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In much of sub-Saharan Africa, the HIV epidemic is growing fastest among teenagers. The rapid spread of HIV among adolescents in South Africa has been described as “explosive”. For example in 2005, HIV incidence among South African youth aged 15–24 years was estimated at 3.3%. Hence, any future prevention strategy in this setting will, of necessity, have to target young adolescents prior to sexual debut. Singh and colleagues discuss challenges that face South African researchers in enroling adolescent participants in HIV studies. They believe these challenges are common to most of sub-Saharan Africa, where future HIV prevention research will need to be conducted if we are to fast track efforts to develop novel prevention strategies to reduce the spread of HIV in this important population. The authors conclude that the need to protect adolescents from harm in research needs to be carefully balanced with the need to undertake research in this population to find solutions to the HIV epidemic. To this end, rigid legislation and/or ethical guidelines that pertain to adolescent participation in research and their uncritical application are counterproductive. Those concerned need to be cognizant of this inherent conflict and create an enabling ethical-legal framework to avoid inadvertently doing more harm than good to the intended study population.
Migration is an important process of change for rural populations in developing countries. By their very act of migrating, migrants are different from those who do not migrate. Coast studied how the sexual behaviour of rural-urban migrants differs from that of rural residents, how HIV knowledge levels vary between rural-urban migrants and rural residents, and what factors are associated with either intentions of behaviour change or reported behaviour? The analysis compared individual-level analyses of two populations, one (composed of recent rural-urban migrants) in an urban area and one made up of residents in a rural area. Detailed migration histories (N = 96 rural-urban migrants) and in-depth interviews form the basis of the analysis. The results are counter-intuitive: rural-urban migrants (both married and unmarried) are not having sex in town. Despite limited understanding of the nature of HIV, the migrant population studied here regulates its behaviour in a way that reflects local understandings of the disease. This finding is important, not least because it challenges the view that HIV in sub-Saharan Africa is largely transmitted to rural areas by return migrants. Maasai rural-urban migrants in Tanzania (both married and unmarried) are not having sex in town. The author goes on to explore the policy and service provision implications of the results.
Corona R, Beckett MK, et al. Do Children Know Their Parent's HIV Status? Parental Reports of Child Awareness in a Nationally Representative Sample. Ambul Pediatr 2006;6:138-44. http://www.sciencedirect.com/science/journal/15301567
Corona and colleagues aimed to determine the rates and predictors of child awareness of parental HIV status and the effect of that knowledge on children. The authors conducted interviews with 274 parents from a nationally representative sample of HIV-infected adults receiving health care for HIV in the United States. HIV-infected parents reported that 44% of their children (5-17 years old) were aware of their parent's HIV status, and parents had discussed with 90% of those children the possibility that HIV or AIDS might lead to their parent's death. Multivariate analyses revealed that parents with higher income, with an HIV risk group of heterosexual intercourse, with higher CD4 counts, with greater social isolation, and with younger children were less likely to report that their child knew the parent was HIV positive. Parents reported that 11% of children worried they could catch HIV from their parent. Reasons children did not know their parent's HIV status included that the parent was worried about the emotional consequences of disclosure (67%), was worried the child would tell other people (36%), and did not know how to tell their child (28%). The authors conclude that clinicians may be able to support and guide HIV-infected parents in deciding whether, when, and how to disclose their infection to their children.
The concepts of health and self have become intimately entangled in contemporary western society. Health is figured as a marker of identity, as a vehicle of self-production and self-actualisation, while the individual is also made increasingly responsible for his or her health. Persson and Newman explore how "self" is constituted in discourses that shape the ways in which people understand and do health and medicine, particularly discourses of neo-liberalism and of the immune system. They situate the discussion in the context the antiretroviral drug efavirenz. This drug, commonly described as "potent", can have a number of troubling effects on a person's everyday sense of self, including insomnia, confusion, cognitive disorders, depression, de-personalisation, psychosis, and suicidal ideation. While efavirenz may be clinically effective in its capacity to suppress the virus, these effects are at odds with the implicit aim of HIV medicine to restore and secure the self by way of immunological integrity and strength. These effects also bring into focus the predicament of choice under the contemporary political conditions of neo-liberalism with its emphasis on health as an enterprise of the autonomous, rational self. In exploring first-person accounts, the paper unpacks a number of the binary concepts on which contemporary discourses of health and medicine rely, such as immunity and vulnerability, potency and fragility, rationality and madness, self and non-self, and asks whether the individual under neo-liberalism is being asked the impossible.
High levels of HIV and unintended pregnancy among young people are urgent public health problems in South Africa. Studies among youth have generally focused on protection against one or the other of these risks, but not both. Maharaj analysed data collected in 2001 from 2,067 sexually active men and women aged 15-24 in KwaZulu-Natal (South Africa) to assess reasons for condom use, and levels and determinants of use. Overall, 59% of respondents said that they used condoms at last sexual intercourse, including 6% who used them with another method. The main reason for use (cited by 64% of users) was protection against both pregnancy and HIV infection. Two-thirds of respondents thought that becoming or making someone pregnant in the next few weeks would be a big problem; fewer than one in five viewed their risk of HIV infection as medium or high. Among both sexes, young people who would consider a pregnancy highly problematic were more likely to use condoms than their counterparts who would view a pregnancy as no problem. In sharp contrast, after controlling for fear of pregnancy, young men and women who perceived themselves as having a medium to high risk of HIV infection were less likely to use condoms than their counterparts who perceived themselves as being at no risk. The author concludes that prevention programmes could increase condom use in this population by increasing awareness of the twin risks of pregnancy and HIV infection, and by promoting condoms for protection against these dual risks.
This study documents gay men's communication patterns about unprotected sex. Gay men (N=206) completed a structured interview about their social networks. The 167 men who had had unprotected sex identified 1390 social relations; 32.6% had involved discussing an episode of unprotected sex. Discussions about unprotected sex were associated with the nature of the relationship, whether the other party was gay or lesbian, how often the parties spent time together, whether the relationship had been sexual, and the density of the other parties' social network. The authors conclude that social networks provide an important context for the maintenance of safer sex cultures.
Schneider H, Blaauw D, et al. Health Systems and Access to Antiretroviral Drugs for HIV in Southern Africa: Service Delivery and Human Resources Challenges. Reprod Health Matters 2006;14:12-23. http://www.sciencedirect.com/science/journal/09688080
Without strengthened health systems, significant access to antiretroviral therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up antiretroviral access in countries with both massive epidemics and weak health systems. The authors draw on their experience in southern Africa and on the WHO framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The authors propose a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, evaluating community health workers and their potential role in HIV treatment access, undertaking international action on the brain drain, and making greater investments in the national human resource functions of planning, production, remuneration and management.
Mantell JE, Morar NS, et al."We have our protector": misperceptions of protection against HIV among participants in a microbicide efficacy trial. Am J Public Health 2006;96:1073-77. http://www.ajph.org/cgi/content/abstract/96/6/1073
Mantell and colleagues examined perceptions of the effectiveness and acceptability of a candidate microbicide among 94 South African female sex workers who had participated in a microbicide efficacy trial for HIV prevention. The conducted 16 focus groups in 2001, 12 to 15 months after participants were informed that the candidate microbicide had been determined to be ineffective in preventing HIV and other sexually transmitted infections (STIs). Participants clearly indicated that they understood the experimental nature of the candidate microbicide, and they recognized that they had been informed after the trial that the product was ineffective. Nevertheless, most continued to believe that the candidate microbicide helped prevent HIV and other STIs, alleviated reproductive tract pain and STI symptoms, and helped to clean the vagina. These findings underscore the importance of understanding women's perceptions of the efficacy of candidate microbicides and the rationale for these beliefs. These issues need to be addressed in counselling throughout microbicide trials for HIV prevention. These results also demonstrate how desperate many women at high risk of HIV infection may be for new HIV prevention technologies.
HIV type 1, the cause of human AIDS, represents a zoonotic infection of staggering proportions and social impact. Yet, uncertainty persists regarding its natural reservoir. The virus most closely related to HIV-1 is a simian immunodeficiency virus (SIV) thus far identified only in captive members of the chimpanzee subspecies Pan troglodytes troglodytes. In this paper, Keele and colleagues report the detection of SIVcpz antibodies and nucleic acids in faecal samples from wild-living Pan troglodytes troglodytes apes in southern Cameroon where prevalence rates in some ape communities reached 29-35%. By sequence analysis of endemic SIVcpz strains, the authors could trace the origins of pandemic (group M) and non-pandemic (group N) HIV-1 to distinct, geographically isolated chimpanzee communities. The authors conclude that these findings establish Pan troglodytes troglodytes as the natural reservoir of HIV-1.
Gorbach PM, Sopheab H, et al. Changing behaviors and patterns among Cambodian sex workers: 1997-2003. J Acquir Immune Defic Syndr 2006 Apr 24 [Epub ahead of print]. http://gateway.ut.ovid.com/gw2/ovidweb.cgi
Gorbach and colleagues aimed to identify patterns and behaviours among direct and indirect female sex workers (DFSWs and IDFSWs, respectively) across Cambodia's five major cities from 1997 to 2003. They conducted interviews with DFSWs and IDFSWs following random selection from clusters in the five cities. They found that from 1997 to 2003, consistent condom use with clients increased from 53% to 96% among DFSWs and from 30% to 84% among IDFSWs. DFSWs reported staying in their profession longer, had fewer clients per day, stayed longer in each brothel, were in increasingly larger brothels, and were tested more for HIV. Reported condom use with clients was significantly higher among DFSWs who were never married, were in larger brothels, and charged more for sex, but lower for DFSWs with “sweethearts” and who reported abnormal vaginal discharge. For IDFSWs, reported condom use with clients was higher for those reporting abnormal vaginal discharge and HIV testing, and lower for those with “sweethearts”. The authors conclude that from 1997 to 2003, Cambodian direct and indirect sex workers increased their use of condoms each year with commercial as well as non-commercial partners, confirming that HIV prevention programmes can produce significant changes in risk behaviours.
The banner's image is part of a painting by George Lilanga "Youth Chats" (2000), acrylic on canvas, 142 x 252 cm belonging to The Pigozzi Collection, Geneva (www.caacart.com) and on loan from it.
