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

HIV and Prisons

Sarang A, Rhodes T, Platt L, Kirzhanova V, Shelkovnikova O, Volnov V, Blagovo D, Rylkov A. Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study. Addiction 2006;101:1787-96.

Evidence highlights the prison as a high risk environment in relation to HIV and hepatitis C virus (HCV) transmission associated with injecting drug use. Sarang and colleagues undertook qualitative studies among 209 people who inject drugs in three Russian cities: Moscow (n=56), Volgograd (n=83) and Barnaul in western Siberia (n=70). Over three-quarters (77%) reported experience of police arrest related to their drug use, and 35% (55% of men) a history of imprisonment or detention. Findings emphasise the critical role that penitentiary institutions may play as a structural factor in the diffusion of HIV associated with drug injection in the Russian Federation. While drugs were perceived to be generally available in penitentiary institutions, sterile injection equipment was scarce and as a consequence routinely reused, including within large groups. Attempts to clean borrowed needles or syringes were inadequate, and risk reduction was severely constrained by a combination of lack of injecting equipment availability and punishment for its possession. Perceptions of relative safety were also found to be associated with assumptions of HIV negativity, resulting from a perception that all prisoners are HIV tested upon entry with those found HIV positive segregated. The authors conclude that the study shows an urgent need for HIV prevention interventions in the Russian penitentiary system.


Dolan K, Kite B, Black E, Aceijas C, Stimson GV, for the Reference Group on HIV/AIDS Prevention and Care among Injecting Drug Users in Developing and Transitional Countries. HIV in prison in low-income and middle-income countries. Lancet Infect Dis 2007;7:32-41

High prevalence of HIV infection and the over-representation of people who inject drugs in prisons combined with HIV risk behaviour create a crucial public-health issue for correctional institutions and, at a broader level, the communities in which they are situated. However, data relevant to this problem are limited and difficult to access. Dolan and colleagues reviewed imprisonment, HIV prevalence, and the proportion of prisoners who inject drugs in 152 low-income and middle-income countries. Information on imprisonment was obtained for 142 countries. Imprisonment rates ranged from 23 per 100000 population in Burkina Faso to 532 per 100000 in Belarus and Russia. Information on HIV prevalence in prisons was found for 75 countries. Prevalence was greater than 10% in prisons in 20 countries. Eight countries reported prevalence of people who inject drugs in prison of greater than 10%. HIV prevalence among prisoners who inject drugs was reported in eight countries and was greater than 10% in seven of those. Evidence of HIV transmission in prison was found for seven low-income and middle-income countries. HIV is a serious problem for many countries, especially where injection drug use occurs. The authors conclude that because of the paucity of data available, the contribution of HIV within prison settings is difficult to determine in many low-income and middle-income countries. They add that systematic collection of data to inform HIV prevention strategies in prison is urgently needed. The introduction and evaluation of HIV prevention strategies in prisons are warranted.

Editors’ note: No institution outside hospitals has higher HIV prevalence around the world. Although more data are needed, the actions needed to prevent intramural transmission are well known – implementation and evaluation are urgently needed.

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Treatment

Newman CE, Bonar M, Greville HS, Thompson SC, Bessarab D, Kippax SC. Barriers and incentives to HIV treatment uptake among Aboriginal people in Western Australia. AIDS 2007;21(Suppl 1):S13-S17.

Newman and colleagues examined the barriers and incentives to HIV treatment uptake among Aboriginal people in Western Australia. In-depth, semi-structured interviews were conducted between February and September 2003 with 20 Aboriginal people who were HIV-positive; almost half the total number of Aboriginal people known to be living with HIV in Western Australia at that time. Despite having access to treatments in both urban and rural areas, only 11 of the 20 participants were on antiretroviral treatment at the time of interview. Four of the women had been prescribed treatment during pregnancy only. The main barriers to treatment uptake were fear of disclosure and discrimination, heavy alcohol consumption and poverty. The incentives were pregnancy and access to services whose approach can be described as broad-based and holistic, i.e. supporting people in the context of their everyday lives by providing psychosocial and welfare support as well as healthcare. The authors conclude that for many Aboriginal people, maintaining social relationships, everyday routines and the respect of friends, families and community is a greater priority than individual health per se. Treatment regimens must be tailored to fit the logistical, social and cultural context of everyday life, and be delivered within the context of broad-based health services, in order to be feasible and sustainable.


MacArthur RD, Novak RM, Peng G, Chen L, Xiang Y, Hullsiek KH, Kozal MJ, van den Berg-Wolf M, Henely C, Schmetter B, Dehlinger M; CPCRA 058 Study Team; Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). A comparison of three highly active antiretroviral treatment strategies consisting of non-nucleoside reverse transcriptase inhibitors, protease inhibitors, or both in the presence of nucleoside reverse transcriptase inhibitors as initial therapy (CPCRA 058 FIRST Study): a long-term randomised trial. Lancet 2006;368:2125-35.

Long-term data from randomised trials on the consequences of treatment with a protease inhibitor (PI), non-nucleoside reverse transcriptase inhibitor (NNRTI), or both are lacking. MacArthur and colleagues report results from the FIRST trial, which compared initial treatment strategies for clinical, immunological, and virological outcomes. Between 1999 and 2002, 1397 ART-naive patients, presenting at 18 clinical trial units with 80 research sites in the USA, were randomly assigned in a ratio of 1:1:1 to a protease inhibitor (PI) strategy (PI plus nucleoside reverse transcriptase inhibitor [NRTI]; n=470), a non-nucleoside reverse transcriptase inhibitor (NNRTI) strategy (NNRTI plus NRTI; n=463), or a three-class strategy (PI plus NNRTI plus NRTI; n=464). Primary endpoints were a composite of an AIDS-defining event, death, or CD4 cell count decline to less than 200 cells per mm3 for the PI versus NNRTI comparison, and average change in CD4 cell count at or after 32 months for the three-class versus combined two-class comparison. Analyses were by intention-to-treat. A total of 388 participants developed the composite endpoint, 302 developed AIDS or died, and 188 died. NNRTI versus PI hazard ratios (HRs) for the composite endpoint, for AIDS or death, for death, and for virological failure were 1.02 (95% CI 0.79-1.31), 1.07 (0.80-1.41), 0.95 (0.66-1.37), and 0.66 (0.56-0.78), respectively. 1196 patients were assessed for the three-class versus combined two-class primary endpoint. Mean change in CD4 cell count at or after 32 months was +234 cells per mm3 and +227 cells per mm3 for the three-class and the combined two-class strategies (p=0.62), respectively. HRs (three-class vs combined two-class) for AIDS or death and virological failure were 1.15 (0.91-1.45) and 0.87 (0.75-1.00), respectively. HRs (three-class vs combined two-class) for AIDS or death were similar for participants with baseline CD4 cell counts of 200 cells per mm3 or less and of more than 200 cells per mm3 (p=0.38 for interaction), and for participants with baseline HIV RNA concentrations less than 100 000 copies per mL and 100,000 copies per mL or more (p=0.26 for interaction). Participants assigned the three-class strategy were significantly more likely to discontinue treatment because of toxic effects than were those assigned to the two-class strategies (HR 1.58; p<0.0001). The authors conclude that initial treatment with either an NNRTI-based regimen or a PI-based regimen, but not both together, is a good strategy for long-term antiretroviral management in treatment-naive patients with HIV.

Editors’ note: The take home message is to start treatment naïve patients on an antiretroviral combination drawn from two classes not three; there are equivalent clinical benefits and fewer side effects.

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Nutrition

Leshabari SC, Koniz-Booher P, Astrom AN, de Paoli MM, Moland KM. Translating global recommendations on HIV and infant feeding to the local context: The development of culturally sensitive counselling tools in the Kilimanjaro Region, Tanzania. Implement Sci 200;1(1):22. http://www.implementationscience.com/content/1/1/22

Leshabari and colleagues describe the process used to develop an integrated set of culturally sensitive, evidence-based counselling tools through qualitative participatory research. The aim of the programme was to contribute to improving infant feeding counselling services for women living with HIV in the Kilimanjaro Region of Tanzania. Formative research using a combination of qualitative methods preceded the development of the intervention and mapped existing practices, perceptions and attitudes towards HIV and infant feeding among mothers, counsellors and community members. Intervention Mapping protocol guided the development of the overall programme strategy. Theories of behaviour change, a review of the international HIV and infant feeding guidelines and formative research findings contributed to the definition of performance and learning objectives. Key communication messages and colourful graphic illustrations related to infant feeding in the context of HIV were then developed and/or adapted from existing generic materials. Draft materials were field tested with intended audiences and subjected to stakeholder technical review. An integrated set of infant feeding counselling tools, referred to as 'job aids', was developed that includes brochures on feeding methods that were found to be socially and culturally acceptable, a Question and Answer Guide for counsellors, a counselling card on the risk of transmission of HIV, and an infant feeding toolbox for demonstration. Each brochure describes the steps to ensure safer infant feeding using simple language and images based on local ideas and resources. The brochures are meant to serve as both a reference material during infant feeding counselling in the ongoing prevention of mother to child transmission (pMTCT) of HIV programme and as take home material for the mother. The study underscores the importance of formative research and a systematic theory based approach to developing a programme aimed at improving counselling and changing customary feeding practices. The identification of perceived barriers and facilitators for change contributed to developing the key counselling messages and graphics, reflecting the socio-economic reality, cultural beliefs and norms of mothers and their significant others.

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Vulnerability and Outcome

Kongnyuy EJ, Wiysonge CS, et al. Wealth and sexual behaviour among men in Cameroon. BMC Int Health Hum Rights 2006,6:11. http://www.biomedcentral.com/1472-698X/6/11

The 2004 Demographic and Health Survey (DHS) in Cameroon revealed a higher prevalence of HIV in richest and most educated people than their poorest and least educated compatriots. It is not certain whether the higher prevalence results partly or wholly from wealthier people adopting more unsafe sexual behaviours, surviving longer due to greater access to treatment and care, or being exposed to unsafe injections or other HIV risk factors. As unsafe sex is currently believed to be the main driver of the HIV epidemic in sub-Saharan Africa, Kongnyuy and colleagues examined the association between wealth and sexual behaviour in Cameroon among 4409 sexually active men aged 15-59 years who participated in the DHS. When controlled for potential confounding by marital status, place of residence, religion and age, men in the richest third of the population were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.43, 95% CI 0.32-0.56) and more likely to have had at least two concurrent sex partners in the last 12 months (OR 1.38, 95% CI 1.12-1.19) and more than five lifetime sex partners (OR 1.97, 95% CI 1.60-2.43). However, there was no difference between the richest and poorest men in the purchase of sexual services. Regarding education, men with secondary or higher education were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.24, 95% CI 0.16-0.38) and more likely to have started sexual activity at age 17 years or less (OR 2.73, 95% CI 2.10-3.56) and have had more than five lifetime sexual partners (OR 2.59, 95% CI 2.02-3.31). There was no significant association between education and multiple concurrent sexual partnerships in the last 12 months or purchase of sexual services. The authors conclude that unsafe sexual behaviours may explain the higher HIV prevalence among wealthier men in the country. They add that while these findings do not suggest a redirection of HIV prevention efforts from the poor to the wealthy, they do call for efforts to ensure that HIV prevention messages get across all strata of society.

Editors’ note: It is interesting that financial ability to directly purchase sexual services is not the explanation for increased HIV in wealthier men in Cameroon. Qualitative studies would help explain the assumptions these men make about their risk of HIV in non-commercial encounters but just reflecting these findings to this population may effect a change – it’s within their power to protect themselves.

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Greater Involvement of People Living with HIV

Chung K, Lounsbury DW. The role of power, process, and relationships in participatory research for statewide HIV/AIDS programming. Soc Sci Med 2006 Jul 5; [Epub ahead of print] http://www.sciencedirect.com/

Participatory, community-based research is relatively new to mainstream medical research, but it is not new to health research. Participation in research is often conceptualised as a continuum in which different levels of participation imply different amounts of community control over the process and outcomes. At one end lies the conventional research situation in which community members are passive participants in the research process and have little influence over the process or outcome. At the other end lies a far more empowering situation in which community members work as equal partners to define and execute the research as well as to determine its applications. Theoretically, participatory research is situated at this far end of the continuum. Chung and Lounsbury present a case study of a participatory process that was used to understand the needs of persons living with HIV in a US state. The case illustrates that participation in a community-based research project is a dynamic phenomenon that must be negotiated among an evolving web of roles and relationships. Using a continuum to model the multiple modes of community participation, the authors follow the changing nature of participation over the course of a single project. Their analysis illustrates the different levels of participation given by the continuum as well as the dynamic nature of participation. A shared understanding of participation evolves as the roles and relationships of those involved are negotiated and renegotiated. However, lack of reflection over power differentials can lead to disempowering outcomes even after achieving a seemingly participatory process. In conclusion, Chung and Lounsbury say, this case reveals that failing to resolve divergent assumptions about power and purpose can lead to fissures that are difficult to overcome.

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