant, 20% Catholic, and 15% Muslim, while 10% practice African traditional religions. This study of 40 religious leaders representing 5 faith-based organisations (3 mainstream Christian, 1 indigenous Pentecostal, and 1 Muslim) revealed that religious leaders, who are uniquely positioned to champion HIV prevention across Malawi, have largely refused or been reluctant to do so. Condoms are condemned except for discordant couples and there is little acknowledgement that the disadvantaged position of women along with double standards for sexual behaviour place women at heightened risk of HIV exposure. A human rights-public health approach that respects the right of everyone to sound scientific evidence to preserve health and encourages everyone to act responsibly would be a synergistic contribution that religious organisations could make now to the AIDS response in Malawi.

Ladenheim D, Horn O, Werneke U, Phillpot M, Murungi A, Theobald N, Orkin C. Potential health risks of complementary alternative medicines in HIV patients. HIV Med. Volume 9, Issue 8, Pages: 653-659

The objective of this study was to determine the prevalence and purpose of complementary alternative medicines use in people receiving treatment for HIV infection. To identify and quantify potential health risks of complementary alternative medicines use in this population and to explore options for improved pharmacovigilance. A cross-sectional questionnaire survey of 293 patients receiving antiretroviral (ARV) therapy at three specialist HIV out-patient clinics in central London, UK was conducted. The use of herbal medicines and supplements was explored, and potentially adverse side effects or significant drug interactions with conventional therapies were identified. Of the 293 patients included, 61% (n=179) were taking herbal remedies or supplements and 35% (n=103) were using physical treatments. Twenty-seven per cent (n=80) used a combination of both. Twenty per cent (n=59) potentially compromised their HIV management through using complementary alternative medicines therapy. Ten per cent (n=29) were advised to stop their complementary alternative medicines and 15% (n=43) were made aware of potential drug interactions and adverse effects and were advised to monitor their care. There are potentially significant health risks posed by the concomitant use of complementary alternative medicines in patients taking ARV therapy. Medical practitioners need to be able to identify complementary alternative medicine use in HIV-positive patients and recognize potential health risks. Patients should be encouraged to disclose CAM use to their clinicians and other healthcare professionals.

Editors’ note: Many patients living with chronic illnesses and their associated physical and psychological problems use alternative medicines. This study found potentially serious health risks in patients living with HIV, of whom 20% received warnings and 10% were advised to stop their alternative medicines. Some people were at risk of adverse reactions to them while others risked antiretroviral drug side effects or sub-therapeutic drug levels due to possible interference with the cytochrome P metabolism system used by protease inhibitors and non-nucleoside reverse transcriptase inhibitors.

Peltzer K, Preez NF, Ramlagan S, Fomundam H. Use of traditional complementary and alternative medicine for HIV patients in KwaZulu-Natal, South Africa. BMC Public Health. 2008;8:255.

Traditional medicine use has been reported is common among individuals with moderate and advanced HIV disease. The aim of this cross-sectional study was to assess the use of traditional complementary and alternative medicine for HIV patients prior to initiating antiretroviral therapy in three public hospitals in KwaZulu-Natal, South Africa. Using systematic sampling, 618 HIV-positive patients were selected from outpatient departments from three hospitals and interviewed with a questionnaire. Traditional complementary and alternative medicine was commonly used for HIV in the past six months by study participants (317, 51.3%) and herbal therapies alone (183, 29.6%). The use of micronutrients (42.9%) was excluded from traditional complementary and alternative medicine since mostly vitamins were provided by the health facility. Herbal therapies were the most expensive, costing on average 128 Rand (US$16) per patient per month. Most participants (90%) indicated that their health care provider was not aware that they were taking herbal therapies for HIV (90%). Herbal therapies were mainly used for pain relief (87.1%) and spiritual practices or prayer for stress relief (77.6%). Multivariate logistic regression with use of herbs for HIV as the dependent variable identified being on a disability grant and fewer clinic visits to be associated with use of herbs, and traditional complementary and alternative medicine use for HIV identified being on a disability grant, number of HIV symptoms and family members not contributing to main source of household income to be associated with traditional complementary and alternative medicine use. Traditional herbal therapies and traditional complementary and alternative medicine are commonly used by HIV treatment naïve outpatients of public health facilities in South Africa. Health care providers should routinely screen patients on traditional complementary and alternative medicine use when initiating ART and also during follow-up and monitoring keeping in mind that these patients may not fully disclose other therapies.

Editors’ note: This study revealed that treatment naive HIV patients in South Africa use a variety of traditional herbal therapies and other complementary/alternative medicines that they may be reticent to discuss fully with their care providers and that may negatively affect household income. Creating trust and involving patients more in treatment decision-making processes may help determine which aspects of their alternative treatment can be safely incorporated into their medical regimen.

Remien RH, Berkman A, Myer L, Bastos FI, Kagee A, El-Sadr WM. Integrating HIV care and HIV prevention: legal, policy and programmatic recommendations. AIDS. 2008; Suppl 2:S57-65.

Since the start of the HIV epidemic we have witnessed significant advances in our understanding of the impact of HIV disease worldwide. Furthermore, breakthroughs in treatment and the rapid expansion of HIV care and treatment programmes in heavily affected countries over the past 5 years are potentially critical assets in a comprehensive approach to controlling the continued spread of HIV globally. A strategic approach to controlling the epidemic requires continued and comparable expansion and integration of care, treatment and prevention programmes. As every new infection involves transmission, whether vertically or horizontally, from a person living with HIV, the integration of HIV prevention into HIV care settings has the potential to prevent thousands of new infections, as well as to improve the lives of people living with HIV. In this paper, Remien and colleagues highlight how to better utilize opportunities created by the antiretroviral roll-out to achieve more effective prevention, particularly in sub-Saharan Africa. The authors offer specific recommendations for action in the domains of healthcare policy and practice in order better to utilize the advances in HIV treatment to advance HIV prevention.

Editors’ note: Control of the global HIV epidemic remains elusive with poor coordination, underutilisation of effective interventions to slow the epidemic, and suboptimal expansion of prevention, treatment, care, and support programmes. This paper reviews some basic biological, epidemiological, and behavioural concepts that underpin potential synergies between care/treatment programmes and effective prevention. Failure to retain patients in care and failure to support high levels of adherence in those on antiretroviral therapy have negative consequences for both individuals and for public health. Integration of HIV prevention into HIV care and treatment programmes for people living with HIV is a key strategy advocated here.

Kidorf M, King VL. Expanding the public health benefits of syringe exchange programs. Can J Psychiatry. 2008 Aug;53(8):487-95.

The objective of this study is to provide a brief history of community syringe exchange programmes, describe the clinical profile of those who attend them, identify factors interfering with the transition of syringe exchange programmes participants to more comprehensive substance abuse treatment services, review studies designed to improve rates of treatment seeking, and offer practical suggestions to facilitate links between syringe exchange programmes and substance abuse treatment. Relevant articles were identified using a PubMed literature search of English-language journals from 1997 to 2007. Studies were included that evaluated the effectiveness of syringe exchange programmes or methods for increasing treatment enrolment in syringe exchange programme participants or other out-of-treatment intravenous drug users. Relevant articles prior to 1997 were identified using reference lists of identified articles. Syringe exchange programmes have little impact on rates of drug use or injections. Substance abuse treatment reduces human immunodeficiency virus transmission through drug use reduction and psychosocial functioning improvement, yet syringe exchange programme participants only infrequently engage in treatment. Psychological and pharmacological interventions delivered at the syringe exchange programme setting can improve treatment seeking in syringe exchange programme participants. Use of syringe exchange programmes by substance abuse treatment programs can improve harm-reduction efforts at these settings. Kidorf and colleagues concluded that efforts to improve the link between syringe exchange programmes and substance abuse treatment should include interventions to enhance cooperation across programs, motivate treatment enrolment and syringe exchange programme use, and expand access to treatment. A more fluent and bidirectional continuum of services can enhance the public health benefits of both of these health care delivery settings.

Editors’ note: Community-based syringe exchange programmes and substance use treatment programmes share a common goal – reducing the harm associated with substance use disorder – but they function as independent silos. Conceptualising them as part of a continuum of therapeutic harm reduction services can strengthen the connections between them. Syringe exchange programmes tend to draw in hard-to-reach drug users, who have a more severe spectrum of drug use and may become motivated for treatment. Drug users that are responding poorly to substance use treatment need to be encouraged to participate in community syringe exchange programmes.

Kaboru BB, Muchimba M, Falkenberg T, Höjer B, Faxelid E; The Bridging Gaps Research Team. Quality of STIs and HIV/AIDS care as perceived by biomedical and traditional health care providers in Zambia: Are there common grounds for collaboration? Complement Ther Med. 2008 Jun;16(3):155-162.

Kaboru and colleagues aimed to explore biomedical and traditional health care providers’ perceptions of good quality of care and opinions on weaknesses in the services they provide to patients with HIV and other sexually transmitted infections. Using data from a cross-sectional survey, the authors post-coded two open-ended questions related to biomedical and traditional health care providers’ perceptions on good quality of care and on provided care. The post-coding was done following Donabedian’s framework of assessment of quality of care and allowed transformation of qualitative data into quantitative. The analysis is based on comparison of frequencies, proportions, and subsequent chi-square tests and odds ratios. The study set in Ndola and Kabwe, Zambia measured proportions of responses from 152 biomedical and 144 traditional health care providers. Substantial proportions of providers from both sectors perceived drugs availability (63% of biomedical and 70% of traditional health care providers) and welcoming attitude (73% of biomedical and 64% of traditional health care providers) as important components of good quality care. Biomedical health care providers were more likely than traditional health care providers to mention proper examination, medical management (provider’s technical ability) and explanation of causes and prognosis of the disease as important. More traditional health care providers than biomedical ones cited short waiting time and cost of care. A majority of biomedical health care providers (87%) and of traditional health care providers (80%) reported deficiencies in their sexually transmitted infection- and HIV-related services. Both groups regarded training of providers and nutritional support and health education to patients as lacking. None of the traditional health care providers alluded to voluntary counselling and testing or supportive/home-based care as aspects needing improvement. Drugs availability and welcoming attitude were two aspects of quality highly valued by biomedical and traditional health care providers. Future collaborative interventions need to respond to aspects of joint concern including training of providers, nutritional support, and health education to patients. Further, there is an imperative of expanding and adapting voluntary counselling and testing, home-based care and palliative care to traditional health care providers for better care of HIV and other sexually transmitted infections.

Editors’ note: This study comparing the views of both traditional and biomedical care providers provides food for thought on how to improve quality of care for patients who access either or both types of providers. Better collaboration for joint health action in the community could reduce drug interactions, decrease costs for patients, and enhance the comparative contribution of each type of provider.

Continued political and civil unrest in low-resource countries underscores the ongoing need for specialised reproductive health services for displaced people. Displaced women particularly face high maternal mortality, unmet need for family planning, complications following unsafe abortion, and gender-based violence, as well as sexually transmitted diseases, including HIV. Relief and development agencies and UN bodies have developed technical materials, made positive policy changes specific to crisis settings and are working to provide better reproductive health care. Substantial gaps remain, however. The collaboration within the field of reproductive health in crises is notable, with many agencies working in one or more networks. The five-year RAISE Initiative brings together major United Nations agencies and non-governmental organisations from the fields of relief and development, and builds on their experience to support reproductive health service delivery, advocacy, clinical training and research. The readiness to use common guidance documents, develop priorities jointly and share resources has led to smoother operations and less overlap than if each agency worked independently. Trends in the field, including greater focus on internally displaced persons and those living in non-camp settings, as well as refugees in camps, the protracted nature of emergencies, and an increasing need for empirical evidence, will influence future progress.

Editors’ note: The RAISE (Reproductive Health Access, Information, and Services in Emergencies) Initiative is a partnership with a long-term perspective (2006-2011) of Columbia University and Marie Stopes International with United Nations, humanitarian, and development organisations. RAISE and other networks arose from the collaborative work of 40 UN, government, and non-governmental organisations that formed the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) in 1995. Since collaborative work across this field has been long lasting and productive, it is useful to examine what underpinned both the trends and key advances.

Rosen S, Fox MP, Gill CJ. Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review. PLoS Med. 2007;4(10):e298.

Long-term retention of patients in Africa’s rapidly expanding antiretroviral therapy programmes for HIV is essential for these programmes’ success but has received relatively little attention. In this paper Rosen and colleagues present a systematic review of patient retention in antiretroviral therapy programmes in sub-Saharan Africa. They searched Medline, other literature databases, conference abstracts, publications archives, and the "grey literature" (project reports available online) between 2000 and 2007 for reports on the proportion of adult patients retained (i.e., remaining in care and on antiretroviral therapy) after 6 months or longer in sub-Saharan African, non-research antiretroviral therapy programs, with and without donor support. Estimated retention rates at 6, 12, and 24 months were calculated and plotted for each program. Retention was also estimated using Kaplan-Meier curves. In sensitivity analyses the authors considered best-case, worst-case, and midpoint scenarios for retention at 2 years; the best-case scenario assumed no further attrition beyond that reported, while the worst-case scenario assumed that attrition would continue in a linear fashion. The authors reviewed 32 publications reporting on 33 patient cohorts (74,192 patients, 13 countries). For all studies, the weighted average follow-up period reported was 9.9 months, after which 77.5% of patients were retained. Loss to follow-up and death accounted for 56% and 40% of attrition, respectively. Weighted mean retention rates as reported were 79.1%, 75.0% and 61.6% at 6, 12, and 24 months, respectively. Of those reporting 24 months of follow-up, the best program retained 85% of patients and the worst retained 46%. Attrition was higher in studies with shorter reporting periods, leading to monthly weighted mean attrition rates of 3.3%/month, 1.9%/month, and 1.6%/month for studies reporting to 6, 12, and 24 months, respectively, and suggesting that overall patient retention may be overestimated in the published reports. In sensitivity analyses, estimated retention rates ranged from 24% in the worse case to 77% in the best case at the end of 2 years, with a plausible midpoint scenario of 50%. Since the inception of large-scale antiretroviral therapy access early in this decade, antiretroviral therapy programs in Africa have retained about 60% of their patients at the end of 2 years. Loss to follow-up was the major cause of attrition, followed by death. Better patient tracing procedures, better understanding of loss to follow-up, and earlier initiation of antiretroviral therapy to reduce mortality are needed if retention is to be improved. Retention varies widely across programmes, and programmes that have achieved higher retention rates can serve as models for future improvements.

Editors’ note: An estimated half of people starting antiretroviral treatment in Africa in programmes that publish their results are no longer receiving treatment after two years. Starting treatment earlier to prevent mortality and concerted efforts to discover and remedy the conditions that lead people to drop out of programmes are obvious first steps. Sharing what works in patient monitoring and tracing, as well as in overcoming transport, nutritional, financial, and other barriers, is urgently needed.

Toure S, Kouadio B, Seyler C, Traore M, Dakoury-Dogbo N, Duvignac J, Diakite N, Karcher S, Grundmann C, Marlink R, Dabis F, Anglaret X; Aconda Study Group. Rapid scaling-up of antiretroviral therapy in 10,000 adults in Côte d’Ivoire: 2-year outcomes and determinants. AIDS. 2008;22(7):873-82.

Toure and colleagues aimed to assess the rates and determinants of mortality, loss to follow-up, and immunological failure in a nongovernmental organization-implemented program of access to antiretroviral treatment in Côte d’Ivoire. In each new treatment center, professionals were trained in HIV care, and a computerized data system was implemented. Individual patient and programme level determinants of survival, loss to follow-u,p and immunological failure were assessed by multivariate analysis. Between May 2004 and February 2007, 10,211 patients started antiretroviral treatment in 19 clinics (median pre-antiretroviral treatment CD4 cell count, 123 cells/microl; initial regimen zidovudine-lamivudine-efavirenz, 20%; stavudine-lamivudine-efavirenz, 22%; stavudine-lamivudine-nevirapine, 52%). At 18 months on antiretroviral treatment, the median gain in CD4 cell count was +202 cells/microlitre, the probability of death was 0.15, and the probability of being loss to follow-up was 0.21. In addition to the commonly reported determinants of impaired outcomes (low CD4 cell count, low BMI, low haemoglobin, advanced clinical stage, old age and poor adherence), two factors were also shown to independently jeopardize prognosis: male sex (men vs. women: hazard ratio = 1.52 for death, 1.27 for loss to follow-up, 1.31 for immunological failure); and attending a recently opened clinic (inexperienced vs. experienced centers: hazard ratio = 1.40 for death, 1.58 for loss to follow-up). None of the three outcomes was associated with the drug regimen. In this rapidly scaling-up program, survival and immune reconstitution were good; women and patients followed up in centers with longer experience had better outcomes; and outcomes were similar in zidovudine/stavudine-based regimens and in efavirenz/nevirapine-based regimens. Decreasing the rate of loss to follow-up should now be the top priority in antiretroviral treatment rollout.

Editors’ note: An easy-to-manage computerized data monitoring system in 10 mostly primary health care units provided real-time indicators of numbers of patients in care and their treatment progress. Male sex was associated with immunological failure, mortality, and higher rates of programme withdrawal, suggesting that these are interlinked. Experienced centres should be twinned with new treatment centres for assistance in monitoring and improving the economical, managerial, logistical, and organizational characteristics that influence patient outcomes.

The ART-LINC Collaboration of the International Databases to Evaluate AIDS (IeDEA). Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America. Trop Med Int Health. 2008;13(7):870-9

The collaboration set out to describe temporal trends in baseline clinical characteristics, initial treatment regimens, and monitoring of patients starting antiretroviral therapy in resource-limited settings. The collaborators analysed data from 17 antiretroviral therapy programmes in 12 countries in sub-Saharan Africa, South America and Asia.  Patients aged 16 years or older with documented date of start of highly active antiretroviral therapy were included. Data were analysed by calculating medians, interquartile ranges and percentages by regions and time periods. Not all centres provided data for 2006 and therefore 2005 and 2006 were combined. A total of 36 715 patients who started antiretroviral therapy 1996-2006 were included in the analysis. Patient numbers increased substantially in sub-Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005-2006. In South America 20 regimes were used in 2005-2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/mul (interquartile range 53-194) in 2005-2006 in Africa, 134 cells/mul (interquartile range 72-191) in Asia, and 197 cells/mul (interquartile range 61-277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/mul in 2005-2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/mul in Africa, 65 cells/mul in Asia and 10 cells/mul in South America. In 2005-2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America.  Corresponding figures for 6-month CD4 cell counts were 74%, 77% and 81%.  The public health approach to providing ART proposed by the World Health Organization has been implemented in sub-Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV-infected men.

Editors´note: This database of HIV-infected patients followed clinically in resource-limited settings permits valuable analyses of trends over time in the scale-up of the public health approach to antiretroviral treatment. Standardised first-line and second-line regimens, simplified decision making, and standardised clinical and laboratory monitoring are key features of this approach. Although patients in South America are starting on treatment with less severe immunodeficiency, the majority of African and Asian patients are starting late, which has important implications both for early mortality and for more rapid disease progression.

Hallett TB, Gregson S, Dube S, Garnett GP. The Impact of Monitoring HIV Patients Prior to Treatment in Resource-Poor Settings: Insights from Mathematical Modelling. PLoS Med. 2008;5(3):e53

The roll-out of antiretroviral treatment in developing countries concentrates on finding patients currently in need, but over time many HIV-infected individuals will be identified who will require treatment in the future. Hallett and colleagues investigated the potential influence of alternative patient management and antiretroviral treatment initiation strategies on the impact of antiretroviral treatment programmes in sub-Saharan Africa. They developed a stochastic mathematical model representing disease progression, diagnosis, clinical monitoring, and survival in a cohort of 1,000 hypothetical HIV-infected individuals in Africa. If individuals primarily enter antiretroviral treatment programmes when symptomatic, the model predicts that only 25% will start treatment and, on average, 6 life-years will be saved per person treated. If individuals are recruited to programmes while still healthy and are frequently monitored, and CD4(+) cell counts are used to help decide when to initiate antiretroviral treatment, three times as many are expected to be treated, and average life-years saved among those treated increases to 15. The impact of programmes can be improved further by performing a second CD4(+) cell count when the initial value is close to the threshold for starting treatment, maintaining high patient follow-up rates, and prioritising monitoring the oldest (>/= 35 y) and most immune-suppressed patients (CD4(+) cell count </= 350). Initiating antiretroviral treatment at higher CD4(+) cell counts than the World Health Organization recommends leads to more life-years saved, but disproportionately more years spent on antiretroviral treatment. The authors conclude that the overall impact of antiretroviral treatment programmes will be limited if rates of diagnosis are low and individuals enter care too late. Frequently monitoring individuals at all stages of HIV infection and using CD4 cell count information to determine when to start treatment can maximise the impact of ART.

Editors´note: This modelling work demonstrates that measuring CD4 cells frequently will save more life-years because it can trigger the start of antiretroviral treatment before the immune system is irreversibly damaged. In resource-limited settings, more life years can be saved per year on antiretroviral treatment by frequent CD4 cell count measurements. Therefore, there are strong arguments in favour of improved patient monitoring even before treatment initiation.

Nilmanat K, Street AF. Karmic quest: Thai family caregivers promoting a peaceful death for people with AIDS. Contemp Nurse. 2007;27(2):94-103.

Nilmanat and colleagues report the constructions of karma by four Thai family caregivers living with a dying person with AIDS in southern Thailand. These four families form a subset of a larger ethnographic case study exploring the experiences of families living with a relative with AIDS. Serial interviews, observations, and field journals were used as data collection methods with the four families. The findings indicated that the karmic quest is a dominant theme in the narratives of these families caring for their loved ones dying with AIDS.  The ‘calm and peaceful’ death that is described in the palliative care literature equated with their desire for the Buddhist philosophy of a harmonious death. The families used the law of karma and reincarnation as their main frame of reference and mobilised their religious resources to create meaning and purpose. Karmic healing activities were aimed at ending suffering, promoting a peaceful and calm death and ensuring a better life in the next one. The findings are important for the development of palliative nursing practice in Thailand by acknowledging religious and cultural values to promote peaceful death.

Editors´note: Palliative care aims to provide the best quality of life and relieve the suffering of people living with an incurable illness while offering comfort and support to their families and carers. It is a holistic approach which takes account of emotional, psychological, and spiritual needs as well as physical ones. In southern Thailand, Buddhist philosophy and karmic healing activities provide just such a holistic approach.

Ridge D, Williams I, Anderson J, Elford J. Like a prayer: the role of spirituality and religion for people living with HIV in the UK. Sociol Health Illn. 2008;30(3):413-28.

Over 40,000 people are now living with diagnosed HIV in the United Kingdom (UK). There is, however, uncertainty about how people with HIV use religion or spirituality to cope with their infection. Adopting a modified grounded theory approach, Ridge and colleagues analysed individual and group interviews with the people most affected by HIV in the UK: black African heterosexual men and women and gay men (mostly white). For the majority of black African heterosexual men and women in our study, religion was extremely important. The authors found that gay men in the study were less religious than black Africans, although many were spiritual in some way. Black African individuals constructed their spiritual narratives as largely Christian or collective, while gay men described more individualistic or ‘New Age’ approaches.  The authors developed a six-level heuristic device to examine the ways in which prayer and meditation were deployed in narratives to modulate subjective wellbeing. These were: (i) creating a dialogue with an absent counsellor; (ii) constructing a compassionate ‘life scheme’; (iii) interrupting rumination; (iv) establishing mindfulness; (v) promoting positive thinking, and (vi) getting results. That people with HIV report specific subjective benefits from prayer or meditation presents a challenge to secular healthcare professionals and sociologists.

Editors´note: Open-ended in-depth interviews and focus groups revealed that most black Africans in this study were deeply spiritual in their approach to living with HIV and despite high stigma levels in their place of worship they relied heavily on their religion for support. Although some gay men had deep misgivings about religion and its wounding hostility to gay sexuality, they sought meaning in life, were striving to live in harmony and balance, and saw earth as a stepping-stone to another existence. In both groups, whether it was secular, spiritual, or religious in nature, prayer helped interrupt negative rumination and promoted mindfulness.