Articles tagged as "National responses"

December
13
2011

Young people

A tale of two countries: rethinking sexual risk for HIV among young people in South Africa and the United States

Pettifor AE, Levandowski BA, Macphail C, Miller WC, Tabor J, Ford C, Stein CR, Rees H, Cohen M. J Adolesc Health. 2011 Sep;49(3):237-243.e1.

Pettifor and colleagues compared the sexual behaviours of young people in South Africa and the United States of America with the aim to better understand the potential role of sexual behaviour in HIV transmission in these two countries that have strikingly different HIV epidemics. Nationally representative, population-based surveys of young people aged 18-24 years from South Africa (n = 7548) and the USA (n = 13,451) were used for the present study. The prevalence of HIV was 10.2% in South Africa and <1% in the USA. Young women and men in the USA reported an earlier age of first sex than those in South Africa (mean age of coital debut for women: USA [16.5], South Africa [17.4]; for men: USA [16.4], SA [16.7]). The median number of lifetime partners is higher in the USA than in South Africa: women: USA (4), South Africa (2); men: USA (4), South Africa (3). The use of condom at last sex is reported to be lower in the USA than in South Africa: women: USA (36.1%), South Africa (45.4%); men: USA (48%), South Africa (58%). On average, young women in South Africa report greater age differences with their sex partners than young women in the USA. Young people in the USA report riskier sexual behaviours than young people in South Africa, despite the much higher prevalence of HIV infection in South Africa. Factors above and beyond sexual behaviour likely play a key role in the ongoing transmission of HIV in South African youth, and thus should be urgently uncovered to develop maximally effective prevention strategies.

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Editor’s note: This comparison of two nationally representative surveys of young people starkly underscores that behaviour is not the sole determinant of HIV risk. South African young people had their first sex at a later age, have fewer sexual partners, and practise more safer sex than their American counterparts. How can the more than 10-fold difference in HIV prevalence be explained?  The first thought goes to larger age gaps between sexual partners. This means sexual mixing with older partners who can act as a bridge population to younger cohorts…. but there has to be more to it than that. In South Africa, male circumcision levels are far lower, herpes simplex 2 infection levels are higher, genital tract inflammation is higher, co-infections (tuberculosis, helminths) that can increase viral set points are more common, and the prevalence of the CCR5Δ32 coreceptor is lower. But social determinants, such as gender power imbalances, poverty, coerced sex and rape, lack of youth friendly services, and stigma are likely playing important roles. Although these surveys were conducted in 2003 (South Africa) and 2001-2 (USA) using somewhat different methodologies, the finding that ‘ordinary’ sexual behaviour can place young people, particularly young women, in South Africa at such high risk should galvanise leaders at all levels to call for urgent action. Advocates are calling out ‘where the hell is the gel’ and researchers are testing microfinance and conditional cash transfers, but it will take a paradigm shift at all levels to prioritise investment in protecting young people from what is a preventable, chronic, lifelong disease. 

National responses
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September
25
2011

Knowledge translation

Using research to influence sexual and reproductive health practice and implementation in sub-Saharan Africa: a case-study analysis

Tulloch O, Mayaud P, Adu-Sarkodie Y, Opoku BK, Lithur No, Sickie E, Delany-Moretlwe S, Wambura M, Changalucha J, Theobald S. Health Res Policy Syst. 2011 Jun 16;9 Suppl 1:S10.

Research institutions and donor organizations are giving growing attention to how research evidence is communicated to influence policy. In the area of sexual and reproductive health and HIV there is less weight given to understanding how evidence is successfully translated into practice. Policy issues in sexual and reproductive health can be controversial, influenced by political factors and shaped by context such as religion, ethnicity, gender and sexuality. The case-studies presented in this paper analyse findings from sexual and reproductive health and HIV research programmes in sub-Saharan Africa: 1) Maternal syphilis screening in Ghana, 2) Legislative change for sexual violence survivors in Ghana, 3) Male circumcision policy in South Africa, and 4) Male circumcision policy in Tanzania. The authors’ analysis draws on two frameworks: Sumner et al's synthesis approach and Nutley's research use continuum. The analysis emphasises the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change—especially in sexual and reproductive health where there are complex interactions between policy actors. Both frameworks demonstrate how policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximise research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural, and practical.

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Editor’s note: The analyses of the case studies of sexual and reproductive health (SRH) policy changes provided here are thought-provoking. Research evidence in this highly politicised field does not simply speak for itself. For research findings to influence SRH policy and programming—sometimes called GRIPP (getting research into policy and practice)—networks of collaborative partnerships, media coverage, knowledge brokers, advocacy, and tailored communication strategies are needed to connect researchers with policy makers and practitioners. Weak public understanding and engagement with science constitutes an initial hurdle that must be overcome to aid stakeholders in understanding the policy implications of new research findings. As described in the male circumcision case study from South Africa, participation of scientists in civil-society government structures facilitated ‘change from within’. In Tanzania, knowledge translation of the male circumcision findings into services is requiring an inclusive, interconnected constructive partnership and continuous communication between policymakers, researchers, advocacy groups, donors, and health practitioners. These case studies demonstrate that the existing policy context is the key pre-condition for research use but policy outcomes can be influenced by concrete actions that increase the probability of research being used by policy actors.

National responses
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September
25
2011

National responses

Challenging urban health: towards an improved local government response to migration, informal settlements, and HIV in Johannesburg, South Africa

Vearey J. Glob Health Action. 2011;4. doi: 10.3402/gha.v4i0.5898. Epub 2011 Jun 9

J. Vearey explored local government responses to the urban health challenges of migration, informal settlements, and HIV in Johannesburg, South Africa. Urbanisation in South Africa is a result of natural urban growth and (to a lesser extent) in-migration from within the country and across borders. This has led to the development of informal settlements within and on the periphery of urban areas. The highest HIV prevalence nationally is found within urban informal settlements. South African local government has a 'developmental mandate' that calls for government to work with citizens to develop sustainable interventions to address their social, economic, and material needs. Through a mixed-methods approach, four studies were undertaken within inner-city Johannesburg and a peripheral urban informal settlement. Two cross-sectional surveys - one at a household level and one with migrant antiretroviral clients - were supplemented with semi-structured interviews with multiple stakeholders involved with urban health and HIV in Johannesburg, and participatory photography and film projects undertaken with urban migrant communities. The findings show that local government requires support in developing and implementing appropriate intersectoral responses to address urban health. Existing urban health frameworks do not deal adequately with the complex health and development challenges identified; it is essential that urban public health practitioners and other development professionals in South Africa engage with the complexities of the urban environment. A revised, participatory approach to urban health - 'concept mapping' - is suggested which requires a recommitment to intersectoral action, 'healthy urban governance' and public health advocacy.

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Editor’s note: Over half the world’s population is now urban and, as a result of rural-urban migration and cross-border migration from other countries into urban areas, almost 60% of the South African population is urban. Urban growth in South Africa is putting pressure on HIV and other health services, on adequate housing, and on basic services such as water, sanitation, and refuse removal. Urban health and development challenges include urban inequalities, migration, informal settlements, urban HIV prevalence, residents with ‘weak rights to the city’, and survivalist livelihood strategies. Applying social determinants of health frameworks, such as the ‘urban living conditions model’, the WHO Commission on Social Determinants of Health conceptual framework for action, and the conceptual framework of the WHO Knowledge Network on Urban Settings, to the interlinked challenges of migration and informal settlements in the urban South Africa setting can be disappointing. By definition such frameworks are intended to provide a guide to understanding a complex reality rather than answers on where and how to intervene. The alternative proposed here is concept mapping, whereby local government officials engage with the diversity of urban populations to create a city-specific concept map, anchored in intersectoral action, healthy urban governance, and public health advocacy, to inform tailored, multi-level responses to urban health challenges.

National responses
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June
19
2011

Young people and condoms

Making sense of condoms: social representations in young people's HIV-related narratives from six African countries

Winskell K, Obyerodhyambo O, Stephenson R. Soc Sci Med. 2011 Feb 4

Condoms are an essential component of comprehensive efforts to control the HIV epidemic, both for those who know their status and for those who do not. Although young people account for almost half of all new HIV infections, reported condom use among them remains low in many sub-Saharan African countries. In order to inform education and communication efforts to increase condom use, Winskell and colleagues examined social representations of condoms among young people aged 10-24 in six African countries/regions with diverse HIV prevalence rates: Swaziland, Namibia, Kenya, South-East Nigeria, Burkina Faso, and Senegal. They used a unique data source, namely 11,354 creative ideas contributed from these countries to a continent-wide scriptwriting contest, held from 1 February to 15 April 2005, on the theme of AIDS. The authors stratified each country sample by the sex, age (10-14, 15-19, 20-24), and urban/rural location of the author and randomly selected up to 10 narratives for each of the 12 resulting strata, netting a total sample of 586 texts for the six countries. They analyzed the narratives qualitatively using thematic data analysis and narrative-based methodologies. Differences were observed across settings in the prominence accorded to condoms, the assessment of their effectiveness, and certain barriers to and facilitators of their use. Moralization emerged as a key impediment to positive representations of condoms, while humour was an appealing means to normalize them. The social representations in the narratives identify communication needs in and across settings and provide youth-focused ideas and perspectives to inform future intervention efforts.

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Editors’ note: The ‘Scenarios for Africa’ contest invited young Africans to contribute scripts for 5-minute fiction films about HIV. Winning ideas were selected by national and international juries and thus far 35 films in over 25 languages have been produced by leading African directors. These researchers examined selected narrative scripts from 6 non-neighbouring countries for insights into how young people make sense of the role of condoms in the response to AIDS and how they would communicate their understanding to others. Social representations are not like attitudes that are based on conscious evaluative judgements. Rather, they are often pre-conscious and they communicate culturally-shared norms and values in symbolic form. This study assessed the social representations of condoms among young people through analysis of their spontaneous mentions of condoms, rather than through their answers to quantitative questions. The results are fascinating and should inform condom programming tailored to context-specific challenges. Although there was no consistent relationship between social representations of condoms and HIV prevalence or majority religion, there was a striking relationship between how prominent condoms are and how favourably they are viewed in the film scripts submitted by a country’s young people and the level of condom use reported by young people in the country’s Demographic and Health Survey. Among the many implications of the study findings are the urgent need to promote male role models who insist on condom use and refuse to concede under pressure and the importance of positive messages, drawing on humour, to overcome misinformation and moralisation.

National responses
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June
19
2011

National responses

Strange bedfellows: the Catholic Church and Brazilian National AIDS Programme in the response to HIV/AIDS in Brazil

Murray LR, Garcia J, Muñoz-Laboy M, Parker RG. Soc Sci Med. 2011 Mar;72(6):945-52.

The HIV epidemic has raised important tensions in the relationship between Church and State in many parts of Latin America where government policies frequently negotiate secularity with religious belief and doctrine. Brazil represents a unique country in the region due to the presence of a national religious response to AIDS articulated through the formal structures of the Catholic Church. As part of an institutional ethnography on religion and HIV in Brazil, Murray and colleagues conducted an extended, multi-site ethnography from October 2005 through March 2009 to explore the relationship between the Catholic Church and the Brazilian National AIDS Programme. This case study links a national, macro-level response of governmental and religious institutions with the enactment of these politics and dogmas on a local level. Shared values in solidarity and citizenship, similar organizational structures, and complex interests in forming mutually beneficial alliances were the factors that emerged as the bases for the strong partnership between the two institutions. Dichotomies of Church and State and micro and macro forces were often blurred as social actors responded to the epidemic while also upholding the ideologies of the institutions they represented. The authors argue that the relationship between the Catholic Church and the National AIDS Programme was formalized in networks mediated through personal relationships and political opportunity structures that provided incentives for both institutions to collaborate.

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Editors’ note: Latin America is a region with one of the strongest organized religious movements worldwide and Brazil is the country with the world’s largest population—125 million people or 73% of the population—that reports being Catholic. The first cases of AIDS were reported in the early 1980s when Brazil was in the midst of countrywide political discussion about its future. This discussion’s result was a vision of political solidarity that shaped an economically, socially, and politically democratic Brazil. Religious community organisations had been active in confronting the country’s dictatorship, based on principles anchored in Liberation Theology that emphasised grass-roots involvement, emancipation, building individual self-esteem, and people’s ownership of social problems and solutions. This 5-year ethnographic study examines the ebb and flow of the relationships between the Catholic Church and government structures responding to AIDS through data collected at 5 field sites in Sao Paulo, Rio de Janeiro, Porto Alegre, Brasilia, and Recife. Common ground was found early in the epidemic around the theme of care and support, with the Church providing care for needy people living with HIV, with HIV-positive priests reaching out to the civil society and human rights department of the National AIDS Programme, and with the relative autonomy of church dioceses to respond to local needs with a degree of autonomy. Although solidarity took precedence over ideology in these partnerships, the topic of prevention was fraught with debate, with the ‘lesser evil’ argument about condoms seen as supporting decadence which contrasted with the view that ‘it’s a sin not to use it’. This case study of Brazil provides useful insights into the role of historical political processes and social actors in constructing religious responses to the HIV epidemic.

National responses
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June
19
2011

National responses

The integration of multiple HIV/AIDS projects into a coordinated national programme in China

Wu Z, Wang Y, Mao Y, Sullivan SG, Juniper N, Bulterys M. Bull World Health Organ. 2011 Mar 1;89(3):227-33.

External financial support from developed countries is a major resource for any developing country's national AIDS programme. The influence of donors on the content and implementation of these programmes is thus inevitable. China is a large developing country that has received considerable international support for its AIDS programme. In the early stage of the response, each large HIV project independently implemented their activities according to their project framework. When internationally funded projects were few and the quantity of domestic support was minimal, their independent implementation did not pose a problem. When many HIV projects were simultaneously implemented in the same locations, problems emerged such as inconsistency and overlap in data collection. China has thus coordinated and integrated all large international and domestic HIV projects into one national programme. The process of integration began slowly and initially consisted of unified data collection. Integration is now complete and encompasses the processes of project planning, budgeting, implementation, monitoring and evaluation. The process was facilitated by having a single coordinating body, cooperation from international agencies, and financial commitment from the government. Some problems were encountered during this process, such as initial reluctance from health-care staff to allocate additional time to coordinate projects. This paper describes that process of integrating domestic and foreign HIV projects and may serve as a useful example for other developing countries for management of scarce resources.

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Editors’ note: China has made striking changes in its response to AIDS, following the ‘Three Ones’ key principles of one agreed action framework that provides the basis for coordinating the work of all partners, one national AIDS coordinating authority, and one agreed country level monitoring and evaluation system. Local AIDS authorities had become inundated with report writing to a multitude of different donors, a problem of misspent or unspent funds emerged in areas with many overlapping projects, and inconsistencies in data collection, coding schemes, and data reliability hampered government-led planning. The first step was to unify and standardize data collection with the result that 56 forms with 225 variables were reduced to 25 forms and 19 indicators. The online comprehensive HIV data system that became operational in January 2008 includes data on newly identified HIV infections, drug users in the methadone programme, and people living with HIV on the national free antiretroviral therapy programme. It was analysis of data in this database that led China to the decision to offer antiretroviral therapy to HIV-positive people in discordant couples, regardless of CD4 count, when linkages revealed significant levels of HIV transmission prior to medical eligibility for antiretroviral therapy. Budget integration has helped ensure adequate funding for full implementation of activities complementary to the national programme. For example, the national harm reduction programme uses government funds for the purchase of equipment, methadone, and personnel training and Global Fund funds for methadone treatment and needle exchange service delivery. Although integration means up-front investment in coordinating planning, budgeting, implementation, and evaluation of multiple projects, it reaps dividends in time and effort saved later in project management and in increased effectiveness of the AIDS response.

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March
27
2011

National responses

Decision making for HIV prevention and treatment scale up: bridging the gap between theory and practice

Alistar SS, Brandeau ML. Med Decis Making. 2010 Dec 29

Effectively controlling the HIV epidemic will require efficient use of limited resources. Despite ambitious global goals for HIV prevention and treatment scale up, few comprehensive practical tools exist to inform such decisions. Alistar and colleagues briefly summarize modelling approaches for resource allocation for epidemic control, and discuss the practical limitations of these models. They describe typical challenges of HIV resource allocation in practice and some of the tools used by decision makers. The authors identify the characteristics needed in a model that can effectively support planners in decision making about HIV prevention and treatment scale up. An effective model to support HIV scale-up decisions will be flexible, with capability for parameter customization and incorporation of uncertainty. Such a model needs certain key technical features: it must capture epidemic effects; account for how intervention effectiveness depends on the target population and the level of scale up; capture benefit and cost differentials for packages of interventions versus single interventions, including both treatment and prevention interventions; incorporate key constraints on potential funding allocations; identify optimal or near-optimal solutions; and estimate the impact of HIV interventions on the health care system and the resulting resource needs. Additionally, an effective model needs a user-friendly design and structure, ease of calibration and validation, and accessibility to decision makers in all settings. Resource allocation theory can make a significant contribution to decision making about HIV prevention and treatment scale up. What remains now is to develop models that can bridge the gap between theory and practice.

Abstract

Editors’ note: This helpful review describes the variety of modelling approaches that have been developed since the field of resource allocation for epidemic control became a topic of interest in the 1920s. It focuses on three broad categories of models (linear, dynamic, and simulation), providing examples of each from the HIV prevention literature. Issues that models often do not address include the impact of joint interventions on HIV infections averted—not additive because you cannot prevent the same HIV infection twice—decreasing/increasing returns to scale, allocation of resources to treatment programmes, ethical and equity concerns, human and financial resource implications for the entire healthcare system, and being user-friendly for decision-makers. A practical resource allocation model would have input flexibility, pertinent technical capabilities, and usability—the challenge now is to translate the theory into practice. The time is ripe—good investment decisions are essential to reap returns.

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February
21
2011

National Responses

Scale-up and Continuation of Antiretroviral Therapy in South African Treatment Programs, 2005-2009

Klausner JD, Serenata C, Obra H, Mattson CL, Brown J, Wilson M, Mbengashe T, Goldman TM. J Acquir Immune Defic Syndr. 2010 Nov 23.

South Africa has the greatest burden of HIV-infection in the world with about 5.2 million HIV-infected adults. In 2003, the South African Government launched a comprehensive HIV and AIDS care treatment program supported by the United States in 2004 through the President's Emergency Plan for AIDS Relief (PEPFAR). To describe the scale-up and continuation of antiretroviral therapy in South African Government and PEPFAR-supported sites in South Africa, Klausner and colleagues conducted a retrospective analysis of routinely collected program reporting data, 2005-2009. From 2005 through 2009, the average rate of persons initiated on antiretroviral therapy in PEPFAR-supported South African Government treatment programmes increased nearly four-fold from 6,327 a month in 2005-2006 to 24,622 a month in 2008-2009 resulting in an increase from 33,543 patients on continued treatment in April-June 2005 to 631,985 patients in July-September 2009. Of those 631,985 patients receiving treatment, 65% were women. Men were more likely to be lost to follow-up (9.2% vs. 7.8%, PR 1.18, 95% CI 1.17-1.19) and more likely to die (5.6% vs. 4.1%, PR 1.36, 95% CI 1.35-1.37) than women. Scale-up and continuation of antiretroviral therapy in South Africa has been a remarkable medical accomplishment. Because more women receive and continue treatment, more efforts are needed to treat and retain men.

Abstract:

Editors’ note: In 2009, 918,407 patients were on antiretroviral treatment in South Africa representing 61% of those in need based on 2009 criteria – a dramatic increase from the 10% coverage of 2005. Now the goal posts have changed to CD4 cell counts of 350 cells/µl and HIV incidence remains alarmingly high with over 400,000 new infections in 2009. In its strategic plan for 2007 to 2011, the South African government stated its aim to treat 80% of those in need by 2011. However, if 40% of those estimated to be living with HIV in South Africa today have CD4 counts less than 350 cells/µl, it is likely that over 2 million people are in need to treatment. South Africa has increased its monthly treatment initiation rate nearly 4-fold from 6327 in 2006-7 to 24,622 in 2008-9 and has launched a large-scale health campaign that includes HIV testing and counselling. Critical to ramping up treatment coverage is acceleration of the growth rate in new treatment initiations. Mounting effective HIV prevention strategies now will help reduce future treatment demand. Reducing the price of drugs and diagnostics, developing innovative efficient service delivery models, and confronting stigma to increase willingness to learn one’s serostatus are among the building blocks for continued expansion of the treatment programme in South Africa.

National responses
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February
21
2011

Monitoring and Evaluation

Evaluation of three sampling methods to monitor outcomes of antiretroviral treatment programmes in low- and middle-income countries

Tassie JM, Malateste K, Pujades-Rodríguez M, Poulet E, Bennett D, Harries A, Mahy M, Schechter M, Souteyrand Y, Dabis F; ART Linc of IeDEA and MSF Collaborations PLoS One. 2010 Nov 10;5(11):e13899

Retention of patients on antiretroviral therapy over time is a proxy for quality of care and an outcome indicator to monitor antiretroviral therapy programmes. Using existing databases (Antiretroviral in Lower Income Countries of the International Databases to Evaluate AIDS and Médecins sans Frontières), Tassie and colleagues evaluated three sampling approaches to simplify the generation of outcome indicators. The researchers used individual patient data from 27 antiretroviral therapy sites and included 27,201 antiretroviral therapy naive adults (≥15 years) who initiated antiretroviral therapy in 2005. For each site, they generated two outcome indicators at 12 months, retention on antiretroviral therapy and proportion of patients lost to follow-up, first using all patient data and then within a smaller group of patients selected using three sampling methods (random, systematic, and consecutive sampling). For each method and each site, 500 samples were generated, and the average result was compared with the unsampled value. The 95% sampling distribution was expressed as the 2.5(th) and 97.5(th) percentile values from the 500 samples. Overall, retention on antiretroviral therapy was 76.5% (range 58.9-88.6) and the proportion of patients lost to follow-up, 13.5% (range 0.8-31.9). Estimates of retention from sampling (n = 5696) were 76.5% (95% sampling distribution 75.4-77.7) for random, 76.5% (75.3-77.5) for systematic and 76.0% (74.1-78.2) for the consecutive method. Estimates for the proportion of patients lost to follow-up were 13.5% (12.6-14.5), 13.5% (12.6-14.3) and 14.0% (12.5-15.5), respectively. With consecutive sampling, 50% of sites had sampling distribution within ±5% of the unsampled site value. The results suggest that random, systematic, or consecutive sampling methods are feasible for monitoring antiretroviral therapy indicators at national level. However, sampling may not produce precise estimates in some sites.

Abstract:

Editor’s note : Patient retention in antiretroviral therapy 12 months after starting treatment is a core UNGASS indicator and 47% of 149 low- and middle-income countries reported their progress on this indicator in 2009. Producing these statistics is a challenge. Some countries have automated information systems based on electronic medical records but most countries struggle to generate their statistics for the national level and often have no site-specific data to suggest needed programme improvements. This study used existing databases to compare the findings when all the data are used or a sampling strategy is used. In random sampling, each patient had an equal probability of being included in the data. In systematic sampling, the first patient was randomly chosen and then the next one was chosen according to a preset interval until 500 were selected. In consecutive sampling, after the random selection of the first patient, the next 499 consecutive patients were included. The results were comparable, suggesting that sampling could be a user-friendly technique to reduce workload, to improve the sustainability of local and national monitoring systems, both in tracking yearly retention in antiretroviral therapy programmes and assessing loss to follow-up, and to produce information for improving performance locally.

National responses
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February
21
2011

Monitoring and Evaluation

Protecting HIV information in countries scaling up HIV services: a baseline study

Beck EJ, Mandalia S, Harling G, Santas XM, Mosure D, De Lay PR J Int AIDS Soc. 2011 Feb 6;14(1):6

Individual-level data are needed to optimize clinical care and monitor and evaluate HIV services. Confidentiality and security of such data must be safeguarded to avoid stigmatization and discrimination of people living with HIV. Beck and colleagues set out to assess the extent that countries scaling up HIV services have developed and implemented guidelines to protect the confidentiality and security of HIV information. Questionnaires were sent to UNAIDS field staff in 98 middle- and lower-income countries, some reportedly with guidelines (G-countries) and others intending to develop them (NG-countries). Responses were scored, aggregated and weighted to produce standard scores for six categories: information governance, country policies, data collection, data storage, data transfer and data access. Responses were analyzed using regression analyses for associations with national HIV prevalence, gross national income per capita, OECD income, receiving US PEPFAR funding, and being a G- or NG-country. Differences between G- and NG-countries were investigated using non-parametric methods. Higher information governance scores were observed for G-countries compared with NG-countries; no differences were observed between country policies or data collection categories. However, for data storage, data transfer and data access, G-countries had lower scores compared with NG-countries. No significant associations were observed between country score and HIV prevalence, per capita gross national income, OECD economic category, and whether countries had received PEPFAR funding. Few countries, including G-countries, had developed comprehensive guidelines on protecting the confidentiality and security of HIV information. Countries must develop their own guidelines, using established frameworks to guide their efforts, and may require assistance in adapting, adopting and implementing them.

Abstract:

Editor’s note: Concerns about confidentiality may deter people from coming forward for HIV testing or entering antiretroviral therapy. Whether a medical information system is paper-based or electronic, the confidentiality and security of its data must be assured: At the same time, the information has to be appropriately accessible for patient management and service monitoring and evaluation. Privacy is both a legal and an ethical concept and it provides the framework for implementing confidentiality and security guidelines. Physical protection of data includes protection against environmental threats, such as floods and fire and power outages, and protection from inadvertent or deliberate use of sensitive information. As this baseline study reveals, this is a neglected policy area in many countries. The process of this evaluation may have provoked needed policy discussions in participating countries. Beyond global reporting requirements, countries need accurate, contemporary information to improve clinical care and to monitor and evaluate services. They need to ensure that medical records and the data extracted from them are truly confidential and secure – interim guidelines are available to assist in establishing the balance between maximising benefit and minimising harm.

National responses
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