Articles tagged as "Structural determinants and vulnerability"

Agricultural and microfinance programmes might be part of the mix to achieve the virologic suppression goal

Shamba Maisha: randomized controlled trial of an agricultural and finance intervention to improve HIV health outcomes in Kenya.

Weiser SD, Bukusi EA, Steinfeld RL, Frongillo EA, Weke E, Dworkin SL, Pusateri K, Shiboski S, Scow K, Butler LM, Cohen CR. AIDS. 2015 Jul 23. [Epub ahead of print]

Objectives: Food insecurity and HIV/AIDS outcomes are inextricably linked in sub-Saharan Africa. We report on health and nutritional outcomes of a multisectoral agricultural intervention trial among HIV-infected adults in rural Kenya.

Design: This is a pilot cluster randomized controlled trial.

Methods: The intervention included a human-powered water pump, a microfinance loan to purchase farm commodities, and education in sustainable farming practices and financial management. Two health facilities in Nyanza Region, Kenya were randomly assigned as intervention or control. HIV-infected adults 18 to 49 years old who were on antiretroviral therapy and had access to surface water and land were enrolled beginning in April 2012 and followed quarterly for 1 year. Data were collected on nutritional parameters, CD4 T-lymphocyte counts, and HIV RNA. Differences in fixed-effects regression models were used to test whether patterns in health outcomes differed over time from baseline between the intervention and control arms.

Results: We enrolled 72 and 68 participants in the intervention and control groups, respectively. At 12 months follow-up, we found a statistically significant increase in CD4 cell counts (165 cells/µl, P < 0.001) and proportion virologically suppressed in the intervention arm compared with the control arm (comparative improvement in proportion of 0.33 suppressed, odds ratio 7.6, 95% confidence interval: 2.2-26.8). Intervention participants experienced significant improvements in food security (3.6 scale points higher, P < 0.001) and frequency of food consumption (9.4 times per week greater frequency, P = 0.013) compared to controls.

Conclusion: Livelihood interventions may be a promising approach to tackle the intersecting problems of food insecurity, poverty and HIV/AIDS morbidity.

Abstract access 

Editor’s notes: There is compelling evidence of a vicious cycle between food insecurity and HIV transmission, morbidity and mortality. Studies have been finding alarmingly high rates of moderate and severe food insecurity among ART initiates in east Africa, at least 70%. At a time when the world is aiming to achieve the 90-90-90 targets, (90% of HIV positive individuals knowing their status, 90% of people being on ART and 90% of people on ART being virally suppressed) and thus increase viral suppression to 90%, among people on antiretroviral therapy, it is clear that the effectiveness and efficiency of treatment will depend on how food insecurity is addressed, within and/or alongside the HIV programme.

In this pilot study in Kenya, the authors report on an agricultural and microfinance programme provided to food-insecure adults living with HIV, who had access to farming land and surface water. Study participants were mainly established patients who had been on ART for an average of 2.8 years. The study finds a significant increase in CD4 cell counts (165 cells/mm3) and a comparative increase in the proportion of patients with virologic suppression, of 33%. In addition, significant improvements were found on the food security scale. These included the diversity and frequency of food consumption, as well as increases in BMI, despite no significant changes in food expenditures. However, it is important to note that the programme and control samples were unbalanced, with the programme group starting with higher food insecurity and a lower proportion of virologic suppression. Moreover, with only two sites, the study could not separate the programme effects from cluster-level variables, underscoring the need for a larger cluster RCT to confirm these findings.

Although this is a pilot RCT with a small sample size and other limitations, it provides promising evidence that a multi-sectoral agricultural and microfinance programme can have direct effects on ART outcomes, as well as impacting on food insecurity and nutrition outcome measures. While previous studies have reported on the effects of food assistance for people on ART, this study is an important addition to the evidence, as it is one of the first to report on a potentially sustainable agricultural-microfinance programme. Also, by measuring multiple outcomes across sectors, it allows for a more balanced appraisal of the programmes societal benefits, rather than only considering its HIV dividend. 

Africa
Kenya
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Community health workers can improve emotional wellbeing of mothers in a high HIV prevalence setting

Alcohol use, partner violence, and depression: a cluster randomized controlled trial among urban South African mothers over 3 years.

Rotheram-Borus MJ, Tomlinson M, Roux IL, Stein JA. Am J Prev Med. 2015 Jul 28. pii: S0749-3797(15)00225-1. doi: 10.1016/j.amepre.2015.05.004. [Epub ahead of print]

Introduction: Pregnant South African women with histories of drinking alcohol, abuse by violent partners, depression, and living with HIV are likely to have their post-birth trajectories over 36 months significantly influenced by these risks.

Design: All pregnant women in 24 Cape Town neighborhoods were recruited into a cluster RCT by neighborhood to either: (1) a standard care condition (n=12 neighborhoods, n=594 mothers); or (2) a home-visiting intervention condition (n=12 neighborhoods, n=644 mothers).

Setting/participants: Pregnant women residing in urban, low-income neighborhoods in Cape Town, South Africa.

Intervention: Home visiting included prenatal and postnatal visits by community health workers (Mentor Mothers) focusing on general maternal and child health, HIV/tuberculosis, alcohol use, and nutrition.

Main outcome measures: Mothers were assessed in pregnancy and at 18 and 36 months post birth: 80.6% of mothers completed all assessments between 2009 and 2014 and were included in these analyses performed in 2014. Longitudinal structural equation modeling examined alcohol use, partner violence, and depression at the baseline and 18-month interviews as predictors of maternal outcomes at 36 months post birth.

Results: Relative to standard care, intervention mothers were significantly less likely to report depressive symptoms and more positive quality of life at 36 months. Alcohol use was significantly related to use over time, but was also related to depression and HIV status at each assessment and partner violence at 36 months.

Conclusions: Alcohol, partner violence, and depression are significantly related over time. A home-visiting intervention improved the emotional health of low-income mothers even when depression was not initially targeted.

Abstract  Full-text [free] access

Editor’s notes: This study evaluates the use of community health workers (CHW) to implement a programme to improve maternal wellbeing among low-income mothers in Cape Town, South Africa from pregnancy until 36 months after birth. This is a setting with high prevalence of HIV (about 30% of pregnant women are HIV positive in the Western Cape), and the programme followed a behaviour-change model focused on alcohol and HIV (but not intimate partner violence [IPV] or depression). The programme was associated with improved maternal emotional health at 36 months. However, there was relatively little change in alcohol use or IPV.  Overall, the study underlines the inter-relationships between alcohol use, intimate partner violence, HIV and depression. Further, it suggests that future programmes should train CHWs to expand their activities to depression and IPV as well as HIV, and alcohol.

Africa
South Africa
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Starting ART earlier may not only improve health outcomes, but perhaps save money too?

Time and money: the true costs of health care utilization for patients receiving 'free' HIV/TB care and treatment in rural KwaZulu-Natal.

Chimbindi N, Bor J, Newell ML, Tanser F, Baltusen R, Hontelez J, de Vlas S, Lurie M, Pillay D, Bärnighausen T. J Acquir Immune Defic Syndr. 2015 Jun 18. [Epub ahead of print]

Background: HIV and TB services are provided free-of-charge in many sub-Saharan African countries, but patients still incur costs.

Methods: Patient-exit interviews were conducted with a representative sample of 200 HIV-infected patients not yet on ART (pre-ART), 300 ART patients, and 300 TB patients receiving public sector care in rural South Africa. For each group, we calculated health expenditures across different spending categories, time spent traveling to and utilizing services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models.

Results: Total monthly health expenditures (7.3 South African Rand: 1 USD) were: 171 (95%CI 134-207) for pre-ART, 164 (95%CI 141-187) for ART, and 122 (95%CI 105-140) for TB patients. Total monthly time costs (in hours) were: 3.4 (95%CI 3.3-3.5) for pre-ART, 5.0 (95%CI 4.7-5.3) for ART and 3.2 (95%CI 2.9-3.4) for TB patients. Though costs were similar across groups, pre-ART patients spent significantly more on traditional healers, chemists, and private doctors, while ART and TB patients spent more on transport to clinic visits. 31% of pre-ART, 39% of ART and 41% of TB patients borrowed money or sold assets to finance health costs.

Conclusions: Patients receiving nominally free care for HIV/TB face large private costs. Subsidized transport, fewer clinic visits, and drug pick-up points closer to home could reduce costs for ART patients, potentially improving adherence and retention. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under TASP, may not impose substantial costs on patients.

Abstract access

Editor’s notes: At the time of this study, in 2010 in South Africa, people living with HIV and on antiretroviral therapy (ART) made monthly visits to the clinic to collect their medication and for clinic observation in their first year on ART. They visited every other month in subsequent years. People receiving TB treatment also attended the clinic once a month. People living with HIV who had not yet started ART visited the clinic every six or 12 months, depending on the CD4 cell count. The authors were surprised to find that for the third group, people who they term ‘pre-ART’, the costs of health care utilisation were roughly equivalent to the costs for people receiving monthly or bi-monthly ART and/or TB treatment.  The difference is attributed in this paper to the time and money spent by people living with HIV yet to commence ART on traditional healers and self-medication. Hence, the conclusion that the earlier initiation of ART is unlikely to increase health utilisation costs. Indeed, alternative treatment schedules, with people on ART visiting health facilities less frequently as their years on treatment progress, can reduce costs further for people on ART. The assumption made in the paper is that pre-ART people starting treatment cease to access alternative care. Given the context of this study, where the authors claim that the use of alternative therapies for people on ART is not common, this may be correct. The possibility exists that given that data were collected through patient-exit interviews, people taking ART or TB medication may have been cautious about disclosing their use of alternative therapies. Concerns over sharing such information with interviewers attached to a medical research organisation, are not uncommon. This is an area in need of further, mixed methods, research to investigate the ‘true costs of health care utilisation’. This current paper takes us a step towards that goal. 

Africa
South Africa
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Police violence and female sex work in south India

Change over time in police interactions and HIV risk behavior among female sex workers in Andhra Pradesh, India.

Erausquin JT, Reed E, Blankenship KM. AIDS Behav. 2015 Jun;19(6):1108-15. doi: 10.1007/s10461-014-0926-5.

Little is known about the effectiveness of intervening to change interactions between female sex workers (FSWs) and police in order to reduce HIV risk. Using data collected in the context of a HIV prevention intervention that included components to change policing practices (n = 1680), we examine the association of FSWs' reports of negative police interactions and HIV risk behaviors and whether these associations varied over time. Results show negative police interactions declined significantly over time. FSWs who had more than one negative police interaction were more likely to experience STI symptoms (AOR 2.97 [95 % CI 2.27-3.89]), inconsistently use condoms with their clients (AOR 1.36 [95 % CI 1.03-1.79]), and accept more money for condomless sex (AOR 2.37 [95 % CI 1.76-3.21]). Over time, these associations were stable or increased. Even where interventions have reduced the number of police incidents experienced by FSWs, stakeholders in HIV prevention must remain vigilant in challenging these incidents.

Abstract access 

Editor’s notes: Laws relating to sex work are frequently ambiguous. This allows considerable police discretion about who to arrest and under what charges. Bribes and arrest both have real monetary costs for female sex workers, who are already usually economically vulnerable. Financial pressure and or poverty can push women into agreeing to riskier sex with riskier clients in riskier places. This paper examined if negative police experience is associated with increased HIV risk behaviours; and if negative police experience changed over time following comprehensive HIV prevention programming.

The study found negative police interactions in the previous six months were frequent. Police raided workplace (36.1%), police arrested respondent (14.5%), police accepted bribe or gift so respondent could avoid trouble (14.8%), police had sex with respondent so she could avoid trouble (11.1%) and police took condoms away (7.6%). Negative police interactions were linked with an increased HIV risk including STI symptoms in the past 12 months; inconsistent condom use with clients in the past seven days and accepting more money for sex without a condom. However, there was a reduction over time in the proportion of women experiencing one or more negative police interactions in the past six months (21.2% versus 16.2%).  Risk behaviours also reduced over time.

This study adds to emerging literature that it is possible to intervene against violence exposure and negative police interaction as part of HIV prevention programming. It also underscores the importance of structural drivers in enhancing HIV risk among female sex worker populations.

Asia
India
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Men who have sex with men in sub-Saharan Africa: a review of the evidence

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review.

Dijkstra M, van der Elst EM, Micheni M, Gichuru E, Musyoki H, Duby Z, Lange JM, Graham SM, Sanders EJ. Int Health. 2015 May;7(3):151-162. Epub 2015 Jan 16.

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011-2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online training.

Abstract  Full-text [free] access

Editor’s notes: Same sex practices remain criminalised in sub-Saharan Africa. Gay men and other men who have sex with men face stigma, discrimination, harassment and arrest. Health care workers frequently have no training on issues affecting gay men and other men who have sex with men and are ill-prepared to work sensitively with them. Together these can deter these men from accessing health care and HIV/STI services, increasing their risk of HIV and other poor health outcomes.

This study conducted a systematic review of gay men and other men who have sex with men in sub-Saharan Africa. The findings were used to update an on-line training programme for health care workers in Kenya. This previously comprised modules on i) men who have sex with men and HIV in Africa ii) homophobia: stigma and its effects; iii) sexual identity, coming out and disclosure; iv) anal sex and common sexual practices; v) HIV and STIs; vi) condom and lubricant use; vii) mental health: anxiety, depression and substance use; and viii) risk-reduction counselling. The review updated the training programme with new evidence and two new modules were introduced: ix) ART adherence; and x) community engagement.

Health care workers play a crucial role in reducing stigma and discrimination facing gay men and other men who have sex with men. This systematic review provided a valuable step in updating an important, accessible training programme. Reducing homoprejudice and ensuring health care workers have accurate and up-to-date knowledge are key to improving service uptake by gay men and other men who have sex with men.

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How the type of chronic illness in a household affects a child’s risk of abuse: findings from South Africa

Household illness, poverty and physical and emotional child abuse victimisation: findings from South Africa's first prospective cohort study.

Meinck F, Cluver LD, Boyes ME. BMC Public Health. 2015 May 1;15(1):444. doi: 10.1186/s12889-015-1792-4.

Background: Physical and emotional abuse of children is a large scale problem in South Africa, with severe negative outcomes for survivors. Although chronic household illness has shown to be a predictor for physical and emotional abuse, no research has thus far investigated the different pathways from household chronic illness to child abuse victimisation in South Africa.

Methods: Confidential self-report questionnaires using internationally utilised measures were completed by children aged 10-17 (n = 3515, 56.7% female) using door-to-door sampling in randomly selected areas in rural and urban locations of South Africa. Follow-up surveys were conducted a year later (96.7% retention rate). Using multiple mediation analyses, this study investigated direct and indirect effects of chronic household illness (AIDS or other illness) on frequent (monthly) physical and emotional abuse victimisation with poverty and extent of the ill person's disability as hypothesised mediators.

Results: For children in AIDS-ill families, a positive direct effect on physical abuse was obtained. In addition, positive indirect effects through poverty and disability were established. For boys, a positive direct and indirect effect of AIDS-illness on emotional abuse through poverty were detected. For girls, a positive indirect effect through poverty was observed. For children in households with other chronic illness, a negative indirect effect on physical abuse was obtained. In addition, a negative indirect effect through poverty and positive indirect effect through disability was established. For boys, positive and negative indirect effects through poverty and disability were found respectively. For girls, a negative indirect effect through poverty was observed.

Conclusions: These results indicate that children in families affected by AIDS-illness are at higher risk of child abuse victimisation, and this risk is mediated by higher levels of poverty and disability. Children affected by other chronic illness are at lower risk for abuse victimisation unless they are subject to higher levels of household disability. Interventions aiming to reduce poverty and increase family support may help prevent child abuse in families experiencing illness in South Africa.

Abstract  Full-text [free] access

Editor’s notes: Research has illustrated that children in an HIV- affected household in sub-Saharan Africa are at an increased risk of child maltreatment. This is the first longitudinal study to examine pathways from household chronic illness to child abuse in the developing world through multiple mediation analysis. Using confidential self-report questionnaires the study collected data from 3515 children (aged 10 to 17 years) in South Africa.

What is striking in their findings is the difference that they found in the relationship between risk of child abuse and the type of illness affecting the household, mediated by poverty and disability. They noted higher levels of physical and emotional abuse among HIV-affected households compared to households without HIV. However, they also found that households affected by other chronic illness had lower abuse prevalence rates. Given that diabetes and high blood pressure are more likely to affect older age people, the authors hypothesise that the ill member of the household would likely have access to a state pension and thus benefit from some protection from the risk of poverty. The exception to this hypothesis were households within this group who had high levels of disability.

This study provides a valuable contribution because previous research has primarily focused on AIDS or cancer-affected households. These households are likely to need to manage higher levels of associated stigma, a shorter perceived life expectancy and more complex treatment options. As such previous research may have presented a more extreme relationship between illness status of household and a child’s risk of abuse. The findings highlight the significance for activities and programming in identifying two groups of households which are at heightened risk for child abuse: HIV affected households; and households affected by other chronic conditions. 

Africa
South Africa
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The impact of cash transfers on orphans and other children made vulnerable by HIV

Effects of cash transfers on children's health and social protection in sub-Saharan Africa: differences in outcomes based on orphan status and household assets.

Crea TM, Reynolds AD, Sinha A, Eaton JW, Robertson LA, Mushati P, Dumba L, Mavise G, Makoni JC, Schumacher CM, Nyamukapa CA, Gregson S. BMC Public Health. 2015 May 28;15:511. doi: 10.1186/s12889-015-1857-4.

Background: Unconditional and conditional cash transfer programmes (UCT and CCT) show potential to improve the well-being of orphans and other children made vulnerable by HIV/AIDS (OVC). We address the gap in current understanding about the extent to which household-based cash transfers differentially impact individual children's outcomes, according to risk or protective factors such as orphan status and household assets.

Methods: Data were obtained from a cluster-randomised controlled trial in eastern Zimbabwe, with random assignment to three study arms - UCT, CCT or control. The sample included 5331 children ages 6-17 from 1697 households. Generalized linear mixed models were specified to predict OVC health vulnerability (child chronic illness and disability) and social protection (birth registration and 90% school attendance). Models included child-level risk factors (age, orphan status); household risk factors (adults with chronic illnesses and disabilities, greater household size); and household protective factors (including asset-holding). Interactions were systematically tested.

Results: Orphan status was associated with decreased likelihood for birth registration, and paternal orphans and children for whom both parents' survival status was unknown were less likely to attend school. In the UCT arm, paternal orphans fared better in likelihood of birth registration compared with non-paternal orphans. Effects of study arms on outcomes were not moderated by any other risk or protective factors. High household asset-holding was associated with decreased likelihood of child's chronic illness and increased birth registration and school attendance, but household assets did not moderate the effects of cash transfers on risk or protective factors.

Conclusion: Orphaned children are at higher risk for poor social protection outcomes even when cared for in family-based settings. UCT and CCT each produced direct effects on children's social protection which are not moderated by other child- and household-level risk factors, but orphans are less likely to attend school or obtain birth registration. The effects of UCT and CCT are not moderated by asset-holding, but greater household assets predict greater social protection outcomes. Intervention efforts need to focus on ameliorating the additional risk burden carried by orphaned children. These efforts might include caregiver education, and additional incentives based on efforts made specifically for orphaned children.

Abstract  Full-text [free] access

Editor’s notes: In sub-Saharan Africa, there is growing evidence on the impact of cash transfers on youth HIV risk, health outcomes of orphans and other children made vulnerable by HIV and on social protection outcomes such as school attendance. Using data from a cluster randomised controlled trial in Zimbabwe, the authors sought to understand the extent to which individual level children’s risk factors and household asset accumulation influence the effects of cash transfers on child health (chronic illness and disability) and child social protection (birth registration status and school attendance) outcomes.

There was no evidence to illustrate that the type of orphan status, maternal or paternal or both, was associated with child disability or chronic illness. There was some evidence that suggested that orphan status predicted social vulnerability, i.e., risk for not obtaining birth registration. However the receipt of an unconditional cash transfer buffered this risk for paternal orphans, suggesting birth registration being a gendered activity and that mothers of paternal orphans might use cash incentives to invest in the human capital of their children. Results also demonstrate that cash transfers, both unconditional and conditional, and household accumulation of assets have positive effects on social protection outcomes including birth registration and school attendance, separately. But the effect of cash transfers is not influenced by the amount of assets held by a household. Furthermore, in contrast to other studies, there is no evidence from these findings to illustrate that cash transfers have an effect on health outcomes. However, asset holding seems to have a weak, but positive effect on children’s chronic illness, but no effect on chronic disability. This suggests that households with some assets are able to use these assets to access health care services to treat chronic illness. Furthermore these households with greater assets may also experience better living conditions which perhaps contribute to better health outcomes.

Given the financial burden of HIV on households caring for orphan and vulnerable children, programme efforts for HIV prevention should focus on addressing this burden. This study contributes to the evidence base from other countries in sub-Saharan Africa.  Findings from Malawi and Kenya, for example, have illustrated that the provision of cash transfers to HIV affected households provide a substantial boost that is effective in improving outcomes among vulnerable children, in particular certain social protection outcomes, such as school attendance.

Africa
Zimbabwe
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Good dads stay healthy!

" . . . I should maintain a healthy life now and not just live as I please . . . ": men's health and fatherhood in rural South Africa.

Hosegood V, Richter L, Clarke L. Am J Mens Health. 2015 May 25. pii: 1557988315586440. [Epub ahead of print]

This study examines the social context of men's health and health behaviors in rural KwaZulu-Natal, South Africa, particularly in relationship to fathering and fatherhood. Individual interviews and focus groups were conducted with 51 Zulu-speaking men. Three themes related to men's health emerged from the analysis of transcripts: (a) the interweaving of health status and health behaviors in descriptions of "good" and "bad" fathers, (b) the dominance of positive accounts of health and health status in men's own accounts, and (c) fathers' narratives of transformations and positive reinforcement in health behaviors. The study reveals the pervasiveness of an ideal of healthy fathers, one in which the health of men has practical and symbolic importance not only for men themselves but also for others in the family and community. The study also suggests that men hold in esteem fathers who manage to be involved with their biological children who are not coresident or who are playing a fathering role for nonbiological children (social fathers). In South Africa, men's health interventions have predominantly focused on issues related to HIV and sexual health. The new insights obtained from the perspective of men indicate that there is likely to be a positive response to health interventions that incorporate acknowledgment of, and support for, men's aspirations and lived experiences of social and biological fatherhood. Furthermore, the findings indicate the value of data on men's involvement in families for men's health research in sub-Saharan Africa.

Abstract access 

Editor’s notes: As the authors of this paper note, a lot of research has looked at men’s sexual and health-associated behaviour as risk factors for HIV infection of their partners and themselves. Far less attention has been paid to men’s family situation and how this, and how they view their family role, shapes their health behaviours. This paper begins to fill that gap. Using data from in-depth interviews and group discussions with 51 men in KwaZulu-Natal, South Africa, the authors describe how men view themselves as ‘fathers’ and how this affects what they do. Each of the men set out what this role means for how they behave and believe other fathers should behave. While the authors note that the sample would have been biased towards men happy to talk about being a father, the results are quite striking. The men frequently described the positive things they did for their children and wanted to do for their families. They claimed their own health behaviours to be exemplary. The men compared ‘good’ fathers with ‘bad’ fathers’, men who drank and were sexually promiscuous. All the respondents were ‘good’ fathers. Not one of the men disclosed their HIV-status during the interviews. The authors note that the men were much freer discussing diet, weight, smoking and alcohol than HIV. Given HIV-associated stigma and the negative stereotypes of promiscuous men spreading infection, it is hardly surprising that men constructed a positive identity through their narratives and distanced themselves from personal HIV-associated discussion. Tailored health messages which reinforce the behaviour of ‘good fathers’ are likely to have a greater impact on these men’s sexual behaviour than messages that aim to scare.

Africa
South Africa
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Alcohol and ART do not mix – but how to get the message across?

Qualitative study of changes in alcohol use among HIV-infected adults entering care and treatment for HIV/AIDS in rural southwest Uganda.

Sundararajan R, Wyatt MA, Woolf-King S, Pisarski EE, Emenyonu N, Muyindike WR, Hahn JA, Ware NC. AIDS Behav. 2015 Apr;19(4):732-41. doi: 10.1007/s10461-014-0918-5.

Alcohol has a substantial negative impact on the HIV epidemic in sub-Saharan Africa, particularly in Uganda, where heavy alcohol consumption is common. Using a content analytic approach, this qualitative study characterizes changes in alcohol use among 59 HIV-infected Ugandan adults (>18 years old), who reported any alcohol use in the previous year as they entered HIV care. Most participants reported attempting to cease or reduce alcohol intake over the study period. Reasons for decreased use included advice from clinicians, interference with social obligations, threats to financial security, and negative impact on social standing. Participants reported difficulty abstaining from alcohol, with incentives to continue drinking including desire for social inclusion, stress relief, and enjoyment of alcohol. These contrasting incentives created a moral quandary for some participants, who felt 'pulled' between 'good' and 'bad' influences. Results suggest brief interventions addressing self-identified obstacles to change may facilitate long-term reductions in drinking in this population.

Abstract  Full-text [free] access

Editor’s notes: The heavy consumption of alcohol may facilitate the risk of infection with HIV.  Alcohol use can also affect adherence to antiretroviral therapy and may also have an impact on disease progression. This paper on alcohol use among people initiating antiretroviral therapy in Uganda is an important addition to the literature. As well as using in-depth interviews to gather information from people newly initiated on antiretroviral therapy, the research team also observed clinic consultations and other activities. As a result, the authors can describe in this paper the rather moralistic tone adopted by some counsellors who urged participants to stop drinking alcohol without really explaining why. This contrasted with information provided by clinicians on the risk of alcohol interfering with the absorption of medication; something that participants found much more persuasive. The authors describe the benefits as well as risks associated with alcohol use, noting that these factors are very similar to challenges faced by general populations in other settings. This leads the authors to conclude that - motivational interviewing - an approach to alcohol use reduction which has proved successful in resource-rich settings could work in resource-limited settings like Uganda. Such programmes provide a way for participants to develop strategies to address obstacles to change, while receiving support from trained staff at the clinic. This paper not only provides valuable information from a well-designed study but also provides encouragement for the use of brief programmes in Africa.    

Africa
Uganda
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Multiple harms faced by Azerbaijani prisoners

Burden of substance use disorders, mental illness, and correlates of infectious diseases among soon-to-be released prisoners in Azerbaijan.

Azbel L, Wickersham JA, Wegman MP, Polonsky M, Suleymanov M, Ismayilov R, Dvoryak S, Rotberga S, Altice FL. Drug Alcohol Depend. 2015 Mar 19. pii: S0376-8716(15)00136-2. doi: 10.1016/j.drugalcdep.2015.02.034. [Epub ahead of print]

Background: Despite low HIV prevalence in the South Caucasus region, transmission is volatile. Little data are available from this region about addiction and infectious diseases among prisoners who transition back to communities.

Methods: A nation-wide randomly sampled biobehavioral health survey was conducted in 13 non-specialty Azerbaijani prisons among soon-to-be-released prisoners. After informed consent, participants underwent standardized health assessment surveys and testing for HIV, hepatitis B and C, and syphilis.

Results: Of the 510 participants (mean age=38.2 years), 11.4% were female, and 31.9% reported pre-incarceration drug injection, primarily of heroin. Prevalence of HCV (38.2%), HIV (3.7%), syphilis (3.7%), and HBV (2.7%) was high. Among the 19 HIV-infected inmates, 14 (73.7%) were aware of their HIV status, 12 (63.2%) were receiving antiretroviral therapy (ART), and 5 (26.3%) had CD4<350cells/mL (4 of these were on ART). While drug injection was the most significant independent correlate of HCV (AOR=12.9; p=0.001) and a significant correlate of HIV (AOR=8.2; p=0.001), both unprotected sex (AOR=3.31; p=0.049) and working in Russia/Ukraine (AOR=4.58; p=0.008) were also correlated with HIV.

Conclusion: HIV and HCV epidemics are concentrated among people who inject drugs (PWIDs) in Azerbaijan, and magnified among prisoners. A transitioning HIV epidemic is emerging from migration from high endemic countries and heterosexual risk. The high diagnostic rate and ART coverage among Azerbaijani prisoners provides new evidence that HIV treatment as prevention in former Soviet Union (FSU) countries is attainable, and provides new insights for HCV diagnosis and treatment as new medications become available. Within prison evidence-based addiction treatments with linkage to community care are urgently needed.

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Editor’s notes: This is an important study describing prevalence of HIV, hepatitis B and hepatitis C among a prison population in Azerbaijan. The importance of the study stems from the need to monitor infections among a highly vulnerable population of prisoners. While the study does not report on current injecting drug use among the population, a third of the sample reported injecting drugs prior to their detention and will need support with their injecting drug use while in prison. This will include the provision of opioid substitution therapy and needle-syringe programmes.  This study highlights the vulnerability of prisoners to HIV, hepatitis B and hepatitis C and the need for harm reduction in prisons. At the same time, the study also highlights other adverse health outcomes relating to drug use or being in prison in terms of poor mental health outcomes among the sample. It illustrates an association between a measure of anxiety disorder and HIV infection. The strengths of this study lie in the large sample that were recruited from a broad range of prison facilities across the country, increasing the representativeness of the findings to all people living in prisons. Findings suggest an association between HIV infection and condomless sex, as well as a history of working in Russia and Ukraine. This suggests the potential for transmission of HIV across the region and points to the potential for sexual transmission of HIV in a region where transmission has been historically driven by injecting drug use. Findings contribute to the growing evidence for the urgent need for hepatitis C virus (HCV) treatment and increased access to needle-syringe programmes and opioid substitution therapy within prisons and communities in the region.  The high adherence among prisoners to HIV treatment demonstrates the provision of HCV treatment to the population is entirely feasible. Previous evidence from Russia has illustrated the difficulties for people living in prisons in maintaining HIV treatment post-release and this study underscores the need for support to facilitate the integration of individuals into harm reduction programmes including HIV treatment in community settings post-release. 

Europe
Azerbaijan
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