In 2008, the Capacity Project partnered with the Lesotho Ministry of Health and Social Welfare in a study of the gender dynamics of HIV and AIDS caregiving in three districts of Lesotho to account for men's absence in HIV and AIDS caregiving and investigate ways in which they might be recruited into the community and home-based care (CHBC) workforce. The researchers used qualitative methods, including 25 key informant interviews with village chiefs, nurse clinicians, and hospital administrators and 31 focus group discussions with community health workers, community members, ex-miners, and HIV-positive men and women. Study participants uniformly perceived a need to increase the number of CHBC providers to deal with the heavy workload from increasing numbers of patients and insufficient new entries. HIV and AIDS caregiving is a gender-segregated job, at the core of which lie stereotypes and beliefs about the appropriate work of men and women. This results in an inequitable, unsustainable burden on women and girls. The authors recommend that HIV and AIDS and human resources stakeholders must address occupational segregation and the underlying gender essentialism and male primacy if there is to be more equitable sharing of the HIV and AIDS caregiving burden and any long-term solution to health worker shortages.
Equity and HIV/AIDS
Criminalisation and legal and policy barriers play a key role in increasing HIV vulnerability for men who have sex with men (MSM) and transgender people, says the World Health Organisation in this report. More than 75 countries currently criminalise same-gender sexual activity and transgender people lack legal recognition in most countries. These legal conditions force MSM and transgender people to risk criminal sanctions if they want to discuss their level of sexual risk with a service provider and also give police the authority to harass organisations that provide services to these populations. Long-standing evidence indicates that MSM and transgender people experience significant barriers to quality health care due to widespread stigma against homosexuality and ignorance about gender variance in mainstream society and within health systems. Social discrimination against MSM and transgender people has also been described as a key driver of poor physical and mental health outcomes in these populations across diverse settings. In addition to being disproportionately burdened by STI and HIV, MSM and transgender people experience higher rates of depression, anxiety, smoking, alcohol abuse, substance use and suicide as a result of chronic stress, social isolation and disconnection from a range of health and support services.
This cross-sectional facility-based survey was based on 70 structured face-to-face interviews combined with qualitative research that included two focus group discussions with pregnant women and five in-depth interviews with providers at antenatal care clinics in Marondera. Studies elsewhere have shown that the greatest barriers to the use of PMTCT services are linked to socio-cultural beliefs and influences, including fear of discrimination associated with testing and being HIV positive, and negative perceptions about the effectiveness of anti-retrovirals. None of these barriers were raised by participants in this study. Instead the main barriers were linked to the health system’s failure to meet the needs of pregnant women. Thus, SHIELD concludes, the main reasons why women cannot access PMTCT services are barriers faced in accessing antenatal services, including the cost and acceptability of these services. SHIELD makes a number of recommendations: remove or reduce the cost of antenatal care and delivery user fees for pregnant women, increase women’s access to reliable information, improve the quality of services, and provide training courses for health workers about how to engage with patients in a more acceptable manner.
In this study, researchers assessed whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. Ten communities participated in Project Accept in Tanzania, and eight in Zimbabwe. At each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT (SVCT), and the other community was assigned to receive community-based VCT (CBVCT) plus access to SVCT. The researchers found that the proportion of clients receiving their first HIV test during the study was higher in CBVCT communities than in SVCT communities in all three countries. Although HIV prevalence was higher in SVCT communities than in CBVCT communities, CBVCT detected almost four times more HIV cases than did SVCT across the three study sites. Repeat HIV testing in CBVCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. The researchers conclude that CBVCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing.
In this study, researchers investigated whether anti-retroviral therapy (ART) services for urban HIV-positive adults in two urban areas in South Africa are distributed in an equitable manner, in terms of socio-economic status and gender. HIV-positive people were found to be relatively poor. Over 60% of those with HIV fell into the poorest 40% of the South African population. The users of ART services were in general poorer than the HIV-positive population. Seventy percent of these users fell into the poorest 40% of the South African population. This finding was however not statistically significant, and the proportion of HIV-positive people that were women (or men) was no different to the sex distribution in the users of ART services. Taken together, these findings suggest that the use of ART services in urban South Africa is equitable. The researchers expressed hope that their study will add impetus to commitments to reaching and sustaining full coverage of ART for all in need.
Researchers speaking on the final day of the Sixth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention, held in Rome, Italy, from 17-20 July 2011, focused on the growing interest in the scientific path to an HIV cure. Discussions around an HIV cure have been growing over the past 12 months and are now gaining momentum with the establishment of an-IAS convened working group concentrating its initial efforts on establishing a global scientific strategy. IAS hopes to unveil their new global scientific strategy at the Seventh International AIDS Conference in Washington in 2012. Researchers also highlighted the need to scale up programmes that could more effectively address both the issues of injecting drug use linked HIV transmission and the still unacceptably high mortality rates amongst pregnant women and young children in sub-Saharan Africa.
According to this UNAIDS report, the global rate of new HIV infections declined by nearly 25% between 2001 and 2009. In South Africa, the rate of new HIV infections fell by more than 35%, with above-average declines in new HIV infections recorded in sub-Saharan Africa. The report found that in the third decade of the epidemic, people were starting to adopt safer sexual behaviours, reflecting the impact of HIV prevention and awareness efforts. However, there are still important gaps – for example, young women are less likely to be informed about HIV prevention than young men. While the rate of new HIV infections has declined globally, the total number of HIV infections remains high, at about 7,000 per day. According to the report, investments in the HIV response in low- and middle-income countries rose nearly 10-fold between 2001 and 2009, from US$ 1.6 billion to US$ 15.9 billion. However, in 2010, international resources for HIV declined, despite the fact that many low-income countries remain heavily dependent on external financing.
The Soweto Men’s Study assessed HIV prevalence and associated risk factors among men who have sex with men (MSM) in Soweto, South Africa. Using respondent-driven sampling (RDS) recruitment methods, researchers recruited 378 MSM over 30 weeks in 2008. All results were adjusted for RDS sampling design. Overall HIV prevalence was estimated at 13.2%, with 33.9% among gay-identified men, 6.4% among bisexual-identified men, and 10.1% among straight-identified MSM. In multivariable analysis, HIV infection was associated with being older than 25, gay self-identification, monthly income less than ZAR500, purchasing alcohol or drugs in exchange for sex with another man and reporting between six and nine partners in the prior six months, including a regular female partner. The results of the study confirm that MSM are at high risk for HIV infection, with gay men at highest risk. HIV prevention and treatment for MSM are urgently needed, the authors conclude.
Do orphaned children and adolescents have elevated risk for HIV infection? In this study, researchers examined the state of evidence regarding the association between orphan status and HIV risk in studies of youth aged 24 years and younger. Using systematic review methodology, they identified 10 studies reporting data from 12 countries comparing orphaned and non-orphaned youth on HIV-related risk indicators, including HIV serostatus, other sexually transmitted infections, pregnancy and sexual behaviours. Meta-analysis of HIV testing data from 19,140 participants indicated significantly greater HIV seroprevalence among orphaned (10.8%) compared with non-orphaned youth (5.9%). Trends across studies showed evidence for greater sexual risk behaviour in orphaned youth. In conclusion, studies on HIV risk in orphaned populations, which mostly include samples from sub-Saharan Africa, show nearly two-fold greater odds of HIV infection among orphaned youth and higher levels of sexual risk behaviour than among their non-orphaned peers. Interventions to reduce risk for HIV transmission in orphaned youth are needed to address the sequelae of parental illness and death that might contribute to sexual risk and HIV infection.
In June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. In this study, researchers assessed progress toward this UNGASS target in Manicaland, Zimbabwe, using repeated household-based population sero-survey data. Progress towards the target was measured by calculating the proportional change in HIV prevalence among youth and young ANC attendees over three survey periods (rounds 1 to 3). The researchers found that HIV prevalence among youth in the general population declined by 50.7% from round 1 to 3. Among young ante-natal care (ANC) attendees, the proportional decline in prevalence of 43.5% was similar to that in the population, although ANC data significantly underestimated the population prevalence decline from round 1 to 2 and underestimated the increase from round 2 to 3. Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines. In Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends.