HIV This Week

Welcome to the forty-ninth issue of HIV This Week! In this issue, we cover young people (development bank accounts expand time horizons: a trial among adolescents orphaned by AIDS in rural Uganda; a cognitive-behavioural trial among homeless youth encourages condom use), basic science (where is the home base of HIV in the body? – it’s the gut!; how to use our own inborn mucosal immunity for HIV prevention), serostatus disclosure (telling sexual partners in Uganda: the case for couple counselling and testing; fewer emotional problems in Zambian HIV-positive adolescents who know their serostatus compared to those who don’t), global, multilateral, and bilateral responses (what does ’diagonal financing’ mean and would it work?), molecular epidemiology (molecular phylodynamics reveal HIV outbreaks from 1995 to 2000 among men who have sex with men in London), structural determinants and vulnerability (spotlight on esquineros and movidas in Peru), sexual transmission and prevention (condom use in sub-Saharan Africa and Asia: a systematic review), gender: transactional sex ( ‘skinning the goat’ in Tanzania: mistrust, disrespect, and transactional sex among youth; money gifts as loving gestures in premarital partnerships in southern Malawi), injecting drug use (even the police are more positive than drug users about methadone maintenance treatment in Yunnan, China; peer delivered needle and syringe programmes, family involvement, and community support anchor harm reduction in rural northern Vietnam; what to do about first time injectors at medically supervised safer injection facilities),and infant feeding (grandmothers are a force to contend with in Malawi).

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For full PDF access to this issue:HIV This Week Issue #49

Cate Hankins	Nicolai Lohse	Tania Lemay	Diane Addison
Chief Scientific Adviser	Research Officer	Research Consultant	Intern

Ssewamala FM, Alicea S, Bannon WM Jr, Ismayilova L. A novel economic intervention to reduce HIV risks among school-going AIDS orphans in rural Uganda.J Adolesc Health 2008;42(1):102-4

This study tested an economic intervention to reduce HIV risks among AIDS-orphaned adolescents. Adolescents (n = 96) were randomly assigned to receive the intervention or usual care for orphans in Uganda. Data obtained at baseline and 12-month follow-up revealed significant differences between the treatment and control groups in HIV prevention attitudes and educational planning. Editors’ note: Unusual RCT testing an economic intervention to reduce HIV risk among (AIDS-orphaned) adolescents.

Editors’ note: The authors hypothesized that greater resources would improve adolescents’ expectations for the future, leading to continued schooling and positive health behaviours. The experimental arm received career planning, career goals, microfinance, and a Child/Youth Development Account. The latter was funded by contributions from the adolescent’s family members/friends with 2 to 1 matching funds from the intervention. The results were more positive attitudes to HIV prevention, increased educational planning, and sufficient funds for 2 years of post-primary education compared with decreased educational plans in the control arm. This simple, feasible family economic intervention warrants larger scale clinical trials involving children orphaned by AIDS and other vulnerable children, with expanded outcome measures.

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Slesnick N, Kang MJ. The impact of an integrated treatment on HIV risk behavior among homeless youth: a randomized controlled trial. J Behav Med. 2008;31(1):45-59

While many studies provide useful information on the risk behaviours in which homeless youth engage, few prior studies evaluate HIV risk-related reduction strategies. In this study, homeless youth (n = 180) were recruited from a drop-in centre and randomly assigned to one of two conditions, either an integrated individual cognitive-behavioural treatment and HIV prevention intervention that focused on skills building and education or to treatment as usual. All youth were assessed at entry into the programme and at 3 and 6 month follow-up points. Findings showed an interaction between treatment condition, age, and time. In the interaction, youth assigned to the integrated treatment reported greater condom usage than youth assigned to treatment as usual, with younger youth assigned to treatment as usual showing no change in condom use. The number of sexual partners reported by youth in both treatment conditions was also reduced over time. However, youth in both conditions continued to engage in other high-risk behaviours. The integrated treatment findings are promising and suggest that interventions which target both HIV risk behaviour in addition to other life areas ( substance use, mental health, and housing) among homeless youth may be necessary in order to significantly impact high-risk behaviours among this unique group.

Editors’ note: Addressing the real life issues that are high among the concerns of homeless youth can make condom use more relevant. Small studies with short time horizons such as this one should be replicated and extended but need to be accompanied by programmes that tackle the root cause of homelessness among youth.

Chun TW, Nickle DC, Justement JS, Meyers JH, Roby G, Hallahan CW, Kottilil S, Moir S, Mican JM, Mullins JI, Ward DJ, Kovacs JA, Mannon PJ, Fauci AS. Persistence of HIV in Gut-Associated Lymphoid Tissue despite Long-Term Antiretroviral Therapy. J Infect Dis. 2008;197: 714-20.

Human immunodeficiency virus (HIV) persists in peripheral blood mononuclear cells despite sustained, undetectable plasma viremia resulting from long-term antiretroviral therapy. However, the source of persistent HIV in such infected individuals remains unclear. Given recent data suggesting high levels of viral replication and profound depletion of CD4(+) T cells in gut-associated lymphoid tissue of animals infected with simian immunodeficiency virus and HIV-infected humans, Chun and colleagues sought to determine the level of CD4(+) T cell depletion as well as the degree and extent of HIV persistence in the gut-associated lymphoid tissue of infected individuals who had been receiving effective antiviral therapy for prolonged periods of time. The authors demonstrate incomplete recoveries of CD4(+) T cells in the gut-associated lymphoid tissue of aviremic, HIV-infected individuals who had received up to 9.9 years of effective antiretroviral therapy. In addition, the authors demonstrate higher frequencies of HIV infection in gut-associated lymphoid tissue, compared with peripheral blood mononuclear cells, in these aviremic individuals and provide evidence for cross-infection between these 2 cellular compartments. Together, these data provide a possible mechanism for the maintenance of viral reservoirs revolving around the gut-associated lymphoid tissue of HIV-infected individuals despite long-term viral suppression and suggest that the gut-associated lymphoid tissue may play a major role in the persistence of HIV in such individuals.

Editors’ note: Gut-associated lymphoid tissue is the largest component of the human lymphoid system and contains the highest number of CD4+ T cells. This study reveals that persistent depletion of CD4+ T cells in the gut, indicating a lack of mucosal immune reconstitution, is due to ongoing HIV replication despite undetectable plasma viral loads achieved through existing drug regimens. New drugs are needed to stop HIV seeding from the gut into the bloodstream if this important viral reservoir is to be controlled.

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Iqbal SM, Kaul R. Mucosal innate immunity as a determinant of HIV susceptibility. Am J Reprod Immunol. 2008;59(1):44-54.

Most human immunodeficiency virus (HIV) is acquired during sex, across a mucosal membrane. Despite many advances in our understanding of HIV pathogenesis, the initial events during mucosal transmission have been poorly characterized, and a better understanding of these events will probably be a key to the development of successful microbicide(s) and/or a preventative HIV vaccine. While a vast majority of mucosal HIV exposures do not result in productive infection, implying that innate mucosal immune defenses are highly protective, failure of these mucosal defenses resulted in over 3 million new HIV infections in 2006. Iqbal and colleagues review recent findings regarding HIV mucosal immunopathogenesis, emphasizing the importance of innate immunity in natural protection from infection, and examine how natural or induced perturbations in the mucosal innate system may underpin HIV transmission. Given the great challenges to the development of HIV microbicides and vaccines, identification and enhancement of ‘natural’ innate immune defenses present attractive avenues for development of safe, non-toxic microbicides.

Editors’ note: At stake is how to translate natural HIV protection into HIV prevention. On the genetic side, discovery in highly exposed persistently seronegative people of the CCR5- r 32 mutation that confers near complete resistance to sexual HIV acquisition led to a new class of CCR5 inhibitor antiretroviral drugs. On the innate (inborn) immunity side, the challenge is to turn key innate proteins that have low toxicity and demonstrated real life efficacy into effective microbicides, pumping up what we already have.

King R, Katuntu D, Lifshay J, Packel L, Batamwita R, Nakayiwa S, Abang B, Babirye F, Lindkvist P, Johansson E, Mermin J, Bunnell R. Processes and Outcomes of HIV Serostatus Disclosure to Sexual Partners among People Living with HIV in Uganda. AIDS Behav. 2008;12(2):232-43. Epub 2007 Sep 8.

Disclosure of HIV serostatus to sexual partners supports risk reduction and facilitates access to prevention and care services for people living with HIV. To assess health and social predictors of disclosure as well as to explore and describe the process, experiences and outcomes related to disclosure of men and women living with HIV in Eastern Uganda, King and colleagues conducted a study among clients of The AIDS Support Organization (TASO) in Jinja, Uganda. The authors enrolled TASO clients in a cross-sectional study on transmission risk behaviour. Demographic and behavioural data and CD4 cell count measurements were collected. Among 1,092 participants, 42% were currently sexually active and 69% had disclosed their HIV serostatus to their most recent sexual partner. Multivariate logistic regression analysis showed that disclosure of HIV-status was associated with being married, having attended TASO for more than 2 years, increased condom use, and knowledge of partner’s serostatus. From these clients, 45 men and women were purposefully selected and interviewed in-depth on disclosure issues. Positive outcomes included risk reduction behaviour, partner testing, increased care-seeking behaviour, anxiety relief, increased sexual communication, and motivation to plan for the future.

Editors’ note: Almost half of the participants disclosed indirectly, a culturally appropriate method of conveying personal information in this setting but one that requires more human resources. Given the strong association found between knowledge of serostatus and disclosure, widespread promotion of couples counselling, with the option of mutual disclosure, can link couples to family-focused HIV treatment, care, and prevention opportunities. Both Uganda and Kenya are expanding home-based testing programmes that do exactly that.

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Menon A, Glazebrook C, Campain N, Ngoma M. Mental Health and Disclosure of HIV Status in Zambian Adolescents With HIV Infection: Implications for Peer-Support Programmes. J Acquir Immune Defic Syndr. 2007;46(3):349-54

Menon and colleagues aimed to examine emotional and behavioural difficulties in Zambian adolescents living with HIV, and to determine the relationship between disclosure of HIV status and mental health. In a cross-sectional survey, 127 adolescents living with HIV aged 11 to 15 years were recruited through clinics in the Lusaka region. Mental health was assessed using the youth report version of the Strengths and Difficulties Questionnaire (SDQ). Caregivers completed the parent SDQ. Sixty-two participants were invited for a semi-structured interview which probed views on attending a peer support group. Compared to a British community sample, participants had increased mental health problems (OR, 2.1), particularly emotional symptoms (OR = 3.6), and peer problems (OR = 7.1). The majority of the study subjects (n = 94) were receiving antiretroviral treatment, but only 48 (37.8%) had their HIV status disclosed to them. Those who had not had their HIV status disclosed to them were younger (P < 0.001) and less likely to be receiving antiretroviral treatment (P < 0.001). Controlling for these factors they were also more likely to score in the abnormal range of the emotional difficulties subscale (OR = 2.63, 95% CI: 1.11 to 6.26). Of 38 interviews transcribed, content analysis showed that only 3 individuals were opposed to participation in a peer-group programme, with the majority (23/38 ) expressing reasoned and positive responses, regardless of disclosure status. In conclusion, high rates of emotional and peer problems were found in this sample but disclosure of HIV status did not have a negative effect on mental health. Interventions to promote disclosure could facilitate access to emotional and peer support.

Editors’ note: Children with HIV are at increased risk of mental health problems but not necessarily as a result of their health status. In this study, Zambian young people aged 11 to 15 years aware of their serostatus were 2.5 times less likely to score in the abnormal range for emotional difficulty, after controlling for age, sex, and medication, than those who did not know. Since this is a cross-sectional study, it is difficult to know whether more psychologically stable children are more likely to learn their serostatus and even, whether families who choose to disclose have higher expressivity levels or tend to have more psychologically stable children. What is clear is that knowledge of serostatus is the door to participation in a peer support group that can provide psychological support.

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

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

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

Lewis F, Hughes GJ, Rambaut A, Pozniak A, Leigh Brown AJ. Episodic sexual transmission of HIV revealed by molecular phylodynamics. PLoS Med. 2008;5(3):e50.

The structure of sexual contact networks plays a key role in the epidemiology of sexually transmitted infections, and their reconstruction from interview data has provided valuable insights into the spread of infection. For HIV, the long period of infectivity has made the interpretation of contact networks more difficult, and major discrepancies have been observed between the contact network and the transmission network revealed by viral phylogenetics. The high rate of HIV evolution in principle allows for detailed reconstruction of links between virus from different individuals, but often sampling has been too sparse to describe the structure of the transmission network. The aim of this study was to analyze a high-density sample of an HIV-infected population using recently developed techniques in phylogenetics to infer the short-term dynamics of the epidemic among men who have sex with men. Sequences of the protease and reverse transcriptase coding regions from 2,126 patients, predominantly men who have sex with men , from London were compared: 402 of these showed a close match to at least one other subtype B sequence. Nine large clusters were identified on the basis of genetic distance; all were confirmed by Bayesian Monte Carlo Markov chain phylogenetic analysis. Overall, 25% of individuals with a close match with one sequence are linked to 10 or more others. Dated phylogenies of the clusters using a relaxed clock indicated that 65% of the transmissions within clusters took place between 1995 and 2000, and 25% occurred within 6 months after infection. The likelihood that not all members of the clusters have been identified renders the latter observation conservative. In conclusion, reconstruction of the HIV transmission network using a dated phylogeny approach has revealed the HIV epidemic among men who have sex with men in London to have been episodic, with evidence of multiple clusters of transmissions dating to the late 1990s, a period when HIV prevalence is known to have doubled in this population. The quantitative description of the transmission dynamics among men who have sex with men will be important for parameterization of epidemiological models and in designing intervention strategies.

Editors’ note: This first report of the application of phylodynamics to HIV-sequence data-mining reveals discrete outbreaks among men who have sex with men in London over a 5 year period in the late 1990s fuelled by efficient transmission during acute infection. As pointed out in the accompanying editorial by Pilcher et al in this open access journal, this suggests the need for stronger emphasis on outbreak detection and network intervention strategies. This may be increasingly possible as more newly diagnosed patients have resistance testing performed but ensuring the confidentiality and security of data will be key in balancing individual privacy rights with scientific and public health objectives.

Cáceres CF, Konda KA, Salazar X, Leon SR, Klausner JD, Lescano AG, Maiorana A, Kegeles S, Jones FR, Coates TJ; The NIMH HIV/STD Collaborative Intervention Trial. New Populations at High Risk of HIV/STIs in Low-income, Urban Coastal Peru. AIDS Behav. 2007 Dec 27 [Epub ahead of print]

The HIV epidemic in Peru is concentrated primarily among men who have sex with men. HIV interventions have focused exclusively on a narrowly defined group of men who have sex with men and female sex workers to the exclusion of other populations potentially at increased risk. Interventions targeting men who have sex with men and female sex workers are insufficient and there is evidence that focusing prevention efforts solely on these populations may ignore others that do not fall directly into these categories. Cáceres and colleagues describe non-traditional, vulnerable populations within low-income neighbourhoods. These populations were identified through the use of ethnographic and epidemiologic formative research methods and the results are reported in this publication. Although the traditional vulnerable groups are still in need of prevention efforts, this study provides evidence of previously unrecognized populations at increased risk that should also receive attention from HIV and other sexually transmitted diseases prevention programmes.

Editors’ note: Highlighting the importance of ‘know your epidemic’, this study found esquineros (“street corner men” with limited education, who are financially dependent on their families and tend to engage in petty crime) and movidas (“active women” who spend time, drink alcohol, and have sex with esquineros) have similar HIV and syphilis prevalence as the general population but markedly different sexual risk behaviours. Prevention programmes focused on the general population or on known populations at higher risk of HIV exposure will not reach these sub-populations which need context-appropriate services.

Foss AM, Hossain M, Vickerman PT, Watts CH. A systematic review of published evidence on intervention impact on condom use in sub-Saharan Africa and Asia. Sex Transm Infect. 2007;83:510-6.

There has been much debate about the value of condoms in HIV and sexually transmitted infections prevention programming. This should be informed by evidence about intervention impact on condom use, but there is limited compiled literature. This review aims to quantify intervention impact on condom use in sub-Saharan Africa and Asia, in different types of partnerships. Foss and colleagues conducted a systematic review of papers published between 1998 and 2006 presenting evaluations of interventions involving condom promotion in sub-Saharan Africa and Asia. Data on reported post-intervention levels of condom use, and various measures of changes in condom use, by partnership type, were compiled. A total of 1374 abstracts were identified. Sixty-two met the inclusion criteria (42 reporting significant increases in condom use): 44 from sub-Saharan Africa and 18 from Asia. Many (19) reported on condom use in commercial sex (15 significant), six on use with casual partners (three significant), 11 on use in marital/steady partnerships (nine significant), 14 on use by youths (eight significant) and 20 combined partnership types (11 significant). There is substantial evidence of interventions targeted at sex workers and clients achieving large increases in condom use. Far less evidence exists of intervention impact on condom use in casual relationships. In primary partnerships, post-intervention condom use was low unless one partner knew that he/she had HIV or was at high risk, or was avoiding pregnancy. Evaluations of interventions targeting youths recorded limited increases in condom use. The findings illustrate the range of evidence about post-intervention condom use in different partnerships, and how patterns of use are influenced by partnership type and perceptions of risk. Where possible, intervention studies should also assess biological endpoints, since prevention of infection is the measure of most interest in the evaluation of condom promotion interventions.

Editors’ note: This valuable review, focused on evaluation of approaches to increase condom use in a variety of sexual relationship types in sub-Saharan Africa and Asia, reveals greater effectiveness for programmes focused on sex work encounters and on marital/steady partnerships that have good reasons to use condoms. It highlights a key knowledge deficit – how to increase condom use in casual partnerships.

Maganja RK, Maman S, Groues A, Mbwambo JK. Skinning the goat and pulling the load: transactional sex among youth in Dar es Salaam, Tanzania. AIDS Care. 2007;19:974-81.

Transactional sex has been associated with risk of HIV infection in a number of studies throughout sub-Saharan Africa. Urban young women are economically vulnerable and at heightened risk of HIV infection in Tanzania; yet there are few studies that have explored relationship dynamics, including transactional sex, in this setting. This paper sheds light on the broader context of sexual relationships among youth at risk for HIV, how transactional sex plays out in these relationships, and how the transactional nature of relationships affects women’s risk for HIV. Maganja and colleagues conducted 60 in-depth interviews and 14 focus group discussions with young men and women, 16-24 years old, in Dar es Salaam, Tanzania. These data guided the development of a community-based HIV and violence prevention intervention for young men. Youth described the exchange of sex for money or other material goods in all types of sexual relationships. While the exchange was explicit in casual relationships, young women voiced material and monetary expectations from their committed partners as well. Young men described their pursuit of multiple partners as sexually motivated, while women sought multiple partners for economic reasons. Young men were aware of the expectations of material support from partners, and acknowledged that their ability to provide for a partner affected both the longevity and exclusivity of their relationships. Youth described a deep mistrust of the motivations and commitment of their sexual partners. Furthermore, young women’s financial dependence on men affected their ability to negotiate safe sexual behaviours in both casual and committed relationships. Programmes designed to reduce HIV risk among Tanzanian youth need to take into account the transactional component of sexual relationships and how such exchanges differ according to partner type.

Editors’ note: Giving and receiving gifts from sexual partners is a worldwide phenomenon. When the strategy is ‘skinning the goat’ ( Tanzania), ‘detoothing’ ( Uganda), or extracting resources from male partners, women are less likely to negotiate safer sex and both sexes may mistrust and disrespect each other. Prevention programmes that overlook these dynamics influencing risk and safety are missing the boat. The challenge is to find ways to shift gender imbalances in access to resources, engage young men to change attitudes to power and control in relationships, and encourage alternative ways of expressing love and respect by both sexes.

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Poulin M. Sex, money, and premarital partnerships in southern Malawi. Soc Sci Med. 2007;65(11):2383-93.

In this paper, Poulin argues two main points. First, in premarital, sexual partnerships in rural Malawi, the purpose of money exchange extends beyond the alleviation of female partners’ economic constraints. Second, by clarifying this broader purpose, it becomes possible to recognize where women exert control over their own sexual selves. These findings come from field observations and a rich set of in-depth interviews (N=54), bolstered on occasion by survey data, conducted with young women and men, aged 15-24 years, in the Balaka district in the southern region of the country. This research demonstrates that, contrary to typical expectations, money and gift transfers in sexual partnerships are part and parcel of the courting practices of young Malawian women and men. Transfers are as much about the expression of love and commitment as they are about meeting the financial needs of women or the acquisition of sex for men. Using narrative information to shed light on the semiotics of the sex-money link, these findings from Malawi offer a new perspective that broadens usual interpretations of transactional sex, the understanding of which is critical in a responding to AIDS.

Editors’ note: For young people in this rural Malawi district, money gifts mark commitment, love, and movement towards marriage. Girls interpret them as loving gestures and boys intend for them to be interpreted that way. Many young women appear to have decision-making power over partner choice, condom use, and acting on sexual desire – challenging typical notions of ‘transactional sex’ and encouraging us to be more nuanced in our understanding.

Yang L, Li J, Zhang Y, Li H, Zhang W, Dai F, Ren Z, Qi G, Cheng W. Societal perception and support for methadone maintenance treatment in a Chinese province with high HIV prevalence. Am J Drug Alcohol Abuse. 2008;34(1):5-16.

Methadone maintenance treatment was first piloted in April 2004 in Yunnan, China, to reduce HIV transmission. This study aimed to examine public support for methadone maintenance treatment and was based on cross-sectional data collected in March-April 2006 on a random sample of 411 police staff, medical/health professionals, community members, and drug users. Multivariate logistic regressions were used to analyze the data. The support was the strongest amongst the police and medical professionals but the lowest in drug users. A considerable proportion of the respondents viewed methadone maintenance treatment as contradictory to China’s drug control policies and this factor was negatively associated with support for methadone maintenance treatment. Dissemination of more accurate knowledge and the resolution of these conflicts are urgently needed to increase the public support for methadone maintenance treatment.

Editors’ note: This study in Yunnan province underscores the need to discover the reasons that drug users themselves are the people least supportive of methadone maintenance, particularly as China proceeds to scale-up dramatically such programmes. The reason could be as basic as inadequate knowledge about the effectiveness and safety of methadone substitution.

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 Walsh N, Gibbie TM, Higgs P. The development of peer educator-based harm reduction programmes in northern Vietnam. Drug Alcohol Rev. 2008;27(2):200-3.

Injecting drug use remains an important risk factor for transmission in Vietnam, with an estimated 50% of the 290 000 people living with HIV reporting injecting drug use as a risk factor. Despite this, effective harm reduction interventions are generally lacking. Walsh and colleagues describe the implementation of peer-based harm reduction programmes in two rural provinces of Vietnam. Peer educators were trained in basic HIV prevention, including harm reduction. After significant preparation work with the Provincial AIDS Committees of Bac Giang and Thanh Hoa and other relevant national, provincial and local authorities, the interventions were commenced. Harm reduction interventions were delivered through outreach as well as on site. These included needle and syringe distribution and collection. Community advocacy occurred throughout the life of the project. Local authorities and peers believed that while there was a general reduction in stigma and discrimination, legal barriers associated particularly with the carrying of injecting equipment remained. This affected the ability of peer educators to work with their clients. Nonetheless, peer-based delivery of harm reduction interventions, including needle and syringe programmes, is feasible and acceptable in these two rural Vietnamese provinces. Community acceptance and uptake of these interventions are key to successful expansion across the region. Active participation by families of drug users seems crucial. This initiative demonstrates that despite a difficult policy environment, peer-delivered needle and syringe programmes are feasible within a rural Asian environment as long as there is adequate local political and community support.

Editors’ note: This local harm reduction programme delivered through peer educators mobilised communities to change attitudes, engaged families, was acceptable to police and other local government officials, and resulted in a large reduction in discarded needles and syringes. Shifts in drug policy with the release of thousands of detainees from drug rehabilitation suggest the potential for scaling–up community-based harm reduction programmes more widely in Vietnam.

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Kerr T, Tyndall MW, Zhang R, Lai C, Montaner JS, Wood E. Circumstances of first injection among illicit drug users accessing a medically supervised safer injection facility. Am J Public Health. 2007;97:1228-30.

There have been concerns that safer injecting facilities may promote initiation into injection drug use. Kerr and colleagues examined length of injecting career and circumstances surrounding initiation into injection drug use among 1065 users of North America’s first safer injecting facility and found that the median years of injection drug use were 15.9 years, and that only 1 individual reported performing a first injection at the safer injecting facility. These findings indicate that the safer injecting facility’s benefits have not been offset by a rise in initiation into injection drug use.

Editors’ note: This supervised injecting facility requires all new visitors to sign a waiver indicating that they have injected previously, a fact that is well known in the community. Deterring people who are insistent on injecting for the first time could be a problem since such individuals tend to use another person’s injecting equipment and are at high risk of overdose. One solution would be for them to be assessed first by an on site addictions counsellor, encouraging consideration of the option of referral for treatment.

Bezner Kerr R, Dakishoni L, Shumba L, Msachi R, Chirwa M. “We Grandmothers Know Plenty”: Breastfeeding, complementary feeding and the multifaceted role of grandmothers in Malawi. Soc Sci Med. 2008;66(5):1095-105.

This paper has two purposes: first of all, Bezner Kerr and colleagues examine grandmothers’ role and views of child feeding practices in northern Malawi, and their influence on younger women’s practices. Secondly, the authors consider the implications of these findings for health promotion activities and models of health education. Data were collected from semi-structured interviews, focus groups, and a participatory workshop. Findings demonstrate that, to address child feeding practices which have an effect on nutrition, attention must be paid to the broader context that influences child nutrition, including extended family relations. Paternal grandmothers have a powerful and multifaceted role within the extended family in northern Malawi, both in terms of childcare and in other arenas such as agricultural practices and marital relations. Grandmothers often differ in their ideas about early child feeding from conventional Western medicine. Some practices have existed in the area at least since colonial times, and have strong cultural significance. Despite the important integrated role that older women have within households and communities in this part of Malawi, hospital personnel often have disparaging and paternalistic attitudes towards ‘grannies’ and their knowledge. Health education rarely involves grandmothers, and even if they are involved, their perspectives are not taken into consideration. Hospital staff often reject grandmother knowledge as part of a broader modernization paradigm which views ‘traditional knowledge’ as backward. Grandmothers view current child health conditions within a broader context of changing livelihood conditions and a high prevalence of HIV. The paper concludes by discussing the challenges of involving grandmothers in health education, and the difficulties of incorporating local knowledge into a medical system that largely rejects it.

Editors’ note: Top-down approaches to change feeding practices, which do not take into account the views of key decision-makers or gate-keepers, in this case paternal grandmothers, are bound to face resistance. These women have power and influence over their daughter-in-laws, who are typically the focus of health education about infant feeding, and are experiencing themselves added care giving burdens as a result of high HIV prevalence. Establishing relationships of respect between health personnel and grandmothers who are central figures in agricultural production, social knowledge, and child feeding decisions is the first step. Actively engaging grandmothers in nutrition education can make it possible for young women to exclusively breastfeed, as recommended for infant well-being.