Articles tagged as "National responses"

Global programmes and local discrimination: the inadequate support of women living with HIV in West Papua and its impact on PMTCT

(Not) getting political: indigenous women and preventing mother-to-child transmission of HIV in West Papua.

Munro J, McIntyre L. Cult Health Sex. 2015 Aug 25:1-16. [Epub ahead of print]

This paper builds on critiques that call for a more nuanced and contextualised understanding of conditions that affect HIV prevention by looking at West Papuan women's experiences of prevention of mother-to-child transmission services. Drawing on qualitative, ethnographic research with indigenous women and health workers, the paper demonstrates that women experience poor-quality HIV education and counselling, and that indigenous practices and concerns are largely not addressed by HIV services. We attribute this to a combination of national anti-indigenous and anti-separatist political concerns with donor-led interventions that result in limited localisation and reduced effectiveness of HIV prevention measures. In West Papua, services are needed that enhance cooperation and shared commitment, and that acknowledge and work to overcome existing inequalities, ethnic tensions and discrimination in the health system. Beyond Indonesia, donor-led HIV programmes and interventions need to balance avoidance of politically sensitive issues with complicity in perpetuating health inequalities. Translating global health interventions and donor priorities into locally compelling HIV prevention activities involves more than navigating local cultural and religious beliefs. Programme development and implementation strategies that entail confronting structural questions as well as social hierarchies, cleavages and silences are needed to render more effective services; strategies that are inherently political.

Abstract access 

Editor’s notes: West Papua is witnessing one of the fastest growing HIV epidemics in the world, especially among its indigenous populations (prevalence is 2.9%). Translation of HIV prevention programmes to the local situation is complicated by unequal, discriminatory and racialised relationships between the Indonesian government and indigenous Papuans. This is made worse by the exclusion of indigenous Papuans from health services management and governance. Tensions between Papuan HIV NGO staff and Indonesian healthcare workers create obstacles to delivery of health promotion and HIV testing. International HIV agency funders and representatives ignore these tensions for political reasons.

Indigenous people are stigmatised as ‘hypersexual’ and ‘wild’ which causes poor service design and delivery of prevention of mother-to-child transmission. Because of racial stereotypes, Papuan women receive inadequate education and support in the healthcare system. Many women do not fully understand prevention of mother-to-child transmission, antiretroviral therapy, infant feeding choices, and delivery choices. Women are uncomfortable with healthcare workers and do not trust their advice, which is inadequate and does not consider peoples’ views. Women often drop out of HIV care after testing. Women were very isolated, with their partners often working far away. Women disclose their HIV status to very few people even with their families and usually do not know other positive mothers. International donor agencies need to engage with existing local political tensions that result in poor quality treatment of service users. HIV prevention programmes can exacerbate local inequalities if these are not recognised in HIV policy and service provision. 

Asia
Indonesia
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Wide variation in national HIV policies associated with HIV testing and treatment across six African countries

A comparative analysis of national HIV policies in six African countries with generalized epidemics.

Church K, Kiweewa F, Dasgupta A, Mwangome M, Mpandaguta E, Gomez-Olive FX, Oti S, Todd J, Wringe A, Geubbels E, Crampin A, Nakiyingi-Miiro J, Hayashi C, Njage M, Wagner RG, Ario AR, Makombe SD, Mugurungi O, Zaba B. Bull World Health Organ. 2015 Jul 1;93(7):457-67. doi: 10.2471/BLT.14.147215. Epub 2015 Apr 28.

Objective: To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.

Methods: We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.

Findings: There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.

Conclusion: Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.

Abstract  Full-text [free] access

Editor’s notes: Despite evidence on reduction in HIV attributable mortality, concerns still remain on the high attrition rates across the diagnosis-to-treatment cascade. This paper uses a comparative policy analysis to track differences in national HIV policy responses to the HIV epidemic. The methodology used is notable as it offers a helpful conceptual framework for the HIV policy and service factors influencing specific differences in HIV-associated adult mortality across the diagnosis-to-treatment cascade.

The range of policies between countries was unexpected, given the explanation offered by the authors that African countries tend to adopt standards and guidance from WHO. Furthermore, while countries showed progressive elements, no country had the comprehensive policy context necessary for a decisive impact on service access. Important differences were also noted in the influential weight given to some policies, in the timing of policy implementation in some indicators, and in whether WHO national standards were or were not adopted by countries.

These findings are particularly useful in better understanding the incentives and barriers to accessing antiretroviral therapy in different contexts.

Africa
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Harnessing the successful political prioritisation of HIV to reduce the burden of congenital syphilis

Prevention of mother-to-child transmission of syphilis and HIV in China: What drives political prioritization and what can this tell us about promoting dual elimination?

Wu D, Hawkes S, Buse K. Int J Gynaecol Obstet. 2015 Apr 29. pii: S0020-7292(15)00202-7. doi: 10.1016/j.ijgo.2015.04.005. [Epub ahead of print]

Objective: The present study aims to identify reasons behind the lower political priority of mother-to-child transmission (MTCT) of syphilis compared with HIV, despite the former presenting a much larger and growing burden than the latter, in China, over the 20 years prior to 2010.

Methods: We undertook a comparative policy analysis, based on informant interviews and documentation review of control of MTCT of syphilis and HIV, as well as nonparticipant observation of relevant meetings/trainings to investigate agenda-setting prior to 2010.

Results: We identified several factors contributing to the lower priority accorded to MTCT of syphilis: relative neglect at a global level, dearth of international financial and technical support, poorly unified national policy community with weak accountability mechanisms, insufficient understanding of the epidemic and policy options, and a prevailing negative framing of syphilis that resulted in significant stigmatization.

Conclusion: A dual elimination goal will only be reached when prioritization of MTCT of syphilis is enhanced in both the international and national agendas.

Abstract  Full-text [free] access

Editor’s notes:  In 2009, China had nearly 11 000 reported cases of congenital syphilis, compared to 57 cases of mother-to-child HIV transmission, yet congenital syphilis was not a policy priority. The authors investigate and compare the policy responses to the two infections in order to understand the determinants of prioritisation in Chinese health policy. The national policy response to the mother-to-child transmission of HIV highlights the importance of global agendas. These include reporting mechanisms, international financial and technical assistance, credible indicators, as well as cohesive national policy communities that coalesce around a formal mechanism of coordination and policy influence, namely the Chinese National Centre for Women and Children’s Health. In addition, the specific national policy environment and other focusing events were critical to the prioritisation of the mother-to-child transmission of HIV. The new leadership was moving towards a socio-economic equality agenda, and the recent severe acute respiratory syndrome (SARS) outbreak had further underscored the importance of controlling infectious diseases. Alongside this, the national ‘blood selling’ scandal, during which hundreds of thousands of rural Chinese acquired HIV through blood selling in the 90s, was receiving increasing attention in international media. This contributed to a different framing of the HIV issue, away from the stigmatising ‘immoral’ narrative to an ‘innocent victims’ narrative. Congenital syphilis, unfortunately, continued to suffer from a stigmatising framing. However, delivery platforms for the effective prevention of mother-to-child transmission of HIV have been established and could be used for a dual control and elimination approach, with greater health benefits. The authors conclude that greater policy prioritisation could be achieved with a more nuanced framing of the two infections as being linked when it comes to underlying vulnerability and feasibility of solutions. It will require a strong partnership and collaboration between the mother-to-child transmission of syphilis and HIV policy communities.       

Asia
China
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Elimination of mother-to-child HIV transmission: still a pipe dream?

HIV testing among pregnant women who attend antenatal care in Malawi.

Tenthani L, Haas AD, Egger M, van Oosterhout JJ, Jahn A, Chimbwandira F, Tal K, Myer L, Estill J, Keiser O. J Acquir Immune Defic Syndr. 2015 May 6. [Epub ahead of print] 

Malawi adopted the Option B+ strategy in 2011. Its success in reducing MTCT depends on coverage and timing of HIV testing. We assessed HIV status ascertainment and its predictors during pregnancy. HIV status ascertainment was 82.3% (95%-CI 80.2-85.9) in the pre-Option B+ period and 85.7% (95%-CI 83.4-88.0) in the Option B+ period. Higher HIV ascertainment was independently associated with higher age, attending ANC more than once, and registration in 2010. The observed high variability of HIV ascertainment between sites (50.6%-97.7%) and over time suggests that HIV test kits shortages and insufficient numbers of staff posed major barriers to reducing MTCT.

Abstract access 

Editor’s notes: UNAIDS has called for an end to mother-to-child HIV transmission through the Global Plan towards the elimination of new infections among children and keeping their mothers alive. WHO guidelines on the use of antiretroviral medicines for treating and preventing HIV infection in 2013 recommends two options for pregnant and breastfeeding women. One of which is lifelong antiretroviral therapy (ART) for all pregnant women living with HIV regardless of CD4 count or disease stage, commonly referred to as Option B+. The Global Plan requires that 90% of all women living with HIV have access to ART. The success of the Global Plan will depend on sufficient numbers of women being tested for HIV.

This study includes data from 19 secondary and primary health facilities offering antenatal care in Malawi, the first country to introduce the Option B+ strategy in 2011. Introduction of the Option B+ strategy did not result in a significant change in the proportion of women who underwent HIV testing.  HIV ascertainment varied widely across facilities from 50% to 98%, and fluctuated greatly within sites over short time periods. The observed sudden decreases in numbers of women who received an HIV test suggest that important barriers to HIV testing exist at facility level. Previous studies have illustrated that temporary shortages of HIV testing kits and staff interrupt regular antenatal (ANC) HIV testing in health facilities. Women who had had multiple ANC visits were more likely to have had their HIV status ascertained, likely because multiple visits increased their chance to attend when staff and kits were available. Unfortunately, this study was unable to determine individual-level factors associated with HIV testing not having occurred.

We now have highly effective programmes that can virtually eliminate new HIV infections  among children globally. To attain this goal, urgent attention must be paid to strengthening health systems. Elimination of new infections among children will require attention to the whole cascade of care from diagnosis of HIV, through to provision of results and treatment and supporting women to take ART consistently.   

Africa
Malawi
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In or out of HIV-care? It depends who you ask

Sorting through the lost and found: are patient perceptions of engagement in care consistent with standard continuum of care measures?

Castel AD, Tang W, Peterson J, Mikre M, Parenti D, Elion R, Wood A, Kuo I, Willis S, Allen S, Kulie P, Ikwuemesi I, Dassie K, Dunning J, Saafir-Callaway B, Greenberg A. J Acquir Immune Defic Syndr. 2015 May 1;69 Suppl 1:S44-55. doi: 10.1097/QAI.0000000000000575.

Background: Indicators for determining one's status on the HIV care continuum are often measured using clinical and surveillance data but do not typically assess patient perspectives. We assessed patient-reported care status along the care continuum and whether it differed from medical records and surveillance data.

Methods: Between June 2013 and October 2014, a convenience sample of clinic-attending HIV-infected persons was surveyed regarding care-seeking behaviors and self-perceived status along the care continuum. Participant responses were matched to DC Department of Health surveillance data and clinic records. Participants' care patterns were classified using Health Resources Services Administration-defined care status: in care (IC), sporadic care (SC), or out of care (OOC). Semistructured qualitative interviews were analyzed using an open coding process to elucidate relevant themes regarding participants' perceptions of engagement in care.

Results: Of 169 participants, most were male participants (64%) and black (72%), with a mean age of 50.7 years. Using self-reported visit patterns, 115 participants (68%) were consistent with being IC, 33 (20%) SC, and 21 (12%) OOC. Among OOC participants, 52% perceived themselves to be fully engaged in HIV care. In the previous year, among OOC participants, 71% reported having a non-HIV-related medical visit and 90% reported current antiretroviral use. Qualitatively, most SC and OOC persons did not see their HIV providers regularly because they felt healthy.

Conclusions: Participants' perceptions of HIV care engagement differed from actual care receipt as measured by surveillance and clinical records. Measures of care engagement may need to be reconsidered as persons not receiving regular HIV care maybe accessing other health care and HIV medications elsewhere.

Abstract access 

Editor’s notes: This interesting mixed methods study examined engagement and retention in HIV care among people living with HIV in Washington DC. In addition to the convenience sample of clinic attendees listed in the abstract of the paper, data were also accessed on people who had not received clinical care in the previous 12 months, according to clinic records. These people were being focused on by a Department of Health initiative to re-engage them in care. As the clinic staff contacted people to re-engage with them they were offered the opportunity to be recruited into this study. A very helpful diagram on page S46 of this paper sets out this recruitment strategy. This sampling approach allowed the authors to compare data collected from an interviewer-administered structured survey (collecting self-reported data) with data abstracted from clinic records (with the participant’s consent)  and data from Department of Health surveillance records. In addition 62 of the participants took part in in-depth interviews. In keeping with other studies on linkage to care, the authors found that participants who were considered ‘out of care’ by the Department of Health and clinic records did not necessarily consider themselves to be out of care. These were often people who were doing well and saw no need to visit the clinic regularly, particularly if, for individuals on antiretroviral therapy, they were able to access drug supplies from other sources. 

The study also suggests the importance of understanding the limitations of different data sources.  While the limitations of self-reported data are well known, the authors also highlight the drawback of using clinic records. The Department of Health re-engagement initiative had found that 57% of the people thought to be out of care were actually receiving care elsewhere. The authors therefore stress the importance of using a combination of data sources in care surveillance. 

Many people considered to be ‘out of care’ by their clinic were surprised to have had this label applied to them. The authors suggest that this finding emphasises the need for better communication between provider and patient so that treatment goals and the importance of regular clinic visits are understood. However, they go on to say that this finding also supports the on-going process of rethinking definitions of ‘engagement in care’ to be more responsive to individual needs and perceptions. Indeed the change in the United States Department of Health and Human Services guidelines to recommend that patients who are virally suppressed can be monitored less-frequently, is in keeping with this suggestion.

Northern America
United States of America
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Multiple harms faced by Azerbaijani prisoners

Burden of substance use disorders, mental illness, and correlates of infectious diseases among soon-to-be released prisoners in Azerbaijan.

Azbel L, Wickersham JA, Wegman MP, Polonsky M, Suleymanov M, Ismayilov R, Dvoryak S, Rotberga S, Altice FL. Drug Alcohol Depend. 2015 Mar 19. pii: S0376-8716(15)00136-2. doi: 10.1016/j.drugalcdep.2015.02.034. [Epub ahead of print]

Background: Despite low HIV prevalence in the South Caucasus region, transmission is volatile. Little data are available from this region about addiction and infectious diseases among prisoners who transition back to communities.

Methods: A nation-wide randomly sampled biobehavioral health survey was conducted in 13 non-specialty Azerbaijani prisons among soon-to-be-released prisoners. After informed consent, participants underwent standardized health assessment surveys and testing for HIV, hepatitis B and C, and syphilis.

Results: Of the 510 participants (mean age=38.2 years), 11.4% were female, and 31.9% reported pre-incarceration drug injection, primarily of heroin. Prevalence of HCV (38.2%), HIV (3.7%), syphilis (3.7%), and HBV (2.7%) was high. Among the 19 HIV-infected inmates, 14 (73.7%) were aware of their HIV status, 12 (63.2%) were receiving antiretroviral therapy (ART), and 5 (26.3%) had CD4<350cells/mL (4 of these were on ART). While drug injection was the most significant independent correlate of HCV (AOR=12.9; p=0.001) and a significant correlate of HIV (AOR=8.2; p=0.001), both unprotected sex (AOR=3.31; p=0.049) and working in Russia/Ukraine (AOR=4.58; p=0.008) were also correlated with HIV.

Conclusion: HIV and HCV epidemics are concentrated among people who inject drugs (PWIDs) in Azerbaijan, and magnified among prisoners. A transitioning HIV epidemic is emerging from migration from high endemic countries and heterosexual risk. The high diagnostic rate and ART coverage among Azerbaijani prisoners provides new evidence that HIV treatment as prevention in former Soviet Union (FSU) countries is attainable, and provides new insights for HCV diagnosis and treatment as new medications become available. Within prison evidence-based addiction treatments with linkage to community care are urgently needed.

Abstract access 

Editor’s notes: This is an important study describing prevalence of HIV, hepatitis B and hepatitis C among a prison population in Azerbaijan. The importance of the study stems from the need to monitor infections among a highly vulnerable population of prisoners. While the study does not report on current injecting drug use among the population, a third of the sample reported injecting drugs prior to their detention and will need support with their injecting drug use while in prison. This will include the provision of opioid substitution therapy and needle-syringe programmes.  This study highlights the vulnerability of prisoners to HIV, hepatitis B and hepatitis C and the need for harm reduction in prisons. At the same time, the study also highlights other adverse health outcomes relating to drug use or being in prison in terms of poor mental health outcomes among the sample. It illustrates an association between a measure of anxiety disorder and HIV infection. The strengths of this study lie in the large sample that were recruited from a broad range of prison facilities across the country, increasing the representativeness of the findings to all people living in prisons. Findings suggest an association between HIV infection and condomless sex, as well as a history of working in Russia and Ukraine. This suggests the potential for transmission of HIV across the region and points to the potential for sexual transmission of HIV in a region where transmission has been historically driven by injecting drug use. Findings contribute to the growing evidence for the urgent need for hepatitis C virus (HCV) treatment and increased access to needle-syringe programmes and opioid substitution therapy within prisons and communities in the region.  The high adherence among prisoners to HIV treatment demonstrates the provision of HCV treatment to the population is entirely feasible. Previous evidence from Russia has illustrated the difficulties for people living in prisons in maintaining HIV treatment post-release and this study underscores the need for support to facilitate the integration of individuals into harm reduction programmes including HIV treatment in community settings post-release. 

Europe
Azerbaijan
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HIV and sexuality curricula programmes that address gender or power are five times more effective than those that do not

The case for addressing gender and power in sexuality and HIV education: a comprehensive review of evaluation studies.

Haberland NA. Int Perspect Sex Reprod Health. 2015 Mar;41(1):31-42. doi: 10.1363/4103115.

Context: Curriculum-based sexuality and HIV education is a mainstay of interventions to prevent STIs, HIV and unintended pregnancy among young people. Evidence links traditional gender norms, unequal power in sexual relationships and intimate partner violence with negative sexual and reproductive health outcomes. However, little attention has been paid to analyzing whether addressing gender and power in sexuality education curricula is associated with better outcomes.

Methods: To explore whether the inclusion of content on gender and power matters for program efficacy, electronic and hand searches were conducted to identify rigorous sexuality and HIV education evaluations from developed and developing countries published between 1990 and 2012. Intervention and study design characteristics of the included interventions were disaggregated by whether they addressed issues of gender and power.

Results: Of the 22 interventions that met the inclusion criteria, 10 addressed gender or power, and 12 did not. The programs that addressed gender or power were five times as likely to be effective as those that did not; fully 80% of them were associated with a significantly lower rate of STIs or unintended pregnancy. In contrast, among the programs that did not address gender or power, only 17% had such an association.

Conclusions: Addressing gender and power should be considered a key characteristic of effective sexuality and HIV education programs.

Abstract  Full-text [free] access

Editor’s notes: Curriculum-based sexuality and HIV education plays a central role in the prevention of sexually transmitted infections (STI), HIV and unintended pregnancy among young people. This paper synthesizes current evidence from 22 rigorous evaluation studies that assessed the impacts of different curricula based programmes on HIV, STI or pregnancy risk. The nearly opposite outcomes of programmes that address gender and power compared to those that do not, was striking, with programmes that addressed gender or power being five times as likely to be effective as those that did not.

Several common characteristics of effective programmes were identified. In addition to having interactive and learner-centered pedagogical approaches, effective programmes tended to give explicit attention to gender or power in relationships. Effective programmes fostered critical thinking about how gender norms or inequalities in power manifest and operate and influence life, sexual relationships or health. The programmes also support participants to value themselves and recognize their ability to effect change in their life, relationship or community.

The review findings are consistent with broader theory and evidence that links gender, power and intimate partner violence with sexual and reproductive health outcomes, including HIV. The findings illustrate the value of addressing gender in sexual health programming, illustrating that this is not a luxury for programmes, but rather a critical component of successful programming. 

Africa, Northern America
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Re-focusing the response in Niger – a greater need for sex worker programmes?

Reorienting the HIV response in Niger toward sex work interventions: from better evidence to targeted and expanded practice. 

Fraser N, Kerr CC, Harouna Z, Alhousseini Z, Cheikh N, Gray R, Shattock A, Wilson DP, Haacker M, Shubber Z, Masaki E, Karamoko D, Görgens M. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S213-20. doi: 10.1097/QAI.0000000000000456.

Background: Niger's low-burden, sex-work-driven HIV epidemic is situated in a context of high economic and demographic growth. Resource availability of HIV/AIDS has been decreasing recently. In 2007-2012, only 1% of HIV expenditure was for sex work interventions, but an estimated 37% of HIV incidence was directly linked to sex work in 2012. The Government of Niger requested assistance to determine an efficient allocation of its HIV resources and to strengthen HIV programming for sex workers. 

Methods: Optima, an integrated epidemiologic and optimization tool, was applied using local HIV epidemic, demographic, programmatic, expenditure, and cost data. A mathematical optimization algorithm was used to determine the best resource allocation for minimizing HIV incidence and disability-adjusted life years (DALYs) over 10 years. 

Results: Efficient allocation of the available HIV resources, to minimize incidence and DALYs, would increase expenditure for sex work interventions from 1% to 4%-5%, almost double expenditure for antiretroviral treatment and for the prevention of mother-to-child transmission, and reduce expenditure for HIV programs focusing on the general population. Such an investment could prevent an additional 12% of new infections despite a budget of less than half of the 2012 reference year. Most averted infections would arise from increased funding for sex work interventions. 

Conclusions: This allocative efficiency analysis makes the case for increased investment in sex work interventions to minimize future HIV incidence and DALYs. Optimal HIV resource allocation combined with improved program implementation could have even greater HIV impact. Technical assistance is being provided to make the money invested in sex work programs work better and help Niger to achieve a cost-effective and sustainable HIV response.

Abstract access  

Editor’s notes: Niger has a low-level HIV epidemic concentrated in key populations such as female sex workers, with prevalence levels of 17% in 2011. Only around 23% of female sex workers report using a condom at every sexual act, making them a highly vulnerable group. Additionally there are barriers to using the health centres such as service costs, and the geographic distance.

This article summarizes the HIV epidemic and response situation in Niger with a focus on female sex workers, including modelled trends using Optima. It then presents new evidence on different resource allocation scenarios and the projected impact on the HIV epidemic. Optima, a deterministic mathematical model for HIV optimization and prioritization, was applied to local epidemiologic, demographic, programmatic, expenditure, and cost data. 

The optimization function uses an algorithm to find the best allocation of resources to meet the objective of either minimizing HIV incidence or disability-adjusted life years (DALYs) until 2024. Contrary to the current approach of allocating 31% of spending to the general population and less than 1% to female sex workers, the Optima function advocates increased spending on antiretroviral therapy from 27% to 48%. Optima supports a focussed approach to reduce HIV incidence in female sex workers including mapping populations and a “programme intelligence” approach akin to that implemented in India and Nigeria.   

Africa, Asia
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How policies can fuel stigma

Assessment of policy and access to HIV prevention, care, and treatment services for men who have sex with men and for sex workers in Burkina Faso and Togo.

Duvall S, Irani L, Compaore C, Sanon P, Bassonon D, Anato S, Agounke J, Hodo A, Kugbe Y, Chaold G, Nigobora B, MacInnis R. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S189-97. doi: 10.1097/QAI.0000000000000450.

Background: In Burkina Faso and Togo, key populations of men who have sex with men (MSM) and sex workers (SW) have a disproportionately higher HIV prevalence. This study analyzed the 2 countries' policies impacting MSM and SW; to what extent the policies and programs have been implemented; and the role of the enabling environment, country leadership, and donor support.

Methods: The Health Policy Project's Policy Assessment and Advocacy Decision Model methodology was used to analyze policy and program documents related to key populations, conduct key informant interviews, and hold stakeholder meetings to validate the findings.

Results: Several policy barriers restrict MSM/SW from accessing services. Laws criminalizing MSM/SW, particularly anti-solicitation laws, result in harassment and arrests of even nonsoliciting MSM/SW. Policy gaps exist, including few MSM/SW-supportive policies and HIV prevention measures, e.g., lubricant not included in the essential medicines list. The needs of key populations are generally not met due to policy gaps around MSM/SW participation in decision-making and funding allocation for MSM/SW-specific programming. Misaligned policies, e.g., contradictory informed consent laws and protocols, and uneven policy implementation, such as stockouts of sexually transmitted infection kits, HIV testing materials, and antiretrovirals, undermine evidence-based policies. Even in the presence of a supportive donor and political community, public stigma and discrimination (S&D) create a hostile enabling environment.

Conclusions: Policies are needed to address S&D, particularly health care provider and law enforcement training, and to authorize, fund, guide, and monitor services for key populations. MSM/SW participation and development of operational guidelines can improve policy implementation and service uptake.

Abstract access 

Editor’s notes: This paper summarizes an interesting policy analysis of approaches to the provision of HIV services for gay men and other men who have sex with men and sex workers in Togo and Burkina Faso. Both countries are experiencing similar HIV epidemics, categorised as ‘mixed’ with high HIV prevalence among key populations nested within a generalised HIV epidemic. The policy analyses focus on assessing the ‘enabling’ environment defined as policies and programmes for gay men and other men who have sex with men and sex workers that support or hinder HIV prevention and treatment programming. The analysis clearly illustrates the importance of an enabling environment to facilitate use of programmes as well as shaping attitudes towards gay men and other men who have sex with men and sex workers.  Findings illustrate similar policy environments across both countries. While there are no specific laws preventing gay men and other men who have sex with men and sex workers using services, laws that criminalise sex between men or the exchange of sex result in people being harassed. Or laws are wrongly applied by police and discourage people from using services for fear of harassment and negative attitudes of health workers. Community-based organisations led by gay men and other men who have sex with men are not allowed to participate in developing national HIV strategies, which results in programmes not being tailored to specific population needs. The study clearly illustrates the gap between policy and practice. Even when a policy exists supporting a focussed activity for gay men and other men who have sex with men or sex workers, this is not implemented because of lack of appropriate implementation mechanisms. The paper provides important insights into what are the priorities for advocacy and policy development for gay men and other men who have sex with men and sex workers and calls for more research to illuminate the full range of barriers to services. Any advocacy efforts need to be accompanied by education campaigns to reduce stigma and discrimination against gay men and other men who have sex with men and sex workers. 

Africa
Burkina Faso, Togo
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People who inject drugs and the effects of stigma on HIV treatment

A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Jarve, Estonia.

Burke SE, Calabrese SK, Dovidio JF, Levina OS, Uuskula A, Niccolai LM, Abel-Ollo K, Heimer R. Soc Sci Med. 2015 Feb 16;130C:154-161. doi: 10.1016/j.socscimed.2015.02.018. [Epub ahead of print]

Experiences of stigma are often associated with negative mental and physical health outcomes. The present work tested the associations between stigma and health-related outcomes among people with HIV who inject drugs in Kohtla-Jarve, Estonia and St. Petersburg, Russia. These two cities share some of the highest rates of HIV outside of sub-Saharan Africa, largely driven by injection drug use, but Estonia has implemented harm reduction services more comprehensively. People who inject drugs were recruited using respondent-driven sampling; those who indicated being HIV-positive were included in the present sample (n = 381 in St. Petersburg; n = 288 in Kohtla-Jarve). Participants reported their health information and completed measures of internalized HIV stigma, anticipated HIV stigma, internalized drug stigma, and anticipated drug stigma. Participants in both locations indicated similarly high levels of all four forms of stigma. However, stigma variables were more strongly associated with health outcomes in Russia than in Estonia. The St. Petersburg results were consistent with prior work linking stigma and health. Lower barriers to care in Kohtla-Jarve may help explain why social stigma was not closely tied to negative health outcomes there. Implications for interventions and health policy are discussed.

Abstract access 

Editor’s notes: This study provides extremely important evidence on the impact of anticipated and felt stigma in relation to HIV and drug use on health outcomes among people who inject drugs in the context of high prevalence of HIV. People who inject drugs in both Russia and Estonia are highly marginalised. Previous studies indicate prevalence to be as high as 90% in Kohtla-Järve and incidence of five per 100 person-years in St Petersburg. Despite their close geographical proximity the two cities are framed by very different social and structural policies that enable and disable the provision of HIV prevention programmes to people who inject drugs. In Estonia, the provision of needle–syringe programmes and opioid substitution therapy is widespread and supported by the government. In Russia the limited harm reduction programmes are provided by non-governmental organisations with little or no support from government. Ambiguous drug policies often prohibit the use of needle –syringe programmes on the grounds they promote drug use. Opioid substitution therapy (OST) is not prescribed and people who inject drugs are viewed as potential criminals by police. People who inject drugs are frequently put under surveillance through a mandatory registration system by police and drug treatment (narcology) clinics. High levels of both internalised and anticipated stigma in relation to HIV and drug use were found in both sites. In Estonia this was not associated with poorer HIV outcomes including access to HIV care, CD4 count or self-reported HIV symptoms. Conversely in St Petersburg, internalised stigma associated with drug use was associated with lower CD4 count, reduced access to HIV care and increased HIV symptoms. This underscores the effectiveness of low-threshold HIV prevention and treatment services for people who inject drugs in the treatment of HIV, despite the existence of other social and cultural norms that stigmatise HIV and drug use. This study demonstrates the effect of stigma on HIV outcomes. However, further research is needed to understand the mechanisms through which stigma interplays with other social and structural factors, such as migration, poverty and criminalisation, to impact on health outcomes among people who inject drugs.

The study has clear policy implications. They include the need for structural interventions such as increased government support for harm reduction. These are necessary to prevent the reproduction of HIV and drug-use related stigma and its harmful impacts. Shorter-term programmes are required in Russia, including the urgent scale up of harm reduction activities and HIV treatment and care for people who inject drugs as well as the provision of inter-personal support to assist people who inject drugs in facing stigma within health services. 

Europe
Estonia, Russian Federation
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