Articles tagged as "Civil society and community responses / Resilience"

When are children ‘mature enough’ to know their HIV status? Caregivers’ and children’s perspectives on discussing HIV and ART at home in Jinja District, Uganda

Tensions in communication between children on antiretroviral therapy and their caregivers: a qualitative study in Jinja district, Uganda.

Kajubi P, Whyte SR, Kyaddondo D, Katahoire AR. PLoS One. 2016 Jan 19;11(1):e0147119. doi: 10.1371/journal.pone.0147119. eCollection 2016.

Introduction: HIV treatment and disclosure guidelines emphasize the importance of communicating diagnosis and treatment to infected children in ways that are appropriate to children's developmental stage and age. Minimal attention, however, has been given to communication challenges confronted by HIV-infected children and their caregivers. This study examined the tensions between children and their caregivers arising from differing perspectives regarding when and what to communicate about antiretroviral therapy (ART).

Methods: This qualitative study was conducted between November 2011 and December 2012 and involved 29 HIV-infected children aged 8-17 years on ART and their caregivers. Data were collected through observations and in-depth interviews, which took place in homes, treatment centres and post-test clubs. Children and caregivers were sampled from among the 394 HIV-infected children and (their) 393 caregivers who participated in the cross-sectional survey that preceded the qualitative study. ATLAS.ti. Version 7 was used in the management of the qualitative data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis.

Results: While the children felt that they were mature enough to know what they were suffering and what the medications were for, the caregivers wanted to delay discussions relating to the children's HIV diagnosis and medication until they felt that the children were mature enough to deal with the information and keep it a secret and this caused a lot of tension. The children employed different tactics including refusing to take the medicines, to find out what they were suffering from and what the medications were for. Children also had their own ideas about when, where and with whom to discuss their HIV condition, ideas that did not necessarily coincide with those of their caregivers, resulting in tensions.

Conclusions: Guidelines should take into consideration differing perceptions of maturity when recommending ages at which caregivers should communicate with their children about diagnosis and ART. Health care providers should also encourage caregivers to recognize and respect children's efforts to learn about and manage their condition. Children's questions and expressions of feelings should be treated as openings for communication on these issues.

Abstract  Full-text [free] access

Editor’s notes: Caregivers’ ideas of when children are ready to know about their HIV status can often differ from children’s own views. This qualitative study explored children’s and caregivers’ views about HIV status disclosure in the Jinja District in eastern Uganda. A purposive sample of 29 children living with HIV (aged 8-17) was recruited. Participants who were aware of their own HIV status were interviewed (21/29). Great care was taken to avoid accidental disclosure during the study. Caregivers’ views on children’s maturity were not linked to a specific age. Caregivers considered children ‘mature enough’ to know about their status when they believed that children could: 1) understand the implications of their diagnosis; 2) keep secrets 3) take responsibility for their antiretroviral therapy (ART) and 4) begin sexual activity. Some carers thought their child was not mature, but the child saw themselves as being mature enough. Children wanted to know what health condition they had and why they were taking treatment. Children perceived caregivers’ reticence as betrayal. Children deployed strategies such as refusing to take ART or go to the clinic unless they were told what the medication was for. However, children who had been told their status became responsible for their own ART adherence. Older children who were independent often did not discuss HIV or ART with anyone in the household. This could mean they lacked support with adherence issues they might have. The study offers an important and detailed account of the complicated question of disclosure and of communication about HIV and ART in the home. The authors advance our understanding of the importance of age in this process. They highlight the strengths and weaknesses of different approaches to managing adherence in children. The study illustrates the need to improve and extend communication about HIV within and beyond the clinic. The authors highlight that discussions about HIV and ART should be revisited at different points in time to ensure comprehension. This useful paper adds to research exploring children’s agency and resilience strategies in the context of silence and stigma about their HIV status. 

Africa
Uganda
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‘Cash, care and classroom’: social protection to reduce adolescents’ risk of HIV

Applying a family-level economic strengthening intervention to improve education and health-related outcomes of school-going AIDS-orphaned children: lessons from a randomized experiment in southern Uganda.

Ssewamala FM, Karimli L, Torsten N, Wang JS, Han CK, Ilic V, Nabunya P. Prev Sci. 2016 Jan;17(1):134-43. doi: 10.1007/s11121-015-0580-9.

Children comprise the largest proportion of the population in sub-Saharan Africa. Of these, millions are orphaned. Orphanhood increases the likelihood of growing up in poverty, dropping out of school, and becoming infected with HIV. Therefore, programs aimed at securing a healthy developmental trajectory for these orphaned children are desperately needed. We conducted a two-arm cluster-randomized controlled trial to evaluate the effectiveness of a family-level economic strengthening intervention with regard to school attendance, school grades, and self-esteem in AIDS-orphaned adolescents aged 12-16 years from 10 public rural primary schools in southern Uganda. Children were randomly assigned to receive usual care (counseling, school uniforms, school lunch, notebooks, and textbooks), "bolstered" with mentorship from a near-peer (control condition, n = 167), or to receive bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account (Suubi-Maka treatment arm, n = 179). The two groups did not differ at baseline, but 24 months later, children in the Suubi-Maka treatment arm reported significantly better educational outcomes, lower levels of hopelessness, and higher levels of self-concept compared to participants in the control condition. Our study contributes to the ongoing debate on how to address the developmental impacts of the increasing numbers of orphaned and vulnerable children and adolescents in sub-Saharan Africa, especially those affected by HIV/AIDS. Our findings indicate that innovative family-level economic strengthening programs, over and above bolstered usual care that includes psychosocial interventions for young people, may have positive developmental impacts related to education, health, and psychosocial functioning.

Abstract access 

Editor’s notes: The HIV epidemic has left many sub-Saharan countries with an extraordinarily large youth population, many of whom lost one or both parents to HIV-associated mortality. As a result, younger children tend to have much less support to stay in education and older children often have increased responsibility to support the household. There is thus a need to provide orphaned children with both financial and psycho-social support to achieve their educational goals, and on a broader scale, to prepare the youth for the workforce. This study found that providing orphaned children with a package of school supplies and support services as well as financial services (opening a matched child savings account and workshops on microenterprise development) yielded better educational outcomes than the package without the additional financial services. However, how either group compares to non-orphaned children is unclear. Future research would benefit from a third comparison group, in which non-orphaned children’s educational outcomes are also compared.

The effect of the programme on both educational and mental outcomes among orphans is important. Educational outcomes may have been driven by improved self-confidence and motivation as a result of the savings account and microenterprise training. It is unclear whether these supplemental activities were simply a signal of the community support for the orphaned children, which in turn increased self-confidence, or if the children were directly influenced by their improved economic prospects. Further research to uncover the actual mechanism of the improved outcomes would be useful for future programme design. 

Africa
Uganda
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Depression in people living with HIV – importance of family dynamics

The importance of the family: a longitudinal study of the predictors of depression in HIV patients in South Africa.

Wouters E, Masquillier C, le Roux Booysen F. AIDS Behav. 2016 Jan 18. [Epub ahead of print]

As a chronic illness, HIV/AIDS requires life-long treatment adherence and retention and thus sufficient attention to the psychosocial dimensions of chronic disease care in order to produce favourable antiretroviral treatment (ART) outcomes in a sustainable manner. Given the high prevalence of depression in chronic HIV patients, there is a clear need for further research into the determinants of depression in this population. In order to comprehensively study the predictors of depressive symptoms in HIV patients on ART, the socio-ecological theory postulates to not only incorporate the dominant individual-level and the more recent community-level approaches, but also incorporate the intermediate, but crucial family-level approach. The present study aims to extend the current literature by simultaneously investigating the impact of a wide range individual-level, family-level and community-level determinants of depression in a sample of 435 patients enrolled in the Free State Province of South Africa public-sector ART program. Structural equation modeling is used to explore the relationships between both latent and manifest variables at two time points. Besides a number of individual-level correlates—namely education, internalized and external stigma, and avoidant and seeking social support coping styles—of depressive symptoms in HIV patients on ART, the study also revealed the important role of family functioning in predicting depression. While family attachment emerged as the only factor to continuously and negatively impact depression at both time points, the second dimension of family functioning, changeability, was the only factor to produce a negative cross-lagged effect on depression. The immediate and long-term impact of family functioning on depression draws attention to the role of family dynamics in the mental health of people living with HIV/AIDS. In addition to individual-level and community-based factors, future research activities should also incorporate the role of the family context in research into the mental health of HIV patients, as our results demonstrate that the familial context in which a person with HIV on ART resides is inextricably interconnected with his/her health outcomes.

Abstract access 

Editor’s notes: Effective treatment in the form of antiretroviral therapy now exists for HIV. This means that people living with HIV can have a near-normal life expectancy, provided treatment is started early and adherence to treatment is good. In many settings, including low-income countries, HIV has transitioned from being a terminal illness to a controllable chronic disease. And this brings new challenges for health care providers. As with many chronic illnesses that require lifelong treatment, a diagnosis of HIV can induce depressive symptoms. People living with HIV face a number of additional challenges including stigma, which can impact negatively on mental health. Furthermore, in high HIV prevalence areas people are likely to have witnessed AIDS-related deaths of friends and family. The challenge of providing additional psychosocial care to a growing population of people living with HIV is daunting. This is especially true in resource-poor settings where mental health care services are already stretched. There is a need for research to understand the determinants of depression in order to inform development of appropriate programmes.

This study contributes data on a range of family-level determinants in addition to individual-level and community-level determinants for depression in HIV-positive people. Few studies have focussed on depression in HIV-positive people and the impact of family functioning. Unlike this study, those that have were not conducted in high HIV prevalence, resource-poor settings. The investigators report that family attachment was the only factor that continuously impacted on depression in this population at two different time points. This highlights the role of family dynamics in the mental health and well-being of people living with HIV. Further research that incorporates in-depth qualitative methods is necessary, not only to confirm these findings but to also broaden our understanding of the determinants for depression.  

Africa
South Africa
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Large multi-centre study finds few differences between mortality in migrant and native populations in western Europe

Mortality in migrants living with HIV in western Europe (1997-2013): a collaborative cohort study.

Migrants Working Group on behalf of COHERE in EuroCoord. Lancet HIV. 2015 Dec;2(12):e540-9. doi: 10.1016/S2352-3018(15)00203-9. Epub 2015 Nov 18.

Background: Many migrants face adverse socioeconomic conditions and barriers to health services that can impair timely HIV diagnosis and access to life-saving treatments. We aimed to assess the differences in overall mortality by geographical origin in HIV-positive men and women using data from COHERE, a large European collaboration of HIV cohorts from 1997 to 2013.

Methods: In this observational cohort study, we included HIV-positive, antiretroviral-naive people accessing care in western Europe from COHERE. Individuals were eligible if enrolled in a cohort that collected information on geographical origin or ethnic origin from Jan 1, 1997, to March 19, 2013, aged 18-75 years, they had available information about sex, they were not infected perinatally or after the receipt of clotting factor concentrates, and were naive to combination antiretroviral therapy at cohort entry. Migrants' origins were grouped into seven regions: western Europe and similar countries (Australia, Canada, New Zealand, and the USA); eastern Europe; North Africa and the Middle East; sub-Saharan Africa; Latin America; the Caribbean; and Asia and the rest of Oceania (excluding Australia and New Zealand). Crude and adjusted mortality rate ratios were calculated by use of Poisson regression stratified by sex, comparing each group with the native population. Multiple imputation with chained equations was used to account for missing values.

Findings: Between Oct 25, 1979, and March 19, 2013, we recruited 279 659 individuals to the COHERE collaboration in EuroCoord. Of these 123 344 men and 45 877 women met the inclusion criteria. Our data suggested effect modification by transmission route (pinteraction=0.12 for men; pinteraction=0.002 for women). No significant difference in mortality was identified by geographical origin in men who have sex with men. In heterosexual populations, most migrant men had mortality lower than or equal to that of native men, whereas no group of migrant women had mortality lower than that in native women. High mortality was identified in heterosexual men from Latin America (rate ratio [RR] 1.46, 95% CI 1.00-2.12, p=0.049) and heterosexual women from the Caribbean (1.48, 1.29-1.70, p<0.0001). Compared with that in the native population, mortality in injecting drug users was similar or low for all migrant groups.

Interpretation: Characteristics of and risks faced by migrant populations with HIV differ for men and women and for populations infected heterosexually, by sex between men, or by injecting drug use. Further research is needed to understand how inequalities are generated and maintained for the groups with higher mortality identified in this study.

Abstract access 

Editor’s notes: This topical analysis on migrant health from the large COHERE collaboration examined mortality in people living with HIV who are treatment-naïve and enrolling for care in 11 western European countries. Routinely collected data were analysed to explore differences in mortality by region of origin. Overall, few differences in mortality were seen between migrant and native populations, with a general trend of similar or lower mortality among migrants than native populations.  However, diversity within migrant groups even from the same region makes it challenging to interpret summary data. The authors provide interesting insights into these difficulties. For example, the reasons for migration are likely to result in different socio-economic conditions in the host country, but heterogeneity in mortality between sub-groups may be masked when looking at overall mortality in migrants compared with the native population. The authors discuss both the “healthy migrant effect” (the fact that it is often healthier, younger populations who are able to migrate), and the “salmon bias” (the fact people who are ill often return to their place of origin). Both of these effects can lead to an observed lower disease burden in migrants than native populations. At a time when immigration is a hotly debated issue in western Europe this study highlights the challenges in assessing migrant health and the need for further empirical and methodological research in this area.

Europe
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Violence and educational outcomes among young children in South Africa and Malawi

Exposure to violence predicts poor educational outcomes in young children in South Africa and Malawi.

Sherr L, Hensels IS, Skeen S, Tomlinson M, Roberts KJ, Macedo A. Int Health. 2015 Dec 17. pii: ihv070. [Epub ahead of print]

Background: Violence during childhood may affect short and long-term educational factors. There is scant literature on younger children from resource poor settings.

Methods: This study assessed child violence experiences (harsh punishment and exposure to domestic or community violence) and school enrolment, progress and attendance in children attending community-based organisations in South Africa and Malawi (n=989) at baseline and at 15 months' follow-up, examining differential experience of HIV positive, HIV affected and HIV unaffected children.

Results: Violence exposure was high: 45.4% experienced some form of psychological violence, 47.8% physical violence, 46.7% domestic violence and 41.8% community violence. Primary school enrolment was 96%. Violence was not associated with school enrolment at baseline but, controlling for baseline, children exposed to psychological violence for discipline were more than ten times less likely to be enrolled at follow-up (OR 0.09; 95% CI 0.01 to 0.57). Harsh discipline was associated with poor school progress. For children HIV positive a detrimental effect of harsh physical discipline was found on school performance (OR 0.10; 95% CI 0.02 to 0.61).

Conclusion: Violence experiences were associated with a number of educational outcomes, which may have long-term consequences. Community-based organisations may be well placed to address such violence, with a particular emphasis on the challenges faced by children who are HIV positive.

Abstract  Full-text [free] access

Editor’s notes: There is substantial evidence that demonstrates the negative effects of the experience of violence in childhood on child mental health. However, there is little evidence on the impact of violence on educational outcomes. This is due to measurement and study design, such as data being primarily cross-sectional and studies being confined to adolescents, where younger children are excluded. This study reports data from a longitudinal study of young children aged 4–13 years affected by HIV enrolled at community-based organisations (CBOs) in South Africa and Malawi. The study examined the relationship between exposure to violence at home or in the community on educational outcomes at baseline and follow-up (12–15 months later). In particular, attention was given to HIV positive and HIV affected children in order to explore the effects of HIV as a factor of either violence experience or educational risk in this age group. HIV affected children are children who may not be HIV positive themselves, but living in a household with a HIV positive member.

In this sample of young children (n=989), close to 14% were HIV positive. School enrolment and attendance was high, although HIV positive children had slightly lower attendance and enrolment in the correct grade for their age, compared to HIV affected children. At baseline, overall exposure to violence at home and in the community was very high. Over half of the sample had been exposed to two or more types of violence, whereas less than one in six reported no violence exposure at all. At both baseline and at follow-up, there was no association found between community violence and school enrolment and attendance or grade progression. In terms of violence experienced at home (domestic violence), at baseline there was an association with grade progression for children in households with no HIV. At follow-up, in particular for children living with HIV, use of physical violence to discipline the child had a detrimental effect on grade progression. Furthermore, at follow-up, the use of psychological violence to discipline children had an effect on school enrolment. Hence, children of caregivers using psychological violence for discipline were significantly less likely to be enrolled in school at follow-up, if they were not enrolled at baseline. Thus, findings from this study highlight that despite high rates of violence exposure in this population, children who are HIV positive, in particular, appear to be most at risk of poor educational outcomes. This is likely to be due to a range of inter-related risk factors that affect educational outcomes: parental death, shifting care arrangements, change in school, illness-induced poverty and increased care-giving responsibilities.  All these factors might affect a child’s ability to access schooling and perform well in the context of HIV. As shown, educational outcomes were specifically linked to harsh punishment, as opposed to community or domestic violence. Thus, CBOs that provide services for children affected by HIV might be key to intervening on this issue. Furthermore, younger children in HIV endemic countries are particularly vulnerable and educational achievement in the early years is an important pre-requisite for ongoing educational milestones.  

Africa
Malawi, South Africa
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HIV tests at church-based baby showers raise odds of testing 11-fold for pregnant women

Effect of a congregation-based intervention on uptake of HIV testing and linkage to care in pregnant women in Nigeria (baby shower): a cluster randomised trial.

Ezeanolue EE, Obiefune MC, Ezeanolue CO, Ehiri JE, Osuji A, Ogidi AG, Hunt AT, Patel D, Yang W, Pharr J, Ogedegbe G. Lancet Glob Health. 2015 Nov;3(11):e692-700. doi: 10.1016/S2214-109X(15)00195-3.

Background: Few effective community-based interventions exist to increase HIV testing and uptake of antiretroviral therapy (ART) in pregnant women in hard-to-reach resource-limited settings. We assessed whether delivery of an intervention through churches, the Healthy Beginning Initiative, would increase uptake of HIV testing in pregnant women compared with standard health facility referral.

Methods: In this cluster randomised trial, we enrolled self-identified pregnant women aged 18 years and older who attended churches in southeast Nigeria. We randomised churches (clusters) to intervention or control groups, stratified by mean annual number of infant baptisms (<80 vs ≥80). The Healthy Beginning Initiative intervention included health education and on-site laboratory testing implemented during baby showers in intervention group churches, whereas participants in control group churches were referred to health facilities as standard. Participants and investigators were aware of church allocation. The primary outcome was confirmed HIV testing. This trial is registered with ClinicalTrials.gov, identifier number NCT 01795261.

Findings: Between Jan 20, 2013, and Aug 31, 2014, we enrolled 3002 participants at 40 churches (20 per group). 1309 (79%) of 1647 women attended antenatal care in the intervention group compared with 1080 (80%) of 1355 in the control group. 1514 women (92%) in the intervention group had an HIV test compared with 740 (55%) controls (adjusted odds ratio 11.2, 95% CI 8.77-14.25; p<0.0001).

Interpretation: Culturally adapted, community-based programmes such as the Healthy Beginning Initiative can be effective in increasing HIV screening in pregnant women in resource-limited settings.

Abstract Full-text [free] access

Editor’s notes: HIV testing is a key entry point for prevention of mother-to-child transmission. Community-based, decentralised HIV testing outside health facilities can increase uptake of testing among pregnant women, but this does not always follow through into good linkage to care.

In Nigeria faith-based organisations have a strong social network and a wider presence than health facilities. This trial co-ordinated churches in predominantly Christian southeast Nigeria to identify pregnant women early and organise a baby shower where on-site laboratory tests were provided. To avoid stigma the programme offered testing for five other conditions alongside HIV. Women who tested positive for HIV infection were linked to care and followed up at a post-delivery baby reception at the church. Women in the programme arm were more likely to have an HIV test and if positive they were more likely to access care before delivery and to start ART during pregnancy.

The results illustrate the benefits of engagement with faith-based organisations to reach communities that are poorly served by health facilities. The fact male partners played a role in the baby shower may have increased uptake, as pregnant women are more likely to accept HIV testing when male partners are also involved. The main costs were Mama Packs (a gift of essentials for a safe delivery, presented at the baby shower) and integrated lab tests. The activity was so popular that communities continued with it after the trial ended. The programme is now being adapted for mosques in northern Nigeria and Hindu temples in India. 

Africa
Nigeria
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Can children recognise HIV-associated symptoms in their carers? Evaluation of a verbal assessment tool for children in South Africa.

Measuring child awareness for adult symptomatic HIV using a verbal assessment tool: concordance between adult-child dyads on adult HIV-associated symptoms and illnesses.

Becker E, Kuo C, Operario D, Moshabela M, Cluver L. Sex Transm Infect. 2015 Nov;91(7):528-33. doi: 10.1136/sextrans-2014-051728. Epub 2015 Jan 13.

Objectives: This study assessed children's awareness for adult HIV-associated symptoms and illnesses using a verbal assessment tool by analysing inter-rater reliability between adult-child dyads. This study also evaluated sociodemographic and household characteristics associated with child awareness of adult symptomatic HIV.

Methods: A cross-sectional survey using a representative community sample of adult-child dyads (N=2477 dyads) was conducted in KwaZulu-Natal, South Africa. Analyses focused on a subsample (n=673 adult-child dyads) who completed verbal assessment interviews for symptomatic HIV. We used an existing validated verbal autopsy approach, originally designed to determine AIDS-related deaths by adult proxy reporters. We adapted this approach for use by child proxy reporters for reporting on HIV-associated symptoms and illnesses among living adults. Analyses assessed whether children could reliably report on adult HIV-associated symptoms and illnesses and adult provisional HIV status.

Results: Adult-child pairs concurred above the 65th percentile for 9 of the 10 HIV-associated symptoms and illnesses with sensitivities ranging from 10% to 100% and specificities ranging from 20% to 100%. Concordant reporting between adult-child dyads for the adult's provisional HIV status was 72% (sensitivity=68%, specificity=73%). Children were more likely to reliably match adult's reports of provisional HIV status when they lived in households with more household members, and households with more robust socioeconomic indicators including access to potable water, food security and television.

Conclusions: Children demonstrate awareness of HIV-associated symptoms and illnesses experienced by adults in their household. Children in households with greater socioeconomic resources and more household members were more likely to reliably report on the adult's provisional HIV status.

Abstract Full-text [free] access

Editor’s notes: This study tested a new tool for assessing whether children who are caring for adults living with HIV in their household are able to recognise HIV-associated symptoms and illnesses. The study was conducted with households in one rural and one urban site in KwaZulu-Natal, South Africa. The authors report on the analysis of results from a sub-sample of 673 dyads, composed of one adult and one child living in the same household. With the help of researchers, children aged 10-17, completed a verbal tool that was adapted for this study from a previous ‘verbal autopsy’ tool used to assess AIDS-associated deaths. The adult in each of the dyads also completed an adult version of the study’s adapted tool. The tool contained questions on ten symptoms and illnesses associated with HIV. Some of these strongly indicate HIV presence when found in a combination of two or more (e.g. TB; oral candidiasis; diarrhoea; herpes). Children-adult responses were compared in each dyad and tested for concurrency and sensibility. Overall, children and adult responses matched for more than 65% for nine out of ten of the symptoms/illnesses listed. There were variations in reliable matching depending on symptoms/illnesses. Some symptoms may have been harder for children to report on behalf of the adult, for example, constant diarrhoea. The tool used with the children may be useful for improving our understanding of the issues faced by young carers in households where some members are living with HIV. The tool may also help to understand strategies put in place by young carers looking after an adult with HIV-associated illnesses.

Africa
South Africa
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Regressive laws on same sex relationships increases stigma and reduces health service use

The immediate effect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort.

Schwartz SR, Nowak RG, Orazulike I, Keshinro B, Ake J, Kennedy S, Njoku O, Blattner WA, Charurat ME, Baral SD, TRUST Study Group. Lancet HIV. 2015 Jul 1;2(7):e299-e306.

Background: In January, 2014, the Same-Sex Marriage Prohibition Act was signed into law in Nigeria, further criminalising same-sex sexual relationships. We aimed to assess the immediate effect of this prohibition act on stigma, discrimination, and engagement in HIV prevention and treatment services in men who have sex with men (MSM) in Nigeria.

Methods: The TRUST cohort study uses respondent-driven sampling to assess the feasibility and effectiveness of engagement of MSM in HIV prevention and treatment services at a clinical site located with a community-based organisation trusted by the MSM community. TRUST is a prospective implementation research cohort of MSM (≥16 years) in Abuja, Nigeria. We compared HIV clinical outcomes and stigma, including fear and avoidance of health care, across baseline and quarterly visits before and after implementation of the Same-Sex Marriage Prohibition Act. Outcomes assessed were measures of stigma and discrimination, loss to follow-up, antiretroviral therapy status, and viral load. We compared outcomes before and after the legislation with chi2 statistics, and estimated incident stigma-related events and loss to follow-up with Poisson regression.

Findings: Between March 19, 2013, and Aug 7, 2014, 707 MSM participated in baseline study procedures, contributing to 756 before legislation (prelaw) and 420 after legislation (postlaw) visits. Reported history of fear of seeking health care was significantly higher in postlaw visits than in prelaw visits (n=161 [38%] vs n=187 [25%]; p<0.0001), as was avoidance of health care (n=118 [28%] vs n=151 [20%]; p=0.001). In incidence analyses, of 192 MSM with follow-up data and no history of an event at baseline, reported fear of seeking health care was higher in the postlaw than the prelaw period (n=144; incidence rate ratio 2.57, 95% CI 1.29-5.10; p=0.007); loss to follow-up and incident healthcare avoidance were similar across periods. Of the 161 (89%) of 181 HIV-infected MSM with HIV viral loads available, those who had disclosed sexual behaviour with a health-care provider were more often virally suppressed at baseline than those with no previous disclosure (18 [29%] of 62 vs 13 [13%] of 99 men; p=0.013).

Interpretation: These analyses represent individual-level, quantitative, real-time prospective data for the health-related effects resulting from the enactment of legislation further criminalising same-sex practices. The negative effects of HIV treatment and care in MSM reinforce the unintended consequences of such legislation on global goals of HIV eradication. Strategies to reach MSM less likely to engage in HIV testing and care in highly stigmatised environments are needed to reduce time to HIV diagnosis and treatment.

Abstract access 

Editor’s notes: Despite the recent implementation of progressive laws on same-sex relationships and marriage in several settings, other countries – including Nigeria – have moved to criminalise same sex practises. As well as broader human rights concerns, there is the risk that policies that criminalise same-sex practices, or the community groups addressing the health-related needs of these populations, might restrict the coverage of HIV prevention, treatment and care programmes. However, despite these concerns, there is extremely limited quantitative evidence on the impact of such policies. In Nigeria, the Same-Sex Marriage Prohibition Act was passed in 2011, coming into law in 2014. Before this legislation, consensual sex between male same-sex couples was already prohibited. The new law further criminalised same sex practices, including prohibiting participation in organisations and service provision. This study opportunistically analysed data from an on-going prospective cohort study of gay men and other men who have sex with men in Abuja, which had started prior to the law’s implementation, and continued after its introduction. The study assessed the degree to which this legislation impacted on gay men and other men who have sex with men’s fear and health service use. Unsurprisingly, perhaps, the study illustrates that the law did impact negatively on gay men and other men who have sex with men – significantly increasing their fear of and avoidance of health services, as well as increasing their levels of harassment and experience of blackmail. Prior to the new legislation, levels were already high, with the new law seeming to exacerbate existing barriers and stigma. The findings are important, illustrating how regressive laws can increase the stigmatisation of already marginalised groups, and undermine the gay men and other men who have sex with men’s access to health associated services. Supportive policy environments, along with HIV programmes for marginalised populations, form an essential part of an effective HIV response.

Africa
Nigeria
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Community-based rapid testing boosts case finding among MSM in China

Case finding advantage of HIV rapid tests in community settings: men who have sex with men in 12 programme areas in China, 2011.

Zhang D, Qi J, Fu X, Meng S, Li C, Sun J. Int J STD AIDS. 2015 May;26(6):402-13. doi: 10.1177/0956462414542986. Epub 2014 Jul 15.

We sought to describe the advantage of rapid tests over ELISA tests in community-based screening for HIV among men who have sex with men (MSM) in urban areas of China. Data of 31 406 screening tests conducted over six months in 2011 among MSM across 12 areas were analyzed to compare the differences between those receiving rapid testing and ELISA. Rapid tests accounted for 45.8% of these screening tests. The rate of being screened positive was 7.2% among rapid tests and 5.3% for ELISA tests (X(2)= 49.161, p < 0.001). This advantage of rapid test in HIV case finding persisted even when socio-demographic, behavioural, screening recruitment channel and city were controlled for in logistic regression (exp[beta] = 1.42, p < 0.001, 95% CI = 1.27,1.59). MSM who received rapid tests, compared with those tested by ELISA, were less likely to use condoms during last anal sex (50.8% vs. 72.3%, X(2)= 1706.146, p < 0.001), more likely to have multiple sex partners (55.7% vs. 49.5%, X(2)= 238.188, p < 0.001) and less likely to have previously undergone HIV testing (38.8% vs. 54.7%, X(2)= 798.476, p < 0.001). These results demonstrate the robustness of the advantage of rapid tests over traditional ELISA tests in screening for MSM with HIV infection in cooperation with community-based organizations in urban settings in China.

Abstract access

Editor’s notes: The prevalence of HIV among gay men and other men who have sex with men in China has increased from 1% to 5% between 2006 and 2011. The increase in prevalence has motivated the development of a new HIV testing strategy to reach this key population. The China-Gates HIV Programme facilitated partnerships between local government health departments with community-based organizations (CBO) to reach and offer rapid HIV screening tests to gay men and other men who have sex with men in 14 cities and one province. Between July and December 2011, 17 015 men were tested through established HIV testing sites (run solely by the health departments, which used enzyme-linked immunosorbent assay [ELISA] testing) and another 14 391 men were tested at sites which were established, promoted, and run by the government-CBO partnerships. These sites used rapid HIV tests, and referred to the health department for confirmatory testing. After controlling for sociodemographic characteristics, transmission risk factors and geographic location, the odds of testing positive for HIV was 42% higher for men who were screened at partnership sites. This partnership demonstrates an innovative, culturally appropriate and scale-able model. For key populations, partnerships of this nature can lead to earlier treatment initiation and a reduction in secondary transmission.

Asia
China
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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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