Articles tagged as "Structural determinants and vulnerability"

Structural determinants/interventions

Krishnan S, Dunbar MS, Minnis AM, Medlin CA, Gerdts CE, Padian NS. Poverty, Gender Inequities and Women’s risk of HIV/AIDS. Ann N Y Acad Sci 2007 Oct 22; [Epub ahead of print]

Entrenched economic and gender inequities together are driving a globally expanding, increasingly female, AIDS epidemic. To date, significant population-level declines in HIV transmission have not been observed at least in part because most approaches to prevention have presumed a degree of individual control in decision-making that does not speak to the reality of women’s and girls’ circumstances in many parts of the world. Such efforts have paid insufficient attention to critical characteristics of the risk environment, most notably poverty and gender-power inequities. Even fewer interventions have addressed specific mechanisms through which these inequities engender risky sexual practices that result in women’s disproportionately increased vulnerabilities to HIV infection. This paper focuses on identifying those mechanisms, or structural pathways, which stem from the interactions between poverty and entrenched gender inequities and recommending strategies to address and potentially modify those pathways. Krishnan and colleagues highlight four such structural pathways to HIV risk, all of which have the potential to be transformed: 1) lack of access to critical information and health services for HIV and sexually transmitted infection (STI) prevention; 2) limited access to formal education and skills development; 3) intimate partner violence; and 4) the negative consequences of migration prompted by insufficient economic resources. The authors argue for interventions that enhance women’s access to education, training, employment, and HIV and STI prevention information and tools; minimize migration; and by working with men and communities, at the same time reduce women’s poverty and promote gender equitable norms. In conclusion, the authors identify challenges in developing and evaluating strategies to address these structural pathways.

Editors’ note: Understanding the multiple dimensions of a risk environment that is impinging on individual “choices” is pivotal to addressing the structural pathways that mediate that risk environment’s influence on behaviour. For example, limited access to education and skills can lead to migration for economic opportunity that may increase the likelihood of transactional sex. Programmes addressing the latter will have limited effect without attention to “upstream” determinants.


Kim JC, Watts CH, Hargreaves JR, Ndhlovu LX, Phetla G, Morison LA, Busza J, Porter JD, Pronyk P. Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa. Am J Public Health 2007;97:1794-802.

Kim and colleagues sought to obtain evidence about the scope of women’s empowerment and the mechanisms underlying the significant reduction in intimate partner violence documented by the Intervention With Microfinance for AIDS and Gender Equity (IMAGE) cluster-randomized trial in rural South Africa. The IMAGE intervention combined a microfinance program with participatory training on understanding HIV infection, gender norms, domestic violence, and sexualityOutcome measures included past year’s experience of intimate partner violence and 9 indicators of women’s empowerment. Qualitative data about changes occurring within intimate relationships, loan groups, and the community were also collected. Results showed that after two years, the risk of past-year physical or sexual violence by an intimate partner was reduced by more than half (adjusted risk ratio=0.45; 95% confidence interval=0.23, 0.91). Improvements in all 9 indicators of empowerment were observed. Reductions in violence resulted from a range of responses enabling women to challenge the acceptability of violence, expect and receive better treatment from partners, leave abusive relationships, and raise public awareness about intimate partner violence. In conclusion, the authors’ findings, both qualitative and quantitative, indicate that economic and social empowerment of women can contribute to reductions in intimate partner violence.

Editors’ note: Stand alone health programmes can encounter difficulties in recruiting and retaining vulnerable women. This study demonstrates the synergy of deliberately integrating public health interventions into development initiatives, such as microfinance. High uptake of the intervention, consistent village level violence reduction and its congruency with changes in structural pathway variables such as economic well-being and empowerment, and plausible mechanisms suggested by qualitative findings converge to support the effectiveness of this intervention. It should be scaled-up in the context of macro-economic and policy initiatives addressing gender inequities.

Thomas F. Global rights, local realities: Negotiating gender equality and sexual rights in the Caprivi Region, Namibia. Cult Health Sex 2007;9:599-614.

Gender inequalities are frequently cited as a major reason for high HIV-prevalence rates in southern Africa. While steps have been taken to promote and pass legislation that upholds equal rights for women, this paper examines the ways in which discourses of gender equality and ensuing sexual rights can have complex, contradictory, and even adverse implications when they are mobilised, resisted, and reinterpreted at local level. Drawing upon research undertaken in the Caprivi Region of Namibia, this paper examines the ways in which men and women respond to ideas about gender equality, and seeks to place these responses within the wider context of socio-economic change and understandings of morality prevalent within the region. The tendency of many young women to seek out relationships with older men and the increasing costs of bride-wealth payments play a key role in reinforcing patriarchal attitudes and fuelling non respect for women’s rights both before and within marriage. In addition, a failure to adhere to customary norms, which uphold men’s dominant role, continues to threaten the support networks and assets available to women. The consequences of this situation are examined with particular focus on implications for the future transmission of HIV.

Editors’ note: This paper describes a “catch-22” situation in which adherence to the customary norms that can undermine women’s civil rights is necessary for women to access the social and economic entitlements they need for day-to-day subsistence. Promoting sexual rights and gender equality requires looking for openings and creating opportunities for negotiation to change customary norms so that they build on locally accepted core values such as respect, fairness, and justice. Only then will enforcement of national legislation promoting gender equality find fertile ground.

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Substance use and MSM

Spindler HH, Scheer S, Chen SY, Klausner JD, Katz MH, Valleroy LA, Schwarcz SK. Viagra, methamphetamine, and HIV risk: results from a probability sample of MSM, San Francisco. Sex Transm Dis 2007 Feb 28; [Epub ahead of print]

The objectives of this study was to determine the prevalence and factors of Viagra use in combination with crystal methamphetamine and its association with HIV risk behaviour in a probability sample of men who have sex with men (MSM). Spindler and colleagues chose a cross-sectional, random-digit dial telephone survey of MSM in San Francisco conducted between June 2002 and January 2003. Of the 1976 MSM, 13.5% used Viagra alone, 7.1% used methamphetamine without Viagra, 9.6% used Viagra with a mood-altering substance (excluding methamphetamine), and 5.1% used Viagra with methamphetamine. Of the MSM using Viagra with methamphetamine, 57% were HIV-infected and 24% of these men reported serodiscordant unprotected insertive intercourse. Viagra used with methamphetamine was independently associated with a higher risk of serodiscordant unprotected insertive intercourse, serodiscordant unprotected receptive intercourse, and a recent diagnosis of a sexually transmitted disease. The authors conclude that MSM who use Viagra with crystal methamphetamine have high prevalence rates of HIV and engage in HIV risk behaviours.

Editors’ note: The results of this survey of almost 2000 men who have sex with men should wake up our readers. The whopping 57% prevalence among those using both Viagra and crystal meth is shocking.

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Nutrition

Drain PK, Kupka R, Mugusi F, Fawzi WW. Micronutrients in HIV-positive persons receiving highly active antiretroviral therapy. Am J Clin Nutr 2007;85:333-45.

Photo credit: UNAIDS/L.Taylor
Photo credit: UNAIDS/L.Taylor
In HIV-infected persons, low serum concentrations of vitamins and minerals, termed micronutrients, are associated with an increased risk of HIV disease progression and mortality. Micronutrient supplements can delay HIV disease progression and reduce mortality in HIV-positive persons not receiving highly active antiretroviral therapy. With the transition to more universal access to antiretroviral therapy, a better understanding of micronutrient deficiencies and the role of micronutrient supplements in HIV-positive persons receiving antiretroviral therapy has become a priority. The provision of simple, inexpensive micronutrient supplements as an adjunct to antiretroviral therapy may have several cellular and clinical benefits, such as a reduction in mitochondrial toxicity and oxidative stress and an improvement in immune reconstitution. Drain and colleagues reviewed observational and trial evidence on micronutrients in HIV-positive persons receiving antiretroviral therapy to summarize the current literature and to suggest future research priorities. A small number of observational studies have suggested that some, but not all, micronutrients may become replete after antiretroviral therapy initiation, and few intervention studies have found that certain micronutrients may be a beneficial adjunct to antiretroviral therapy. However, most of these studies had some major limitations, including a small sample size, a short duration of follow-up, a lack of adjustment for inflammatory markers, and an inadequate assessment of HIV-related outcomes. Therefore, few data are available to determine whether antiretroviral therapy ameliorates micronutrient deficiencies or to recommend or refute the benefit of providing micronutrient supplements to HIV-positive persons receiving antiretroviral therapy. Because micronutrient supplementation may cause harm, randomized placebo-controlled trials are needed. Future research should determine whether antiretroviral therapy initiation restores micronutrient concentrations, independent of inflammatory markers, and whether micronutrient supplements affect HIV-related outcomes in HIV-positive persons receiving antiretroviral therapy.

Editors’ note: There is no doubt that nutrition is important in optimizing health status but, as this review suggests, it has not been demonstrated that micronutrient supplements provide benefit to people living with HIV, whether or not they are on antiretroviral treatment.
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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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Nutrition and HIV

Paton NI, Sangeetha S, et al. The impact of malnutrition on survival and the CD4 count response in HIV-infected patients starting antiretroviral therapy. HIV Medicine 2006;7:323–30

The impact that malnutrition at the time of ART initiation has on survival and CD4 count responses is not known. Paton and colleagues conducted a cohort study of patients attending the national HIV referral centre in Singapore who had CD4 counts less than 250 cells/ml; measurement of body weight was performed at the time of starting ART. They extracted demographic and clinical variables from an existing database, calculated the body mass index (BMI), and defined moderate to severe malnutrition as BMI less than 17 kg/m2. The authors included 394 patients in the analysis, of whom 79 died during a median study follow-up of 2.4 years. Significant independent predictors of death in these patients were moderate to severe malnutrition (HR 2.19, 95% CI 1.29–3.73), advanced stage of HIV disease (HR 2.47, 95% CI 1.20–5.07), and non-HAART treatment (HR 0.50, 95% CI 0.27–0.93). Malnutrition did not impair the magnitude of the increase in CD4 counts at 6 or 12 months. Paton and colleagues conclude that malnutrition at the time of starting ART was significantly associated with decreased survival, but the effect appeared not to be mediated by impaired immune reconstitution. They recommend that, given the increasing access to ART in developing countries and the high frequency of HIV-associated wasting, studies of nutritional therapy as an adjunct to the initiation of HAART are urgently needed.

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