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

HIV and older people

HIV attitudes, awareness and testing among older adults in Africa

Negin J, Nemser B, Cumming R, Lelerai E, Ben Amor Y, Pronyk P. AIDS Behav. 2011 Jul 8.

In Africa, older adults aged 50 and older are still sexually active and play a critical role as caregivers, yet little is known about their attitudes towards HIV and awareness of services. In this study, surveys were conducted in nine African sites. A multilevel model was fitted to evaluate the relationship between age and outcome variables. The study reveals that people aged 50 years and older have lower levels of HIV-related knowledge and awareness than those aged 25-49. Older adults were less likely to have been tested for HIV and women aged 50 and older showed particularly low levels of awareness.

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Editor’s note: In 2010, a study estimated that 3 million people aged 50 and over were living with HIV in sub-Saharan Africa, representing fully 14% of those over age 15 with HIV infection. Some of these people have aged into this age category due to the life-prolonging benefits of antiretroviral therapy but others are becoming newly infected each day. Many do not know that they have HIV infection. Why do we never hear about older people with HIV? Our HIV prevention progress indicators for sexual transmission refer to people aged 15-49 years and prevalence data collected through Demographic and Health Surveys (DHS) and presented by UNAIDS do not include people aged 50 years and older. This measurement neglect is reflected in lack of programming to raise awareness and knowledge levels, develop communication and condom negotiation skills, and address stigma and discrimination in this age group commonly seen primarily as a caregiver source. Some countries are jumping ahead: South Africa has held caregiver workshops to improve attitudes and knowledge and has added males older than 50 to its list of most-at-risk populations (key populations). Across the nine clusters in eight countries in this Millennium Villages Project study, the lowest ‘ever tested for HIV’ levels were in Senegal (0% for both men and women) and the highest in Rwanda (23% for men and 17% for women). More attention to people aged 50 and older is needed now if they are to avoid HIV infection, access HIV testing, start timely antiretroviral treatment, and have a positive intergenerational influence on community attitudes and knowledge as sexually active and informed educators, as well as caretakers.

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Social determinants

Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations

Auerbach JD, Parkhurst JO, Cáceres CF.  Glob Public Health. 2011 Jul 11.

A key component of the shift from an emergency to a long-term response to AIDS is a change in focus from HIV prevention interventions focused on individuals to a comprehensive strategy in which social/structural approaches are core elements. Such approaches aim to modify social conditions by addressing key drivers of HIV vulnerability that affect the ability of individuals to protect themselves and others from HIV. The development and implementation of evidence-based social/structural interventions have been hampered by both scientific and political obstacles that have not been fully explored or redressed. This paper provides a framework, examples, and some guidance for how to conceptualise, operationalise, measure, and evaluate complex social/structural approaches to HIV prevention to help situate them more concretely in a long-term strategy to end AIDS.

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Editor’s note: The critical role of social determinants of health in shaping people’s decisions to act, i.e. their agency, has been recognised for a long time. These determinants include social and structural factors, such as poverty, gender inequality, and human rights violations that increase people’s vulnerability to HIV. But what are the social and structural factors that contribute to the resilience of individuals, communities, and societies against HIV? The first step in better understanding vulnerability and resilience is to assess context-specific contributing/influencing factors. These can then inform the development of a socially plausible hypothesis of causal chains linked to HIV transmission, with intervention possibilities to consider at various levels, from the most proximal to the most distal. Distal level structural interventions may institute policy-legal changes, create or reinforce environmental enablers, produce changes in harmful social norms, catalyse social and political change, and introduce economic initiatives. The challenges of evaluating the impact of structural interventions on HIV incidence are daunting but both quantitative and qualitative social science methods can start by assessing impact more generally. It is important to recall that virtually all of these social changes are important from a social justice viewpoint. UNAIDS succinct definition of combination prevention underscores the importance of integrating strategies to address social determinants: ‘ …the strategic, simultaneous use of different classes of prevention activities (biomedical, behavioural, social/structural) that operate on multiple levels (individual, relationship, community, societal) to respond to the specific needs of particular audiences…through prioritising, partnerships, and engagement of affected communities.’

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Mobility

HIV Prevention for migrants in transit: developing and testing TRAIN

Bahromov M, Weine S. AIDS Educ Prev. 2011 Jun;23(3):267-80.

This study was a pilot investigation of the feasibility, acceptability, and effects of TRAIN (Transit to Russia AIDS Intervention with Newcomers) a three-session HIV preventive intervention for Tajik male labour migrants performed in transit. Sixty adult Tajik male labour migrants on the 5-day train ride from Dushanbe to Moscow were randomly assigned to either the intervention or a control condition. Each initially completed an in-person survey then another 3 days later (immediately postintervention), and participated in a cell phone survey three months later. All participants came to all intervention sessions, were satisfied with the programme, and completed all postassessments. In comparison with the controls, the TRAIN group reported significant increases in condom use with sex workers and non-sex workers, condom knowledge, worry about HIV, talking with persons about HIV, talking with wife about HIV, community activities, and religious activities. HIV prevention performed in transit is feasible, accceptable, and potentially efficacious in diminishing HIV risk behaviours in labour migrants.

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Editor’s note: The TRAIN programme is the first published example of an HIV prevention trial performed in transit. Train 227 from Dushanbe to Moscow crosses the borders of 4 countries: Uzbekistan, Turkmenistan, Kazakhstan, and Russia. The vast majority of its 630 people in its 20-passenger rail cars are Tajik male labour migrants. They are difficult to reach when they are at home with their families in the winter and then are dispersed across the metropolis when they reach Moscow. This trial found that a time-limited programme of 3 sessions conducted over 3 days in the off hours of the train’s dining car was acceptable and had short-term effects such as increased condom use with sex workers reported 3 months after the programme. Next steps include designing programmes for migrants’ wives, on their own or with their husbands, and expanding the TRAIN programme through well-designed effectiveness studies. A key issue for the researchers is how to address the violations of the human rights of the Tajik migrants who were harassed and bribed by border police from each country along the way.

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HIV testing

Community-based intervention to increase HIV testing and case detection in people aged 16-32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study

Sweat M, Morin S, Celentano D, Mulawa M, Singh B, Mbwambo J, Kawichai S, Chingono A, Khumalo-Sakutukwa G, Gray G, Richter L, Kulich M, Sadowski A, Coates T; the Project Accept study team. Lancet Infect Dis. 2011; 11(7):525-532.

In developing countries, most people infected with HIV do not know their infection status. Sweat and colleagues aimed to assess whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. Project Accept is underway in ten communities in Tanzania, eight in Zimbabwe, and 14 in Thailand. Communities at each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT, and the other community was assigned to receive community-based VCT plus access to standard clinic-based VCT. Randomisation and assignment of communities to intervention groups was done by the statistics centre by computer; no one was masked to treatment assignment because the interventions were community based. Intervention was provided for about 3 years (2006-09). The primary endpoint of HIV incidence is pending completion of assessments after the intervention. In this interim analysis, the authors examined the secondary endpoint of uptake in HIV testing, differences in characteristics of clients receiving their first HIV test, and repeat testing. Analyses were limited to clients aged 16-32 years. This study is registered with ClinicalTrials.gov, number NCT00203749. The proportion of clients receiving their first HIV test during the study was higher in community-based VCT communities than in standard clinic-based VCT communities in Tanzania (2341 [37%] of 6250 vs 579 [9%] of 6733), Zimbabwe (5437 [51%] of 10 700 vs 602 [5%] of 12 150), and Thailand (7802 [69%] of 11 290 vs 2319 [23%] 10 033). The mean difference in the proportion of clients receiving HIV testing between community-based VCT and standard clinic-based VCT communities was 40·2% (95% CI 15·8-64·7; p=0·019) across three community pairs (one per country). HIV prevalence was higher in standard clinic-based VCT communities than in community-based VCT communities, but community-based VCT detected almost four times more HIV cases than did standard clinic-based VCT across the three study sites (952 vs 264; p=0·003). Repeat HIV testing in community-based VCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. Community-based VCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing.

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Editor’s note: This trial comparing clinic-based versus community-based voluntary HIV counselling and testing in Tanzania, Zimbabwe, and Thailand has yet to report on its primary outcome of HIV incidence. However, the results concerning its secondary outcome of HIV testing uptake are compelling. The numbers of people having a first test ever for HIV was 4 times higher in Tanzania, 10 times higher in Zimbabwe, and 3 times higher in Thailand at community-based sites compared to fixed site clinics in hospitals and health centres. HIV prevalence was higher in the fixed sites but more people found out that they had HIV in the community-based sites because many more people took advantage of the mobile services to find out their status. An amazing 55% of community residents aged 16 to 32 years were mobilised to come forward for testing, underscoring the importance of effective demand creation for high uptake of mobile services linked to post-test community-based support. HIV counselling and testing lowers HIV risk behaviour in people living with HIV and in couples and it is the gateway to life-prolonging HIV treatment and care. Reaching millions of people with the opportunity to learn their serostatus will require multiple strategies. Project Accept demonstrates that offering HIV testing and counselling through mobile services can fill a gap not met by fixed services, particularly in rural areas.

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Civil society responses

The effects of national and international HIV/AIDS funding and governance mechanisms on the development of civil-society responses to HIV/AIDS in East and Southern Africa

Kelly KJ, Birdsall K. AIDS Care. 2010;22 Suppl 2:1580-7

This study takes stock of the exponential growth in the number of new civil-society organisations working in the HIV field in East and Southern Africa during the period 1996-2004. Kelly and Birdsall researched this development through a survey of 439 civil-society organisations in six countries and case studies focused on the evolution of community responses to HIV in specific communities in eight countries. The authors describe the types of civil-society organisations that emerged, their relationships with governments and donors, and their activities, organisational characteristics, and funding requirements. The data presented show that the vision of social mobilisation of HIV responses through community-level organisations has faced strong external challenges. Evidence from survey data, national HIV spending assessments, and case studies shows that in some respects the changing international aid environment undermines the prospects for development of the civil-society sector's contributions in HIV responses. Of particular interest is to understand how the "Three Ones" and the Paris Declaration on Aid Effectiveness have reshaped international funding for HIV responses. There has been relatively little attention paid to the impact of the new management and funding modalities - including national performance frameworks, general budget support, joint funding arrangements, and basket funds - on civil-society agencies at the forefront of community HIV responses. Evidence is presented to show that in important respects the new modalities limit the unique contribution that civil-society organisations can make to national HIV responses. It is also shown that the drive to rapidly intensify the scale of HIV responses has involved using community organisations as service providers for externally formulated programmes. The authors discuss this as a strong threat to the development of sustainable civil-society economies as well as to civil-society organisations' diversity and responsiveness. The ways in which civil-society organisations are responding to these challenges are discussed, pointing to possibilities for a new phase of development of the civil-society sector.

Abstract 

Editors’ note: If you work at country level, or support those that do; if you are interested in capacity building; or if you want to know how AIDS financing, the Three Ones, and the Paris Declaration on Aid Effectiveness have affected civil society responses to HIV, then this is essential reading for you. Surveys in high HIV prevalence countries (Lesotho, Malawi, Mozambique, Namibia, Swaziland, and Zambia) and case studies in these 6 countries plus South Africa and Tanzania reveal the concerning effects that AIDS funding architecture has had on the work of community- and national-level civil society organisations. A ‘scaling out’ has occurred of medium-sized national non-governmental organisations with long, strong track records that had previously received financial and capacity-building support through direct funding from bilateral donors. Pioneering, ‘on the ground’ civil society organisations, often the heart of the community-driven response reaching those most in need, now have fragile futures due to the unpredictability of funding. Further, that funding does not include investment in basic operating costs, organisational planning, or capacity development. National-level and community-level civil society organisations act predominantly now in service-provision roles, often as sub-contractors without opportunities to develop capacity to design, plan, budget, or implement programmes that are not externally mandated. Clearly, there is a need for long-term strategic thinking at national and international levels about how best to strengthen civil society’s country- and community-level contribution to the response – it is losing its diversity and its voice.

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Child-led microfinance

Community relations and child-led microfinance: a case study of caregiving children in Kenya

Skovdal M. AIDS Care. 2010;22 Suppl 2:1652-61

Rampant levels of AIDS and poverty have made many children in sub-Saharan Africa the primary caregivers of their ageing or ailing guardians. This paper reports on a social action fund initiative that brought caregiving children together to set up and run income generating activities as a group with the aim of strengthening their coping capabilities. To further our understanding of child-led microfinance activities, this paper explores how intra-community relations can both facilitate and undermine child-led activities, and how these activities in turn can further strengthen some intra-community relations. Twenty-one children (aged 12-17) and six guardians participated in this study. Data included draw-and-write compositions (n=21), essays (n=16), workshop notes and proposals (n=8) and in-depth interviews (n=16). A thematic analysis revealed that the children actively drew on the expertise and involvement of some guardians in the project as well as on each other, developing supportive peer relations that helped strengthen their coping capabilities. However, the children's disenfranchised position in the community meant that some adults took advantage of the child-led activities for their own personal gain. Some children also showed a lack of commitment to collective work, undermining the morale of their more active peers. Nevertheless, both guardians and the children themselves began to look at caregiving children differently as their engagement in the project began to earn them respect from the community - changing guardian/child relations. The paper concludes that microfinance interventions targeting children and young people must consider children's relationships with each other and with adults as key determinants of project success.

Abstract

Editors’ note: This interesting report describes the involvement and perspectives of caregiving children in a participatory microfinance programme. The sample size was small and self-selected since only children who wanted to share their experiences gave their views. However, the social action fund activities that they were involved in appeared to enhance their social status, their confidence, and their sense of agency. A clear lesson was the importance of intra-community relations in both facilitating and hindering the children’s project, suggesting the importance of community buy-in to child-led microfinance. This new area of research is aimed at evaluating the results of social action fund initiatives in furthering children’s empowerment and enhancing their skills and social, political, and financial resources to cope with adversity.

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Researcher-community partnerships

Assessing Change in Successful Collaboration Factors over Time

Ziff MA, Willard N, Harper GW, Bangi AK, Johnson J, Ellen JM. Glob J Community Psychol Pract. 2010 Jan;1(1):32-39.

Fifteen research sites within the Adolescent Medicine Trials Network for HIV Interventions launched Connect to Protect community coalitions in urban areas across the United States and in Puerto Rico. Each coalition has the same overarching goal: Reducing local youth HIV rates by changing community structural elements such as programs, policies, and practices. These types of transformations can take significant amounts of time to achieve; thus, ongoing successful collaboration among coalition members is critical for success. As a first step toward building their coalitions, staff from each research site invited an initial group of community partners to take part in Connect to Protect activities. In this paper, Ziff and colleagues focus on these researcher-community partnerships and assess change in collaboration factors over the first year. Respondents completed the Wilder Collaboration Factors Inventory at five time points, approximately once every two to three months. Results across all fifteen coalitions show significant and positive shifts in ratings of process/structure (p<.05). This suggests that during the first year they worked together, Connect to Protect researcher-community partners strengthened their group infrastructures and operating procedures. The findings shed light on how collaboration factors evolve during coalition formation and highlight the need for future research to examine change throughout subsequent coalition phases.

Abstract:

Editor’s note: A key lesson to draw from this report is the importance of establishing methods for managing researcher-community partnerships and for building and operating coalitions. Further, it is critical to monitor processes and organisational structures over time so that coalition members can take stock of needed improvements and respond to them. The inventory used here assessed 20 successful collaboration factors every two to three months. They were grouped into 6 categories: purpose, member characteristics, communication, process/structure, environment, and resources. Understanding of roles and responsibilities improved over time as did decision-making opportunities and strategies, and workload management. There are definitely some good ideas here to consider as we work with partners to develop tools to help monitor whether good participatory practices are being used to full effect in biomedical HIV prevention trials.

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Civil Society

From spectators to implementers: civil society organizations involved in AIDS programmes in China

Li H, Kuo NT, Liu H, Korhonen C, Pond E, Guo H, Smith L, Xue H, Sun J. Intl J Epidemiology 2010;39:ii65–ii71

Over the past 20 years, civil society organizations in China have significantly increased their involvement in the AIDS response. This article aims to review the extent of civil society participation in China AIDS programmes over the past two decades. A desk review was conducted to collect Chinese government policies, project documents, and published articles on civil society participation on HIV programmes in China over the past two decades. Assessment focused on five aspects: (i) the political environment; (ii) access to financial resources; (iii) the number of civil society organizations working on HIV; (iv) the scope of work; and (v) the impact of civil society organizations involvement on programmes. The number of civil society organizations specifically working on HIV increased from 0 before 1988 to over 400 in 2009. Among a sample of 368 civil society organizations, 135 (36.7%) were registered. Civil society organizations were primarily supported by international programmes. Government financial support to civil society organizations has increased from USD 248 000 in 2002 to USD 1.46 million in 2008. Initially, civil society played a minimal role. It is now widely involved in nearly all aspects of HIV-related prevention, treatment, and care efforts, and has had a positive impact; for example, increased adherence to antiretroviral treatment and HIV testing among hard-to-reach groups. The main challenges faced by civil society organizations include registration, capacity and long-term financial support. Civil society organizations have significantly increased their participation and contribution to AIDS programmes in China. Policies for registration and financial support to civil society organizations need to be developed to enable them to play an even greater role in AIDS programmes.

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Editors’ note: This article is chosen from a December 2010 supplement, focused entirely on the response to AIDS in China, which provides evidence and perspectives on China’s progress towards the Millennium Development Goals, policy implementation, the scale-up and impact of HIV prevention services, and efforts to strengthen epidemiological estimates and improve monitoring and evaluation. This one underscores the increasingly valuable role that civil society organisations (CSOs) are playing in the HIV response and the barriers to and facilitators of their involvement. Since the 2003 outbreak of severe acute respiratory distress syndrome (SARS), the political environment for the AIDS response has expanded, with strong public statements by senior government officials and supportive AIDS-specific polices and regulations. However, the legal framework is provisional and restrictive for CSOs, with very stringent criteria for registration as a CSO and a limit of only one CSO permitted to work on an issue per administrative level. Groups working on the same issue in different places are prohibited from forming a regional, provincial, or national organisation. Further, funds from international sources such as the Global Fund and foundations can only be used for activities and not for operational costs. To strengthen and sustain its AIDS response for the critical years ahead, China can foster further the important contributions of its CSOs by creating a supportive legal and regulatory environment to facilitate their work.




 

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Faith-based responses (Civil Society)

YOUR Blessed Health: an HIV-prevention program bridging faith and public health communities.

Griffith DM, Campbell B, Allen JO, Robinson KJ, Stewart SK. Public Health Rep. 2010;125 Suppl 1:4-11.

African American faith-based institutions are not necessarily equipped to balance their moral and spiritual missions and interpretation of religious doctrine with complex health issues such as human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). YOUR Blessed Health is a faith-based, six-month pilot project designed to increase the capacity of faith-based institutions and faith leaders to address HIV and sexually transmitted infections (STIs) in 11- to 19-year-old African Americans. In addition to increasing the knowledge and skills of young people, the intervention seeks to change churches' norms to provide more open settings where young people can talk with faith leaders about sex, relationships, sexually transmitted infections, and HIV. YOUR Blessed Health expands the roles of adult faith leaders, particularly pastors' spouses, to include health education as they implement the intervention in their congregations and communities. The intervention includes a flexible menu of activities for faith leaders to select from according to their institutional beliefs, doctrines, and culture.

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Editors’ note: Flint, Michigan now has more than the Michael Moore film ‘Roger and Me’ to its credit. This innovative pilot project, YOUR Blessed Health, engaged the African-American faith community through 12 churches across 6 denominations and 2 housing communities in Flint. Among its unique features was the customization of the programme to fit the beliefs and doctrines of each church so that HIV transmission and prevention could be effectively discussed, balancing moral and spiritual missions and interpretations of church doctrine with the public crisis of HIV among African-Americans. The intent was to change how these issues were addressed both now and in the long term so that churches become more open and accepting settings for the discussion of behaviours and factors that put young people at risk of acquiring HIV. Another unique feature was engaging pastors’ spouses as lead trainers – they understand the pastor’s vision and the church’s culture – to counter young people’s sense of invincibility with accurate facts about HIV. Faith-based organisations in all religions have an important role to play in addressing the HIV epidemic in positive ways that can make a real difference. They can only do this when there is a will for open discussion of the issues and the design and implementation of context-specific solutions.

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Faith-based responses

Islam and harm reduction

 

Kamarulzaman A, Saifuddeen SM. Int J Drug Policy.2009.Dec [Epub ahead of print].

 

Although drugs are haram and therefore prohibited in Islam, illicit drug use is widespread in many Islamic countries throughout the world. In the last several years increased prevalence of this problem has been observed in many of these countries which has in turn led to increasing injecting drug use driven HIV epidemics across the Islamic world. Whilst some countries have recently responded to the threat through the implementation of harm reduction programmes, many others have been slow to respond. In Islam, The Quran and the Prophetic traditions or the Sunnah are the central sources of references for the laws and principles that guide the Muslims' way of life and by which policies and guidelines for responses including that of contemporary social and health problems can be derived. The preservation and protection of the dignity of man, and steering mankind away from harm and destruction are central to the teachings of Islam. When viewed through the Islamic principles of the preservation and protection of the faith, life, intellect, progeny and wealth, harm reduction programmes are permissible and in fact provide a practical solution to a problem that could result in far greater damage to the society at large if left unaddressed.

 

For abstract access click here: 1 

Editors’ note: Following an in-depth tour of the epidemiology of illicit drug consumption, injecting drug use, and the HIV epidemic in Islamic countries, this paper presents the basic guidelines provided in the Quran and the Sunnah (Prophetic traditions) that support needle exchange programmes and opioid substitution therapy. The pragmatic evidence-informed public health approach of harm reduction programmes in the Islamic Republic of Iran, Malaysia and Indonesia contrasts starkly with the rejection of harm reduction in Libya, Tunisia, Syria, and Jordan. Despite the tenets of Islam, resistance in the latter countries appears ideological with roots in a criminal justice perspective. As the authors underscore, harm reduction is a public health issue that not only does not violate shariah law, it follows Islamic principles.

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