HIV This Week

HIV/AIDS, growth and poverty in KwaZulu-Natal and South Africa: an integrated survey, demographic and economy wide analysis.

Thurlow J, Gow J, George G. J Int AIDS Soc 2009;12:18.

This paper estimates the economic impact of HIV on the KwaZulu-Natal province and the rest of South Africa. Thurlow et al extended previous studies by employing: an integrated analytical framework that combined firm surveys of workers’ HIV prevalence by sector and occupation; a demographic model that produced both population and workforce projections; and a regionalized economy-wide model linked to a survey-based micro-simulation module. This framework permits a full macro-microeconomic assessment. Results indicate that HIV greatly reduces annual economic growth, mainly by lowering the long-run rate of technical change. However, impacts on income poverty are small, and inequality is reduced by HIV. This is because high unemployment among low-income households minimises the economic costs of increased mortality. By contrast, slower economic growth hurts higher income households despite lower HIV prevalence. They conclude that the increase in economic growth that results from addressing HIV is sufficient to offset the population pressure placed on income poverty. Moreover, incentives to mitigate HIV lie not only with poorer infected households, but also with uninfected higher income households. Their findings reveal the substantial burden that HIV places on future economic development in KwaZulu-Natal and South Africa, and confirms the need for policies to curb the economic costs of the pandemic.

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Editors’ note: This macro-microeconomic assessment of the present and future impact of HIV on the KwaZulu-Natal economy used survey data on HIV prevalence among managers, skilled workers, and labourers in 15 companies across four sectors: agriculture, manufacturing, tourism, and transport sectors. These findings were used to calibrate a demographic model and then its projections were imposed on a dynamic computable general equilibrium model linked to a household-survey based micro-simulation model. Sound complicated? Yes, it definitely is, however this approach integrating demographic, economy-wide, and survey-based models produces striking estimates. The Gross Domestic Product (GDP) growth rate in KwaZulu-Natal is lowered by 1.6% per year and although that does not sound like much, it results in an economy that would be 43% smaller in 2025 than it would be in the absence of HIV. These are the kinds of results that policy makers understand and that can motivate them to mobilise investments to curb HIV transmission and improve treatment access.

Murphy DA, Marelich WD. Resiliency in young children whose mothers are living with HIV/AIDS. AIDS Care. 2008;20(3):284-91.

Resiliency was investigated among well children 6-11 years of age (N = 111) whose mothers were living with AIDS or were HIV symptomatic to determine if mother’s HIV status was a risk factor that could effect child resiliency, as well as to investigate other factors associated with resiliency. Assessments were conducted with mother and child dyads over four time points (baseline, 6-, 12-, and 18-month follow-ups). Maternal illness was a risk factor for resiliency: as maternal viral load increased, resiliency was found to decrease. Longitudinally, resilient children had lower levels of depressive symptoms (by both mother and child report). Resilient children also reported higher levels of satisfaction with coping self-efficacy. A majority of the children were classified as non-resilient; implications for improving resiliency among children of HIV-positive mothers are discussed.

Editors’ note: Resiliency at the individual level, as opposed to community resilience, refers to a person’s capacity for successful adaptation despite challenging circumstances. Rather than simply avoiding negative outcomes, resilience means demonstrating adequate adaptation in the presence of adversity. Resilient children have a more active approach to problem solving, tend to perceive experiences constructively, have better self-esteem, and have high self-reports of effectiveness. A strong adult attachment, problem solving and coping skills training, and psychotherapeutic interventions for depression can help build resiliency in vulnerable children.

Morin SF, Morfit S, Maiorana A, Aramrattana A, Goicochea P, Mutsambi JM, Robbins JL, Richards TA. Building community partnerships: case studies of Community Advisory Boards at research sites in Peru, Zimbabwe, and Thailand. Clin Trials. 2008;5(2):147-56.

Differences in resources, knowledge, and infrastructure between countries initiating and countries hosting HIV prevention research trials frequently yield ethical dilemmas. Community Advisory Boards have emerged as one strategy for establishing partnerships between researchers and host communities to promote community consultation in socially sensitive research. Morin and co-authors undertook to understand the evolution of Community Advisory Boards and community partnerships at international research sites conducting HIV prevention trials. Three research sites of the HIV Prevention Trials Network (HPTN) were selected to include geographical representation and diverse populations at risk for HIV exposure – Lima, Peru; Chitungwiza, Zimbabwe; and Chiang Mai, Thailand. Data collection included review of secondary data, including academic publications and site-specific progress reports; observations at the research sites; face-to-face interviews with Community Advisory Boards members, research staff, and other key informants; and focus groups with study participants. Rapid assessment techniques were used for data analysis. The authors found that two of the three Community Advisory Boards developed new strategies for community representation in response to new studies. All three Community Advisory Boards expanded their original function and became advocates for broader community interests beyond HIV prevention. The participation and input of community representatives, in response to critical incidents that occurred at the sites over the past five years, helped to solidify partnerships between researchers and communities. In terms of limitations the authors point out that Rapid Assessment is an exploratory methodology designed to provide an understanding of a situation based on the integration of multiple data sources, collected within a short period of time, without a formal examination of transcribed and coded data. Case studies, as a method, are meant to draw out what can be learned from a single case but are not, in the scientific sense, generalizable. They conclude that in developing countries, Community Advisory Boards can be dynamic entities that enhance the HIV research process, assist in responding to issues involving research ethics, and prepare communities for HIV research.

Editors´note: This assessment of changes in community advisory board conduct and roles over a five year period found that at each site a conflict or challenge arose in which the views and assistance of community advisory board members became not only valuable to the research team but also important for the future success of the research. These conflicts or challenges generated substantial interactions of mutual benefit as issues were debated which led to a more genuine partnership. Community advisory boards clearly can be dynamic entities striving to better represent and advocate for the communities.

Djomand G, Metch B, Zorrilla CD, Donastorg Y, Casapia M, Villafana T, Pape J, Figueroa P, Hansen M, Buchbinder S, Beyrer C; for the 903 Protocol Team. The HVTN Protocol 903 Vaccine Preparedness Study: Lessons Learned in Preparation for HIV Vaccine Efficacy Trials. J Acquir Immune Defic Syndr. 2008;48(1):82-9 2008

Successful recruitment and retention of HIV-uninfected at-risk participants are essential for HIV vaccine efficacy trials. A multicountry vaccine preparedness study was started in 2003 to assess enrolment and retention of HIV-negative high-risk participants, and to assess their willingness to participate in future vaccine efficacy trials. HIV-negative high-risk adults were recruited in the Caribbean, in Southern Africa, and in Latin America, and were followed for 1 year. Participants included men who have sex with men, heterosexual men and women, and female sex workers. History of sexually transmitted infections and sexual risk behaviours were recorded with HIV testing at 0, 6, and 12 months, and willingness to participate in future vaccine trials was recorded at 0 and 12 months. Recruitment, retention, and willingness to participate in future trials were excellent at 3 of the 6 sites, with consistent declines in risk behaviours across cohorts over time. Although not powered to measure seroincidence, HIV seroincidence rates per 100 person-years (95% confidence interval [CI]) were as follows: 2.3 (95% CI: 0.3 to 8.2) in Botswana, 0.5 (95% CI: 0 to 2.9) in the Dominican Republic, and 3.1 (95% CI: 1.1 to 6.8 ) in Peru. The HIV Vaccine Trials Network 903 study helped to develop clinical trial site capacity, with a focus on recruitment and retention of high-risk women in the Americas, and improved network and site expertise about large-scale HIV vaccine efficacy trials.

Editors´note: Finding populations with sufficient risk for HIV infection to support the seroincidence demands of trials is a start but they must also have high rates of retention for there to be adequate power to confirm or refute the study’s hypothesis. Even participating in a study to assess enrolment, retention, and HIV incidence can lead to declines in risk behaviour and HIV incidence, above those already happening in the overall general population. Such a positive effect of being studied is sometimes called the Hawthorne Effect.

Hughes S, L Cuffe R, Lieftucht A, Garrett Nichols W. Informing the selection of futility stopping thresholds: case study from a late-phase clinical trial. Pharm Stat. 2008 Mar 27 [Epub ahead of print]

In an environment where (i) potential risks to subjects participating in clinical studies need to be managed carefully, (ii) trial costs are increasing, and (iii) there are limited research resources available, it is necessary to prioritize research projects and sometimes re-prioritize if early indications suggest that a trial has low probability of success. Futility designs allow this reprioritization to take place. This paper reviews a number of possible futility methods available and presents a case study from a late-phase study of an HIV therapeutic, which utilized conditional power-based stopping thresholds. The two most challenging aspects of incorporating a futility interim analysis into a trial design are the selection of optimal stopping thresholds and the timing of the analysis, both of which require the balancing of various risks. The paper outlines a number of graphical aids that proved useful in explaining the statistical risks involved to the study team. Further, the paper outlines a decision analysis undertaken which combined expectations of drug performance with conditional power calculations in order to produce probabilities of different interim and final outcomes, and which ultimately led to the selection of the final stopping thresholds.

Editors´note: Early indications that a trial has low probability of success – with success defined as confirming or refuting the trial hypothesis – can lead to the stopping of a trial for futility. Although this saves resources, stopping a trial prior to its conclusion because its key endpoints will not be met makes it impossible to determine whether results for secondary endpoints would have generated useful hypotheses for future investigation. It is important to decide up front what the stopping rules will be with respect to all endpoints and understand the consequences and anticipate them.

Russell TV, Do AN, Setik E, Sullivan PS, Rayle VD, Fridlund CA, Quan VM, Voetsch AC, Fleming PL. Sexual Risk Behaviors for HIV/AIDS in Chuuk State, Micronesia: The Case for HIV Prevention in Vulnerable Remote Populations. PLoS ONE. 2007; 2(12):e1283.

After the first two cases of locally-acquired HIV infection were recognized in Chuuk State, Federated States of Micronesia, a public health response was initiated. The purpose of the response was to assess the need for HIV education and prevention services, to develop recommendations for controlling further spread of HIV in Chuuk, and to initiate some of the prevention measures. A public health team conducted a survey and rapid HIV testing among a sample of residents on the outer islands in Chuuk. Local public health officials conducted contact tracing and testing of sex partners of the two locally-acquired cases of HIV infection. A total of 333 persons completed the survey. The majority knew that HIV is transmitted through unprotected sexual contact (81%), injection drug use (61%), or blood transfusion (64%). Sexual activity in the past 12 months was reported among 159 participants, including 90 females and 69 males. Compared to women, men were more likely to have had multiple sex partners, to have been drunk during sex, but less likely to have used a condom in the past 12 months. The two men with locally acquired HIV infection had unprotected anal sex with a third Chuukese man who likely contracted HIV while outside of Chuuk. All 370 persons who received voluntary, confidential HIV counselling and testing had HIV negative test results. Despite the low HIV seroprevalence, risky sexual behaviours in this small isolated population raise concerns about the potential for rapid spread of HIV. The lack of knowledge about risks, along with stigmatizing attitudes towards persons infected with HIV and high risk sexual behaviours indicate the need for resources to be directed toward HIV prevention in Chuuk and on other Pacific Islands.

Editors’ note: With only 1500 residents living on this small group of islands, confidentiality would not have been maintained if classical “contact tracing and testing of sex partners”, as implied by the abstract, had occurred. The innovation was for local village officials to convene a public meeting on each of the four islands to explain general health outreach activities, including the offer of HIV testing and counselling. When known contacts of either of the two index cases came forward for HIV testing, health department staff notified them of their potential exposure and provided expanded counselling on HIV risk reduction, without loss of confidentiality. Geographic isolation does not protect people from HIV and the constraints to respecting confidentiality in small populations need to be overcome creatively, as was done here.

Weiser S, Leiter K, Bangsberg D, Butler L, Percy-de Korte F, Hlaze Z, Phaladze N, Lacopino V, Heisler M. Food Insufficiency is Associated with High-Risk Sexual Behaviour among Women in Botswana and Swaziland. PLoS Med. 2007;4(10):1589-97

Photo credit: Christian Aid/Photo Voice/Beatrice

Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behaviour has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behaviour. We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a non-primary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27–2.36), sex exchange (AOR 1.84, 95% CI 1.74–1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03–2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24–2.28). Associations between food insufficiency and risky sex were much attenuated among men. Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women’s legal and social rights may play an important role in decreasing HIV transmission risk for women.

Editors’ notes: Insufficient food to meet daily needs and infection with HIV are major causes of death in southern Africa. Good nutrition is essential for a strong immune system. Protecting and promoting access to food can act on the socio-behavioural plain to reduce HIV exposure and on the biological plain to both reduce the risk of becoming infected if exposed and to maintain good health for longer once infected. Supporting women’s subsistence farming and enhancing their control over their food supplies as well as their sexual lives are key steps to improving their resilience to HIV.

Piot P, Greener R, Russell S. Squaring the Circle: AIDS, Poverty, and Human Development. Plos Med. 2007;4(10):1571-5.

It is often asserted that AIDS is at the core of a “vicious circle” whereby the impacts of AIDS increase poverty and social deprivation, while poverty and social deprivation increase vulnerability to HIV infection. In examining this view, it is important to distinguish between the “downstream” effects of AIDS on poverty, and the “upstream” effects of poverty upon the risk of acquiring HIV. Understanding these interactions is vital to the development and implementation of effective strategies to prevent and treat HIV. Six elements are key to an effective, sustainable response. First, AIDS money has the most impact when strategies are based on the concept of “know and act on your epidemic”. UNAIDS’ Practical Guidelines for Intensifying HIV Prevention provide practical guidance to tailor national HIV prevention responses so that they respond to the epidemic dynamics and social context of the country and each populations who remain most vulnerable to HIV infection. Second, a growing number of small-scale activities indicate the value of combining HIV programmes with poverty reduction initiatives. The challenge now, however, is to make the shift from small-scale projects to large-scale programmes. Third, the provision of HIV treatment can help prevent poverty—and indirectly contribute to HIV prevention as well—by helping to break down stigma. Access for the poor to HIV treatment and prevention services requires action to increase investment in antiretroviral treatment—by both national and international funders; reduce the cost of antiretroviral drugs; improve HIV service delivery systems; and provide better services for the poor. Fourth, development plans (whether they concern the development of productive sectors or the provision of social safety nets) must “pass the AIDS test”, contributing to HIV prevention and treatment in the communities they work in. Fifth, both poverty reduction programmes and AIDS strategies must reduce vulnerability to HIV— particularly for women and young people. Doing so involves protecting human rights and tackling issues around social marginalization and stigma. Sixth, addressing AIDS in the world’s poorest countries and communities depends on increased and sustained international support, driven by high-level political will. Complex problems famously require complex solutions. In this case, it is crucial to place AIDS squarely at the centre of all socio-economic development, and provide long-term, high-level domestic and international investment in HIV prevention and treatment in the world’s poorest countries.

Editors’ notes: Economic and gender inequalities along with weakened social cohesion are key influences on sexual behaviour and risk of HIV transmission. The clear pattern of associations between the level of income inequality measured by the Gini coefficient and HIV prevalence in sub-Saharan Africa speak to the need to improve governance in general as well as strengthen the AIDS response.

Foster G. Under the radar: community safety nets for AIDS-affected households in sub-Saharan Africa. AIDS Care 2007;19 Suppl 1:S54-63.

Safety nets are mechanisms to mitigate the effects of poverty on vulnerable households during times of stress. In sub-Saharan Africa, extended families, together with communities, are the most effective responses enabling access to support for households facing crises. This paper reviews literature on informal social security systems in sub-Saharan Africa, analyses changes taking place in their functioning as a result of HIV and describes community safety net components including economic associations, cooperatives, loan providers, philanthropic groups and HIV initiatives. Community safety nets target households in greatest need, respond rapidly to crises, are cost efficient, based on local needs and available resources, involve the specialized knowledge of community members and provide financial and psycho-social support. Their main limitations are lack of material resources and reliance on unpaid labour of women. Changes have taken place in safety net mechanisms because of HIV, suggesting the resilience of communities rather than their impending collapse. Studies are lacking that assess the value of informal community-level transfers, describe how safety nets assist the poor or analyse modifications in response to HIV. The role of community safety nets remains largely invisible under the radar of governments, non-governmental organizations and international bodies. External support can strengthen this system of informal social security that provides poor HIV-affected households with significant support.

Editors’ note: Vulnerability is much studied but relatively little is known about community resilience and how to better foster and support it. What forms does solidarity take and why is it more likely to be expressed in some communities and not in others? How can men be encouraged to become involved as much as women in creating and maintaining social safety nets? Understanding the mechanisms and manifestations of resilience is as key to the response to HIV as understanding the origins and underpinnings of vulnerability.

The HIV epidemic feeds on, and worsens, unacceptable situations of poverty, gender inequity, social insecurity, limited access to healthcare and education, war, debt and macroeconomic and social instability. The number of people living with HIV and AIDS continues to increase in several regions, most markedly in sub-Saharan Africa, the Pacific, Eastern Europe and Central Asia. The persistent nature of the epidemic and its increasing incidence in less powerful, more economically marginalised communities signals a need for a critical review of past policy and practice, particularly where this has left unchanged or worsened the risk environments that lead to new infection. Available evidence suggests that the caring and consumption burdens of AIDS have largely been met by households, limiting the capacities for future caring and mitigation of impact. Social cohesion or the collective networking, action, trust and solidarity of society, plays a positive role in reducing risk and dealing with vulnerability but is itself negatively affected by AIDS. This paper introduces the programme of work reported in this supplement of AIDS Care with an analysis of background evidence of community responses to HIV. It explores how interventions from state institutions and non-governmental organizations (NGOs) support and interact with these household, family and community responses. How far is risk prevention reliant on individuals’ limited resources and power to act, while risk environments are left unchanged? How far are the impacts of AIDS borne by households and extended families, with weak solidarity support? Where are the examples of wider social responses that challenge the conditions that influence risk and that support household recovery? Through review of literature, this background paper sets out the questions that the studies reported in this supplement have, in various settings, sought to explore more deeply.

Editors’ note: This supplement of AIDS Care focuses specifically on community responses to HIV, the resilience-vulnerability continuum, equity-inclusion and the nature of social solidarity. The author is from the Training and Research Support Centre (TARSC) at the UNRISD Programme on Community Responses to AIDS in Geneva, Switzerland.

 The astounding rise in the number of orphans due to the HIV epidemic has left many Ethiopian families and communities with enormous childcare problems. Available studies on the capacity and sustainability of the extended family system, which culturally performs the role of care for children in need, suggest two competing theories. The first is grounded in the social rupture thesis and assumes that the traditional system of orphan care is stretched by the impact of the epidemic, and is actually collapsing. By contrast, the second theory counter-suggests that the flexibility and strength of the informal childcare practise, if supported by appropriate interventions, can still support a large number of orphans. Based on a seven-month period of child-focused, qualitative research fieldwork in Ethiopia involving observations; in-depth interviews with orphans (42), social workers (12) and heads of households (18); focus group discussions with orphans (8), elderly people and community leaders (6); and story-writing by children in school contexts, this article explores the trade-offs and social dynamics of orphan care within extended family structures in Ethiopia. It argues that there is a rural-urban divide in the capacity to cater for orphans that emanates from structural differences as well as the socio-cultural and economic values associated with children. The care of orphans within extended family households is also characterised by multiple and reciprocal relationships in care-giving and care-receiving practices. By calling for a contextual understanding of the ‘orphan burden’, the paper concludes that interventions for orphans may consider care as a continuum in the light of four profiles of extended families, namely rupturing, transient, adaptive, and capable families.

 Editors’ note: This thoughtful article suggests that the first step in planning programmes to support orphan care requires an understanding of natural coping mechanisms which will differ by geography and culture, as well as over time.

Yap L, Butler T, Richters J, Kirkwood K, Grant L, Saxby M, Ropp F, Donovan B. Do condoms cause rape and mayhem? The long-term effects of condoms in New South Wales’ prisons. Sex Transm Infect. 2006 Dec 19; [Epub ahead of print]

Concerns raised by opponents to condom provision in prisons have not been objectively examined and the issue continues to be debated. Yap and colleagues examined the long-term effects of the introduction of condoms and dental dams into New South Wales prisons in 1996, focusing on particular concerns raised by politicians, prison officers, prison nurses, and prisoners. These groups were worried that: (a) condoms would encourage prisoners to have sex, (b) condoms would lead to an increase in sexual assaults in prisons, (c) prisoners would use condoms to hide and store drugs and other contraband, and (d) prisoners would use condoms as weapons. Data sources included the New South Wales Inmate Health Surveys in 1996 and 2001 and official reports from the New South Wales Department of Corrective Services. The 1996 IHS involved 657 men and 132 women randomly selected from all prisons with a 90% response rate. The 2001 survey involved 747 men and 167 women inmates with an 85% response rate. There was a decrease in reports of both consensual male-to-male sex and male sexual assaults 5 years after the introduction of condoms into prisons in 1996. Condoms were often used for concealing contraband items and other purposes but this was not associated with an increase in drug injecting in prison. Only three incidents of a condom being used in assaults on prison officers were recorded between 1996 and 2005; none were serious. The authors conclude that they found no evidence of serious adverse consequences of distributing condoms and dental dams to prisoners in New South Wales. Condoms are an important public health measure in the fight against HIV and sexually transmitted diseases; they should be made freely available to prisoners as they are to other high- risk groups in the community.

Editors’ note: Condoms have been available in Canadian penitentiaries since 1994 and in prisons in New South Wales since 1996 but the vast majority of prisons worldwide do not make condoms available to inmates with dire results. Results such as these can be used to influence correctional system leadership, particularly when national laws invest them with responsibility for detainee health on their watch.

Sarang A, Rhodes T, Platt L, Kirzhanova V, Shelkovnikova O, Volnov V, Blagovo D, Rylkov A. Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study. Addiction 2006;101:1787-96.

Evidence highlights the prison as a high risk environment in relation to HIV and hepatitis C virus (HCV) transmission associated with injecting drug use. Sarang and colleagues undertook qualitative studies among 209 people who inject drugs in three Russian cities: Moscow (n=56), Volgograd (n=83) and Barnaul in western Siberia (n=70). Over three-quarters (77%) reported experience of police arrest related to their drug use, and 35% (55% of men) a history of imprisonment or detention. Findings emphasise the critical role that penitentiary institutions may play as a structural factor in the diffusion of HIV associated with drug injection in the Russian Federation. While drugs were perceived to be generally available in penitentiary institutions, sterile injection equipment was scarce and as a consequence routinely reused, including within large groups. Attempts to clean borrowed needles or syringes were inadequate, and risk reduction was severely constrained by a combination of lack of injecting equipment availability and punishment for its possession. Perceptions of relative safety were also found to be associated with assumptions of HIV negativity, resulting from a perception that all prisoners are HIV tested upon entry with those found HIV positive segregated. The authors conclude that the study shows an urgent need for HIV prevention interventions in the Russian penitentiary system.

Dolan K, Kite B, Black E, Aceijas C, Stimson GV, for the Reference Group on HIV/AIDS Prevention and Care among Injecting Drug Users in Developing and Transitional Countries. HIV in prison in low-income and middle-income countries. Lancet Infect Dis 2007;7:32-41

High prevalence of HIV infection and the over-representation of people who inject drugs in prisons combined with HIV risk behaviour create a crucial public-health issue for correctional institutions and, at a broader level, the communities in which they are situated. However, data relevant to this problem are limited and difficult to access. Dolan and colleagues reviewed imprisonment, HIV prevalence, and the proportion of prisoners who inject drugs in 152 low-income and middle-income countries. Information on imprisonment was obtained for 142 countries. Imprisonment rates ranged from 23 per 100000 population in Burkina Faso to 532 per 100000 in Belarus and Russia. Information on HIV prevalence in prisons was found for 75 countries. Prevalence was greater than 10% in prisons in 20 countries. Eight countries reported prevalence of people who inject drugs in prison of greater than 10%. HIV prevalence among prisoners who inject drugs was reported in eight countries and was greater than 10% in seven of those. Evidence of HIV transmission in prison was found for seven low-income and middle-income countries. HIV is a serious problem for many countries, especially where injection drug use occurs. The authors conclude that because of the paucity of data available, the contribution of HIV within prison settings is difficult to determine in many low-income and middle-income countries. They add that systematic collection of data to inform HIV prevention strategies in prison is urgently needed. The introduction and evaluation of HIV prevention strategies in prisons are warranted.

Editors’ note: No institution outside hospitals has higher HIV prevalence around the world. Although more data are needed, the actions needed to prevent intramural transmission are well known – implementation and evaluation are urgently needed.

Kongnyuy EJ, Wiysonge CS, et al. Wealth and sexual behaviour among men in Cameroon. BMC Int Health Hum Rights 2006,6:11. http://www.biomedcentral.com/1472-698X/6/11

The 2004 Demographic and Health Survey (DHS) in Cameroon revealed a higher prevalence of HIV in richest and most educated people than their poorest and least educated compatriots. It is not certain whether the higher prevalence results partly or wholly from wealthier people adopting more unsafe sexual behaviours, surviving longer due to greater access to treatment and care, or being exposed to unsafe injections or other HIV risk factors. As unsafe sex is currently believed to be the main driver of the HIV epidemic in sub-Saharan Africa, Kongnyuy and colleagues examined the association between wealth and sexual behaviour in Cameroon among 4409 sexually active men aged 15-59 years who participated in the DHS. When controlled for potential confounding by marital status, place of residence, religion and age, men in the richest third of the population were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.43, 95% CI 0.32-0.56) and more likely to have had at least two concurrent sex partners in the last 12 months (OR 1.38, 95% CI 1.12-1.19) and more than five lifetime sex partners (OR 1.97, 95% CI 1.60-2.43). However, there was no difference between the richest and poorest men in the purchase of sexual services. Regarding education, men with secondary or higher education were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.24, 95% CI 0.16-0.38) and more likely to have started sexual activity at age 17 years or less (OR 2.73, 95% CI 2.10-3.56) and have had more than five lifetime sexual partners (OR 2.59, 95% CI 2.02-3.31). There was no significant association between education and multiple concurrent sexual partnerships in the last 12 months or purchase of sexual services. The authors conclude that unsafe sexual behaviours may explain the higher HIV prevalence among wealthier men in the country. They add that while these findings do not suggest a redirection of HIV prevention efforts from the poor to the wealthy, they do call for efforts to ensure that HIV prevention messages get across all strata of society.

Editors’ note: It is interesting that financial ability to directly purchase sexual services is not the explanation for increased HIV in wealthier men in Cameroon. Qualitative studies would help explain the assumptions these men make about their risk of HIV in non-commercial encounters but just reflecting these findings to this population may effect a change – it’s within their power to protect themselves.