HIV This Week

Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: a systematic review. PLoS Med. 2007 Dec;4(12):e339.

Photo credit: UNAIDS/J.Spaull

Recent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, Baral and colleagues conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data. A comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, UNAIDS-classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in a given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3-60.6); low-prevalence countries, 14.4 (95% CI 13.8-14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0-10.2). Significant differences in ORs for HIV infection among men who have sex with men were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2-8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8-24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3-13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7-25.2) where it was not. By region, the odds ratio for men who have sex with men in the Americas was 33.3 (95% CI 32.3-34.2); 18.7 (95% CI 17.7-19.7) for Asia; 3.8 (95% CI 3.3-4.3) for Africa; and 1.3 (95% CI 1.1-1.6) for the low- and middle-income countries of Europe. Men who have sex with men have a markedly greater risk of being infected with HIV compared with general population samples from low- and middle-income countries in the Americas, Asia, and Africa. Odds ratios for HIV infection in men who have sex with men are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium-high prevalence settings. Men who have sex with men from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.

Editors’ note: These results reveal that high HIV prevalence rates among men who have sex with men are not limited to any one epidemic level, prevalence category, region, or income level. Action is required to improve surveillance; conduct social science, epidemiological, and behavioural research; and effectively promote and protect the human rights of men who have sex with men while advocating against the stigma and discrimination which are undermining HIV prevention efforts.

Since the first report of AIDS in 5 men who have sex with men (MSM) from Los Angeles, MSM have accounted for a higher proportion of AIDS cases than any other group in countries such as the United States (44%), Canada (65%), and Australia (64%). Although MSM first brought HIV to the world's attention and, even in the absence of external funding, were the first to promote risk reduction strategies, prevention efforts for MSM appear to have faltered. In this article, Jaffe and colleagues examine current HIV epidemiology in MSM, discuss why the epidemic may be re-emerging, and describe what can be done to address it, particularly in the United States. Despite advances in HIV care, almost 6000 MSM with AIDS in the United States died in 2005, and living with HIV is challenging. However, despite strong evidence for a re-emerging HIV epidemic in MSM, silence on this subject is nearly pervasive. Community mobilization of MSM was an important feature of the early response to HIV when the aphorism “silence equals death” captured the need for action. Many community-based organizations were founded to address this challenge, and the need for their advocacy and health promotion activities remains critically important today. Because most HIV transmission between adults is the result of voluntary behaviour, individuals can substantially influence the likelihood that they will either acquire or transmit HIV. A good example of an approach to personal responsibility is the “HIV Stops With Me” social marketing campaign, which emphasizes the role that HIV-positive individuals can take in ending the epidemic. Advances can occur through open discussion, increased HIV testing, funding to develop and implement evidence-based public health interventions, leadership from the gay community and public health officials, and recognition of the role of personal action.  Failure to address difficult issues implies that the HIV epidemic in men who have sex with men must be accepted as inevitable; this cannot be allowed to happen. The tragedy of the epidemic for an earlier generation of MSM must not be repeated.

Editors’ note: Effective HIV prevention strategies recognize that the job is never done. Re-invigorated, adequately resourced, and sustained community mobilisation for safer sex social norms is needed in many high-income countries where the number of men who have sex with men who are living with HIV is increasing.

Morrow M, Arunkumar M, Pearce E, Dawson HE. Fostering disability-inclusive HIV/AIDS programs in northeast India: a participatory study. BMC Public Health 2007;267:125.

Manipur and Nagaland in northeast India are among the Indian states with the highest prevalence of HIV. Most prevention and care programs focus on identified "high risk" groups, but recent data suggest the epidemic is increasing among the general population, primarily through heterosexual sex. People with disability (PWD) in India are more likely than the general population to be illiterate, unemployed, and impoverished, but little is known of their HIV risk. This project aimed to enable HIV programs in Manipur and Nagaland to be more disability-inclusive. The objectives were to: explore HIV risk and risk perception in relation to PWD among HIV and disability programmers, and PWD themselves; identify HIV-related education and service needs and preferences of PWD; and utilise findings and stakeholder consultation to draft practical guidelines for inclusion of disability into HIV programming. Data were collected through a survey and several qualitative tools. The findings revealed that participants believe PWD in these states are potentially vulnerable to HIV transmission due to social exclusion and poverty, lack of knowledge, gender norms, and obstacles to accessing HIV programs. Neither HIV nor disability organisations currently address the risks, needs, and preferences of PWD. The Guidelines produced in the project and disseminated to stakeholders emphasise opportunities for taking action with minimal cost and resources, such as using the networks and expertise of both HIV and disability sectors, producing HIV material in a variety of formats, and promoting accessibility to mainstream HIV education and services. The human rights obligations and public health benefits of modifying national and state policies and programs to assist this highly disadvantaged population are also highlighted.

Editors’ note: This work highlights an important, underrepresented population with an increased risk of contracting HIV. People with disabilities often experience humiliation and social stigma. They may be vulnerable to exploitation, sexual abuse, and assumptions that they are not sexually active, along with decreased access to HIV prevention and care. HIV programmes and disability services providers need to work with disabled people to enable rapid and effective responses to the HIV-related needs of people with visual, hearing, physical, and intellectual impairments.

Brijnath B. It's about TIME: engendering AIDS in Africa. Cult Health Sex. 2007 Jul-Aug;9(4):371-86.

This paper analyses how TIME magazine represents sub-Saharan African women in its coverage of HIV. As rates of infection escalate across the continent, researchers are increasingly emphasising the need to understand the socioeconomic and cultural contexts that make women particularly vulnerable to infection. Yet popular media representations of AIDS continue to rely on older colonial imageries of Africa as the feminised, diseased 'dark continent'. This article identifies three major themes in TIME's representation of sub-Saharan African women and HIV: the metaphor of Africa as a woman in crisis, the construction of women as the means of transmission, and the engendered nature of the debate about the impact of international development policies. It is argued that the reliance on familiar cultural narratives often obscures the epidemiological, economic, and cultural realities within which sub-Saharan women live. Not merely a consequence of unprotected sex, AIDS in sub-Saharan Africa is also the result of global economics and politics, reflecting the inequities between the West and Africa, male and female, white and black. The paper concludes with a call for further research on the role of representations of HIV and its actual routes of transmission.

Editors’ note: Western media influence the discourse on AIDS at many levels. TIME magazine, which has a circulation of 28 million people, has taken a special interest in AIDS in sub-Saharan Africa. This article underscores the difference between the magazine’s conceptual framework and the lived experience for many women which is rooted in the structural violence of poverty and women’s limited choices which determine with whom they will have sex and under what conditions.

Seeley J, Grellier R, Barnett T. Gender and HIV/AIDS impact mitigation in sub-Saharan Africa--recognising the constraints. SAHARA J 2004;1:87-98.

In discussions of gender and HIV, attention has focused on prevention. This is a vital area. However, Seeley and colleagues argue that there is also a need to focus more attention on the resulting impact of the epidemic, because inequalities that promote the spread of infection are also hampering containment and impact mitigation. The authors propose a framework highlighting the gendered constraints exacerbated by the epidemic. These constraints are reviewed under the following headings: Gender-specific constraints: stemming from the specific nature of gender relations themselves, such as the availability of labour in agriculture, business and for household tasks, as well as access to services and markets, and the incidence of gendered violence. Gender-intensified disadvantages: stemming from the uneven and often inequitable distribution of resources between men and women, including cultural/religious conventions, and the social rules and norms that regulate property rights, inheritance practices and resource endowments. Gender-imposed constraints: resulting from biases and partialities of those individuals who have the authority and power to allocate resources. These include provision of credit, information, agricultural extension and health care. The differential involvement of men and women in development programmes affects access to resources, as does political participation, including involvement in the formulation of policies aimed at poverty reduction. These constraints take us beyond gender relations and sexual behaviour. But women's lives will not change in the short term. The challenges they face in mitigating the impact of HIV will not be addressed by focusing only on their specific vulnerability to HIV infection. Unequal gender relations and the nature of 'development' need to be changed too.

Editors’ note: This conceptual framework is helpful in understanding vulnerability to HIV and its impacts. Gender inequality and the inequitable distribution of resources are constraining both prevention and impact mitigation. Denial by governments and donors of the entrenched nature of these disparities and of the need for sustained social changes stands in the way of addressing women’s lack of access to information, skills, assets, credit, and technology.

Strebel A, Crawford M, Shefer T, Cloete A, Henda N, Kaufman M, Simbayi L, Magome K, Kalichman S. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa. SAHARA J. 2006 Nov;3(3):516-28.

The links between gender roles, gender-based violence, and HIV risk are complex and culturally specific. In this qualitative study Strebel and colleagues investigated how women and men in two black communities in the Western Cape, South Africa, constructed their gender identities and roles, how they understood gender-based violence, and what they believed about the links between gender relations and HIV risk. First the authors conducted 16 key informant interviews with members of relevant stakeholder organisations. Then they held eight focus group discussions with community members in single-sex groups. Key findings included the perception that although traditional gender roles were still very much in evidence, shifts in power between men and women were occurring. Also, gender-based violence was regarded as a major problem throughout communities, and was seen to be fuelled by unemployment, poverty and alcohol abuse. HIV was regarded as particularly a problem of African communities, with strong themes of stigma, discrimination, and especially 'othering' evident. Developing effective HIV interventions in these communities will require tackling the overlapping as well as divergent constructions of gender, gender violence, and HIV which emerged in the study.

Editors’ note: Knowledge and understanding of the specific social context of communities, including social constructions of gender and masculinities as well as shifting gender dynamics, is key to the design and implementation of effective prevention programmes addressing HIV and gender-based violence.

Lohse N, Hansen AB, Gerstoft J, Obel N. Improved survival in HIV-infected persons: consequences and perspectives. J Antimicrob Chemother. 2007 Sep;60(3):461-3.

A human immunodeficiency virus (HIV) patient in 2007 has the option to commence an antiretroviral regimen that is extremely efficacious in suppressing the virus and has few side effects. In a recent study, Lohse and colleagues estimated the median remaining lifetime of a newly diagnosed 25-year-old HIV-positive person to be 39 years. The prospect of a near-normal life expectancy has implications for the people living with HIV as well as for the handling of the disease in the healthcare system. Patients can now on a long-term perspective plan their professional career, join a pension plan, and start a family. Further, they may expect to be treated equally with other members of society with respect to access to mortgage, health insurance, and life insurance. As the infected population ages, more patients will contract age-related diseases, and the disease burden on some individuals may even come to be dominated by non-HIV-related conditions that may have a worse prognosis and therefore become more important than HIV-related conditions. Despite the improvements in antiretroviral therapy, there is still an excess mortality among HIV patients, which appears to be only partially attributable to immunodeficiency, with lifestyle factors potentially playing a pronounced role. Consequently, an effort to further increase survival must target risk factors for both HIV-related and -unrelated mortality. The continuation of the positive trend may be achieved by increased HIV testing, earlier initiation of antiretroviral therapy, improved drug adherence, prevention and treatment of HIV-unrelated co-morbidity, and collaboration with other medical specialists to treat an ageing co-morbidity-acquiring HIV population.

Editors’ note: In Denmark, the estimated median remaining lifetime for a 25 year old person living with HIV has increased from 8 years in 1995-96 to 23 years in 1997-99 to 33 years in 2000-05. In the absence of hepatitis C co-infection it is 39 years in comparison with 51 years for a 25 year old without HIV infection. Increased life expectancy as a result of antiretroviral therapy is highly encouraging but, as pointed out here, attention needs to turn to age-related illness and behavioural risks affecting prognosis.

Larsson EC, Okong P, Thorson A, Ekström AM. Antiretroviral treatment of HIV in Uganda: a comparison of three different delivery models in a single hospital. Trans R Soc Trop Med Hyg 2007 Sep;101(9):885-92.

This exploratory study examined health workers’ perspectives and the type of HIV care received in three different delivery models of antiretroviral treatment (ART) at St. Francis Hospital, Kampala, Uganda. Two of the clinics were financed by external donors and the third through out-of-pocket payments. Key informant interviews with health workers investigated potential challenges with ART care, and exit interviews with patients collected data on the care received. Despite the fact that all three clinics were located in the same hospital, services offered and quality of care varied extensively. Health staff at all ART clinics identified the lack of collaboration between different HIV programmes and low patient adherence as the main challenges. More women than men accessed ART through the externally financed programmes. These programmes provided more comprehensive care because of higher staff density and more frequent laboratory monitoring compared to the private clinic. Despite these shortcomings and the fact that prescriptions were often renewed without a preceding medical check-up at the private clinic, many chose to pay a monthly average equivalent of US$60 for ART in return for privacy and access to drugs without HIV disclosure requirements. Stigma and fear of abandonment were thought to be the main barriers for access to ART.

Editors’ note: Three antiretroviral programmes in the same hospital have major differences in services provided, disclosure requirements, population served, and financing models. Purchasing privacy in the private clinic may lead to treatment interruptions from cash shortages, with a higher resultant risk of antiretroviral drug resistance. Lack of coordination between programmes is an inefficient use of human resources and leads to concurrent registration which contributes to black market activity and medication sharing. Comparative studies such as this can inform rationalisation of services to maximize limited resources.