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

Feasibility and acceptability of routine HIV testing into a general paediatric out-patient clinic

The Acceptability and Feasibility of Routine Pediatric HIV Testing in an Outpatient Clinic in Durban, South Africa.

Ramirez-Avila L, Noubary F, Pansegrouw D, Sithole S, Giddy J, Losina E, Walensky RP, Bassett IV Pediatr Infect Dis J. 2013

Background: Limited access to HIV testing for children impedes early diagnosis and access to ART. Our objective was to evaluate the feasibility and acceptability of routine pediatric HIV testing in an urban, fee-for-service, outpatient clinic in Durban, South Africa. METHODS: We assessed the number of patients (0-15yrs) who underwent HIV testing upon physician referral during a baseline period. We then established a routine, voluntary HIV testing study for pediatric patients, regardless of symptoms. Parents/caretakers were offered free rapid fingerstick HIV testing for their child. For patients <18mo, the biological mother was offered HIV testing and HIV DNA PCR was used to confirm the infant's status. The primary outcome was the HIV testing yield, defined as the average number of positive tests per month during the routine compared to the baseline period. RESULTS: Over a 5-month baseline testing period, 931pediatric patients registered for outpatient care. Of the 124 (13%) patients who underwent testing upon physician referral, 21 (17%, 95% CI 11-25%) were HIV-infected. During a 13-month routine testing period, 2,790 patients registered for care and 2,106 (75%) were approached for participation. Of these, 1,234 were eligible and 771(62%) enrolled. Among those eligible, 637 (52%, 95% CI 49-54%) accepted testing for their child or themselves (biological mothers of infants <18 months).There was an increase in the average number of HIV tests during the routine compared to the baseline HIV testing periods (49 vs. 25 tests per month, p=0.001) but no difference in the HIV testing yield during the testing periods (3 vs. 4 positive HIV tests/month, p=0.06). However, during the routine testing period HIV prevalence remains extraordinarily high with 39 (6%, 95% CI 4-8%) newly-diagnosed HIV-infected children (median 7 years, 56% female). CONCLUSIONS: Targeted and symptom-based testing referral identifies an equivalent number of HIV-infected children as routine HIV testing. Routine HIV testing identifies a high burden of HIV and is a feasible and moderately acceptable strategy in an outpatient clinic in a high prevalence area.

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Editor’s notes: ART coverage of children in resource-limited settings is very low, in part because HIV positive children are being diagnosed late, or not at all. This has significant implications in terms of morbidity and mortality, as without access to treatment these children will die. Additionally late initiation of ART may result in irreversible conditions e.g. chronic lung disease. Routine HIV testing of children in an out-patient setting is one potential strategy which could be used to identify HIV positive children and link them into care. In this study the introduction of routine, voluntary HIV testing of children (0-15 years) into a general out-patient clinic in a high HIV prevalence setting, resulted in more children being tested than previously seen with provider-initiated testing. Despite this, no more HIV positive children were identified. One potential reason, as discussed in the paper, was selection bias; a significant proportion of children registering at the clinic did not have an HIV test. It is possible that children who were considered ineligible for testing, or whose caretakers either declined participation in the study or HIV testing, were at higher risk of being HIV positive. HIV positive children have the right to access life-saving ART; however as shown in this study routine voluntary testing was only moderately acceptable and as a result we may be failing to test those children who are at highest risk. Innovative solutions, such as opt-out testing need to be considered and debated at a national level.

Africa
South Africa
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The challenge of integrating Tuberculosis (TB) and HIV services in South Africa

Current Integration of Tuberculosis (TB) and HIV Services in South Africa, 2011.

Chehab JC, Vilakazi-Nhlapo AK, Vranken P, Peters A, Klausner JD. Current Integration of Tuberculosis (TB) and HIV Services in South Africa, 2011. PLoS One. 2013;8(3):e57791. doi: 10.1371/journal.pone.0057791. Epub 2013 Mar 4.

SETTING: Public Health Facilities in South Africa.

OBJECTIVE: To assess the current integration of TB and HIV services in South Africa, 2011.

DESIGN: Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type.

RESULTS: Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001).

CONCLUSION: As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.

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Editor’s notes: South Africa has decentralised HIV care with impressive speed. This study aimed to quantify TB/HIV integration at a sample of health facilities in South Africa. The investigators measured service integration using a study-specific tool, which highlights the lack of an agreed way of recording and reporting integration of these services. The study highlights that there are still some primary care clinics where ART is not available, and provision of isoniazid preventive therapy remains suboptimal. The investigators do not report the proportion of clinics providing HIV and TB treatment in a single consultation by a single provider for patients requiring both treatments simultaneously. This level of integration, which intuitively would have many advantages for patients, remains rare. Full integration of TB and HIV services may be difficult to achieve while the two services are run as separate vertical programmes with separate reporting systems.

Africa
South Africa
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Community health workers can improve HIV and other health indicator outcomes

Assessment of the uptake of neonatal and young infant referrals by community health workers to public health facilities in an urban informal settlement, KwaZulu-Natal, South Africa.

Nsibande D, Doherty T, Ijumba P, Tomlinson M, Jackson D, Sanders D, Lawn J. BMC Health Serv Res. 2013 Feb 6;13(1):47. [Epub ahead of print]

Globally, 40% of the 7.6 million deaths of children under five every year occur in the neonatal period (first 28 days after birth). Increased and earlier recognition of illness facilitated by community health workers (CHWs), coupled with effective referral systems can result in better child health outcomes. This model has not been tested in a peri-urban poor setting in Africa, or in a high HIV context. The Good Start Saving Newborn Lives (SNL) study (ISRCTN41046462) conducted in Umlazi, KwaZulu-Natal, was a community randomized trial to assess the effect of an integrated home visit package delivered to mothers by CHWs during pregnancy and post-delivery on uptake of PMTCT interventions and appropriate newborn care practices. CHWs were trained to refer babies with illnesses or identified danger signs. The aim of this sub-study was to assess the effectiveness of this referral system by describing CHW referral completion rates as well as mothers' health-care seeking practices. Interviews were conducted using a structured questionnaire with all mothers whose babies had been referred by a CHW since the start of the SNL trial. Descriptive analysis was conducted to describe referral completion and health seeking behaviour of mothers. Of the 2423 women enrolled in the SNL study, 148 sick infants were referred between June 2008 and June 2010. 62% of referrals occurred during the first 4 weeks of life and 22% between birth and 2 weeks of age. Almost all mothers (95%) completed the referral as advised by CHWs. Difficulty breathing, rash and redness/discharge around the cord accounted for the highest number of referrals (26%, 19% and 17% respectively). Only16% of health workers gave written feedback on the outcome of the referral to the referring CHW. We found high compliance with CHW referral of sick babies in an urban South African township. This suggests that CHWs can play a significant role, within community outreach teams, to improve newborn health and reduce child mortality. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health which involves the establishment of family health worker teams including CHWs.

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Editor’s notes: In a number of countries, government supported community health workers (CHW) have been tasked to support facility based primary health services. In addition, as HIV care is increasingly mainstreamed into general primary health care settings, these CHW have also been deployed to support facility based HIV care and treatment services, including PMTCT, in particular with a focus on adherence and retention and return to care. There has been a paucity of documentation of the evidence of impact of CHW, and whether the provision of HIV-specific follow up could well be integrated into their scope of practice. This study provides important information regarding the acceptability of such integrated community follow up methods.

Africa
South Africa
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Integrating HIV care and treatment into primary health care centers

Integration of HIV Care and Treatment in Primary Health Care Centers and Patient Retention in Central Mozambique: A Retrospective Cohort Study.

Lambdin BH, Micek MA, Sherr K, Gimbel S, Karagianis M, Lara J, Gloyd SS, Pfeiffer J. J Acquir Immune Defic Syndr. 2013 Jan 2. [Epub ahead of print]

In 2004, the Mozambican Ministry of Health began a national scale-up of antiretroviral therapy (ART) using a vertical model of HIV clinics co-located within large, urban hospitals. In 2006, the ministry expanded access by integrating ART into primary health care clinics. The authors conducted a retrospective cohort study including adult, ART-naive patients initiating ART between January 2006 and June 2008 in public sector clinics in Manica and Sofala provinces. Cox proportional hazards models with robust variances were used to estimate the association between clinic model (vertical/integrated), clinic location (urban/rural) and clinic experience (1st 6 months/post-1st 6 months) and attrition occurring in early patient follow-up (≤6 months) and attrition occurring in late patient follow-up (>6 months), while controlling for age, sex, education, pre-ART CD4 count, WHO stage and pharmacy staff burden. A total of 11,775 patients from 17 clinics were studied. The overall attrition rate was 37 per 100 person-years. Patients attending integrated clinics had a higher risk of attrition in late follow-up (HR=1.75 (95%CI: 1.04-2.94)), and patients attending urban clinics (HR=0.57 (95%CI: 0.35-0.91)) had a lower risk of attrition in late follow-up. Though not statistically significant, clinics open for longer than 6 months (HR=0.72 (95%CI: 0.51 - 1.02)) had a lower risk of attrition in early follow-up. Patients attending vertical clinics had a lower risk of attrition. Utilizing primary health clinics to implement ART is necessary to reach higher levels of coverage; however, further implementation strategies should be developed to improve patient retention in these settings.

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Editor’s notes: There is no single service delivery strategy that is most appropriate for HIV primary care and provision of antiretroviral treatment. The strategies chosen in generalized epidemics may be quite different from countries with highly concentrated epidemics. High prevalence countries are often choosing to integrate HIV treatment into other primary health care services. As countries move towards universal access, earlier approaches to the delivery of HIV treatment benefit from review – vertical structures for antiretroviral therapy services may not be sustainable as increasing numbers of people living with HIV come into care.  The provision of HIV primary health care does need to respond to the comprehensive service needs of people living with HIV, and the impact of a changeover to a new system of care must be implemented and monitored carefully.  Strategies to minimize loss to follow up and to support retention must be included when these changes occur.

Africa
Mozambique
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Decentralizing pediatric HIV care and treatment into primary care centers

Decentralization of pediatric HIV Care and Treatment in Five sub-Saharan African Countries.

Fayorsey RN, Saito S, Carter RJ, Gusmao E, Frederix K, Koech-Keter E, Tene G, Panya M, Abrams EJ. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHF) versus secondary/tertiary health facilities (SHFs). Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania from January 2008- March 2010 trends were examined in the number of children < 15 years of age initiating antiretroviral treatment (ART) by facility type. Clinic-level lost to follow-up (LTFU) and mortality per 100 person years (PYs) on ART during the period by facility type were compared. During the two year period, 17,155 children enrolled in HIV care and 8,475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, while SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100PYs and 5.2/100PYs, respectively at PHFs and 20.2/100PYs and 6.0/100PYs at SHFs. Adjusted models show PHFs associated with lower LTFU (Adjusted Rate Ratio, ARR=0.55; p=0.022) and lower mortality (ARR=0.66; p=0.028). The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.

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Editor’s notes: Early during treatment scale up pediatric ART remained a referral clinic intervention, limiting the enrollment of children and disrupting efforts to provide ‘one-stop’ visits for families with adults and children living with HIV. Barriers such as provider discomfort with pediatric ART have been addressed by increased training efforts as well as a public health approach of algorithm-based treatment. Increasingly pediatric ART is being provided in the same sites and by the same providers as other primary health services.

Africa
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Task shifting from doctors to nurses results in comparable outcomes

Task shifting HIV care in rural district hospitals in Cameroon: evidence of comparable antiretroviral treatment related outcomes between nurses and physicians in the Stratall ANRS/ESTHER trial.

Boullé C, Kouanfack C, Laborde-Balen G, Carrieri MP, Dontsop M, Boyer S, Aghokeng AF, Spire B, Koulla-Shiro S, Delaporte E, Laurent C; for the Stratall ANRS/ESTHER Study Group. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

Task shifting to nurses for antiretroviral therapy (ART) is promoted by WHO to compensate for the severe shortage of physicians in Africa. The effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon was assessed through a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006-2010. ART-naive patients were followed-up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. The associations between the consultant ratio (i.e. the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to WHO clinical stage 4 in multivariate analyses were assessed. Of the 4,141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success (odds ratio 1.00, 95%CI 0.59-1.72, p=0.990), CD4 recovery (coefficient -3.6, 95%CI -35.6; 28.5, p=0.827), mortality (time ratio 1.39, 95%CI 0.27-7.06, p=0.693) or disease progression (time ratio 1.60, 95%CI 0.35-7.37, p=0.543). This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of non-complex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, as well as for other health interventions.

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Editor’s notes: Most health services in primary health facilities are provided by nurses or clinical officers, with few PHC having physician cadre staffing. The evidence is strong that nurses can ably prescribe and refill ART for adults and children living with HIV, further supporting universal access to HIV treatment. The strategies described in the accompanying articles for decentralization to primary health clinics for adults and children require task shifting in many settings – decentralization and integration of HIV services into primary care will inevitably benefit from an increased reliance on nurses as providers of primary care.

Africa
Cameroon
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Adolescents

Treatment outcomes in HIV-infected adolescents attending a community-based antiretroviral therapy clinic in South Africa

Nglazi MD, Kranzer K, Holele P, Kaplan R, Mark D, Jaspan H, Lawn SD, Wood R, Bekker LG. BMC Infect Dis. BMC Infect Dis. 2012 Jan 25;12:21

Very few data are available on treatment outcomes of adolescents living with HIV infection (whether perinatally-acquired or sexually-acquired) in sub-Saharan Africa. The present study therefore compared the treatment outcomes in adolescents with those of young adults at a public sector community-based antiretroviral treatment programme in Cape Town, South Africa. Treatment outcomes of adolescents (9-19 years) were compared with those of young adults (20-28 years), enrolled in a prospective cohort between September 2002 and June 2009. Kaplan-Meier estimates and Cox proportional hazard models were used to assess outcomes and determine associations with age, while adjusting for potential confounders. The treatment outcomes were mortality, loss to follow-up (LTFU), immunological response, virological suppression, and virological failure. 883 patients, including 65 adolescents (47 perinatally infected and 17 sexually infected) and 818 young adults, received antiretroviral treatment. There was no difference in median baseline CD4 cell count between adolescents and young adults (133.5 vs 116 cells/mL; p = 0.31). Overall mortality rates in adolescents and young adults were 1.2 (0.3-4.8) and 3.1 (2.4-3.9) deaths per 100 person-years, respectively. Adolescents had lower rates of virological suppression (<400 copies/mL) at 48 weeks (27.3% vs 63.1%; p < 0.001). Despite this, however, the median change in CD4 count from baseline at 48 weeks of antiretroviral treatment was significantly greater for adolescents than young adults (373 vs 187 cells/muL; p = 0.0001). Treatment failure rates were 8.2 (4.6-14.4) and 5.0 (4.1-6.1) per 100 person-years in the two groups. In multivariate analyses, there was no significant difference in loss-to-follow-up and mortality between age groups but increased risk in virological failure [AHR 2.06 (95% CI 1.11-3.81; p = 0.002)] in adolescents. Despite lower virological suppression rates and higher rates of virological failure, immunological responses were nevertheless greater in adolescents than young adults whereas rates of mortality and loss-to-follow-up were similar. Further studies to determine the reasons for poorer virological outcomes are needed.

For abstract access click here. 

Editor’s note: An adolescent-centred antiretroviral treatment clinic was introduced in this facility in 2008, in recognition of the increasing numbers of perinatally HIV-infected children reaching adolescence. The findings from this study are intriguing, both with respect to adolescents having a higher rate of virological failure and yet better immunological outcomes than young adults and for the differences between adolescents infected perinatally and those infected through sexual transmission. The youngest perinatally-infected adolescents had been born in 2001, before the advent of PMTCT programmes in South Africa. They tended to have better responses to antiretroviral treatment than adolescents who had been infected sexually and lower loss to follow-up, possibly because of stronger family and friend support systems¾they were more likely to attend the treatment facility with the support of parents. The next step is to collect information on side effects to therapy, drug resistance, and adherence, particularly what makes it easier and what makes it harder for adolescents who are embarking on lifelong treatment to take their medications regularly.

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Adolescents

HIV knowledge and sexual risk behaviour among street adolescents in rehabilitation centres in Kinshasa; DRC: gender differences

Mudingayi A, Lutala P, Mupenda B. Pan Afr Med J. 2011;10:23. Epub 2011 Oct 17

Street children, common in Africa, are increasingly vulnerable to alcohol and drugs of abuse and lack access to both healthcare and knowledge about HIV and AIDS. This study assessed the level of knowledge about sexually transmitted infections (STIs), including HIV, among street adolescents in the Democratic Republic of the Congo. A random sampling of 200 street children (10-25 years of age) was selected from 17 rehabilitation centres in Kinshasa, and a structured questionnaire was administered to all participants in their respective centres. High knowledge, knowledge or awareness of condoms, was defined when a participant gave more than 67% of correct responses. Chi square analysis was used to test differences between the sexes. The knowledge level of respondents was high. 54.3% of males and 45.7% of girls have heard about HIV, and unprotected sex was cited as a mode of transmission by 42.9% of males and 57.1% of females. A high number of children reported a previous sexual experience. Satisfying a natural bodily need was the main reason for having sex. However, the use of condoms is still low in both sexes (26.2 versus 59.3%, p<0.01). Neither gender reported a reason why they are not using a condom. This study highlights the high knowledge about HIV among street adolescents, which contrasts with low condom use and high past sexual experiences with a high number of sexual partners and sexual contacts. Policies targeting these findings are warranted to reverse such trends.

For abstract access click here. 

Editor’s note: There is no doubt that street youth in Kinshasa are a key population at risk for arrest and vulnerable to HIV exposure. The researchers sought to overcome their mistrust by using self-administered questionnaires and assistance from peers not participating in this study to help those who were illiterate. However, there are inconsistencies in this article that are of concern. The results section states that the most common mode of transmission in males is by contacts with urine/stool (30.5%), a figure that contrasts with the 25.9% for urine/stool contact shown in the results table and with the 42.9% cited in both the table and the abstract for unprotected sex, seemingly boys’ most common answer for mode of HIV transmission. But perhaps the most concerning is the view that the level of HIV knowledge in the study participants was high. Only half of these street children (54% of boys and 46% of girls) had heard of HIV, despite what is described as comprehensive HIV education given to these children in the rehabilitation centres in which the study took place.

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Faith-based responses

Pentecostalism and AIDS treatment in Mozambique: creating new approaches to HIV prevention through anti-retroviral therapy

Pfeiffer J, Glob Public Health. 2011;6 Suppl 2:S163-73

Pentecostal fervour has rapidly spread throughout central and southern Mozambique since the end of its protracted civil war in the early 1990s. In the peri-urban bairros and septic fringes of Mozambican cities African Independent Churches with Pentecostal roots and mainstream Pentecostals can now claim over half the population as adherents. Over this same period another important phenomenon has coincided with this church expansion: the AIDS epidemic. Pentecostalism and HIV have travelled along similar vectors and been propelled by deepening inequality. Recognising this relationship has important implications for HIV prevention and treatment strategies. The striking overlap between high HIV prevalence in peri-urban populations and high Pentecostal participation suggests that creative strategies, to include these movements in HIV programming, may influence the long-term success of HIV care and the scale-up of anti-retroviral treatment across the region. The provision of antiretroviral treatment has opened up new possibilities for engaging with local communities, especially Pentecostals and African Independent Churches, who are witnessing the immediate benefits of antiretroviral therapy. Expanded treatment may be the key to successful prevention as advocates of a comprehensive approach to the epidemic have long argued.

For abstract access click here

Editor’s note: At the end of Mozambique’s long civil war in the 1990s, people began to move more back and forth across the borders with South Africa and Zimbabwe. Among the things accompanying them were Pentecostal messages (more than half the population are now adherents) and HIV infection (HIV prevalence varies sharply by province but is higher in those adjacent to these countries). This interesting article analyses the impact of structural adjustment policies and class associations between different Christian religions in Mozambique on poverty and the response to HIV. It argues that Catholicism has a privileged position in health care delivery (the large majority of health care workers report that they are Catholics) and in interrelations with donors and foreign implementing partners. Pentecostals and African Independent Churches have excluded themselves or been excluded from HIV prevention programming based on their patriarchal theology, conservative social policy, and differences in moral discourse about sexual behaviour. Now the hope of antiretroviral therapy has opened up dialogue within Pentecostal churches, engendering a new social solidarity around AIDS, with members encouraged to learn their HIV status and seek treatment at public services. There is a tangible opportunity now for these large faith-based communities to break out of exclusion to participate actively as partners in public health treatment and prevention programming.

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Civil society responses

HIV-prevention interventions targeting men having sex with men in Africa: field experiences from Cameroon

Kalamar M, Maharaj P, Gresh A, Cult Health Sex. 2011 Nov;13(10):1135-49. Epub 2011 Sep 14

The HIV prevalence rate among men who have sex with men in Africa is high, yet a limited number of prevention interventions target this vulnerable group. The study aims to explore factors affecting the design and implementation of HIV-prevention interventions for men who have sex with men in Cameroon using Alternatives-Cameroun as a case study. It further examines the context in which these interventions are created and implemented. Operating in a repressive environment, facing criminalisation and stigmatisation, one organisation, Alternatives-Cameroun, has adopted an 'umbrella approach', using human rights as a platform from which to negotiate for greater recognition of men who have sex with men. Success has been achieved through a 'proximity approach to prevention', setting up a local Access Centre and using a base of volunteers to create interventions that venture into the community. The organisation faces many obstacles such as repressive legislation, stigmatisation, and volunteer fatigue. Findings reveal that understanding local realities and reinforcing multi-sectoral mobilisation around men who have sex with men issues are important first steps towards launching HIV-prevention interventions for men who have sex with men in sub-Saharan Africa.

For abstract access click here

Editor’s note: Alternatives-Cameroun was launched in 2006 in Douala to serve primarily men who have sex with men (locally called nkouandengué) in an environment of denial, stigmatisation, and criminalisation that is not uncommon in other parts of Africa. This case study reveals that the widespread heterocentric perception of HIV in Cameroon influences the risk perception of men who have sex with men. Beliefs that anal sex cannot transmit HIV, a male partner is less risky for a man because there is no risk of pregnancy, and condoms are only for contraception are not uncommon among the men being reached by this community-based organisation. Men may try to camouflage their sexual orientation by having a girlfriend or by having multiple male partners so that they are not seen too often with the same man, which would arouse suspicion. Article 347bis of the Cameroon Penal Code, which criminalises homosexuality with a punishment of imprisonment from 6 months to 5 years and a fine of from 20,000 to 200,000 francs CFA, has created a climate of fear and repression reinforcing social marginalisation and constricting the methods that Alternatives-Cameroun can use to reach men who have sex with men. Based on ‘proximity approach’ principles, it conducts outreach to venues (both bars/clubs and virtual electronic networks), conducts educational workshops, refers men to gay-friendly physicians, and trains peer leaders to reach out to hidden men. The focus is on sexual practices and risk behaviours rather than on sexual orientation or identity. Although the experiences and sociolegal constraints of Alternatives-Cameroon are context-specific, they have resonance for countries across Africa that have not yet repealed similar repressive laws that contravene human rights principles.

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