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.

Questioning gender norms with men to improve health outcomes: Evidence of impact.

Barker G, Ricardo C, Nascimento M, Olukoya A, Santos C. Glob Public Health. 2009; 9:1-15.

This article describes a review of 58 evaluation studies of programmes with men and boys in sexual and reproductive health (including HIV prevention, treatment, care and support); father involvement; gender-based violence; maternal, newborn and child health; and gender socialisation more broadly. While few of the programmes go beyond the pilot stage, or a relatively short-term timeframe, they offer compelling evidence that well-designed programmes with men and boys can lead to positive changes in their behaviours and attitudes related to sexual and reproductive health; maternal, newborn and child health; their interaction with their children; their use of violence against women; their questioning of violence with other men; and their health-seeking behaviour. The evidence indicates that programmes that incorporate a gender-transformative approach and promote gender-equitable relationships between men and women are more effective in producing behaviour change than narrowly focused interventions, as are programmes which reach beyond the individual level to the social context.

Editors’ note: Gender norms are the social expectations of appropriate roles and behaviours for men and women. They vary across historical and local economic, religious, and cultural contexts and are created and reinforced by families, communities, and social/political/legal environments. Because gender norms are learned and internalized, rather than being biologically determined, they can also be questioned and transformed to be more gender-equitable. This review confirms that comprehensive programmes with men and boys that include specific discussions about the social meanings of men and masculinity seem to show the highest levels of effectiveness. More research is needed to assess the impact of public policy changes and social trends on the behaviour of men and boys, on the bidirectional expectations of both sexes, and on early and potentially gender-transformative practices in men’s involvement as fathers .

 Intimate Partner Violence Perpetration, Standard and Gendered STI/HIV Risk Behaviour, and STI/HIV Diagnosis Among A Clinic-Based Sample of Men.

Decker M, Seage G 3 rd, Hemenway D, Gupta J, Raj A, Silverman JG. Sex Transm Infect. 2009 [Epub ahead of print]

The estimated one in three women worldwide victimized by intimate partner violence consistently demonstrate elevated STI/HIV prevalence; abusive male partners’ risky sexual behaviours and subsequent infection are implicated. Little empirical data exist to characterize men’s sexual risk as it relates to violence perpetration and STI/HIV. Data from a survey of men aged 18-35 recruited from three community-based health clinics in an urban area (n=1585) were analyzed to assess the prevalence of intimate partner violence perpetration and relations of such violent behaviour with both standard (e.g., anal sex, injection drug use) and gendered (e.g., coercive condom practices, sexual infidelity) forms of sexual risk, and STI/HIV diagnosis. Approximately one third of participants (32.7%) reported perpetrating violence against an intimate partner in their lifetime; 1 in 8 (12.4%) participants reported history of STI/HIV diagnosis. Men’s intimate partner violence perpetration related to both standard and gendered STI/HIV risk behaviours (AORS 1.72 to 6.22) and to STI/HIV diagnosis (OR 4.85, 95% CI 3.54, 6.66). In a multivariate model, the association of men’s intimate partner violence perpetration with STI/HIV diagnosis was partially attenuated (AOR 2.55, 95% CI 1.77, 3.67), and a subset of gendered sexual risk behaviours were found to be independently related to STI/HIV diagnosis. Men’s perpetration of violence against intimate partners is common among this population. Abusive men are at increased risk for STI/HIV, with gendered forms of sexual risk behaviour partially responsible. Findings indicate the need for interwoven sexual health promotion and violence prevention efforts targeted to men that include addressing gendered sexual risk.

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Editors’ note: In this cross-sectional US study of young, urban, adult men attending community health centres, a third of participants reported having perpetrated physical or sexual violence against an intimate partner. Multivariate analysis found an independent association between a history or such violence and gendered STI/HIV risk (e.g. sexual infidelity, coercive condom practices). Programmes that integrate men’s prevention of intimate partner violence into STI/HIV prevention should focus on modifying masculinity norms that support men’s entitlement to sexual control of women because these attitudes underpin both intimate partner violence and sexual risk behaviour.

HIV prevention while the bulldozers roll: Exploring the effect of the demolition of Goa’s red-light area.

Shahmanesh M, Wayal S, Andrew G, Patel V, Cowan FM, Hart G. Soc Sci Med. 2009; 69:604-12.

Interventions targeting sex-workers are pivotal to HIV prevention in India. Community mobilisation is considered by the National AIDS Control Programme to be an integral component of this strategy. Nevertheless societal factors, and specifically policy and legislation around sex-work, are potential barriers to widespread collectivisation and empowerment of sex-workers. Between November 2003 and December 2005 Shahmanesh and colleagues conducted participatory observation and rapid ethnographic mapping with several hundred brief informant interviews, in addition to 34 semi-structured interviews with key-informants, 16 in-depth interviews with female sex-workers, and 3 focus-group-discussions with clients and mediators. This article provides a detailed examination of the demolition of Baina, one of India’s large red-light areas, in 2004, and one of the first accounts of the effect of dismantling the red-light area on the organisation of sex-work and sex-workers’ sexual risk. The results suggest that the concentrated and homogeneous brothel-based sex-work environment rapidly evolved into heterogeneous, clandestine and dispersed modes of operation. The social context of sex-work that emerged from the dust of the demolition was higher risk and less conducive to HIV prevention. The demolition acted as a negative structural intervention; a catastrophic event that fragmented sex-workers’ collective identity and agency and rendered them voiceless and marginalised. The findings suggest that an abolitionist approach to sex-work and legislation or policy that either criminalises this large group of women, or renders them as invisible victims, will increase the stigma and exclusion they experience. For the targeted HIV prevention approaches advocated by the National AIDS Control Programme to be effective, there is a need for legislation and policy that supports sex-workers’ agency and self-organisation and enables them to create a safer working environment for themselves.

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Editors’ note: The authors of this thoughtful analysis were engaged in a study developing a participatory evidence-based HIV prevention intervention when the demolition of Baina started following a high court judgement. Because the dispersion and marginalisation of women following eviction would make the study impossible the researchers began documenting unfolding events and their effects on the community, as well as on the evolving relationship between the researchers and the community. This rich description helps understand how abolitionist discourses, whether religious or social reformist, converge to strip women who are sex workers of any agency, either by stigmatising them or by depicting them as victims by conflating sex work with trafficking, If you have wondered what a negative structural intervention is and does, and if you ever worked with communities, this is an article that you won’t be able to stop reading.

Household impacts of AIDS: using a life course analysis to identify effective, poverty-reducing interventions for prevention, tratment, and care. Loewenson R, Whiteside A, Hadingham J. Aids Care. 2009; 21:1032-1041

A life course approach was used to assess household level impacts and inform interventions around HIV risk and AIDS vulnerability across seven major age-related stages of life. The focus was sub-Saharan Africa. The authors provided a qualitative review of evidence from published literature, particularly multicountry reviews on impacts of AIDS, on determinants of risk and vulnerability, and reports of large surveys. Areas of potential stress from birth to old age in households affected by AIDS, and interventions for dealing with these specific stresses were identified. While specific interventions for HIV are important at different stages, achieving survival and development outcomes demands a wider set of health, social security, and development interventions. One way to determine the priorities amongst these actions is to give weighting to interventions that address factors that have latent impacts later in life, which interrupt accumulating risk, or that change pathways to reduce the risk of both immediate and later stress. This qualitative review suggests that interventions, important for life cycle transitions in generalized epidemics where HIV risk and AIDS vulnerability are high, lie within and outside the health sector, and suggests examples of such interventions.

Editors’ note: A life course concept views people as passing though various transitions and stages in life with events at one stage having effects at later stages. Points of stress in the life cycle that HIV can affect offer opportunities to influence pathways of accumulating vulnerability. These can range from the obvious example of preventing mother-to-child transmission by antiretroviral prophylaxis to broader interventions, such as promoting more open communication within families. HIV influences the number and quality of ‘buffers’ available to deal with stress, including the buffers of social support, financial resources, and good health. Household and individual resilience to shocks experienced in generalised epidemics can be supported through broader systems approaches within and beyond the health sector that help people to manage the interacting socioeconomic and health challenges of HIV. Examples include explicit interventions to strengthen social networks, increase spending on public services and community safety nets, introduce law reform and enforcement, invest in training and support for family carers, and increase access to education and employment opportunities.

Men who have sex with men and HIV/AIDS in sub-Saharan Africa. Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaffe H. Lancet. 2009;374: 416-422.

Globally, men who have sex with men continue to bear a high burden of HIV infection. In sub-Saharan Africa, same-sex behaviours have been largely neglected by HIV research up to now. The results from recent studies, however, indicate the widespread existence of groups of men who have sex with men across Africa, and high rates of HIV infection, HIV risk behaviour, and evidence of behavioural links between men who have sex with men and heterosexual networks have been reported. Yet most African men who have sex with men have no safe access to relevant HIV information and services, and many African states have not begun to recognise or address the needs of these men in the context of national HIV prevention and control programmes. The HIV community now has considerable challenges in clarifying and addressing the needs of men who have sex with men in sub-Saharan Africa; homosexuality is illegal in most countries, and political and social hostility are endemic. An effective response to HIV requires improved strategic information about all risk groups, including men who have sex with men. The belated response to men who have sex with men with HIV infection needs rapid and sustained national and international commitment to the development of appropriate interventions and action to reduce structural and social barriers to make these accessible.

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 Editors’ note: Major barriers exist in access to effective HIV prevention, treatment, and care and support for men who have sex with men in sub-Saharan Africa. Not the least of these is the need for African political commitment to legal reforms and social protection for sexual minorities and those who work with them. It is not surprising that HIV subtypes in African men who have sex with men are similar to those occurring in the general population given that a high proportion of them report recent female sexual partners and many are married. What is surprising is how little is known about them. Only 17 of 52 African countries reported any information about risk knowledge and behaviour, HIV prevalence, and access to care among men who have sex with men in their 2008 reports of progress on the 2001 Declaration of Commitment. The silence must be broken to start to reverse the inaction that is so harmful to men who have sex with men, and to everyone else in Africa.

Reniers G, Araya T, Davey G, Nagelkerke N, Berhane Y, Coutinho R, Sanders EJ. Steep declines in population-level AIDS mortality following the introduction of antiretroviral therapy in Addis Ababa, Ethiopia. AIDS. 2009;23:511-518.

Assessments of population-level effects of antiretroviral therapy programmes in Africa are rare. Reniers and colleagues use data from burial sites to estimate trends in adult AIDS mortality and the mitigating effects of antiretroviral therapy in Addis Ababa. Antiretroviral therapy has been available since 2003, and for free since 2005. To substitute for deficient vital registration, the authors use surveillance of burials at all cemeteries. They present trends in all-cause mortality, and estimate AIDS mortality (ages 20-64 years) from lay reports of causes of death. These lay reports are first used as a diagnostic test for the true cause of death. As reference standard, the authors use the cause of death established via verbal autopsy interviews conducted in 2004. The positive predictive value and sensitivity are subsequently used as anchors to estimate the number of AIDS deaths for the period 2001-2007. Estimates are compared with Spectrum projections. Between 2001 and 2005, the number of AIDS deaths declined by 21.9% and 9.3% for men and women, respectively. Between 2005 and 2007, the number of AIDS deaths declined by 38.2 for men and 42.9% for women. Compared with the expected number in the absence of antiretroviral therapy, the reduction in AIDS deaths in 2007 is estimated to be between 56.8% and 63.3%, depending on the coverage of the burial surveillance. Five years into the antiretroviral therapy programme, adult AIDS mortality has been reduced by more than half. Following the free provision of antiretroviral therapy in 2005, the decline accelerated and became more sex balanced. Substantial AIDS mortality, however, persists.

Editors’ note: When vital registration systems do not function well enough to provide accurate cause-specific adult mortality estimates, burial surveillance can provide data for realistic estimates of the impact of antiretroviral treatment programmes. During 2003-2005, the Ethiopian national programme required a co-payment of 28-80USD per month and AIDS mortality fell 15.8% in Addis Ababa, more in men than in women. The decline was far sharper between 2005 and 2007 (40.6%) when antiretroviral treatment was free, with greater declines observed for women. This study demonstrates the utility of using other information sources to monitor programme effects when vital registration is deficient and suggests a restraining effect of co-payments on antiretroviral treatment uptake, particularly for women who may have less access to resources for financing treatment.

Marcellin F, Abé C, Loubière S, Boyer S, Blanche J, Koulla-Shiro S, Ongolo-Zogo P, Moatti JP, Spire B, Carrieri MP; and the EVAL Study Group. Delayed first consultation after diagnosis of HIV infection in Cameroon. AIDS. 2009;23:1015-1019.

Marcellin and colleagues set out to study the impact of both decentralization of HIV care and individual factors on delayed first consultation (>/=6 months) after HIV diagnosis in Cameroon, in the context of the national antiretroviral treatment scale-up program. The national cross-sectional multicenter survey EVAL (ANRS 12-116) was conducted from September 2006 to March 2007 in 27 HIV centres in Cameroon. Logistic regression was used to characterize patients with delayed first consultation among 3151 HIV-infected adults. Fifteen percent of patients reported a delay of at least 6 months before their first consultation after HIV diagnosis. In the multivariate analysis adjusted for the frequency of visits to the HIV centre, independent correlates of reporting a delay of at least 6 months before consulting included the characteristics of the HIV centres (created before 2005 and located in small or medium-size hospitals) and the following individual patient characteristics: sex and matrimonial status (women living in a couple), the circumstances of the HIV diagnosis (test not performed in the hospital providing HIV care, test performed during a voluntary screening campaign) and patient’s negative perception of antiretroviral treatment toxicity. Delays before first consultation for HIV care in Cameroon have been reduced, thanks to the full implementation of the national program of decentralization. Results underline the importance of coordinating diagnosis with treatment activities and the need to develop counselling actions, focusing on the balance between antiretroviral treatment effectiveness and its potential side effects. Counselling should also be part of patients’ follow-up after diagnosis during voluntary screening campaigns.

Editors’ note: This is the first nation-wide study in sub-Saharan Africa to explore components of the causal process leading to late access to antiretroviral treatment: late HIV diagnosis versus delayed first consultation after HIV diagnosis. Decentralisation of HIV services in Cameroon has had the benefit of more prompt access to care, with 57% of patients experiencing a delay of less than 1 month between HIV diagnosis and their first medical consultation for HIV care. With many of the factors influencing delayed onset of antiretroviral treatment highlighted by this study, now programme planners and implementers can introduce modifications to reduce the delay. Their focus should be on the 15% who are not assessed for antiretroviral treatment until 6 months or more after HIV diagnosis and those who are lost to follow-up after an initial HIV diagnosis.

Birungi H, Mugisha JF, Obare F, Nyombi JK. Sexual behaviour and desires among adolescents perinatally infected with human immunodeficiency virus in Uganda: implications for programming. J Adolesc Health. 2009;44:184-7.

Counselling programs for adolescents living with human immunodeficiency virus (HIV) encourage abstinence from sex and relationships. This Uganda study, however, found that many of these adolescents are sexually active or desire to be in relationships but engage in poor preventive practices. Programmes for HIV therefore need to strengthen preventive services to this group.

Editors’ note: In this study, 732 adolescents aged 15 to 19 years living with HIV in 4 districts in Uganda were interviewed, 48 participated in focus group discussions, and 12 underwent in-depth interviews for ethnographic case stories. One-third was sexually active and of these 38% had disclosed their HIV status to their current partners. Overall 51% feared disclosing their status to their friends. At first sex, 37% had used condoms and much of current condom use was for pregnancy prevention. Clearly, the sexual and reproductive needs of this unique and growing population of perinatally infected young people are not being adequately met by current service approaches.

Schmiege SJ, Broaddus MR, Levin M, Bryan AD. Randomized trial of group interventions to reduce HIV/STD risk and change theoretical mediators among detained adolescents. JConsult Clin Psychol. 2009;77:38-50.

Criminally involved adolescents engage in high levels of risky sexual behaviour and alcohol use, and alcohol use may contribute to lack of condom use. Detained adolescents (n = 484) were randomized to (1) a theory-based sexual risk reduction intervention (GPI), (2) the GPI condition with a group-based alcohol risk reduction motivational enhancement therapy component (GPI + GMET), or (3) an information-only control (INFO). All interventions were presented in same-sex groups in single sessions lasting from 2 to 4 hr. Changes to putative theoretical mediators ( attitudes, perceived norms, self-efficacy, and intentions) were measured immediately following intervention administration. The primary outcomes were risky sexual behaviour and sexual behaviour while drinking measured 3 months later (65.1% retention). The GPI + GMET intervention demonstrated superiority over both other conditions in influencing theoretical mediators and over the INFO control in reducing risky sexual behaviour. Self-efficacy and intentions were significant mediators between condition and later risky sexual behaviour. This study contributes to an understanding of harm reduction among high-risk adolescents and has implications for understanding circumstances in which the inclusion of group-based alcohol risk reduction motivational enhancement therapy components may be effective.

Editors’ note: Criminally involved adolescents in detention present challenges to effective HIV prevention on several levels but this is, after all, a ‘teachable moment’ when they may more easily contemplate the negative aspects of a behaviour as well as avenues of behaviour change. Most of the 14 to 17 year olds (82.7% male) in this study were sexually active (92.7%) with a median age at first intercourse of 13.02 years. Of these, 82% reported alcohol use during a sexual encounter. In the full group, 90.9% had used alcohol in the past year with the average number of drinks at one time being 4.7. This randomised controlled trial found that incorporating an alcohol-related sexual risk reduction component that was non-confrontational and supportive into a more traditional sexual risk reduction intervention resulted in increased condom use self-efficacy and intentions to use condoms. Retention at 3 months was low but nonetheless these promising findings deserve further study and practical application.

Shinde S, Setia MS, Row-Kavi A, Anand V, Jerajani H. Male sex workers: are we ignoring a risk group in Mumbai, India? Indian J Dermatol Venereol Leprol. 2009;75:41-6.

Male sex workers have recently been recognized as an important risk group for sexually transmitted infections including human immunodeficiency virus infection. Although there are global studies on male sex workers, few such studies describe the behavioural patterns and sexually transmitted infections among this population in India. Male sex workers were evaluated at the Humsafar trust, a community based organization situated in suburban Mumbai, India. Shinde and colleagues report on the demographics, sexual behaviours, and sexually transmitted infections including HIV of these sex workers. Of the 75 male sex workers, 24 were men and 51 were transgenders. The mean age of the group was 23.3 (+ 4.9) years. About 15% were married or lived with a permanent partner. Of these individuals, 85% reported sex work as a main source of income and 15% as an additional source. All the individuals reported anal sex (87% anal receptive sex and 13% anal insertive sex). About 13% of male sex workers had never used a condom. The HIV prevalence was 33% (17% in men vs 41% in transgenders, P = 0.04). The sexually transmitted infection prevalence was 60% (58% in men vs 61% in transgenders, P = 0.8). Syphilis was the most common sexually transmitted infection (28%) in these male sex workers. HIV was associated with being a transgender (41 vs 17%, P = 0.04), age > 26 years (57 vs 28%, P = 0.04), more than one year of sex work (38 vs 8%, P = 0.05), and income P = 0.02). These male sex workers have high-risk behaviours, low consistent condom use, and high prevalence of sexually transmitted infections and HIV infections. These groups should be the focus of intensive public health interventions aimed at reduction of risky sexual practices, and prevention and care for both HIV and sexually transmitted infections.

Editors’ note: This study did not recruit any male sex workers involved solely in the heterosexual sex trade possibly because such men are less likely to attend this clinic treating sexually transmitted infections (STI). Among the sex worker participants were kothis, effeminate men who have sex with men but may also have sex with women, and hijras, male-to-female transgendered people who are primarily the receptive partners because of their female gender identity. Overall, only one-third reported always using condoms, with the most common reasons for non-use being non-availability (43%) and refusal of condom use by the partner (20%). Social marginalization of sex workers in India, as elsewhere, hampers the development of effective programmes to help them avoid HIV infection and obtain treatment for STI and HIV. They appear to be considerably more at risk of acquiring HIV infection than do women who sell sexual services and are particularly likely to benefit from improved access to condoms and skills training to enhance condom negotiation.

Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW. Structural and Environmental Barriers to Condom Use Negotiation With Clients Among Female Sex Workers: Implications for HIV-Prevention Strategies and Policy. Am J Public Health. 2009;99:659-665.

Shannon and colleagues investigated the relationship between environmental-structural factors and condom-use negotiation between female sex workers and clients. They used baseline data from a 2006 Vancouver, British Columbia, community-based cohort of female sex workers, to map the clustering of hot spots for being pressured into unprotected sexual intercourse by a client and assess sexual HIV. The authors then used multivariate logistic modelling to estimate the relationship between environmental-structural factors and being pressured by a client into unprotected intercourse. In multivariate analyses, being pressured to have unprotected sexual intercourse was independently associated with having an individual zoning restriction (odds ratio [OR]=3.39; 95% confidence interval [CI]=1.00, 9.36), working away from main streets because of policing (OR=3.01; 95% CI=1.39, 7.44), borrowing a used crack pipe (OR=2.51; 95% CI=1.06, 2.49), client-perpetrated violence (OR=2.08; 95% CI=1.06, 4.49), and servicing clients in cars or in public spaces (OR=2.00; 95% CI=1.65, 5.73). Given growing global concern surrounding the failings of prohibitive sex-work legislation on sex workers’ health, there is urgent need for environmental-structural HIV-prevention efforts that facilitate sex workers’ ability to negotiate condom use in safer sex-work environments and criminalize abuse by clients and third parties.

Editors’ note: The buying and selling of sexual services has never been illegal in Canada, however it is illegal to communicate in public spaces for the purposes of sexual transaction and the law prohibits ‘keeping or transporting a person to a common bawdy-house”, thus restricting legal indoor sex work. This study used the risk environment framework as its theoretical base, hypothesising that macro- and meso-level factors outside the individual affect negotiation of individual risk. Trained peer researchers, who were former or current sex workers, interviewed 205 sex workers participating in the Maka Project cohort. They were recruited at sex work strolls at staggered times and spaces along these strolls. The analysis of the effects of enforcement of Canada’s prohibitive sex-work policies reveals the need for legal and policy reforms to create safer work environments in which exploitation by clients and third parties is effectively criminalised and condom use is readily and consistently negotiated.

Jafa K, McElroy P, Fitzpatrick L, Borkowf CB, Macgowan R, Margolis A, Robbins K, Youngpairoj AS, Stratford D, Greenberg A, Taussig J, Shouse RL, Lamarre M, McLellan-Lemal E, Heneine W, Sullivan PS. HIV transmission in a state prison system, 1988-2005. PLoS ONE. 2009;4(5):e5416. 

HIV prevalence among state prison inmates in the United States is more than five times higher than among non-incarcerated persons, but HIV transmission within U.S. prisons is sparsely documented. Jafa and colleagues investigated 88 HIV seroconversions reported from 1988-2005 among male Georgia prison inmates. They analyzed medical and administrative data to describe seroconverters’ HIV testing histories and performed a case-crossover analysis of their risks before and after HIV diagnosis. The authors sequenced the gag, env, and pol genes of seroconverters’ HIV strains to identify genetically-related HIV transmission clusters and antiretroviral resistance. They combined risk, genetic, and administrative data to describe prison HIV transmission networks. Forty-one (47%) seroconverters were diagnosed with HIV from July 2003-June 2005 when voluntary annual testing was offered. Seroconverters were less likely to report sex (OR [odds ratio] = 0.02, 95% CI [confidence interval]: 0-0.10) and tattooing (OR = 0.03, 95% CI: <0.01-0.20) in prison after their HIV diagnosis than before. Of 67 seroconverters’ specimens tested, 33 (49%) fell into one of 10 genetically-related clusters; of these, 25 (76%) reported sex in prison before their HIV diagnosis. The HIV strains of 8 (61%) of 13 antiretroviral-naïve and 21 (40%) of 52 antiretroviral-treated seroconverters were antiretroviral-resistant. Half of all HIV seroconversions were identified when routine voluntary testing was offered, and seroconverters reduced their risks following their diagnosis. Most genetically-related seroconverters reported sex in prison, suggesting HIV transmission through sexual networks. Resistance testing before initiating antiretroviral therapy is important for newly-diagnosed inmates.

Editors’ note: Although HIV testing is mandatory at prison entry since 1988 in Georgia, USA and voluntary annual testing was introduced in 2003, HIV testing and counselling is not offered to inmates at the time of release from prison. HIV prevention programming to reduce risk of HIV exposure while incarcerated, an offer of pre-release HIV testing, and referral to ensure uninterrupted medial care on release are custodial corrections responsibilities. Drug resistance testing before and during antiretroviral treatment is particularly important in closed settings such as this where resistant virus clearly is being transmitted.

Kim J, Pronyk P, Barnett T, Watts C. Exploring the role of economic empowerment in HIV prevention. AIDS. 2008;22 Suppl 4:S57-71.

It has been argued that women’s economic vulnerability and dependence on men increases their vulnerability to HIV by constraining their ability to negotiate the conditions, including sexual abstinence, condom use and multiple partnerships, which shape their risk of infection. In the face of escalating infection rates among women, and particularly young women, many have pointed to the potential importance of economic empowerment strategies for HIV prevention responses. Global evidence suggests that the relationship between poverty and HIV risk is complex, and that poverty on its own cannot be viewed simplistically as a driver of the HIV epidemic. Rather, its role appears to be multidimensional and to interact with a range of other factors, including mobility, social and economic inequalities and social capital, which converge in a particularly potent way for young women living in southern Africa. To date, there have been few interventions that have explicitly attempted to combine economic empowerment with the goal of HIV prevention, and even fewer that have been rigorously evaluated. This paper explores how programmes such as microfinance, livelihood training and efforts to safeguard women’s food security and access to property have begun to incorporate an HIV prevention focus. Although such circumscribed interventions, by themselves, are unlikely to lead to significant impacts on a national or regional scale, they are useful for testing cross-sectoral partnership models, generating practical lessons and providing a metaphor for what might be possible in promoting women’s economic empowerment more broadly. Despite numerous calls to ‘mainstream AIDS’ in economic development, cross-sectoral responses have not been widely taken up by government or other stakeholders. Kim and colleagues suggest potential reasons for limited progress to date and conclude by presenting programme and policy recommendations for further exploring and harnessing linkages between economic empowerment and HIV prevention in Southern Africa.

Editors’ note: This powerful article in a journal supplement of papers drawn from a UNAIDS-convened consultation on the vulnerability of young women in southern Africa uses the World Bank definition of empowerment: ‘the process of increasing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes’. It presents the evidence on microfinance, livelihood training, improving food security, and securing women’s property and inheritance rights, as well as recommendations for policy and programming on economic empowerment for HIV prevention. The entire supplement can be downloaded free of charge, if you are among the first 5000 people interested, at https://articleworks.cadmus.com/doc/926318

Reid T, van Engelgem I, Telfer B, Manzi M. Providing HIV care in the aftermath of Kenya’s post-election violence Medecins Sans Frontieres’ lessons learned January – March 2008. Confl Health. 2008;2:15.

Kenya’s post-election violence in early 2008 created considerable problems for health services, and in particular, those providing HIV care. It was feared that the disruptions in services would lead to widespread treatment interruption. Medecins sans Frontières had been working in the Kibera slum for 10 years and was providing antiretroviral therapy to almost 2000 patients when the violence broke out. Medecins sans Frontières responded to the crisis in a number of ways and managed to keep HIV services going. Treatment interruption was less than expected, and Medecins sans Frontières profited by a number of « lessons learned » that could be applied to similar contexts where a stable situation suddenly deteriorates.

Editors’ note: When an apparently stable situation deteriorates rapidly, clinic staff cannot get to work safely and patients cut off from health care services cannot access their medical records detailing their treatment regimens. Furthermore, acute trauma cases change workloads dramatically in clinics where the caseload is normally a mixture of primary health care problems and a comprehensive HIV programme. An updated Emergency Preparedness Plan, close communication ties with the community for daily situation assessments, emergency data management systems, and high levels of treatment literary motivating patients to seek creative solutions, can reduce the risk of antiretroviral treatment interruptions.

Ayikukwei R, Ngare D, Sidle J, Ayuku D, Baliddawa J, Greene J. HIV/AIDS and cultural practices in western Kenya: the impact of sexual cleansing rituals on sexual behaviours. Cult Health Sex. 2008 Aug;10(6):587-99.

This paper reports on an exploratory study examining the role of sexual cleansing rituals in the transmission of HIV among the Luo community in western Kenya. Data were collected using both in-depth interviews and focus group discussions. The study population consisted of 38 widows, 12 community elders and 44 cleansers. Data were collected on non-behavioural causes, behavioural causes, and behavioural indicators associated with sexual rituals. Content analysis revealed five central themes: the effect of the ritual on sexual behaviours; factors contributing to the continued practice of the ritual, including a sub-theme on the commercialization of the ritual; the inseparable relationship between the sanctity of sex, prosperity and fertility of the land; and the effects of modernization on the ritual, including a sub-theme on the effects of mass media on HIV-prevention awareness campaigns. Causal factors of unchanging sexual behaviours are deeply rooted in traditional beliefs, which the community uphold strongly. These beliefs encourage men and women to have multiple sexual partners in a context where the use of condoms is rejected and little HIV testing is carried out.

Editors’ note: Nyanza Province has the highest HIV prevalence in Kenya. This study concludes that the Luo community feels vulnerable because it has not been able yet to devise systems that strike a balance between honouring tradition and protecting the community against HIV. And yet, culture is not immutable – it can change in response to changing circumstances. A month ago, several male Luo politicians reported publicly that they were circumcised when it is Luo tradition to not be circumcised. In Kisumu, the waiting lines for circumcision services continue to grow as young men value the promise of partial protection against HIV that circumcision can afford over the view that being non-circumcised is essential to cultural and community identity. The role of sexual cleansing in the middle of a generalised epidemic may also come under scrutiny by the community in the not so distant future.

Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A. Structural approaches to HIV prevention. Lancet. 2008 Aug 30;372(9640):764-75. Epub 2008 Aug 5.

Recognition that social, economic, political, and environmental factors directly affect HIV risk and vulnerability has stimulated interest in structural approaches to HIV prevention. Progress in the use of structural approaches has been limited for several reasons: absence of a clear definition; lack of operational guidance; and limited data on the effectiveness of structural approaches to the reduction of HIV incidence. In this paper Gupta et al build on evidence and experience to address these gaps. They begin by defining structural factors and approaches. Structural factors include the physical, social, cultural, organisational, community, economic, legal, or policy features of the environment that affect HIV infection. These factors operate at different societal levels and different distances to influence individual risk and to shape social vulnerability to infection. Structural approaches to HIV prevention seek to change social, economic, political, or environmental factors determining HIV risk and vulnerability. They should be implemented in a contextually sensitive way, in recognition of both the need for situational relevance and the interaction between diff erent levels of influence. Gupta et al describe the available evidence on their effectiveness and discuss methodological challenges to the assessment of these often complex efforts to reduce HIV risk and vulnerability. They identify core principles for implementing this kind of work. They also provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.

Editors’ notes: Broad structural factors such as poverty and wealth, gender inequality, age, social marginalisation, laws and policies, and power both shape and constrain individual behaviour. They can be distal (further way from risk–taking, e.g. the economy) or proximal (more directly influencing risk, e.g. personal unemployment). They can undermine HIV prevention programmes that are narrowly focused on individuals. Combining structural approaches that aim to change the social, economic, or environmental factors that determine HIV risk and vulnerability in specified contexts with behavioural or biomedical prevention programmes not only increases programme effectiveness, it can transform social norms to support sustained behaviour change.

Pearce ME, Christian WM, Patterson K, Norris K, Moniruzzaman A, Craib KJ, Schechter MT, Spittal PM. The Cedar Project: Historical trauma, sexual abuse and HIV risk among young Aboriginal people who use injection and non-injection drugs in two Canadian cities. Soc Sci Med. 2008;66(11):2185-2194.

Recent Indigenist scholarship has situated high rates of traumatic life experiences, including sexual abuse, among Indigenous peoples of North America within the larger context of their status as colonized peoples. Sexual abuse has been linked to many negative health outcomes including mental, sexual and drug-related vulnerabilities. There is a paucity of research in Canada addressing the relationship between antecedent sexual abuse and negative health outcomes among Aboriginal people including elevated risk of HIV infection. The primary objectives of this study were to determine factors associated with sexual abuse among participants of the Cedar Project, a cohort of young Aboriginal people between the ages of 14 and 30 years who use injection and non-injection drugs in two urban centres in British Columbia, Canada; and to locate findings through a lens of historical and intergenerational trauma. Pearce and colleagues utilized post-colonial perspectives in research design, problem formulation and the interpretation of results. Multivariate modelling was used to determine the extent to which a history of sexual abuse was predictive of negative health outcomes and vulnerability to HIV infection. Of the 543 eligible participants, 48% reported ever having experienced sexual abuse; 69% of sexually abused participants were female. The median age of first sexual abuse was 6 years for both female and male participants. After adjusting for socio-demographic variables and factors of historical trauma, sexually abused participants were more likely to have ever been on the streets for more than three nights, to have ever self-harmed, to have suicide ideation, to have attempted suicide, to have a diagnosis of mental illness, to have been in the emergency department within the previous 6 months, to have had over 20 lifetime sexual partners, to have ever been paid for sex, and to have ever overdosed. The prevalence and consequences of sexual abuse among Cedar Project participants are of grave concern. Sexual trauma will continue to affect individuals, families, and communities until unresolved historical trauma is meaningfully addressed in client-driven, culturally safe programming.

Editors’ note: Sexual abuse within Aboriginal communities in Canada is believed to have been relatively rare prior to European contact and the residential school system. In 2005, Aboriginal people comprised 3.3% of the Canadian population, 7.5% of HIV infections, and 22% of new infections. The link between sexual abuse and vulnerability to negative sexual and mental health disorders, including HIV infection, has been documented around the world. In Canada and elsewhere, stopping sexual abuse requires zero tolerance community norms that are rooted in a clear understanding of its origins in historical trauma at individual, family, and community levels.

Loutfy MR, Macdonald S, Myhr T, Husson H, Du Mont J, Balla S, Antoniou T, Rachlis A. Prospective cohort study of HIV post-exposure prophylaxis for sexual assault survivors. Antivir Ther. 2008;13(1):87-95

There is a lack of standardized programs for HIV counselling and post-exposure prophylaxis (PEP) in the setting of sexual assault. Loutfy and associates conducted an 18-month prospective cohort study assessing universal HIV counselling for all sexual assault survivors presenting to 18 Ontario Sexual Assault Treatment Centres. HIV PEP was universally offered to those at risk of HIV infection (high risk or unknown risk) presenting < or =72 h after the assault, using Combivir (Lamivudine/Zidovudine) one pill and Kaletra (Lopinavir/Ritonavir) three capsules twice a day for 28 days. Those who accepted HIV PEP were monitored via a schedule of frequent follow ups. The primary outcomes were acceptance and completion rates, and their predictors were determined using multivariable logistic regression. Adverse events were categorized using a standardized toxicity grading system. Of the 900 evaluable participants eligible for PEP, 798 (69 at high risk and 729 at unknown risk) were offered treatment. Acceptance rates were 66.7% (n=46) and 41.3% (n=301) for participants at high risk and unknown risk, respectively. Participants at high risk were 2.2 times more likely to accept PEP than those at unknown risk (adjusted odds ratio 2.2; 95% confidence interval 1.2-4.0; P=0.01). Overall, 23.9% high-risk (n=11) and 33.2% unknown-risk participants (n=100) completed PEP (P=0.20). Predictors of acceptance and completion included assault by a stranger and participant anxiety. Adverse events were common, with 77.1% of participants reporting grade 2-4 symptoms. A province-wide standardized program of universal HIV counselling and offering of PEP to sexual assault survivors with frequent follow up was successfully implemented and feasible.

Editors´note: Post-exposure prophylaxis for sexual assault survivors requires contact with the health system within 72 hours of the attack, availability of antiretroviral drugs and willingness to take them, and, in most cases, consent for HIV testing and counselling. Both anxiety and perceived risk that the assailant could have been HIV-positive influence uptake and completion, but so do side effects. Only 32% of those who started on post-exposure prophylaxis actually finished the 28-day course.

Gazi R, Mercer A, Wansom T, Kabir H, Saha NC, Azim T. An assessment of vulnerability to HIV infection of boatmen in Teknaf, Bangladesh. Confl Health. 2008;2(1):5

Mobile population groups are at high risk for contracting HIV infection. Many factors contribute to this risk, including high prevalence of risky behaviour and increased risk of violence due to conflict and war. The Naf River serves as the primary border crossing point between Teknaf, Bangladesh, and Mynamar [Burma] for both official and unofficial travel of people and goods. Little is known about the risk behaviour of boatmen who travel back and forth between Teknaf and Myanmar. However, Gazi and colleagues hypothesize that boatmen may act as a bridging population for HIV between the high-prevalence country of Myanmar and the low-prevalence country of Bangladesh. Methods included initial rapport building with community members, mapping of boatmen communities, and in-depth qualitative interviews with key informants and members from other vulnerable groups such as spouses of boatmen, female sex workers, and injecting drug users. Information from the first three stages was used to create a cross-sectional survey that was administered to 433 boatmen. Over 40% of the boatmen had visited Myanmar during the course of their work. 17% of these boatmen had sex with sex workers while abroad. There was a significant correlation found between the number of nights spent in Myanmar and sex with commercial sex workers. In the past year, 19% of all boatmen surveyed had sex with another man. Fourteen per cent of boatmen had participated in group sex, with groups ranging in size from three to fourteen people. Condom use was rare [0 to 4.7% during the last month], irrespective of types of sex partners. Regression analysis showed that boatmen who were 25 years and older were statistically less likely to have sexual intercourse with non- marital female partners in the last year compared to the boatmen aged less than 25 years. Similarly, deep sea fishing boatmen and non-fishing boatmen were statistically less likely to have sexual intercourse with non-marital female partners in the last year compared to the day-longfishing boatmen adjusting for all other variables. Boatmen’s knowledge regarding HIV transmission and personal risk perception for contracting HIV was low. Boatmen in Teknaf are an integral part of a high-risk sexual behaviour network between Myanmar and Bangladesh. They are at risk of obtaining HIV infection due to cross-border mobility and unsafe sexual practices. There is an urgent need for designing interventions targeting boatmen in Teknaf to combat an impending epidemic of HIV among this group. They could be included in the serological surveillance as a vulnerable group. Interventions need to address issues on both sides of the border, other vulnerable groups, and refugees. Strong political will and cross-border collaboration are mandatory for such interventions.