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

Prevention services need to focus on newly-started sex workers in South India

Changes in HIV and syphilis prevalence among female sex workers from three serial crosssectional surveys in Karnataka state, South India. 

Isac S, Ramesh BM, Rajaram S, Washington R, Bradley JE, Reza-Paul S, Beattie TS, Alary M. BMJ Open. 2015 Mar 27;5(3):e007106. doi: 10.1136/bmjopen-2014-007106.

Objectives: This paper examined trends over time in condom use, and the prevalences of HIV and syphilis, among female sex workers (FSWs) in South India. 

Design: Data from three rounds of cross-sectional surveys were analysed, with HIV and high-titre syphilis prevalence as outcome variables. Multivariable analysis was applied to examine changes in prevalence over time. 

Setting: Five districts in Karnataka state, India. 

Participants: 7015 FSWs were interviewed over three rounds of surveys (round 1=2277; round 2=2387 and round 3=2351). Women who reported selling sex in exchange for money or gifts in the past month, and aged between 18 and 49 years, were included. 

Interventions: The surveys were conducted to monitor a targeted HIV prevention programme during 2004-2012. The main interventions included peer-led community outreach, services for the treatment and prevention of sexually transmitted infections, and empowering FSWs through community mobilisation.  

Results: HIV prevalence declined significantly from rounds 1 to 3, from 19.6% to 10.8%

(adjusted OR (AOR)=0.48, p<0.001); high-titre syphilis prevalence declined from 5.9% to 2.4% (AOR=0.50, p<0.001). Reductions were observed in most substrata of FSWs, although reductions among new sex workers, and those soliciting clients using mobile phones or from home, were not statistically significant. Condom use 'always' with occasional clients increased from 73% to 91% (AOR=1.9, p<0.001), with repeat clients from 52% to 86% (AOR=5.0, p<0.001) and with regular partners from 12% to 30% (AOR=4.2, p<0.001). Increased condom use was associated with exposure to the programme. However, condom use with regular partners remained low. 

Conclusions: The prevalences of HIV infection and high-titre syphilis among FSWs have steadily declined with increased condom use. Further reductions in prevalence will require intensification of prevention efforts for new FSWs and those soliciting clients using mobile phones or from home, as well as increasing condom use in the context of regular partnerships.

Abstract   Full-text [free] access

Editor’s notes: The HIV epidemic in India has remained largely concentrated in key populations, particularly among female sex workers. One of the most high profile HIV prevention efforts in India has been the Avahan AIDS initiative, which in Karnataka State has reached over 60 000 female sex workers since 2004. The initiative involves peer-mediated safer sex communications, intensive management of sexually transmitted infections, and facilitation of safer sex environments. In the final round of a repeat cross-sectional survey conducted between 2004 and 2011, investigators found that nearly all female sex workers were contacted by a peer educator, had seen a condom demonstration, or had visited a programme clinic. In that time, the prevalence of HIV fell from 19.6% to 10.8% (P<0.01) and the prevalence of new syphilis infections fell from 5.9% to 2.4% (P<0.01). However, HIV prevalence among new female sex workers remained high, reflecting the challenges in reaching women starting sex work before they become HIV positive. The programme is notable for its responsiveness to the HIV prevention needs of female sex workers and the current paper confirms continued increases in condom use and preventive services. However, with the changing nature of sex work, current challenges include preventive services for women soliciting sex through mobile phones, and reaching sex workers soon after they start sex work. 

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The impact of anti-retroviral treatment on home-based carers in Zambia

‘Deep down in their heart, they wish they could be given some incentives’: a qualitative study on the changing roles and relations of care among home-based caregivers in Zambia.

Cataldo F, Kielmann K, Kielmann T, Mburu G, Musheke M. BMC Health Serv Res. 2015 Jan 28;15(1):36. [Epub ahead of print]

Background: Across sub-Saharan Africa, the roll-out of antiretroviral treatment (ART) has contributed to shifting HIV care towards management of a chronic health condition. While the balance of professional and lay tasks in HIV care-giving has been significantly altered due to changing skills requirements and task-shifting initiatives, little attention has been given to the effects of these changes on health workers’ motivation and existing care relations.

Methods: This paper draws on a cross-sectional, qualitative study that explored changes in home-based care (HBC) in the light of widespread ART rollout in the Lusaka and Kabwe districts of Zambia. Methods included observation of HBC daily activities, key informant interviews with programme staff from three local HBC organisations (n = 17) and ART clinic staff (n = 8), as well as in-depth interviews with home-based caregivers (n = 48) and HBC clients (n = 31).

Results: Since the roll-out of ART, home-based caregivers spend less time on hands-on physical care and support in the household, and are increasingly involved in specialised tasks supporting their clients’ access and adherence to ART. Despite their pride in gaining technical care skills, caregivers lament their lack of formal recognition through training, remuneration or mobility within the health system. Care relations within homes have also been altered as caregivers’ newly acquired functions of monitoring their clients while on ART are met with some ambivalence. Caregivers are under pressure to meet clients and their families’ demands, although they are no longer able to provide material support formerly associated with donor funding for HBC.

Conclusions: As their responsibilities and working environments are rapidly evolving, caregivers’ motivations are changing. It is essential to identify and address the growing tensions between an idealized rhetoric of altruistic volunteerism in home-based care, and the realities of lay worker deployment in HIV care interventions that not only shift tasks, but transform social and professional relations in ways that may profoundly influence caregivers’ motivation and quality of care.

Abstract  Full-text [free] access

Editor’s notes: This paper fills an important gap. The authors examine the impact of the roll-out of antiretroviral treatment (ART) on home-based carers. Many papers have focused on recipients of ART and the effect on clinic services of providing ART. Little has been said about the impact of ART on home-based carers. Community health workers providing home-based care have been an important part of the support network for people living with HIV. It has been accepted that they provide the service as volunteers, and many have taken great pride in their work. The authors report a growing resentment at the lack of compensation for their work. Home-based carers have gained skills in supporting people on ART, acting as intermediaries between clinic and the person receiving care. Dwindling donor support for food and other items, provided to people living with HIV, has also affected home-based carers. They were often the ones who brought that aid to people living with HIV, and they are sometimes blamed for the loss. They may also be resented for checking up on ART adherence, affecting the trust between carer and the person living with HIV. This paper highlights the importance of looking at the unintended consequences of changes in healthcare delivery. A timely reminder that shifting treatment responsibilities away from the clinic is not without costs.        

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Negotiating the price for safe sex: A study among rural sex workers in Zimbabwe

The price of sex: condom use and the determinants of the price of sex among female sex workers in eastern Zimbabwe.

Elmes J, Nhongo K, Ward H, Hallett T, Nyamukapa C, White PJ, Gregson S. J Infect Dis. 2014 Dec 1;210 Suppl 2:S569-78. doi: 10.1093/infdis/jiu493.

Background: Higher prices for unprotected sex threaten the high levels of condom use that contributed to the decline in Zimbabwe's human immunodeficiency virus (HIV) epidemic. To improve understanding of financial pressures competing against safer sex, we explore factors associated with the price of commercial sex in rural eastern Zimbabwe.

Methods: We collected and analyzed cross-sectional data on 311 women, recruited during October-December 2010, who reported that they received payment for their most-recent or second-most-recent sex acts in the past year. Zero-inflated negative binomial models with robust standard errors clustered on female sex worker (FSW) were used to explore social and behavioral determinants of price.

Results: The median price of sex was $10 (interquartile range [IQR], $5-$20) per night and $10 (IQR, $5-$15) per act. Amounts paid in cash and commodities did not differ significantly. At the most-recent sex act, more-educated FSWs received 30%-74% higher payments. Client requests for condom use significantly predicted protected sex (P < .01), but clients paid on average 42.9% more for unprotected sex.

Conclusions: Within a work environment where clients' preferences determine condom use, FSWs effectively use their individual capital to negotiate the terms of condom use. Strengthening FSWs' preferences for protected sex could help maintain high levels of condom use.

Abstract  Full-text [free] access

Editor’s notes: This study addresses a relatively neglected issue of how payments for commercial sex among rural sex workers are determined, and which factors are important to price negotiations. In this study from Zimbabwe, the participants were grouped into “more professional”, both the last two clients were commercial, (FSW2) and “less professional”, one of the last two clients was commercial (FSW1). The “more professional” sex workers effectively negotiated transactions, with unprotected sex increasing the mean payment by almost a half, compared with protected sex. This differential pricing was not seen for the “less professional” sex workers, perhaps reflecting limited capacity to negotiate with clients. This study demonstrates the importance of strengthening preferences for protected sex, among female sex workers, including among less visible sex workers. Such strategies may include enhancing social capital and collective action, e.g. collective price-fixing to reduce competitive pressure to engage in unsafe sex. 

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Household food insecurity is associated with poor adherence to antiretroviral therapy

Household food insecurity associated with antiretroviral therapy adherence among HIV-infected patients in Windhoek, Namibia.

Hong SY, Fanelli TJ, Jonas A, Gweshe J, Tjituka F, Sheehan HM, Wanke C, Terrin N, Jordan MR, Tang AM. J Acquir Immune Defic Syndr. 2014 Dec 1;67(4):e115-22. doi: 10.1097/QAI.0000000000000308.

Objective: Food insecurity is emerging as an important barrier to antiretroviral therapy (ART) adherence. The objective of this study was to determine if food insecurity is associated with poor ART adherence among HIV-positive adults in a resource-limited setting that uses the public health model of delivery.

Design: A cross-sectional study using a 1-time questionnaire and routinely collected pharmacy data.

Methods: Participants were HIV-infected adults on ART at the public ART clinics in Windhoek, Namibia: Katutura State Hospital, Katutura Health Centre, and Windhoek Central Hospital. Food insecurity was measured by the Household Food Insecurity Access Scale (HFIAS). Adherence was assessed by the pharmacy adherence measure medication possession ratio (MPR). Multivariate regression was used to assess whether food insecurity was associated with ART adherence.

Results: Among 390 participants, 7% were food secure, 25% were mildly or moderately food insecure and 67% were severely food insecure. In adjusted analyses, severe household food insecurity was associated with MPR <80% [odds ratio (OR), 3.84; 95% confidence interval (CI): 1.65 to 8.95]. Higher household health care spending (OR, 1.92; 95% CI, 1.02 to 3.57) and longer duration of ART (OR, 0.82; 95% CI: 0.70 to 0.97) were also associated with <80% MPR.

Conclusions: Severe household food insecurity is present in more than half of the HIV-positive adults attending a public ART clinic in Windhoek, Namibia and is associated with poor ART adherence as measured by MPR. Ensuring reliable access to food should be an important component of ART delivery in resource-limited settings using the public health model of care.

Abstract access

Editor’s notes:  United Nations Subcommittee on Nutrition defines food insecurity as “the limited or uncertain availability of nutritionally adequate, safe foods, or the inability to acquire personally acceptable foods in socially acceptable ways.” Qualitative studies in resource-limited settings have identified food insecurity as a potential risk for antiretroviral (ART) non-adherence. This is one of the first quantitative studies to analyse this issue. The findings from this cross-sectional survey of people living with HIV on ART in Namibia, are striking.  Four of the ten top reasons given for missing a medication dose, were related to food insecurity, e.g. “Did not take ARVs because they make me hungry and I did not have enough food” or, “Did not take ARVs because I cannot afford good food while taking medicine”. After adjusting for potential confounders, severe household food insecurity was significantly and positively associated with poor ART adherence. Depression and travel to the clinic via walking, biking or hitchhiking were also significantly associated with poor adherence. Research into the potential causal pathway between food insecurity and ART adherence is required, including evaluation of programmes to assess the relative effectiveness of nutritional versus livelihood programmes. 

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Can community based health care form part of a wider primary health care strategy in sub-Saharan Africa?

Integration of community home based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South-Africa and Zambia: a comparative assessment.

Aantjes C, Quinlan T, Bunders J. Global Health. 2014 Dec 11;10(1):85. [Epub ahead of print]

Background: In 2008, the WHO facilitated the primary health care (PHC) revitalisation agenda. The purpose was to strengthen African health systems in order to address communicable and non-communicable diseases. Our aim was to assess the position of civil society-led community home based care programmes (CHBC), which serve the needs of patients with HIV, within this agenda. We examined how their roles and place in health systems evolved, and the prospects for these programmes in national policies and strategies to revitalise PHC, as new health care demands arise.

Methods: The study was conducted in Ethiopia, Malawi, South Africa and Zambia and used an historical, comparative research design. We used purposive sampling in the selection of countries and case studies of CHBC programmes. Qualitative methods included semi-structured interviews, focus group discussions, service observation and community mapping exercises. Quantitative methods included questionnaire surveys.

Results: The capacity of PHC services increased rapidly in the mid-to-late 2000s via CHBC programme facilitation of community mobilisation and participation in primary care services and the exceptional investments for HIV/AIDS. CHBC programmes diversified their services in response to the changing health and social care needs of patients on lifelong anti-retroviral therapy and there is a general trend to extend service delivery beyond HIV-infected patients. We observed similarities in the way the governments of South Africa, Malawi and Zambia are integrating CHBC programmes into PHC by making PHC facilities the focal point for management and state-paid community health workers responsible for the supervision of community-based activities. Contextual differences were found between Ethiopia, South Africa, Malawi and Zambia, whereby the policy direction of the latter two countries is to have in place structures and mechanisms that actively connect health and social welfare interventions from governmental and non-governmental actors.

Conclusions: Countries may differ in the means to integrate and co-ordinate government and civil society agencies but the net result is expanded PHC capacity. In a context of changing health care demands, CHBC programmes are a vital mechanism for the delivery of primary health and social welfare services.

Abstract  Full-text [free] access

Editor’s notes: This paper presents a comprehensive overview of the integration of community home based care (CHBC) with primary health care (PHC) strategies in four countries in sub-Saharan Africa. It emphasises the co-ordination of efforts between government and civil society. Using a multi method approach drawing on surveys, key informant interviews, focus group discussions and in-depth interviews the authors sought to gain an historical perspective on the changing form and content of CHBC and PHC in Ethiopia, Malawi, South Africa and Zambia. They focused on programmes that had been active for more than 10 years, were nationally representative and offered diversity of care. Their findings reveal a commitment to integration of care within PHC strategies in all the countries. This reflects the recent call by WHO to revitalise primary health care approaches in developing countries. The authors identified similarities across the countries, especially government commitment to revitalise PHC, a strong presence of actors providing CHBC, and the extension of focus beyond one disease such as HIV to the care and support for people with chronic conditions. They also identified three different approaches taken. These included supervision by the government (Malawi, Zambia), contracting (South Africa) and referral (Ethiopia). This reveals that approaches to integration need to be context-driven. This is a very useful paper to understand how HIV care is now being integrated into broader medical and social care and lessons learned from innovative HIV care are being applied more widely and in a more coordinated way.

Ethiopia, Malawi, South Africa, Zambia
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Home visits by community workers in South Africa improve maternal and child outcomes

A cluster randomised controlled effectiveness trial evaluating perinatal home visiting among South African mothers/infants.

Rotheram-Borus MJ, Tomlinson M, le Roux IM, Harwood JM, Comulada S, O'Connor MJ, Weiss RE, Worthman CM. PLoS One. 2014 Oct 23;9(10):e105934. doi: 10.1371/journal.pone.0105934. eCollection 2014.

Background: Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks.

Methods: In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received.

Results: Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048).

Conclusions: Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits.

Abstract  Full-text [free] access

Editor’s notes: This trial combines two major trends in the delivery of health care. These include the shift of HIV services from specialist to generalist providers, and task-sharing between generalist and community providers. Community-based workers (CBW) from the Philani Maternal, Child Health and Nutrition Programme in Cape Town, South Africa were recruited to provide and apply health information about maternal and child health, HIV, alcohol use and nutrition to 644 perinatal women in the programme communities. The CBWs complemented the standard of care for health services, which were also available to 594 perinatal women in the control communities. About a quarter of participants were living with HIV. This study is notable for its real-world applicability through its trial design, provision of services to the entire population of eligible perinatal women, range of behavioural and clinical outcomes and rigorous analytic methods. At six months post-partum, women living with HIV in the programme arm were more likely to implement the prevention of mother-to-child regimen and to use condoms with their sex partners. Additionally, the children of these women had improved growth characteristics. Future research must determine whether CBWs can improve the other outcomes assessed in this trial, the cost-effectiveness of the CBWs, and how these gains can be extended to 18 months post-partum.

South Africa
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Addressing the HIV care continuum through home-based HIV testing

Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study.

Barnabas RV, van Rooyen H, Tumwesigye E, Murnane PM, Baeten JM, Humphries H, Turyamureeba B, Joseph P, Krows M, Hughes JP, Celum C. The Lancet HIV Volume 1, Issue 2, November 2014, Pages e68–e76

Antiretroviral therapy significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In settings of high prevalence, outreach strategies are needed to find asymptomatic HIV-positive people, to link them to HIV care, to initiate antiretroviral therapy, and to achieve viral suppression. We aimed to assess the effect of a community-based strategy of HIV testing and counselling (HTC) and linkage to care in households. We did an uncontrolled prospective intervention study in 1600 households in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda, between Sept 27, 2011, and May 6, 2013. The intervention consisted of home HTC and, for HIV-positive people, point-of-care CD4 count testing, referral to care, and follow-up visits by lay counsellors, including the offer of couples HTC. Eligible participants were resident adults who were able to consent to HIV testing. The outcomes at 12 months were linkage to care, antiretroviral therapy initiation among HIV-positive people eligible for therapy (CD4 count ≤350 cells per µL), and viral suppression. We identified 3545 adults in 1549 households in the two communities. 3393 adults (96%) were enrolled and tested for HIV, of whom 635 (19%) were HIV positive. At baseline, 229 (36%) HIV-positive people were newly identified, 406 (64%) were previously known to be HIV positive, and 254 (40%) were taking antiretroviral therapy. By month 12, 619 (97%) HIV-positive people had visited an HIV clinic, and of 123 participants eligible for antiretroviral therapy, 94 (76%) had initiated antiretroviral therapy by 12 months. Of the 77 participants on antiretroviral therapy by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV-positive people, the number with viral suppression (<1000 copies per mL) increased from 287 (50%) to 370 (65%; p<0·0001) at 12 months. There were no reported cases of study-related social harm during the study. Community-based HTC in rural South Africa and Uganda achieved high coverage of testing and linkage to care. Among people eligible for antiretroviral therapy, a high proportion initiated antiretroviral therapy and achieved viral suppression, suggesting high adherence. Our results could be generalisable to other southern African countries with a high burden of HIV, but pilot studies would be useful in other settings before initiation of clinical trials to estimate the effectiveness and cost-effectiveness of the intervention.

Abstract access 

Editor’s notes: HIV testing is the gateway to accessing treatment and prevention services. But the proportion of people who know their status remains low in many high HIV prevalence settings. In addition, there are serious challenges in facilitating linkage to HIV care, antiretroviral therapy (ART) uptake and adherence. Only a quarter of people living with HIV in sub-Saharan Africa are estimated to be virally suppressed on ART. Routine facility-based HIV testing, termed provider-initiated HIV testing and counselling, is recommended by World Health Organization. However, this strategy identifies individuals at a later stage of HIV infection as it relies on presentation to health care facilities after symptoms have developed. Community-based approaches may therefore be more effective in enabling earlier identification of HIV infection.

This study investigates the effectiveness of home-based HIV testing and counselling (HTC), combined with point-of-care CD4 count testing, referral to care and follow-up visits by lay counsellors at one, three, six, nine and 12 months following an HIV diagnosis. The study not only measured uptake of testing but also investigated the effect of the activity on linkage to care, ART initiation and viral suppression after 12 months.

The results of the study are promising, with high rates of uptake of HIV testing, of linkage to HIV care (including of individuals who had tested previously but had not engaged with health care services) and of initiation of ART. In addition, some 77% of individuals who initiated ART achieved viral suppression at 12 months and the numbers of HIV-positive individuals with viral suppression also increased significantly. The main strengths of this study is that it moves beyond HTC and addresses the entire HIV care continuum. The programme used lay counsellors and community workers which would address the healthcare worker shortage as well as potentially enable ownership of the programme by communities.  However, the incremental contribution of each component of this programme (home HTC, point-of-care CD4 testing and follow-up visits) in achieving the various outcomes is not clear. This merits further study before such a programme can be implemented. Cost-effectiveness studies are also needed if this approach is to be scaled-up in resource-limited settings. 

South Africa, Uganda
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What happens to people living with HIV who inject drugs in prison?

Within-prison drug injection among HIV-infected Ukrainian prisoners: prevalence and correlates of an extremely high-risk behaviour.

Izenberg JM, Bachireddy C, Wickersham JA, Soule M, Kiriazova T, Dvoriak S, Altice FL. Int J Drug Policy. 2014 Sep;25(5):845-52. doi: 10.1016/j.drugpo.2014.02.010. Epub 2014 Feb 28.

Background: In Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV.

Methods: A convenience sample of 97 HIV-infected adults recently released from prison within 1-12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI.

Results: Complete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0-30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005).

Conclusions: Among these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

Abstract access 

Editor’s notes: This is a powerful article contributing to the evidence base on the vulnerability of the health of people living in prisons. It highlights a particularly vulnerable sub-population of people living in prisons who are HIV positive. The study uses an innovative approach in recruiting a sample of people living with HIV recently released from prison, reporting a history of injecting drug use (n=95) on the basis that outside of prison people will be able to talk more freely about their drug use. The rationale for this study is simple: to document the existence of HIV risk associated with injecting drug use among people living in prisons. It is important since Ukraine and other countries of the former Soviet Union, have underplayed the need for HIV programmes including needle syringe programmes by denying that injecting drug use takes place in prison. This provides empirical evidence that it does, and among HIV positive people living in prisons, so the risk of HIV transmission to people who inject is high. It provides further evidence for the urgent need for HIV programmes among people who inject drugs  in prison. This is of particular relevance in the context of Ukraine, which has one of the fastest growing HIV epidemics globally, with infection driven by injecting drug use. The punitive approach to drug use in Ukraine is well highlighted through the study, by the fact that 76% of the sample were in prison on a drug-related charge. This paper confirms that injecting or other injecting risk behaviours occurred in prison, as has been evidenced elsewhere, and the majority of the sample injected prior to incarceration. It also shows that there is a lack of HIV programmes in place, particularly considering half the sample was aware of their diagnosis prior to imprisonment and the remainder found out while in prison. The study also shows a high prevalence of TB or history of TB (69%) but low levels of treatment while in prison. These illustrate a clear disregard for the health of people living in prisons, which is a breach of human rights, as well as being a poor public health strategy. Unlike other countries in the region, Ukraine does provide opiate substitution therapy to people who inject drugs, as part of an HIV prevention and treatment strategy. This paper provides further evidence for the need to extend this package of programmes to prison populations

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Making sense of being HIV positive through religion in Papua New Guinea

We call it a virus but I want to say it's the devil inside': redemption, moral reform and relationships with God among people living with HIV in Papua New Guinea.

Kelly-Hanku A, Aggleton P, Shih P. Soc Sci Med. 2014 Aug 19;119C:106-113. doi: 10.1016/j.socscimed.2014.08.020. [Epub ahead of print]

There is growing recognition of the importance of religion and religious beliefs as they relate to the experience of HIV, globally and in Papua New Guinea in particular. Based on 36 in-depth qualitative interviews conducted with people living with HIV receiving HIV antiretroviral therapy in 2008, this paper examines the cultural aetiology of HIV of in Papua New Guinea, the country with the highest reported burden of HIV in the Pacific. Narratives provided drew upon a largely moral framework, which viewed HIV acquisition as a consequence of moral failing and living an un-Christian life. This explanation for suffering viewed the individual as responsible for their condition in much the same way that neo-liberal biomedical discourses do. Moral reform and re-establishing a relationship with God were seen as key actions necessary to effect healing on the material body infected with HIV. Religious understandings of HIV drew upon a pre-existing cultural aetiology of dis-ease and misfortune widespread in Papua New Guinea. Understanding the centrality of Christianity to explanations of disease, and subsequently the actions necessary to bring about health, is essential in order to understand how people with HIV in receipt of antiretroviral therapies internalise biomedical perspectives and reconcile these with Christian beliefs.

Abstract access 

Editor’s notes: This is an insightful paper which reveals how religion and religious belief can impact on the experience of being HIV positive. Drawing on in-depth interviews conducted as part of a mixed-methods study, the authors explored what people from Papua New Guinea (PNG) view as the cause of their illness, and how they respond to their diagnosis. They argue that whilst there has been much anthropological enquiry into religion and HIV in PNG and elsewhere, there has been little attention to the experiences of people living with HIV. In introducing the context the authors highlight the influence of Christianity on everyday life in PNG, which is localised and informed by traditional practices. The findings are deeply illuminating and reveal that the participants understood their illness within moral frameworks. Contagion was explained by “sinful” behaviour, especially promiscuity. Whilst blaming HIV for such moral transgressions has been described elsewhere, these findings reveal that these participants describe their own behaviour in such terms. Responding to their diagnosis involved returning to the church or religious conversion, which created an individual relationship with God that affected healing of the body. These practices could result in lifestyle change and a rejection of previous immoral practices such alcohol and drugs. These narratives contribute to understanding the complexity of meanings that surround HIV. In particular, people from PNG may not consider structural or socio-cultural factors to be the cause of HIV. The authors suggest that in the context of an increasing bio-medicalisation of the response to HIV, a focus on how people live with HIV is very important and needs to take into account religious belief. 

Papua New Guinea
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Female sex workers exposed to community mobilization less exposed to sexually transmitted infections

Community mobilization and empowerment of female sex workers in Karnataka state, south India: associations with HIV and sexually transmitted infection risk. 

Beattie TS, Mohan HL, Bhattacharjee P, Chandrashekar S, Isac S, Wheeler T, Prakash R, Ramesh BM, Blanchard JF, Heise L, Vickerman P, Moses S, Watts C. Am J Public Health. 2014 Jun 12:e1-e10. doi:10.2105/AJPH.2014.301911 [Epub ahead of print]

Objectives: We examined the impact of community mobilization (CM) on the empowerment, risk behaviors, and prevalence of HIV and sexually transmitted infection in female sex workers (FSWs) in Karnataka, India.

Methods: We conducted behavioral-biological surveys in 2008 and 2011 in 4 districts of Karnataka, India. We defined exposure to CM as low, medium (attended nongovernmental organization meeting or drop-in centre), or high (member of collective or peer group). We used regression analyses to explore whether exposure to CM was associated with the preceding outcomes. Pathway analyses explored the degree to which effects could be attributable to CM.

Results: By the final survey, FSWs with high CM exposure were more likely to have been tested for HIV (adjusted odd ratio [AOR] = 25.13; 95% confidence interval [CI] = 13.07, 48.34) and to have used a condom at last sex with occasional clients (AOR = 4.74; 95% CI = 2.17, 10.37), repeat clients (AOR = 4.29; 95% CI = 2.24, 8.20), and regular partners (AOR = 2.80; 95% CI = 1.43, 5.45) than FSWs with low CM exposure. They were also less likely to be infected with gonorrhea or chlamydia (AOR = 0.53; 95% CI = 0.31, 0.87). Pathway analyses suggested CM acted above and beyond peer education; reduction in gonorrhea or chlamydia was attributable to CM.

Conclusions: CM is a central part of HIV prevention programming among FSWs, empowering them to better negotiate condom use and access services, as well as address other concerns in their lives.

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Editor’s notes: Community mobilization is a group empowerment strategy that focuses on the structural drivers of HIV transmission. Starting in 2003, the Karnataka Health Promotion Trust in India collaborated with female sex workers to recruit peer educators. This led to the creation of drop-in centres, distribution of presumptive treatment of gonorrhoea and chlamydia infection, and ultimately the formation of locally-sustained collectives and community-based organisations. In 2011, half of female sex workers in Karnataka were members of one of these groups. Members of these groups were more likely to have used condoms with their sex partners and were less likely to contract either gonorrhoea or chlamydia. The findings suggest that community mobilization may work because it is strongly associated with both collective (power with) and individual (power to) empowerment of sex workers. This is one of the first studies of community engagement to include biological outcomes for HIV and sexually transmitted infection, rather than self-reported measures of behaviour that may be susceptible to bias. The results suggest that such community empowerment approaches may form an integral part of HIV prevention programming in sex worker communities. 

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