Equity and HIV/AIDS

Strengthening the enabling environment for women and girls: what is the evidence in social and structural approaches in the HIV response?
Hardee K, Gay J, Croce-Galis M, Peltz A: Journal of International Aids Society 17(1): 7 January 2014

There is growing interest in expanding public health approaches that address social and structural drivers that affect the environment in which behaviour occurs. Half of those living with HIV infection are women. The sociocultural and political environment in which women live can enable or inhibit their ability to protect themselves from acquiring HIV. This paper examines the evidence related to six key social and structural drivers of HIV for women: transforming gender norms; addressing violence against women; transforming legal norms to empower women; promoting women’s employment, income and livelihood opportunities; advancing education for girls and reducing stigma and discrimination. The paper reviews the evidence for successful and promising social and structural interventions related to each driver. This analysis contains peer-reviewed published research and study reports with clear and transparent data on the effectiveness of interventions. Structural interventions to address these key social and structural drivers have led to increasing HIV-protective behaviours, creating more gender-equitable relationships and decreasing violence, improving services for women, increasing widows’ ability to cope with HIV and reducing behaviour that increases HIV risk, particularly among young people.

Demographic and health surveys indicate limited impact of condoms and HIV testing in four African countries
Hearst N, Ruark A, Hudes ES, Goldsmith J, Green EC: African Journal of AIDS Research 12(1): 9–15, 2013

Condom promotion and HIV testing for the general population have been major components of HIV prevention efforts in sub-Saharan Africa’s high prevalence HIV epidemics, although little evidence documents their public health impact. The authors analysed the latest demographic and health surveys (DHS) and AIDS information surveys (AIS) from four sub-Saharan African countries with high prevalence, heterosexually transmitted HIV epidemics (Côte d’Ivoire, Swaziland, Tanzania and Zambia; N = 48 298) to answer two questions: 1) Are men and women who use condoms less likely to be HIV-infected than those who do not?; and 2) Are men and women who report knowing their HIV status more likely to use condoms than those who do not? Consistent condom use was associated with lower HIV infection rates for Swazi men but with higher HIV infection rates for women in Tanzania and Zambia; it made no significant difference in the other five sex/country subgroups analysed. Inconsistent condom use was not significantly associated with HIV status in any subgroup. Knowing one’s HIV status was consistently associated with higher rates of condom use only among married people who were HIV-positive, even though condom use in this group remained relatively low. Effects of knowing one’s HIV status among other subgroups varied. These results suggest that condoms have had little population-wide impact for HIV/AIDS prevention in these four countries. HIV testing appears to be associated with increased condom use mainly among people in stable partnerships who test positive. HIV testing and condom promotion may be more effective when targeted to specific groups where there is evidence of benefit rather than to general populations.

Governing AIDS through aid to civil society: Global solutions meet local problems in Mozambique
Foller M: African Journal of AIDS Research 12(1): 51–61, 2013

This article explores how international funders influence civil society organisations (CSOs) in Mozambique through funding mechanisms, the creation of partnerships, or inclusion in targeted programmes. The main focus is the relationship between external funders and AIDS non-governmental organisations (NGOs). The main questions the paper aims to answer are: Who is setting the agenda? What power mechanisms are in place to fulfil planned projects and programmes? Are there any forms of resistance from civil society AIDS-organisations in the face of the donor interventions? The actions are analysed through the lens of governmentality theory. The study concluded that external funders have the power to set the agenda through predetermined programmes and using various technologies. Their strongest weapons are audit mechanisms such as the result based management model used as a control mechanism, and there is still a long way to go to achieve a situation with multiple forms of local resistance to the conditions set by economically powerful funders. The standardisation imposed through clustering external funders into like-minded groups and other constellations gives them power to govern the politics of AIDS.

Evaluating traditional healers knowledge and practices related to HIV testing and treatment in South Africa.
George G, Chitindingu E and Gow J: BMC International Health and Human Rights 13(45): 23 October 2013

In a context of inadequate human resources for health, this study investigated whether traditional healers have the knowledge and skill base which could be utilised to assist in the scaling up of HIV prevention and treatment services in South Africa. Using a cross-sectional research design a total of 186 traditional healers from the Northern Cape province were interviewed. Responses on the following topics were obtained: socio-demographic characteristics; HIV training, experience and practices; and knowledge of HIV transmission, prevention and symptoms. Descriptive statistics and chi square tests were used to analyse the responses. Traditional healers’ knowledge of HIV and AIDS was not as high as expected. Less than 50% of both trained and untrained traditional healers would treat a person they suspected of being HIV positive. However, a total of 167 (89%) respondents agreed using a condom can prevent HIV and a majority of respondents also agreed that having one sexual partner (127, 68.8%) and abstaining from sex can prevent HIV (145, 78.8%). Knowledge of treatment practices was better with statistically significant results being obtained. The results indicate that traditional healers could be used for prevention as well as referring HIV positive individuals for treatment. Traditional healers were enthusiastic about the possibility of collaborating with bio-medical practitioners in the prevention and care of HIV and AIDS patients. This is significant considering they already service the health needs of a large percentage of the South African population. However, further development of training programmes and materials for them on HIV and AIDS related issues would seem necessary.

Neglected older women and men: Exploring age and gender as structural drivers of HIV among people aged over 60 in Uganda
Richards E, Zalwango F, Seeley F, Scholten F, Theobald S: African Journal of AIDS Research , 12(2): 71–78, 2013

This study explored how women’s and men’s gendered experiences from childhood to old age have shaped their vulnerability in relation to HIV both in terms of their individual risk of HIV and their access to and experiences of HIV services. It was a small scale-scale study conducted in urban and rural sites in Uganda between October 2011 and March 2012. The study used qualitative methods: in-depth interviews (with 31 participants) and focus group discussions (FGDs) with older women (2) and men (2) in urban and rural sites and 7 key informant interviews (KIIs) with stakeholders from government and non-government agencies working on HIV issues. Women’s position, the cultural management of sex and gender and contextual stigma related to HIV and to old age inter-relate to produce particular areas of vulnerability to the HIV epidemic among older women and men. Women report the compounding factor of gender-based violence marking many of their sexual relationships throughout their lives, including in older age. Both women and men report extremely fragile livelihoods in their old age. Older people are exposed to HIV through multiple and intersecting drivers of risk and represent an often neglected population within health systems. The author argues that research and interventions need to go beyond only conceptualising older people as ‘carers’ to better address their gendered vulnerabilities to HIV in relation to all aspects of policy and programming.

Parents' perceptions of HIV counselling and testing in schools: Ethical, legal and social implications
Gwandure R, Ross E, Dhai A and Gardner J: South African Medical Journal;104(1) 40-42 January 2014

In view of the high prevalence of HIV and AIDS in South Africa, particularly among adolescents, the South African Departments of Health and Education proposed a school-based HIV counselling and testing (HCT) campaign to reduce HIV infections and sexual risk behaviour. Through the use of semi-structured interviews, this qualitative study explored perceptions of parents regarding the ethico-legal and social implications of the proposed campaign. Despite some concerns, parents were generally in favour of the HCT campaign. However, they were not aware of their parental limitations in terms of the Children’s Act. Their views suggest that the HCT campaign has the potential to make a positive contribution to the fight against HIV and AIDS, but needs to be well planned. To ensure the campaign’s success, there is a need to enhance awareness of the programme. All stakeholders, including parents, need to engage in the programme as equal partners.

Access to Antiretroviral therapy in Africa
UNAIDS: 2013

Africa is leading the world in expanding access to antiretroviral therapy, with 7.6 million people across the continent receiving antiretroviral therapy as of December 2012, including 7.5 million people in sub-Saharan Africa. Eastern and Southern Africa is scaling up faster, by more than doubling the number of people on treatment between 2006 and 2012. At least 10 countries (Botswana, Cape Verde, Eritrea, Kenya, Namibia, Rwanda,
South Africa, Swaziland, Zambia and Zimbabwe) reported reaching 80% or more
of adults eligible for antiretroviral therapy, under the 2010 WHO guidelines. However, new WHO guidelines on HIV treatment in 2013 have since made many more people eligible for treatment.

Mapping HIV epidemics in sub-Saharan Africa with use of GPS data
Coburn BJ and Blower S: The Lancet Global Health 1(5): e251-e253, November 2013

WHO and many other organisations are very interested in implementing treatment-as-prevention as a global policy to control the HIV pandemic.1 Widespread treatment of HIV-infected individuals with antiretroviral therapy will reduce HIV transmission, because it decreases viral load and hence infectiousness. To implement the rollout of treatment-as-prevention in an efficient manner, estimation of the number of HIV-infected individuals and where they live is needed. This assessment will be difficult to accomplish, particularly in areas of sub-Saharan Africa with severe HIV epidemics. The authors propose a solution to this problem by using geospatial statistical techniques and global positioning system (GPS) data.

Reproductive decisions of couples living with HIV in Malawi: What can we learn for future policy and research studies?
Gombachika BC, Chirwa E, Malata A, Sundby J and Field H: Malawi Medical Journal, 25(3): 65-71, September 2013

The rapid scale-up of free antiretroviral therapy has lead to a decline in adult mortality at the population level and reduction of vertical transmission. Consequently, some couples living with HIV are maintaining their reproductive decisions; marrying and having children. This paper analyses policies and guidelines on HIV, AIDS and sexual and reproductive health in Malawi for content on marriage and childbearing for couples living with HIV. The authors report that analysis of guidelines and policies showed nonprescriptiveness on issues of HIV, AIDS and reproduction: they do not reflect the social cultural experiences of couples living with HIV. In addition, they found; lack of clinical guidelines, external influence on adoption of the policies and guidelines and weak linkages between HIV and AIDS and sexual and reproductive health services. The findings are argued to provide a strong basis for updating the policies and development of easy-to-follow guidelines in order to effectively provide services to couples living with HIV in Malawi.

Balancing efficiency, equity and feasibility of HIV treatment in South Africa - development of programmatic guidance
Baltussen R, Mikkelsen E, Tromp N, Hurtig A, Byskov J, Olsen O, Bærøe K, Hontelez JA, Singh J and Norheim OF: Cost Effective Resource Allocation 11 (1): 26, 9 October 2013

South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment. the authors argue there are two reasons for this. First, priority setting decisions on HIV treatment are argued to fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process without adequate participatory processes in place to incorporate stakeholders' views and evidence. They propose an alternative approach that integrates procedural fairness and a multi-criteria decision analysis that assesses feasibility, efficiency, and equity of programme options, including trade-offs.