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

Impact on society

Bock J, Johnson. Grandmothers' Productivity and the HIV/AIDS Pandemic in sub-Saharan Africa. J Cross Cult Gerontol. 2008 Jan 8.

The human immunodeficiency virus (HIV) pandemic has left large numbers of orphans in sub-Saharan Africa. Botswana has an HIV prevalence rate of approximately 40% in adults. Morbidity and mortality are high, and in a population of a 1.3 million there are nearly 50,000 children who have lost one or both parents to HIV. The extended family, particularly grandparents, absorbs much of the childrearing responsibilities. This creates large amounts of additional work for grandmothers especially. The embodied capital model and the grandmother hypothesis are both derived from life history theory within evolutionary ecology, and both predict that one important factor in the evolution of the human extended family structure is that post-reproductive individuals such as grandmothers provide substantial support to their grandchildren's survival. Data collected in the pre-pandemic context in a traditional multi-ethnic community in the Okavango Delta of Botswana are analyzed to calculate the amount of work effort provided to a household by women of different ages. Results show that the contributions of older and younger women to the household in term of both productivity and childrearing are qualitatively and quantitatively different. These results indicate that it is unrealistic to expect older women to be able to compensate for the loss of younger women's contributions to the household, and that interventions be specifically designed to support older women based on the type of activities in which they engage that affect child survival, growth, and development.

Editors’ note: This study found that grandmothers are unable to substitute their labour for that of younger women lost to the family because of the energy intensity (strength and stamina) required for grain-processing. Further, the more time they allocate to food production, the less time they have for seeking and processing traditional wild foods that provide high levels of micronutrients and phytochemicals. They also can no longer produce traditional craft items such as the baskets, fishing implements, and tools essential to the productivity of all members of the household. Critically, their grandchildren have no means to acquire the skills and knowledge about traditional activities from them that are key to their long-term survival. Interventions to compensate for lost labour should support grandmothers in pursuing their traditional roles and activities.

Larson BA, Fox MP, Rosen S, Bii M, Sigei C, Shaffer D, Sawe F, Wasunna M, Simon JL. Early effects of antiretroviral therapy on work performance: preliminary results from a cohort study of Kenyan agricultural workers. AIDS. 2008; 22(3):421-5.

This paper estimates the impact of antiretroviral therapy on days harvesting tea per month for tea-estate workers in Kenya. Such information is needed to assess the potential economic benefits of providing treatment to working adults. Data for this analysis come from company payroll records for 59 HIV-infected workers and a comparison group of all workers assigned to the same work teams (reference group, n = 1992) for a period covering 2 years before and 1 year after initiating antiretroviral therapy. Mean difference tests were used to obtain overall trends in days harvesting tea by month. A difference in difference approach was used to estimate the impact of HIV on days working in the pre-antiretroviral therapy period. Information on likely trends in the absence of the therapy was used to estimate the positive impacts on days harvesting tea over the initial 12 months on antiretroviral therapy. No significant difference existed in days plucking tea each month until the ninth month before initiating antiretroviral therapy, when workers worked -2.79 fewer days than references (15% less). This difference grew to 5.09 fewer days (27% less) in the final month before initiating antiretroviral therapy. After 12 months on antiretroviral therapy, Larson and colleagues conservatively estimate that workers worked at least twice as many days in the month than they would have in the absence of antiretroviral therapy. In conclusion treatment had a large, positive impact on the ability of workers to undertake their primary work activity, harvesting tea, in the first year on antiretroviral therapy.

Editors’ note: This study found that tea pluckers placed on antiretroviral treatment worked 7.5 to 9.5 days more harvesting tea in month 12 than they would have worked in the absence of antiretroviral treatment. A large cohort and a longer period of follow-up are required to determine the impact of antiretroviral treatment on work performance over the long term but these are promising initial findings.

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Civil society responses

Atun RA, McKee M, Coker R, Gurol-Urganci I. Health systems' responses to 25 years of HIV in Europe: Inequities persist and challenges remain. Health Policy. 2008; 86(2-3):181-94.

Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and Eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as sex workers, prisoners, injecting drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in Eastern Europe, where civil society or Non-Governmental Organization culture is weak as compared to Western Europe. Scaling up of effective responses in many countries in Eastern Europe will be challenging. Increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of civil society in planning and delivery of client-focused services.

Editors’ note: This desk review combined countries with differing socioeconomic, cultural, and health systems characteristics into four broad groupings: Western, Central, Eastern Europe, and Central Asia. The multi-sectored, client-focused interventions of Western Europe are integrated into mainstream health systems offering broad coverage, but inequities persist for marginalized people. In the countries of Eastern Europe facing HIV, IDU, STI, and TB epidemics, new resources directed at programmatic interventions alone will not be effective in addressing either the HIV epidemic or the persistent inequities that exacerbate it, nor will they be sustainable. The design and implementation of multifaceted and multi-sectored programmes must be shaped by the local, political, economic, social, and legal contexts and serve to strengthen health systems, surveillance, monitoring and evaluation, and civil society engagement.

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Country responses

Russell TV, Do AN, Setik E, Sullivan PS, Rayle VD, Fridlund CA, Quan VM, Voetsch AC, Fleming PL. Sexual Risk Behaviors for HIV/AIDS in Chuuk State, Micronesia: The Case for HIV Prevention in Vulnerable Remote Populations. PLoS ONE. 2007; 2(12):e1283.

After the first two cases of locally-acquired HIV infection were recognized in Chuuk State, Federated States of Micronesia, a public health response was initiated. The purpose of the response was to assess the need for HIV education and prevention services, to develop recommendations for controlling further spread of HIV in Chuuk, and to initiate some of the prevention measures. A public health team conducted a survey and rapid HIV testing among a sample of residents on the outer islands in Chuuk. Local public health officials conducted contact tracing and testing of sex partners of the two locally-acquired cases of HIV infection. A total of 333 persons completed the survey. The majority knew that HIV is transmitted through unprotected sexual contact (81%), injection drug use (61%), or blood transfusion (64%). Sexual activity in the past 12 months was reported among 159 participants, including 90 females and 69 males. Compared to women, men were more likely to have had multiple sex partners, to have been drunk during sex, but less likely to have used a condom in the past 12 months. The two men with locally acquired HIV infection had unprotected anal sex with a third Chuukese man who likely contracted HIV while outside of Chuuk. All 370 persons who received voluntary, confidential HIV counselling and testing had HIV negative test results. Despite the low HIV seroprevalence, risky sexual behaviours in this small isolated population raise concerns about the potential for rapid spread of HIV. The lack of knowledge about risks, along with stigmatizing attitudes towards persons infected with HIV and high risk sexual behaviours indicate the need for resources to be directed toward HIV prevention in Chuuk and on other Pacific Islands.

Editors’ note: With only 1500 residents living on this small group of islands, confidentiality would not have been maintained if classical “contact tracing and testing of sex partners”, as implied by the abstract, had occurred. The innovation was for local village officials to convene a public meeting on each of the four islands to explain general health outreach activities, including the offer of HIV testing and counselling. When known contacts of either of the two index cases came forward for HIV testing, health department staff notified them of their potential exposure and provided expanded counselling on HIV risk reduction, without loss of confidentiality. Geographic isolation does not protect people from HIV and the constraints to respecting confidentiality in small populations need to be overcome creatively, as was done here.

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Private sector responses

Charalambous S, Innes C, Muirhead D, Kumaranayake L, Fielding K, Pemba L, Hamilton R, Grant A, Churchyard GJ. Evaluation of a workplace HIV treatment programme in South Africa. AIDS 2007;21 Suppl 3:S73-8.

Charalambous and colleagues aimed to review the experience of implementing a workplace HIV care programme in South Africa and describe treatment outcomes in sequential cohorts of individuals starting antiretroviral therapy (ART). The authors reviewed an industrial HIV care and treatment programme. Between October 2002 and December 2005, 2262 patients enrolled in the HIV care programme. CD4 cell counts increased by a median of 90, 113 and 164 cells/microl by 6, 12 and 24 months on treatment, respectively. The viral load was suppressed below 400 copies/ml in 75, 72 and 72% of patients at 6, 12 and 24 months, respectively, at an average cost of US$1654, 3567 and 7883 per patient virally suppressed, respectively. Treatment outcomes in sequential cohorts of patients were consistent over time. A total of 93.6% of patients at 14,752 clinic visits reported missing no tablets over the previous 3 days. Almost half the patients (46.8%) experienced one or more adverse events, although most were mild (78.7%). By the end of December 2005, 30% of patients were no longer on ART, mostly because of defaulted or stopped treatment (12.8%), termination of employment (8.2%), or death (4.9%). The authors conclude that this large workplace programme achieved virological results among individuals retained in the programme comparable to those reported for developed countries and that  more work is needed to improve retention. Monitoring treatment outcomes in sequential cohorts is a useful way of monitoring programme performance. As the programme has matured, the costs of programme implementation have reduced. Counselling is a central component of an ART programme. Challenges in implementing a workplace ART programme are similar to the challenges of public-sector programmes.

Editors’ note: Cohort studies such as this one can provide valuable information on retention rates and treatment outcomes over time which can be used to improve programme performance. Although virological outcomes in this large workplace programme were comparable with those of programmes in resource-poor and resource-rich countries, termination of employment led 8% of patients to stop antiretroviral treatment. Providing bridging treatment until patients are transferred to another HIV treatment programme ensures continuity of care without the unstructured treatment interruptions that can encourage disease progression and drug resistance.

Ramachandran V, Shah MK, Turner GL. Does the private sector care about AIDS? Evidence from firm surveys in East Africa. AIDS 2007;21 Suppl 3:S61-72.

Ramachandran and colleagues aimed to identify determinants of HIV prevention activity and pre-employment health checks by private firms in Kenya, Uganda and Tanzania. The authors used data from the World Bank Enterprise Surveys for Uganda, Kenya and Tanzania, encompassing 860 formally registered firms in the manufacturing sector. Econometric analysis of firm survey data was used to identify the determinants of HIV prevention including condom distribution and voluntary counselling and testing (VCT). Multivariate regression analysis was the main tool used to determine statistical significance. The results showed that approximately a third of enterprises invest in HIV prevention. Prevention activity increases with size, most likely because larger firms and firms with higher skilled workers have greater replacement costs. Even in the category of larger firms, less than 50% provide VCT. The authors found that the propensity of firms to carry out pre-employment health checks of workers also varies by the size of firm and skill level of the workforce. Finally, data from worker surveys showed a high degree of willingness on the part of workers to be tested for HIV in the three East African countries.

Editors’ note: This study found that larger firms, those with trained workers or workers with higher skill levels, or those with unionized workers do more to prevent HIV. Given the high proportion of small companies compared to large ones in African countries, the public sector needs to take the lead on HIV prevention in most workplaces.

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Structural determinants and vulnerability

Weiser S, Leiter K, Bangsberg D, Butler L, Percy-de Korte F, Hlaze Z, Phaladze N, Lacopino V, Heisler M. Food Insufficiency is Associated with High-Risk Sexual Behaviour among Women in Botswana and Swaziland. PLoS Med. 2007;4(10):1589-97

Photo credit: Christian Aid/Photo Voice/Beatrice
Photo credit: Christian Aid/Photo Voice/Beatrice

Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behaviour has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behaviour. We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a non-primary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27–2.36), sex exchange (AOR 1.84, 95% CI 1.74–1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03–2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24–2.28). Associations between food insufficiency and risky sex were much attenuated among men. Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women’s legal and social rights may play an important role in decreasing HIV transmission risk for women.

Editors’ notes: Insufficient food to meet daily needs and infection with HIV are major causes of death in southern Africa. Good nutrition is essential for a strong immune system. Protecting and promoting access to food can act on the socio-behavioural plain to reduce HIV exposure and on the biological plain to both reduce the risk of becoming infected if exposed and to maintain good health for longer once infected. Supporting women’s subsistence farming and enhancing their control over their food supplies as well as their sexual lives are key steps to improving their resilience to HIV.

Piot P, Greener R, Russell S. Squaring the Circle: AIDS, Poverty, and Human Development. Plos Med. 2007;4(10):1571-5.

It is often asserted that AIDS is at the core of a “vicious circle” whereby the impacts of AIDS increase poverty and social deprivation, while poverty and social deprivation increase vulnerability to HIV infection. In examining this view, it is important to distinguish between the “downstream” effects of AIDS on poverty, and the “upstream” effects of poverty upon the risk of acquiring HIV. Understanding these interactions is vital to the development and implementation of effective strategies to prevent and treat HIV. Six elements are key to an effective, sustainable response. First, AIDS money has the most impact when strategies are based on the concept of “know and act on your epidemic”. UNAIDS’ Practical Guidelines for Intensifying HIV Prevention provide practical guidance to tailor national HIV prevention responses so that they respond to the epidemic dynamics and social context of the country and each populations who remain most vulnerable to HIV infection. Second, a growing number of small-scale activities indicate the value of combining HIV programmes with poverty reduction initiatives. The challenge now, however, is to make the shift from small-scale projects to large-scale programmes. Third, the provision of HIV treatment can help prevent poverty—and indirectly contribute to HIV prevention as well—by helping to break down stigma. Access for the poor to HIV treatment and prevention services requires action to increase investment in antiretroviral treatment—by both national and international funders; reduce the cost of antiretroviral drugs; improve HIV service delivery systems; and provide better services for the poor. Fourth, development plans (whether they concern the development of productive sectors or the provision of social safety nets) must “pass the AIDS test”, contributing to HIV prevention and treatment in the communities they work in. Fifth, both poverty reduction programmes and AIDS strategies must reduce vulnerability to HIV— particularly for women and young people. Doing so involves protecting human rights and tackling issues around social marginalization and stigma. Sixth, addressing AIDS in the world’s poorest countries and communities depends on increased and sustained international support, driven by high-level political will. Complex problems famously require complex solutions. In this case, it is crucial to place AIDS squarely at the centre of all socio-economic development, and provide long-term, high-level domestic and international investment in HIV prevention and treatment in the world’s poorest countries.

Editors’ notes: Economic and gender inequalities along with weakened social cohesion are key influences on sexual behaviour and risk of HIV transmission. The clear pattern of associations between the level of income inequality measured by the Gini coefficient and HIV prevalence in sub-Saharan Africa speak to the need to improve governance in general as well as strengthen the AIDS response.
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Paediatric drug resistance

LaSala MC. Parental influence, gay youths, and safer sex. Health Soc Work 2007;32:49-55.

To begin to understand the role that family relationships and interactions play in young gay men’s decisions to avoid unsafe sexual practices, parents and sons (ages 16 to 25) in 30 families were qualitatively interviewed about issues and concerns related to HIV risk. Most of the youths reported feeling obliged to their parents to stay healthy, and these feelings of obligation were important factors in their decisions to avoid unsafe sex. Youths who reported no parental influence came from families in which parents had historically been preoccupied with personal or marital problems or in which there was a history of parental rejection. On the basis of these exploratory findings, HIV prevention specialists are advised to recruit parents, assess family relationships, and facilitate parent-child communication in their efforts to encourage gay youths to consistently engage in safer sex practices.

Editors’ note: This article underscores the role that parent-youth communication and involvement play in the commitment of young men who have sex with men to stay healthy. Although this has been reported for all young people, this study of young gay men shows the importance to safer sex practices of facilitating constructive dialogue within families.

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Foster G. Under the radar: community safety nets for AIDS-affected households in sub-Saharan Africa. AIDS Care 2007;19 Suppl 1:S54-63.

Safety nets are mechanisms to mitigate the effects of poverty on vulnerable households during times of stress. In sub-Saharan Africa, extended families, together with communities, are the most effective responses enabling access to support for households facing crises. This paper reviews literature on informal social security systems in sub-Saharan Africa, analyses changes taking place in their functioning as a result of HIV and describes community safety net components including economic associations, cooperatives, loan providers, philanthropic groups and HIV initiatives. Community safety nets target households in greatest need, respond rapidly to crises, are cost efficient, based on local needs and available resources, involve the specialized knowledge of community members and provide financial and psycho-social support. Their main limitations are lack of material resources and reliance on unpaid labour of women. Changes have taken place in safety net mechanisms because of HIV, suggesting the resilience of communities rather than their impending collapse. Studies are lacking that assess the value of informal community-level transfers, describe how safety nets assist the poor or analyse modifications in response to HIV. The role of community safety nets remains largely invisible under the radar of governments, non-governmental organizations and international bodies. External support can strengthen this system of informal social security that provides poor HIV-affected households with significant support.

Editors’ note: Vulnerability is much studied but relatively little is known about community resilience and how to better foster and support it. What forms does solidarity take and why is it more likely to be expressed in some communities and not in others? How can men be encouraged to become involved as much as women in creating and maintaining social safety nets? Understanding the mechanisms and manifestations of resilience is as key to the response to HIV as understanding the origins and underpinnings of vulnerability.

Loewenson R. Exploring equity and inclusion in the responses to AIDS. AIDS Care 2007;19 Suppl 1:S2-11.

Photo credit - UNAIDS/G. PirozziThe HIV epidemic feeds on, and worsens, unacceptable situations of poverty, gender inequity, social insecurity, limited access to healthcare and education, war, debt and macroeconomic and social instability. The number of people living with HIV and AIDS continues to increase in several regions, most markedly in sub-Saharan Africa, the Pacific, Eastern Europe and Central Asia. The persistent nature of the epidemic and its increasing incidence in less powerful, more economically marginalised communities signals a need for a critical review of past policy and practice, particularly where this has left unchanged or worsened the risk environments that lead to new infection. Available evidence suggests that the caring and consumption burdens of AIDS have largely been met by households, limiting the capacities for future caring and mitigation of impact. Social cohesion or the collective networking, action, trust and solidarity of society, plays a positive role in reducing risk and dealing with vulnerability but is itself negatively affected by AIDS. This paper introduces the programme of work reported in this supplement of AIDS Care with an analysis of background evidence of community responses to HIV. It explores how interventions from state institutions and non-governmental organizations (NGOs) support and interact with these household, family and community responses. How far is risk prevention reliant on individuals’ limited resources and power to act, while risk environments are left unchanged? How far are the impacts of AIDS borne by households and extended families, with weak solidarity support? Where are the examples of wider social responses that challenge the conditions that influence risk and that support household recovery? Through review of literature, this background paper sets out the questions that the studies reported in this supplement have, in various settings, sought to explore more deeply.

Editors’ note: This supplement of AIDS Care focuses specifically on community responses to HIV, the resilience-vulnerability continuum, equity-inclusion and the nature of social solidarity. The author is from the Training and Research Support Centre (TARSC) at the UNRISD Programme on Community Responses to AIDS in Geneva, Switzerland.

Abebe T, Aase A. Children, AIDS and the politics of orphan care in Ethiopia: The extended family revisited. Soc Sci Med 2007;64:2058-69.

 The astounding rise in the number of orphans due to the HIV epidemic has left many Ethiopian families and communities with enormous childcare problems. Available studies on the capacity and sustainability of the extended family system, which culturally performs the role of care for children in need, suggest two competing theories. The first is grounded in the social rupture thesis and assumes that the traditional system of orphan care is stretched by the impact of the epidemic, and is actually collapsing. By contrast, the second theory counter-suggests that the flexibility and strength of the informal childcare practise, if supported by appropriate interventions, can still support a large number of orphans. Based on a seven-month period of child-focused, qualitative research fieldwork in Ethiopia involving observations; in-depth interviews with orphans (42), social workers (12) and heads of households (18); focus group discussions with orphans (8), elderly people and community leaders (6); and story-writing by children in school contexts, this article explores the trade-offs and social dynamics of orphan care within extended family structures in Ethiopia. It argues that there is a rural-urban divide in the capacity to cater for orphans that emanates from structural differences as well as the socio-cultural and economic values associated with children. The care of orphans within extended family households is also characterised by multiple and reciprocal relationships in care-giving and care-receiving practices. By calling for a contextual understanding of the ‘orphan burden’, the paper concludes that interventions for orphans may consider care as a continuum in the light of four profiles of extended families, namely rupturing, transient, adaptive, and capable families.

 Editors’ note: This thoughtful article suggests that the first step in planning programmes to support orphan care requires an understanding of natural coping mechanisms which will differ by geography and culture, as well as over time.

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National responses

Wu Z, Sullivan SG, Wang Y, Rotheram-Borus MJ, Detels R. Evolution of China’s response to HIV/AIDS. Lancet 2007;369:679-90.

Four factors have driven China’s response to the HIV pandemic: (1) existing government structures and networks of relationships; (2) increasing scientific information; (3) external influences that underscored the potential consequences of an HIV pandemic and thus accelerated strategic planning; and (4) increasing political commitment at the highest levels. China’s response culminated in legislation to control HIV -the AIDS Prevention and Control Regulations. Three major initiatives are being scaled up concurrently. First, the government has prioritised interventions to control the epidemic in injection drug users, sex workers, men who have sex with men, and plasma donors. Second, routine HIV testing is being implemented in populations at high risk of infection. Third, the government is providing treatment for infected individuals. These bold programmes have emerged from a process of gradual and prolonged dialogue and collaboration between officials at every level of government, researchers, service providers, policymakers, and politicians, and have led to decisive action.

Editors’ note : In the wake of SARS, China has shown tremendous resolve in responding to HIV decisively and matching programming to the dynamics of its epidemic. When China decides to move forward, it commits to deliver. The speed at which antiretroviral treatment access can be increased; the extent to which key populations can be reached with tailored programmes; and whether the voluntariness of HIV testing, combined with anti-stigma and antidiscrimination measures, can be ensured so that knowledge of serostatus will be sought by people are all key to achieving an effective and sustained result.

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Faith- based organisations

Krakauer M, Newbery J. Churches’ responses to HIV/AIDS in two South African communities. J Int Assoc Physicians AIDS Care (Chic Ill) 2007;6:27-35.

Churches have attracted controversy for how they have dealt with AIDS: they have been criticized for moral stigmatism, yet lauded for their charitable works. Krakauer and colleagues examine what churches were doing at the grass-roots level to deal with the impact of AIDS on their communities. This study was conducted in a rural area and an urban area outside of Durban, South Africa, a region with high HIV prevalence rates. The authors examined 2 indigenous churches (Shembe and Zionist) and one international church (Roman Catholic) in each community. The authors found that there was a widespread awareness of AIDS among church leaders and community members, and that churches were used as health resources by their members, yet no AIDS programs were run by any of the churches in the study locations. The authors argue that 4 key characteristics dictated the churches’ responses to AIDS: resources, organizational structure, cultural appeal, and discipline. There are distinct advantages to partnering with churches for AIDS programming, yet significant complexities to navigating a meaningful dialogue with them also exist.

Editors’ note: This study suggests that there is significant untapped potential in faith-based organisations for the response to HIV. Translating high awareness into effective HIV programming for church members and the broader community may require study tours and peer learning about approaches being used effectively in other communities.

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Yap L, Butler T, Richters J, Kirkwood K, Grant L, Saxby M, Ropp F, Donovan B. Do condoms cause rape and mayhem? The long-term effects of condoms in New South Wales' prisons. Sex Transm Infect. 2006 Dec 19; [Epub ahead of print]

Concerns raised by opponents to condom provision in prisons have not been objectively examined and the issue continues to be debated. Yap and colleagues examined the long-term effects of the introduction of condoms and dental dams into New South Wales prisons in 1996, focusing on particular concerns raised by politicians, prison officers, prison nurses, and prisoners. These groups were worried that: (a) condoms would encourage prisoners to have sex, (b) condoms would lead to an increase in sexual assaults in prisons, (c) prisoners would use condoms to hide and store drugs and other contraband, and (d) prisoners would use condoms as weapons. Data sources included the New South Wales Inmate Health Surveys in 1996 and 2001 and official reports from the New South Wales Department of Corrective Services. The 1996 IHS involved 657 men and 132 women randomly selected from all prisons with a 90% response rate. The 2001 survey involved 747 men and 167 women inmates with an 85% response rate. There was a decrease in reports of both consensual male-to-male sex and male sexual assaults 5 years after the introduction of condoms into prisons in 1996. Condoms were often used for concealing contraband items and other purposes but this was not associated with an increase in drug injecting in prison. Only three incidents of a condom being used in assaults on prison officers were recorded between 1996 and 2005; none were serious. The authors conclude that they found no evidence of serious adverse consequences of distributing condoms and dental dams to prisoners in New South Wales. Condoms are an important public health measure in the fight against HIV and sexually transmitted diseases; they should be made freely available to prisoners as they are to other high- risk groups in the community.

Editors’ note: Condoms have been available in Canadian penitentiaries since 1994 and in prisons in New South Wales since 1996 but the vast majority of prisons worldwide do not make condoms available to inmates with dire results. Results such as these can be used to influence correctional system leadership, particularly when national laws invest them with responsibility for detainee health on their watch.

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