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Groce N, Mawar N, Macnamara M. Inclusion of AIDS educational messages in rites of passage ceremonies: Reaching young people in tribal communities. Cult Health Sex 2006;8:303-15
The impact of HIV on tribal populations has received little attention. Often living in remote areas, further isolated by language, tradition and endogamous marriage patterns, members of such communities have been assumed to be at lower risk for HIV. However, there is growing awareness that tribal peoples are sometimes at considerable risk for HIV, as well as other sexually transmitted infections. Young people in such communities may be particularly vulnerable. Traditional practices may forbid discussion of sex at the same time as increasing exposure to outside influences brings new attitudes and expectations about sex and sexuality. Concerned about the implications of the HIV epidemic on tribal populations, Groce and colleagues conducted a review of available data on the HIV epidemic within tribal groups. Based on findings from this review, the authors propose a largely unexplored avenue for reaching tribal populations: namely, the incorporation of HIV related messages into traditional coming of age ceremonies. Such an intervention can be one component of a comprehensive approach to reaching often hard-to-reach populations but it may be an especially effective way to reach young people within these communities.
Magee EM, Small M, et al. Determinants of HIV/AIDS risk behaviours in expectant fathers in Haiti. J Urban Health 2006;83:625-636.
Haiti has an HIV epidemic of the highest magnitude outside of sub-Saharan Africa. Factors such as relationship power imbalances, traditional gender role acceptance, and patriarchal belief systems that devalue women's sexuality have increased Haitian women's vulnerability to HIV infection. Because of these influences and the heterosexually transmitted HIV epidemic, it is important to understand the role that men's beliefs and behaviours play in the continuing risk of young men and women in Haiti. This study gathered information from male community members through semi-structured interviews in order to describe the prevalence of HIV risk behaviours (e.g., condom use, number of sexual partners) among expectant fathers in Haiti and identify predictive psychosocial variables of HIV risk behaviours. Results showed that men who were not married (P=0.05) and men who had medium (P<0.001) and high sexual communication (P<0.001) were more likely to use condoms. This study also showed that high stigma associated with HIV (P<0.05), low HIV knowledge (P<0.01), and high decision making power (P<0.001) were predictors of multiple sex partners for the expectant fathers in the sample. Magee and colleagues conclude that HIV prevention programs should be designed to increase knowledge about HIV transmission, treatment, prevention and personal risk of contraction as well as to correct misconceptions about individuals living with HIV and promote sex communication among partners.
Harvey SM, Henderson JT. Correlates of condom use intentions and behaviors among a community-based sample of Latino men in Los Angeles. J Urban Health 2006;83:558-74.
HIV has disproportionately affected Latino communities. The majority of research addressing HIV risk behaviours within this population has focused on women. However, men who have sex with women (MSW) are a population increasingly becoming infected with HIV and heterosexual contact is the primary source of HIV transmission among Latinos diagnosed with AIDS. It has been assumed that because men are likely to control condom use, relationship factors are less likely to influence safer sex behaviour among men. However, because condom use is an interdependent behaviour, understanding factors that predict safer sex behaviour among MSW is critical. The authors examined the influence of multiple factors on condom use behaviour in a community-based sample of young Latino men. They analysed data from 191 Latino men who completed baseline interviews for an intervention to examine the association of background, intrapersonal and relationship factors with intentions to use condoms and condom use in the past three months. Findings from multivariate analysesindicated that more positive attitudes toward condoms, stronger partner condom norms and greater participation in decision-making about condom use were significantly associated with both condom use and condom use intentions. Additionally, men reporting lower expectations of negative partner reactions to condom requests were more likely to use condoms, and condom use intentions were higher among men reporting more health protective communication in the relationship. Findings suggest that programmes to prevent HIV need to include men as well as women and address the role of relationship factors and dynamics in safer sex practices.
Hogerzeil HV, Samson M, et al. Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts? Lancet 2006; 368:305-311.http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673606690764.pdf
Most countries in the world have become States parties to one or more international human rights treaties, thus creating an obligation by the State to its people towards the realisation of the right to health, which includes access to essential medicines. But whether such access is enforceable in practice is unknown. Hogerzeil and colleagues did a systematic search to identify completed court cases in low-income and middle-income countries in which individuals or groups had claimed access to essential medicines with reference to the right to health in general, or to specific human rights treaties ratified by the government. They identified and analysed 71 court cases from 12 countries in which access to essential medicines was claimed with reference to the right to health. The authors found that in 59 cases, access to essential medicines as part of the fulfilment of the right to health could indeed be enforced through the courts, particularly in Central and Latin America. Success was mainly linked to constitutional provisions on the right to health, supported by the human rights treaties. Other success factors were a link between the right to health and the right to life, and support by public-interest non-government organisations. Individual cases have generated entitlements across a population group, the right to health was not restricted by limitations in social security coverage, and government policies have successfully been challenged in court. Hogerzeil and colleagues conclude that skilful litigation can help to ensure that governments fulfil their constitutional and international treaty obligations. Such assurances are especially valuable in countries in which social security systems are still being developed. However, redress mechanisms through the courts should be used as a last resort. Rather, policymakers should ensure that human rights standards guide their health policies and programmes from the outset.
Editors’ note: If you are interested in reading more about similar advances achieved in the HIV field, take a look at the excellent publication in the UNAIDS Best Practice Collection entitled "Courting Rights: Case studies in litigating the human rights of people living with HIV".
Slutkin G, Okware S, Naamara W, Sutherland D, Flanagan D, Carael M, Blas E, Delay P et al. How Uganda Reversed Its HIV Epidemic. AIDS Behav 2006 Jul 21[Epub ahead of print]
Slutkin and colleagues focus on Uganda as one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Uganda's HIV prevalence declined in the 1990s. The authors describe the prevention programmes and activities that were implemented in Uganda during critical years in its HIVepidemic, 1987-1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighbouring countries. The authors conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other low- and middle-income countries could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programmes that take efforts to a critical breadth and depth of effort.
McCoombe S, Short R. Potential HIV-1 target cells in the human penis. AIDS 2006;20:1491-5.
McCoombe and Short studied the distribution of HIV-1 receptors and degree of keratinisation in the human penis. Penises from nine formalin fixed cadavers aged 64-80 years were obtained from the Department of Anatomy, University of Melbourne. Foreskins were obtained from 21 men aged 18-64 years following circumcision performed at either the Freemason's or Mercy Private Hospitals, Melbourne, Australia. Fresh penile necropsy specimens from eight uncircumcised men aged 23-63 years were obtained from the Victorian Institute of Forensic Medicine, Melbourne. The degree of keratinisation was scored, and the distribution of HIV-1 susceptible cells was mapped in the glans penis, penile urethra, urethral meatus, frenulum, and foreskin. The authors found that cells with HIV-1 receptors were present in all penile epithelia, but Langerhans' cells were most superficial in the inner foreskin and frenulum. The inner foreskin had a significantly thinner keratin layer (1.8 ± 0.1 units), than the outer foreskin (3.3 ± 0.1), or glans penis (3.3 ± 0.2), P<0.05. The authors conclude that superficial Langerhans’ cells on the inner aspect of the foreskin and frenulum are poorly protected by keratin and thus could play an important role in HIV acquisition in men. These findings provide a possible anatomical explanation for the epidemiologically observed protective effect of male circumcision.
Beck EJ, Vitoria M, et al. National adult antiretroviral therapy guidelines in resource-limited countries: concordance with 2003 WHO guidelines? AIDS 2006;20:1497-1502
Beck and colleagues investigated the existence of national adult ART guidelines in 43 WHO 3 by 5 focus countries and compared their content with the 2003 WHO ART guidelines. Questionnaires covered initiation of ART, selection of first or second-line ART, monitoring treatment response and toxicity and dissemination of national guidelines. Weighted concordance scores were created and country scores correlated with national indicators and WHO recommendations. Thirty-nine (91%) countries returned questionnaires, three of which had no national ART guidelines. Of the remaining 36, 16 (44%) recommended to start ART based on WHO clinical staging criteria and CD4 cell count or T-lymphocyte count, 12 (33%) WHO clinical staging criteria and CD4 cell count, and 4(11%) only CD4 cell counts. 35 (97%) recommended a standard first-line regimen and 24 (67%) preferred stavudine + lamivudine + nevirapine; 33 (92%) recommended second-line regimens, and 24 (60%) preferred abacavir + didanosine + lopinavir/ritonavir. Thirty-one (94%) recommended CD4 cell count, possibly combined with other indicators, to monitor ART. Concordance scores were higher in countries with lower health expenditure per capita (P=0.009) and lower GDP per capita (P<0.03). Median concordance scores were: starting ART, 100 [interquartile range (IQR) 67 to 100]; first line therapy, 70 (IQR 60 to 80); second-line regimens, 45 (IQR 27 to 55) andlaboratory investigations, 80 (IQR 80 to 100). The authors conclude that most countries had developed national ART guidelines as part of a comprehensive national HIV program. Concordance with WHO recommendations was strong on starting first-line ART regimens and routine monitoring but lower for second-line recommendations.
Thierman S, Chi BH, et al. Individual-level predictors for HIV testing among antenatal attendees in Lusaka, Zambia. Am J Med Sci 2006;332:13-17.
Despite the availability of antiretroviral prophylaxis, roughly one-fifth of public-sector antenatal patients decline HIV testing in Lusaka, Zambia. Thierman and colleagues administered a survey to determine individual-level predictors of HIV testing. Of 1064 antenatal attendees approached after pre-test counselling, 1060 (>99%) participated. Of these, 686 (65%) agreed to HIV testing. On bivariate analysis controlling for clinic of attendance, women younger than 20 years old (RR 1.14), unmarried (RR 1.14), pregnant for the first time (RR 1.14), with lower educational attainment (RR 1.15), and with lower income (RR 1.14) were all more likely to undergo testing. When HIV risk was considered, women with low self-perceived risk were most likely to undergo HIV testing. As risk perception increased, likelihood for testing decreased (P for trend < 0.001). The authors conclude that although not statistically predictive, they identified prevalent community beliefs that may act as barriers to testing. Because individual-level characteristics were only weakly predictive of HIV testing, they recommend that future work should concentrate on community-level factors.
Clarke JN, McLellan L, Hoffman-Goetz L. The portrayal of HIV/AIDS in two popular African American magazines. J Health Commun 2006;11:495-507
Mainstream magazines and other media have been found to both reflect and influence existing values and beliefs regarding health and medicine. Little is known about how media directed toward specific cultural or other market groups may differ. The present study examined how HIV and AIDS are portrayed within a specific ethno-cultural medium, the two highest circulating magazines directed toward African American and African Canadian readers. The portrayal of HIV from January 1997 to October 2001 in Ebony and Essence magazines was examined through manifest and latent content analysis. African American people were described paradoxically both as powerless victims in the face of the disease and as members of a strong and identifiable community of "sisters" and "brothers" available to respond to prevent and cope with the disease. Polarisation between Blacks and Whites was accomplished by frequent emphasis on the higher rates of HIV amongst Black Americans. Both the church and spirituality were highlighted as means of prevention education and coping.
Tolley EE, Eng E, et al. Examining the context of microbicide acceptability among married women and men in India. Cult Health Sex 2006;8:351-69.
Married women in India are increasingly at risk of HIV, often due to their husbands' extramarital sexual behaviour. Topical microbicides may provide protection to women who are unable to negotiate condom use. During the formative phase of a study to develop measures related to microbicide acceptability, Trolley and colleagues conducted in-depth interviews with 14 'high-risk' and 16 'low-risk' married women and 15 husbands. Some participants had recently completed a 2-week microbicide safety trial. A sequence of in-depth interviews with each participant explored the context of microbicide acceptability, including perceptions of couple harmony, vulnerability to HIV, sexual power, and ability to control life events. Women's perceptions of control and sexual power influenced attitudes towards microbicide use. HIV risk was most commonly associated with partner infidelity and easily detected, according to both men and women, by a lack of marital harmony. Despite this, high-risk women denied perceiving HIV risk until confronted with specific evidence of a husband's positive HIV or STI diagnosis. The authors conclude that this study provides an in-depth examination of HIV risk for Indian married women, identifying potential determinants of microbicide use, and providing guidance for the development of psychometric scales to measure couple harmony, HIV risk perception, and sexual power and control.
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.
