Articles tagged as "Structural determinants and vulnerability"

Addressing property rights may impact on women’s experiences of violence

Perceived impact of a land and property rights program on violence against women in rural Kenya: a qualitative investigation.  

Hilliard S, Bukusi E, Grabe S, Lu T, Hatcher AM, Kwena Z, Mwaura-Muiru E, Dworkin SL. Violence Against Women. 2016 Mar 6. pii: 1077801216632613. [Epub ahead of print] 

The current study focuses on a community-led land and property rights program in two rural provinces in western Kenya. The program was designed to respond to women's property rights violations to reduce violence against women and HIV risks at the community level. Through in-depth interviews with 30 women, we examine the perceived impact that this community-level property rights program had on violence against women at the individual and community level. We also examine perceptions as to how reductions in violence were achieved. Finally, we consider how our findings may aid researchers in the design of structural violence-prevention strategies. 

Abstract access  

Editor’s notes: This paper reports on women’s experiences of violence following reporting of disinheritance to a community–led property rights violations programme in Kenya. The research was set in two rural districts in Kenya, where HIV prevalence is high (23.8-33%) and property rights violations are common. Interviews were conducted with women who participated in GROOTS-Kenya’s Community Land and Property Watch Dog Model (CWDG). This model is comprised of volunteer women and men. These people monitor women’s disinheritance locally and mediate land disputes. They also refer unresolved cases to formal adjudication mechanisms and raise awareness about women’s rights.  

The researchers found that for nearly all of the women, violence ceased immediately on reporting cases of violent disinheritance to the CWDG. The presence of the CWDG led to a broader reduction in sexual and domestic violence against women at the community level. The women explained that this was for four reasons: (a) improved individual- and community-level knowledge about women’s rights/improved knowledge about violence against women, (b) the existence of a community-based mechanism for reporting cases of violence, (c) the responsiveness of the CWDG to cases of violence, and (d) fears that perpetrators had about the legal consequences of perpetrating violence. This research contributes to a growing body of evidence that addressing structural factors such as economic empowerment is important. However, there is a need to strengthen this approach through providing women with property rights.  Property rights may empower women more than other economic empowerment approaches such as micro-finance.  

Africa
Kenya
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HIV and injecting ‘krokodile’

Krokodile Injectors in Ukraine: fueling the HIV Epidemic?

Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. AIDS Behav. 2016 Feb;20(2):369-76. doi: 10.1007/s10461-015-1008-z.

This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 years of age and they had been injecting for over 12 years. Overall, 39% tested positive for HIV, including 45% of krokodile injectors. In the past 30 days, 25% reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85% (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than non-krokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use in the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.

Abstract access

Editor’s notes: This is an important study among a highly vulnerable population of people who inject drugs where HIV prevalence has been consistently high over the last decade. This is one of the first empirical studies to examine the role of krokodile use on HIV risk acquisition. Krokodile is a home produced drug that has become more popular among people who inject drugs in Ukraine and the Russian Federation over the last five years. There is a long history of injection with home-produced opioids and amphetamines in these countries. The key component of krokodile is codeine, an opioid, but severe side effects have been associated with its injection including tissue damage, gangrene and organ failure. This study highlights some of the characteristics and HIV risk behaviours associated with krokodile injection to inform appropriate HIV prevention programming. Findings note that people who inject krokodile are more likely to inject with others. This reflects the home-produced nature of the drug that facilitates more group injecting as people congregate at places where it is produced to buy and inject. Programmes need to focus on strategies to avoid injecting with other people’s used injecting equipment, such as marking equipment, as can happen in group injecting scenarios. This programme would ensure there are sufficient numbers of clean needles/syringes in circulation. Worryingly, a higher prevalence of HIV was observed among people who inject krokodile, most likely associated with their older age and more frequent injecting. Targeted harm reduction information is urgently needed for krokodile users to prevent further HIV transmission and prevent soft tissue damage. There is already a large network of needle-syringe programmes and opioid substitution therapy available for people who inject drugs in Ukraine. However, access is often reduced since people who inject drugs are concerned about being arrested. Registration as a person who injects drugs causes problems with employment, families and police. Collaboration with the police is necessary to increase access to opioid substitution and needle and syringe programmes. Programmes are also required to reduce the stigma associated with injection in order to address the health needs of this population. 

Europe
Ukraine
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‘Cash, care and classroom’: social protection to reduce adolescents’ risk of HIV

Applying a family-level economic strengthening intervention to improve education and health-related outcomes of school-going AIDS-orphaned children: lessons from a randomized experiment in southern Uganda.

Ssewamala FM, Karimli L, Torsten N, Wang JS, Han CK, Ilic V, Nabunya P. Prev Sci. 2016 Jan;17(1):134-43. doi: 10.1007/s11121-015-0580-9.

Children comprise the largest proportion of the population in sub-Saharan Africa. Of these, millions are orphaned. Orphanhood increases the likelihood of growing up in poverty, dropping out of school, and becoming infected with HIV. Therefore, programs aimed at securing a healthy developmental trajectory for these orphaned children are desperately needed. We conducted a two-arm cluster-randomized controlled trial to evaluate the effectiveness of a family-level economic strengthening intervention with regard to school attendance, school grades, and self-esteem in AIDS-orphaned adolescents aged 12-16 years from 10 public rural primary schools in southern Uganda. Children were randomly assigned to receive usual care (counseling, school uniforms, school lunch, notebooks, and textbooks), "bolstered" with mentorship from a near-peer (control condition, n = 167), or to receive bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account (Suubi-Maka treatment arm, n = 179). The two groups did not differ at baseline, but 24 months later, children in the Suubi-Maka treatment arm reported significantly better educational outcomes, lower levels of hopelessness, and higher levels of self-concept compared to participants in the control condition. Our study contributes to the ongoing debate on how to address the developmental impacts of the increasing numbers of orphaned and vulnerable children and adolescents in sub-Saharan Africa, especially those affected by HIV/AIDS. Our findings indicate that innovative family-level economic strengthening programs, over and above bolstered usual care that includes psychosocial interventions for young people, may have positive developmental impacts related to education, health, and psychosocial functioning.

Abstract access 

Editor’s notes: The HIV epidemic has left many sub-Saharan countries with an extraordinarily large youth population, many of whom lost one or both parents to HIV-associated mortality. As a result, younger children tend to have much less support to stay in education and older children often have increased responsibility to support the household. There is thus a need to provide orphaned children with both financial and psycho-social support to achieve their educational goals, and on a broader scale, to prepare the youth for the workforce. This study found that providing orphaned children with a package of school supplies and support services as well as financial services (opening a matched child savings account and workshops on microenterprise development) yielded better educational outcomes than the package without the additional financial services. However, how either group compares to non-orphaned children is unclear. Future research would benefit from a third comparison group, in which non-orphaned children’s educational outcomes are also compared.

The effect of the programme on both educational and mental outcomes among orphans is important. Educational outcomes may have been driven by improved self-confidence and motivation as a result of the savings account and microenterprise training. It is unclear whether these supplemental activities were simply a signal of the community support for the orphaned children, which in turn increased self-confidence, or if the children were directly influenced by their improved economic prospects. Further research to uncover the actual mechanism of the improved outcomes would be useful for future programme design. 

Africa
Uganda
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Emphasising and supporting educational goals among orphaned children

Combination social protection for reducing HIV-risk behavior amongst adolescents in South Africa.

Cluver LD, Orkin MF, Yakubovich AR, Sherr L. J Acquir Immune Defic Syndr. 2016 Jan 27. [Epub ahead of print]

Background: Social protection (i.e. cash transfers, free schools, parental support) has potential for adolescent HIV prevention. We aimed to identify which social protection interventions are most effective and whether combined social protection has greater effects in South Africa.

Methods: In this prospective longitudinal study, we interviewed 3516 adolescents aged 10-18 between 2009 and 2012. We sampled all homes with a resident adolescent in randomly-selected census areas in four urban and rural sites in two South African provinces. We measured household receipt of fourteen social protection interventions and incidence of HIV-risk behaviors. Using gender-disaggregated multivariate logistic regression and marginal-effects analyses, we assessed respective contributions of interventions and potential combination effects.

Results: Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (OR 0.10-0.69). Strong effects of combination social protection were shown, with cumulative reductions in HIV-risk behaviors. For example, girls' predicted past-year incidence of economically-driven sex dropped from 11% with no interventions, to 2% amongst those with a child grant, free school and good parental monitoring. Similarly, girls' incidence of unprotected/casual sex or multiple-partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding, and to 7% with both interventions.

Conclusion: In real-world, high-epidemic conditions, 'combination social protection' shows strong HIV-prevention effects for adolescents and may maximize prevention efforts.

Abstract access 

Editor’s notes: Social and structural programmes help address the disadvantages and inequalities that make people vulnerable to HIV, and may therefore play a key role in adolescent HIV prevention.  However, the particular combination of programmes that may be most effective is not well understood. This longitudinal survey of adolescents aged 10-18 years in high HIV prevalence districts (>30% antenatal prevalence) in South Africa examined the effect of a range of social protection programmes on HIV risk behaviour. The programmes were existing activities provided by the South African government, NGOs or communities.

Receipt of some stand-alone social protection programmes in the areas of cash, psychological support or education was associated with a reduced incidence of HIV risk behaviour.  The optimal combination of programmes depended on the particular risk behaviour under consideration, and differed between boys and girls. Since adolescents may vary in the type of risk to which they are most vulnerable, a multi-component approach is likely to be necessary to have a population-level impact on HIV.

There are some limitations to this study, including the relatively small number of adolescents reporting some risk behaviours. However, the findings illustrate the potential of combination social protection in reducing adolescents’ vulnerability to HIV, and further work in this area would be useful to highlight the important role of public programmes in HIV prevention.

Africa
South Africa
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TB still responsible for large proportion of admissions and in-patient deaths among people living with HIV

TB as a cause of hospitalization and in-hospital mortality among people living with HIV worldwide: a systematic review and meta-analysis.

Ford N, Matteelli A, Shubber Z, Hermans S, Meintjes G, Grinsztejn B, Waldrop G, Kranzer K, Doherty M, Getahun H. J Int AIDS Soc. 2016 Jan 12;19(1):20714. doi: 10.7448/IAS.19.1.20714. eCollection 2016.

Introduction: Despite significant progress in improving access to antiretroviral therapy over the past decade, substantial numbers of people living with HIV (PLHIV) in all regions continue to experience severe illness and require hospitalization. We undertook a global review assessing the proportion of hospitalizations and in-hospital deaths because of tuberculosis (TB) in PLHIV.

Methods: Seven databases were searched to identify studies reporting causes of hospitalizations among PLHIV from 1 January 2007 to 31 January 2015 irrespective of age, geographical region or language. The proportion of hospitalizations and in-hospital mortality attributable to TB was estimated using random effects meta-analysis.

Results: From an initial screen of 9049 records, 66 studies were identified, providing data on 35 845 adults and 2792 children across 42 countries. Overall, 17.7% (95% CI 16.0 to 20.2%) of all adult hospitalizations were because of TB, making it the leading cause of hospitalization overall; the proportion of adult hospitalizations because of TB exceeded 10% in all regions except the European region. Of all paediatric hospitalizations, 10.8% (95% CI 7.6 to 13.9%) were because of TB. There was insufficient data among children for analysis by region. In-hospital mortality attributable to TB was 24.9% (95% CI 19.0 to 30.8%) among adults and 30.1% (95% CI 11.2 to 48.9%) among children.

Discussion: TB remains a leading cause of hospitalization and in-hospital death among adults and children living with HIV worldwide.

Abstract  Full-text [free] access

Editor’s notes: The last 30 years have seen radical improvements in outcomes for many people living with HIV. This study reminds us that in some parts of the world HIV-associated infections, tuberculosis (TB) in particular, still have a devastating effect on thousands of lives.

The importance of TB is widely recognised. WHO aim to reduce deaths due to TB by 75% over the next 10 years.  The question remains: do we really know how many people die due to TB?  Death certification has repeatedly been shown to be unreliable, particularly in the parts of the world where TB is most prevalent. Verbal autopsy is used to estimate cause of death in areas with poor notification systems, but poorly differentiates deaths due to TB and other HIV-associated conditions. Similar challenges are faced when counting and classifying morbidity and hospitalisations. Data are sparse, and determining the cause of an admission is not straightforward, even with access to well-maintained hospital records.  

This review, a sub-analysis of data from a broader study of HIV-associated hospital admissions, is by far the largest of its kind. The authors have been rigorous, given the heterogeneity of the studies included, and their findings are sobering. Among adults living with HIV, in all areas except Europe and South America, TB was the cause of 20-33% of admissions, and some 30% of adults and 45% of children who were admitted with TB were thought to have died from it. These findings are limited by the fact that not all reviewed studies reported on mortality and very few stated how causes of death were assigned.

This paper raises more questions than it answers, but they are important questions.  We are left in no doubt that TB is a major contributor to global morbidity and mortality in HIV-positive people, but we need to look closely at how we count and classify ‘TB deaths’ and ‘TB-associated admissions’. The recent systematic review of autopsy studies cited by the authors also found that almost half the TB seen at autopsy was not diagnosed before death. Global autopsy rates are in decline. Without access to more accurate data, how will we know if we’re winning or losing in our efforts to end TB deaths?

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How gender norms and power may impact on the acceptability, access and adherence to microbicides

Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender-sensitive microbicide introduction.

Doggett EG, Lanham M, Wilcher R, Gafos M, Karim QA, Heise L. J Int AIDS Soc. 2015 Dec 21;18(1):20536. doi: 10.7448/IAS.18.1.20536. eCollection 2015.

Introduction: Microbicides were conceptualized as a product that could give women increased agency over HIV prevention. However, gender-related norms and inequalities that place women and girls at risk of acquiring HIV are also likely to affect their ability to use microbicides. Understanding how gendered norms and inequalities may pose obstacles to women's microbicide use is important to inform product design, microbicide trial implementation and eventually microbicide and other antiretroviral-based prevention programmes. We reviewed published vaginal microbicide studies to identify gender-related factors that are likely to affect microbicide acceptability, access and adherence. We make recommendations on product design, trial implementation, positioning, marketing and delivery of microbicides in a way that takes into account the gender-related norms and inequalities identified in the review.

Methods: We conducted PubMed searches for microbicide studies published in journals between 2000 and 2013. Search terms included trial names (e.g. "MDP301"), microbicide product names (e.g. "BufferGel"), researchers' names (e.g. "van der Straten") and other relevant terms (e.g. "microbicide"). We included microbicide clinical trials; surrogate studies in which a vaginal gel, ring or diaphragm was used without an active ingredient; and hypothetical studies in which no product was used. Social and behavioural studies implemented in conjunction with clinical trials and surrogate studies were also included. Although we recognize the importance of rectal microbicides to women, we did not include studies of rectal microbicides, as most of them focused on men who have sex with men. Using a standardized review template, three reviewers read the articles and looked for gender-related findings in key domains (e.g. product acceptability, sexual pleasure, partner communication, microbicide access and adherence).

Results and discussion: The gendered norms, roles and relations that will likely affect women's ability to access and use microbicides are related to two broad categories: norms regulating women's and men's sexuality and power dynamics within intimate relationships. Though norms about women's and men's sexuality vary among cultural contexts, women's sexual behaviour and pleasure are typically less socially acceptable and more restricted than men's. These norms drive the need for woman-initiated HIV prevention, but also have implications for microbicide acceptability and how they are likely to be used by women of different ages and relationship types. Women's limited power to negotiate the circumstances of their intimate relationships and sex lives will impact their ability to access and use microbicides. Men's role in women's effective microbicide use can range from opposition to non-interference to active support.

Conclusions: Identifying an effective microbicide that women can use consistently is vital to the future of HIV prevention for women. Once such a microbicide is identified and licensed, positioning, marketing and delivering microbicides in a way that takes into account the gendered norms and inequalities we have identified would help maximize access and adherence. It also has the potential to improve communication about sexuality, strengthen relationships between women and men and increase women's agency over their bodies and their health.

Abstract  Full-text [free] access

Editor’s notes: This paper presents a review of the evidence of microbicides research to understand gender-associated factors that could impact on acceptability, access and adherence. These gender norms include women and men’s sexual norms and power differentials in intimate partner relationships. This review included studies conducted between 2000 and 2013 and thus only includes papers on hypothetical research and clinical trials. While the studies were conducted in a variety of contexts the authors found a number of similar norms and power differentials.

In relation to sexual norms, the review revealed findings on sexual risk, sexual pleasure, and sexual preferences. In terms of sexual risk there were differing opinions across the studies of which women were most likely to need microbicides. Some studies suggested that microbicides should be focused on women in steady partnerships where condom negotiation is difficult, while others suggested focusing on key populations such as sex workers. Across many studies the potential for promoting sexual pleasure for both women and men emerged as an advantage of microbicides, and had an impact on acceptability. However, many of the studies highlighted how men’s sexual pleasure takes precedence. In relation to sexual preferences, the much touted idea that men prefer ‘dry’ or ‘tight’ sex was challenged by some of the studies, which found that the lubricating effect of the gel was acceptable.

The review also uncovered issues associated to power inequalities in intimate partner relationships, including power to control time of sex, male partner engagement and communication, and intimate-partner violence. Women reported in many studies their lack of power to control the timing of sex and this is seen as likely to impact on their ability to use coitally-dependant microbicides. However, there is some evidence that men supported women’s use of the gel, although this depended on the type of relationship. While microbicides have been promoted as products that women can use without a partner’s knowledge the review illustrated that women do prefer to communicate with their partners about their use and there is evidence of joint-decision making. Further, there was evidence of women experiencing intimate partner violence in relation to trial participation. There is also some evidence that women were less likely to discuss or use microbicides in violent relationships.

This highly comprehensive review concludes that while microbicides will not empower women they do have the potential to enhance women’s agency in relation to their health and sexuality and may improve communication in their relationships. However, the authors conclude that gender norms and power differentials may impact on acceptability, access and adherence.

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Why get tested for HIV in Russia?

Motivators and barriers to HIV testing among street-based female sex workers in St. Petersburg, Russia.

King EJ, Maman S, Dudina VI, Moracco KE, Bowling JM. Glob Public Health. 2015 Dec 28:1-16. [Epub ahead of print]

Female sex workers are particularly susceptible to HIV-infection in Russia. However, a dearth of information exists on their utilisation of HIV services. A mixed-methods, cross-sectional study was conducted to examine motivators and barriers to HIV testing among street-based sex workers in St. Petersburg, Russia. The health belief model was the theoretical framework for the study. Twenty-nine sex workers participated in in-depth interviews, and 139 sex workers completed interviewer-administered surveys between February and September 2009. Barriers to getting an HIV test were fear of learning the results, worrying that other people would think they were sick, and the distance needed to travel to obtain services. Motivators for getting tested were protecting others from infection, wanting to know one's status and getting treatment if diagnosed. Logistic regression analysis demonstrated that knowing people living with HIV [aOR = 6.75, 95% CI (1.11, 41.10)] and length of time since start of injection drug use [aOR = 0.30, 95% CI (0.09, 0.97)] were significantly associated with recently getting tested. These results are important to consider when developing public health interventions to help female sex workers in Russia learn their HIV status and get linked to care and treatment services if needed.

Abstract access 

Editor’s notes: This paper summarises findings from a mixed-method study among a sample of female sex workers in St Petersburg, Russian Federation, the majority of whom also inject drugs. This is an important study, allowing the voices of a highly marginalised group to be heard and highlighting barriers and facilitators to HIV testing. Improving access to testing among this population is particularly important given the increased risk of HIV infection that they face. They are susceptible to HIV infection through both sexual and injecting transmission routes. The paper raises some important points such as the widespread misunderstanding about the severity of HIV in the absence of symptoms. HIV was not perceived to be a major problem among the population; there were more immediate problems associated with drug use and sex work. The necessity to travel for testing was seen as a barrier to HIV testing. For a population with multiple and complex health needs this is an acute problem given the vertical structure of the Russian health system. There is a lack of integration across sexual health, drug dependency and HIV and other infectious disease treatment services necessary for this population.  Many other structural barriers were reported to testing including  fear of being registered as having HIV, fear of stigma from friends and health care workers, fear of the unknown associated with infection and disease progression and uncertainty about availability of HIV treatment.  Concerns about treatment availability are particularly relevant since people who inject drugs are often denied HIV treatment in the Russian Federation while they continue to use drugs. This point is important in understanding the context in which HIV testing is accessed. Further discussion on what real benefits knowing your status brings weighed up against the disadvantages of knowing, warrants further discussion in the paper. We know that there is limited and often interrupted HIV treatment available and few ancillary services (such as opioid substitution therapy) to support maintenance of treatment.  We also know that there is much stigma associated with being HIV positive. People living with HIV experience frequent problems with employment and concerns about having children taken into care. All these problems are compounded if you use drugs or sell sex. In this context, the benefits of knowing your status is questionable and is bound to influence uptake of testing.

Asia, Europe
Russian Federation
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Large multi-centre study finds few differences between mortality in migrant and native populations in western Europe

Mortality in migrants living with HIV in western Europe (1997-2013): a collaborative cohort study.

Migrants Working Group on behalf of COHERE in EuroCoord. Lancet HIV. 2015 Dec;2(12):e540-9. doi: 10.1016/S2352-3018(15)00203-9. Epub 2015 Nov 18.

Background: Many migrants face adverse socioeconomic conditions and barriers to health services that can impair timely HIV diagnosis and access to life-saving treatments. We aimed to assess the differences in overall mortality by geographical origin in HIV-positive men and women using data from COHERE, a large European collaboration of HIV cohorts from 1997 to 2013.

Methods: In this observational cohort study, we included HIV-positive, antiretroviral-naive people accessing care in western Europe from COHERE. Individuals were eligible if enrolled in a cohort that collected information on geographical origin or ethnic origin from Jan 1, 1997, to March 19, 2013, aged 18-75 years, they had available information about sex, they were not infected perinatally or after the receipt of clotting factor concentrates, and were naive to combination antiretroviral therapy at cohort entry. Migrants' origins were grouped into seven regions: western Europe and similar countries (Australia, Canada, New Zealand, and the USA); eastern Europe; North Africa and the Middle East; sub-Saharan Africa; Latin America; the Caribbean; and Asia and the rest of Oceania (excluding Australia and New Zealand). Crude and adjusted mortality rate ratios were calculated by use of Poisson regression stratified by sex, comparing each group with the native population. Multiple imputation with chained equations was used to account for missing values.

Findings: Between Oct 25, 1979, and March 19, 2013, we recruited 279 659 individuals to the COHERE collaboration in EuroCoord. Of these 123 344 men and 45 877 women met the inclusion criteria. Our data suggested effect modification by transmission route (pinteraction=0.12 for men; pinteraction=0.002 for women). No significant difference in mortality was identified by geographical origin in men who have sex with men. In heterosexual populations, most migrant men had mortality lower than or equal to that of native men, whereas no group of migrant women had mortality lower than that in native women. High mortality was identified in heterosexual men from Latin America (rate ratio [RR] 1.46, 95% CI 1.00-2.12, p=0.049) and heterosexual women from the Caribbean (1.48, 1.29-1.70, p<0.0001). Compared with that in the native population, mortality in injecting drug users was similar or low for all migrant groups.

Interpretation: Characteristics of and risks faced by migrant populations with HIV differ for men and women and for populations infected heterosexually, by sex between men, or by injecting drug use. Further research is needed to understand how inequalities are generated and maintained for the groups with higher mortality identified in this study.

Abstract access 

Editor’s notes: This topical analysis on migrant health from the large COHERE collaboration examined mortality in people living with HIV who are treatment-naïve and enrolling for care in 11 western European countries. Routinely collected data were analysed to explore differences in mortality by region of origin. Overall, few differences in mortality were seen between migrant and native populations, with a general trend of similar or lower mortality among migrants than native populations.  However, diversity within migrant groups even from the same region makes it challenging to interpret summary data. The authors provide interesting insights into these difficulties. For example, the reasons for migration are likely to result in different socio-economic conditions in the host country, but heterogeneity in mortality between sub-groups may be masked when looking at overall mortality in migrants compared with the native population. The authors discuss both the “healthy migrant effect” (the fact that it is often healthier, younger populations who are able to migrate), and the “salmon bias” (the fact people who are ill often return to their place of origin). Both of these effects can lead to an observed lower disease burden in migrants than native populations. At a time when immigration is a hotly debated issue in western Europe this study highlights the challenges in assessing migrant health and the need for further empirical and methodological research in this area.

Europe
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HIV and gay men and other men who have sex with men: an expanding and underfunded epidemic

Financing the response to HIV among gay men and other men who have sex with men: case studies from eight diverse countries.

Grosso A, Ryan O, Tram KH, Baral S. Glob Public Health. 2015 Dec;10(10):1172-84. doi: 10.1080/17441692.2015.1043314. Epub 2015 Jul 3.

Despite reductions in the number of new HIV infections globally, the HIV epidemic among men who have sex with men (MSM) is expanding. This study characterises financing of HIV programmes for MSM and the impact of criminalisation on levels of funding, using data from five countries that criminalise same-sex sexual practices (Ethiopia, Mozambique, Guyana, India and Nigeria) and three that do not (China, Ukraine and Vietnam). For each country, all publicly available documents from the Global Fund to Fight AIDS, Tuberculosis and Malaria for approved HIV/AIDS grants in Rounds 5-9 and Country Operational Plans detailing investments made through the President's Emergency Plan for AIDS Relief (PEPFAR) from US fiscal year (FY) 2007-2009 were examined. Eleven of 20 HIV proposals to the Global Fund contained programmes for MSM totalling approximately $40 million or 6% of proposed budgets. In six countries providing activity-level data on MSM programming, PEPFAR funding that served this population and others ranged from $23.3 million in FY2007 to $35.4 million in FY2009, representing 0.5-25.9% of overall, non-treatment funding over this period. Countries that criminalise same-sex sexual practices spend fewer resources on HIV programmes serving MSM. However, they also show consistent underfunding of programmes serving MSM regardless of context or geography.

 Abstract access

Editor’s notes: Despite encouraging indicators on the reduction of new HIV infections worldwide, the epidemic among gay men and other men who have sex with men continues to grow. This is due to both biological and structural factors. With many governments failing to take responsibility for this at-risk population, funding for gay men and other men who have sex with men-specific programmes often comes from international donors. This study looks at Global Fund and PEPFAR financing of programmes for gay men and other men who have sex with men, comparing funding availability and services offered both in settings where homosexuality is criminalised and settings where it is not.

The study finds that most proposed funding focuses on behaviour change communication, and less frequently on improving sexual health services, community outreach and education. Nations that criminalise homosexuality allocated about 2% of funding towards gay men and other men who have sex with men services, while countries without punitive measures allocated close to 7%. Importantly, both were felt to be inadequately small sums of money in relation to the size of the epidemic. Key stakeholder interviews from criminalising countries suggest that legal restrictions make it more difficult to provide services focused on gay men and other men who have sex with men. Although, little is known about the degree to which gay men and other men who have sex with men access services focused on the general population. The authors also note that countries that criminalise homosexuality may request funds for gay men and other men who have sex with men believing that donors will look favourably on budgets that include these activities. After receiving funds, these countries may re-programme activities, reducing or removing these focussed programmes.

There is comparatively little research done on HIV and gay men and other men who have sex with men in low- and middle-income countries, in particular in African settings. This article contributes to an expanding literature on the subject and raises questions about the role that international donors should play in ensuring an equitable access to services, particularly in the context of reprogramming. This highlights how real impact on the incidence of HIV among gay men and other men who have sex with men requires both demand generation and accountability in equal measure.

Africa, Asia, Europe, Latin America
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Violence experience of women living with HIV: a global study

Violence. Enough already: findings from a global participatory survey among women living with HIV.

Orza L, Bewley S, Chung C, Crone ET, Nagadya H, Vazquez M, Welbourn A. J Int AIDS Soc. 2015 Dec 1;18(6 Suppl 5):20285. doi: 10.7448/IAS.18.6.20285. eCollection 2015.

Introduction: Women living with HIV are vulnerable to gender-based violence (GBV) before and after diagnosis, in multiple settings. This study's aim was to explore how GBV is experienced by women living with HIV, how this affects women's sexual and reproductive health (SRH) and human rights (HR), and the implications for policymakers.

Methods: A community-based, participatory, user-led, mixed-methods study was conducted, with women living with HIV from key affected populations. Simple descriptive frequencies were used for quantitative data. Thematic coding of open qualitative responses was performed and validated with key respondents.

Results: In total, 945 women living with HIV from 94 countries participated in the study. Eighty-nine percent of 480 respondents to an optional section on GBV reported having experienced or feared violence, either before, since and/or because of their HIV diagnosis. GBV reporting was higher after HIV diagnosis (intimate partner, family/neighbours, community and health settings). Women described a complex and iterative relationship between GBV and HIV occurring throughout their lives, including breaches of confidentiality and lack of SRH choice in healthcare settings, forced/coerced treatments, HR abuses, moralistic and judgemental attitudes (including towards women from key populations), and fear of losing child custody. Respondents recommended healthcare practitioners and policymakers address stigma and discrimination, training, awareness-raising, and HR abuses in healthcare settings.

Conclusions: Respondents reported increased GBV with partners and in families, communities and healthcare settings after their HIV diagnosis and across the life-cycle. Measures of GBV must be sought and monitored, particularly within healthcare settings that should be safe. Respondents offered policymakers a comprehensive range of recommendations to achieve their SRH and HR goals. Global guidance documents and policies are more likely to succeed for the end-users if lived experiences are used.

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Editor’s notes: Violence against women who are living with HIV is common globally. This paper reports on a study of 832 women living with HIV from 94 countries who participated in an online survey, recruited through a non-random snowball sampling model. The survey comprised quantitative and qualitative (free text) components. Participants included women who had ever or were currently using injection drugs (14%), who had ever or were currently selling sex (14%), and who had ever or were currently homeless (14%). Lifetime experience of violence among respondents was high (86%). Perpetrators included: intimate partner (59%), family member / neighbour (45%), community member (53%), health care workers (53%) and police, military, prison or detention services (17%). Findings suggest that violence is not a one off occurrence and cannot easily be packaged as a cause or a consequence of HIV. Instead violence occurs throughout women’s lives, takes multiple forms, and has a complex and iterative relationship with HIV.

The study population did not represent all women living with HIV, and was biased towards women with internet access who have an activist interest. Nonetheless, the study provides further evidence of the breadth and frequency of gender based violence experienced by women living with HIV. Key recommendations for policy makers include training of health care workers working in sexual and reproductive services to offer non-discriminatory services to women living with HIV and to effectively respond to disclosures of gender based violence (such as intimate partner violence) as part of the package of care.

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