Articles tagged as "Strengthen HIV integration"

Can children recognise HIV-associated symptoms in their carers? Evaluation of a verbal assessment tool for children in South Africa.

Measuring child awareness for adult symptomatic HIV using a verbal assessment tool: concordance between adult-child dyads on adult HIV-associated symptoms and illnesses.

Becker E, Kuo C, Operario D, Moshabela M, Cluver L. Sex Transm Infect. 2015 Nov;91(7):528-33. doi: 10.1136/sextrans-2014-051728. Epub 2015 Jan 13.

Objectives: This study assessed children's awareness for adult HIV-associated symptoms and illnesses using a verbal assessment tool by analysing inter-rater reliability between adult-child dyads. This study also evaluated sociodemographic and household characteristics associated with child awareness of adult symptomatic HIV.

Methods: A cross-sectional survey using a representative community sample of adult-child dyads (N=2477 dyads) was conducted in KwaZulu-Natal, South Africa. Analyses focused on a subsample (n=673 adult-child dyads) who completed verbal assessment interviews for symptomatic HIV. We used an existing validated verbal autopsy approach, originally designed to determine AIDS-related deaths by adult proxy reporters. We adapted this approach for use by child proxy reporters for reporting on HIV-associated symptoms and illnesses among living adults. Analyses assessed whether children could reliably report on adult HIV-associated symptoms and illnesses and adult provisional HIV status.

Results: Adult-child pairs concurred above the 65th percentile for 9 of the 10 HIV-associated symptoms and illnesses with sensitivities ranging from 10% to 100% and specificities ranging from 20% to 100%. Concordant reporting between adult-child dyads for the adult's provisional HIV status was 72% (sensitivity=68%, specificity=73%). Children were more likely to reliably match adult's reports of provisional HIV status when they lived in households with more household members, and households with more robust socioeconomic indicators including access to potable water, food security and television.

Conclusions: Children demonstrate awareness of HIV-associated symptoms and illnesses experienced by adults in their household. Children in households with greater socioeconomic resources and more household members were more likely to reliably report on the adult's provisional HIV status.

Abstract Full-text [free] access

Editor’s notes: This study tested a new tool for assessing whether children who are caring for adults living with HIV in their household are able to recognise HIV-associated symptoms and illnesses. The study was conducted with households in one rural and one urban site in KwaZulu-Natal, South Africa. The authors report on the analysis of results from a sub-sample of 673 dyads, composed of one adult and one child living in the same household. With the help of researchers, children aged 10-17, completed a verbal tool that was adapted for this study from a previous ‘verbal autopsy’ tool used to assess AIDS-associated deaths. The adult in each of the dyads also completed an adult version of the study’s adapted tool. The tool contained questions on ten symptoms and illnesses associated with HIV. Some of these strongly indicate HIV presence when found in a combination of two or more (e.g. TB; oral candidiasis; diarrhoea; herpes). Children-adult responses were compared in each dyad and tested for concurrency and sensibility. Overall, children and adult responses matched for more than 65% for nine out of ten of the symptoms/illnesses listed. There were variations in reliable matching depending on symptoms/illnesses. Some symptoms may have been harder for children to report on behalf of the adult, for example, constant diarrhoea. The tool used with the children may be useful for improving our understanding of the issues faced by young carers in households where some members are living with HIV. The tool may also help to understand strategies put in place by young carers looking after an adult with HIV-associated illnesses.

Africa
South Africa
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Vulnerabilities of children living with HIV positive adults

Children living with HIV-infected adults: estimates for 23 countries in sub-Saharan Africa.

Short SE, Goldberg RE. PLoS One. 2015 Nov 17; 10(11): e0142580.

Background: In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children's health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children's health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods: Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results: The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion: Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

Abstract Full-text [free] access

Editor’s notes: This paper is an important contribution to the literature on the impact of the HIV epidemic. Using Demographic and Health Survey (DHS) data from 23 countries it highlights the considerable number of children living with HIV-positive adults in sub-Saharan Africa. However, notable exceptions from the analysis (no DHS data available) included South Africa. This, coupled with specific issues related to DHS data collection methods and response rates, means that the number of children living with HIV-positive adults is much higher. Reductions in mortality from HIV due to increased treatment availability and the addition of adults newly acquiring HIV means that population of children living with an HIV-positive adult will continue to increase in the near future.

Children living with HIV-positive adults are clearly vulnerable and like all vulnerable children should be focussed on in efforts to promote child wellbeing. The authors suggest, however, that children living with HIV-positive adults may have distinct vulnerabilities that need to be considered. These include direct exposure to opportunistic infections, social stigma and disrupted networks, as well as increases in poverty. The challenge for many countries is how to identify these children and ensure that focussed programmes are delivered effectively.

Africa
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How many people have really died of HIV/AIDS in South Africa?

HIV/AIDS in South Africa: how many people died from the disease between 1997 and 2010?

Bradshaw D, Msemburi W, Dorrington R, Pillay-van Wyk V, Laubscher R, Groenewald P, team SN. AIDS. 2015 Oct 27. [Epub ahead of print]

Objectives: Empirical estimates of the number of HIV/AIDS deaths are important for planning, budgeting, and calibrating models. However, there is an extensive misattribution of HIV/AIDS as an underlying cause-of-death. This study estimates the true numbers of AIDS deaths from South African vital statistics between 1997 and 2010.

Methods: Individual-level cause-of-death data were grouped according to a local burden of disease list and source causes (i.e. causes under which AIDS deaths are misclassified) that recorded a rapid increase. After adjusting for completeness of registration, mortality rate of the source causes, by age and sex, was regressed on lagged HIV prevalence to estimate the rate of increase correlated with HIV. Background trends in the source-cause mortality rates were estimated from the trend experienced among 75-84 year olds.

Results: Of 214 causes considered, 19 were identified as potential sources for cause misattribution. High proportions of deaths from tuberculosis, lower respiratory infections (mostly pneumonia), diarrhoeal diseases, and ill-defined natural causes were estimated to be HIV-related, with only 7% of the estimated AIDS deaths being recorded as HIV. Estimated HIV/AIDS deaths increased rapidly, then reversed after 2006, totalling 2.8 million deaths over the whole period. The number was lower than model estimates from UNAIDS and the Global Burden of Disease Study.

Conclusion: Empirically based estimates confirm the considerable loss of life from HIV/AIDS and should be used for calibrating models of the AIDS epidemic which generally appear too low for infants but too high for other ages. Doctors are urged to specify HIV on death notifications to provide reliable cause-of-death statistics.

Abstract access 

Editor’s notesIn many countries, the true number of HIV-associated deaths is significantly under-reported in national vital registration data making it difficult to monitor the epidemic trends from this source. This study describes new estimates of HIV-associated mortality based on empirical vital registration data which aimed to provide accurate estimates of the numbers of HIV-associated deaths in South Africa. The study estimates that, from 1997-2010, 2.86 million deaths in South Africa were due to HIV – over one-third of all deaths. However, relatively few deaths, 7%, were registered as HIV-associated. At the peak of the epidemic in 2006 the vital registration derived estimates show lower trends than other models. All models estimated a decline in the number of HIV-associated deaths post-2008, a finding which is consistent with the extensive roll-out of antiretroviral therapy in South Africa, and with trends reported from verbal autopsy data for all deaths in rural South African demographic surveillance sites. This paper highlights the importance of reporting accurate causes for HIV-associated deaths in the death registration process - however, without de-stigmatisation of HIV, this is going to be difficult to achieve.

Africa
South Africa
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Comparing strategies for HIV testing and counselling for children and adolescents

Uptake and yield of HIV testing and counselling among children and adolescents in sub-Saharan Africa: a systematic review.

Govindasamy D, Ferrand RA, Wilmore SM, Ford N, Ahmed S, Afnan-Holmes H, Kranzer K. J Int AIDS Soc. 2015 Oct 14;18(1):20182. doi: 10.7448/IAS.18.1.20182. eCollection 2015.

Introduction: In recent years children and adolescents have emerged as a priority for HIV prevention and care services. We conducted a systematic review to investigate the acceptability, yield and prevalence of HIV testing and counselling (HTC) strategies in children and adolescents (5 to 19 years) in sub-Saharan Africa.

Methods: An electronic search was conducted in MEDLINE, EMBASE, Global Health and conference abstract databases. Studies reporting on HTC acceptability, yield and prevalence and published between January 2004 and September 2014 were included. Pooled proportions for these three outcomes were estimated using a random effects model. A quality assessment was conducted on included studies.

Results and discussion: A total of 16 380 potential citations were identified, of which 21 studies (23 entries) were included. Most studies were conducted in Kenya (n=5) and Uganda (n=5) and judged to provide moderate (n=15) to low quality (n=7) evidence, with data not disaggregated by age. Seven studies reported on provider-initiated testing and counselling (PITC), with the remainder reporting on family-centred (n=5), home-based (n=5), outreach (n=5) and school-linked HTC among primary schoolchildren (n=1). PITC among inpatients had the highest acceptability (86.3%; 95% confidence interval [CI]: 65.5 to 100%), yield (12.2%; 95% CI: 6.1 to 18.3%) and prevalence (15.4%; 95% CI: 5.0 to 25.7%). Family-centred HTC had lower acceptance compared to home-based HTC (51.7%; 95% CI: 10.4 to 92.9% vs. 84.9%; 95% CI: 74.4 to 95.4%) yet higher prevalence (8.4%; 95% CI: 3.4 to 13.5% vs. 3.0%; 95% CI: 1.0 to 4.9%). School-linked HTC showed poor acceptance and low prevalence.

Conclusions: While PITC may have high test acceptability priority should be given to evaluating strategies beyond healthcare settings (e.g. home-based HTC among families) to identify individuals earlier in their disease progression. Data on linkage to care and cost-effectiveness of HTC strategies are needed to strengthen policies.

Abstract  Full-text [free] access

Editor’s notes: In sub-Saharan Africa children and adolescents are a priority group for HIV prevention and care services. Children and adolescents living with HIV are less likely than adults to know their HIV status, to access treatment and to achieve virologic suppression. As with adults, the first essential step to managing HIV in children and adolescents is to provide appropriate HIV testing and counselling services. This is the first systematic review to assess HIV testing and counselling strategies in this age group, 5-19 years. One key finding is the lack of data on testing and counselling services for this age group. Most services replicate strategies developed for adults with little consideration for the specific needs of children and adolescents. The studies illustrated that health care facility-based provider-initiated testing and counselling had relatively high acceptance, yield and linkage-to-care, but tended to identify individuals at a late stage of disease. In contrast, community-based approaches had the potential to diagnose asymptomatic children. Further work on innovative approaches, family-centred and mobile-based, should be assessed.  

HIV testing
Africa
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Contraception for young girls living with HIV: barriers and facilitators to service provision in western Kenya

Barriers and facilitators adolescent females living with HIV face in accessing contraceptive services: a qualitative assessment of providers' perceptions in western Kenya.

Hagey JM, Akama E, Ayieko J, Bukusi EA, Cohen CR, Patel RC. J Int AIDS Soc. 2015 Sep 16;18(1):20123. doi: 10.7448/IAS.18.1.20123. eCollection 2015.

Introduction: Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population.

Methods: We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services - supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers' perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis.

Results: According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services.

Conclusions: Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.

Abstract  Full-text [free] access

Editor’s notes: The article offers a clear picture of barriers and facilitators to access and uptake of contraceptive services for young girls living with HIV. It provides valuable evidence of providers’ views regarding integrated HIV and contraceptive services. The study was carried out with HIV care providers in different areas of western Kenya. The authors found that young girls find it difficult to access services, especially on their own, for fear of being seen as sexually active and/or promiscuous. Parental presence during consultations in HIV services can be a barrier to requesting contraceptives. But some parents are supportive and wish to prevent unintended pregnancies for their daughters. Young girls living with HIV might find it challenging to manage questions from their peers about their HIV medication and contraceptives. Providers’ themselves prioritise abstinence and condoms over offering hormonal contraceptives. Providers can feel protective towards the patients, whom they may see as ‘children’. The authors suggest that further involvement of parents, young boys and male partners can facilitate uptake of contraceptives for young girls living with HIV. The integration of HIV and contraceptive services for young girls can provide a crucial platform to reduce sexually transmitted infections, unintended pregnancies and vertical HIV transmission.

Africa
Kenya
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Leveraging an HIV-specific quality improvement programme to realise system-wide benefits in Haiti

Going beyond the vertical: leveraging a national HIV quality improvement programme to address other health priorities in Haiti.

Joseph JP, Jerome G, Lambert W, Almazor P, Cupidon CE, Hirschhorn LR. AIDS. 2015 Jul;29 Suppl 2:S165-73. doi: 10.1097/QAD.0000000000000715.

Although the central role of quality to achieve targeted population health goals is widely recognized, how to spread the capacity to measure and improve quality across programmes has not been widely studied. We describe the successful leveraging of expertise and framework of a national HIV quality improvement programme to spread capacity and improve quality across a network of clinics in HIV and other targeted areas of healthcare delivery in rural Haiti. The work was led by Zamni LaSante, a Haitian nongovernment organization and its sister organization, Partners In Health working in partnership with the Haitian Ministry of Health in the Plateau Central and Lower Artibonite regions in 12 public sector facilities. Data included routinely collected organizational assessments of facility quality improvement capacity, national HIV performance measures and Zamni LaSante programme records. We found that facility quality improvement capacity increased with spread from HIV to other areas of inpatient and outpatient care, including tuberculosis (TB), maternal health and inpatient services in all 12 supported healthcare facilities. A significant increase in the quality of HIV care was also seen in most areas, including CD4 monitoring, TB screening, HIV treatment (all P < 0.01) and nutritional assessment and prevention of mother-to-child transmission (both P < .05), with an increase in average facility performance from 39 to 72% (P < .01).In conclusion, using a diagonal approach to leverage a national vertical programme for wider benefit resulted in accelerated change in professional culture and increased capacity to spread quality improvement activities across facilities and areas of healthcare delivery. This led to improvement within and beyond HIV care and contributed to the goal of quality of care for all.

Abstract access 

Editor’s notes: With the current changing HIV-funding landscape, there is increased interest in leveraging disease-specific programmes using a ‘diagonal approach’ to achieve a broader health systems goal. This paper describes a good example of leveraging an HIV-specific quality improvement framework to realise multiple benefits. The authors describe a quality improvement programme which was implemented across 12 health facilities in Haiti. Although the programme was initially HIV-specific, it was expanded to other disease areas including family planning, TB screening and management of heart failure. The spread to other disease areas was facilitated by the programme’s focus on capacity building, resulting in strengthened leadership and ownership across the sites. This paper is a great example of the potential for a ‘diagonal approach’ to maximise system-wide benefits within the context of a vertical programme.  

Health care delivery
Northern America
Haiti
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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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In or out of HIV-care? It depends who you ask

Sorting through the lost and found: are patient perceptions of engagement in care consistent with standard continuum of care measures?

Castel AD, Tang W, Peterson J, Mikre M, Parenti D, Elion R, Wood A, Kuo I, Willis S, Allen S, Kulie P, Ikwuemesi I, Dassie K, Dunning J, Saafir-Callaway B, Greenberg A. J Acquir Immune Defic Syndr. 2015 May 1;69 Suppl 1:S44-55. doi: 10.1097/QAI.0000000000000575.

Background: Indicators for determining one's status on the HIV care continuum are often measured using clinical and surveillance data but do not typically assess patient perspectives. We assessed patient-reported care status along the care continuum and whether it differed from medical records and surveillance data.

Methods: Between June 2013 and October 2014, a convenience sample of clinic-attending HIV-infected persons was surveyed regarding care-seeking behaviors and self-perceived status along the care continuum. Participant responses were matched to DC Department of Health surveillance data and clinic records. Participants' care patterns were classified using Health Resources Services Administration-defined care status: in care (IC), sporadic care (SC), or out of care (OOC). Semistructured qualitative interviews were analyzed using an open coding process to elucidate relevant themes regarding participants' perceptions of engagement in care.

Results: Of 169 participants, most were male participants (64%) and black (72%), with a mean age of 50.7 years. Using self-reported visit patterns, 115 participants (68%) were consistent with being IC, 33 (20%) SC, and 21 (12%) OOC. Among OOC participants, 52% perceived themselves to be fully engaged in HIV care. In the previous year, among OOC participants, 71% reported having a non-HIV-related medical visit and 90% reported current antiretroviral use. Qualitatively, most SC and OOC persons did not see their HIV providers regularly because they felt healthy.

Conclusions: Participants' perceptions of HIV care engagement differed from actual care receipt as measured by surveillance and clinical records. Measures of care engagement may need to be reconsidered as persons not receiving regular HIV care maybe accessing other health care and HIV medications elsewhere.

Abstract access 

Editor’s notes: This interesting mixed methods study examined engagement and retention in HIV care among people living with HIV in Washington DC. In addition to the convenience sample of clinic attendees listed in the abstract of the paper, data were also accessed on people who had not received clinical care in the previous 12 months, according to clinic records. These people were being focused on by a Department of Health initiative to re-engage them in care. As the clinic staff contacted people to re-engage with them they were offered the opportunity to be recruited into this study. A very helpful diagram on page S46 of this paper sets out this recruitment strategy. This sampling approach allowed the authors to compare data collected from an interviewer-administered structured survey (collecting self-reported data) with data abstracted from clinic records (with the participant’s consent)  and data from Department of Health surveillance records. In addition 62 of the participants took part in in-depth interviews. In keeping with other studies on linkage to care, the authors found that participants who were considered ‘out of care’ by the Department of Health and clinic records did not necessarily consider themselves to be out of care. These were often people who were doing well and saw no need to visit the clinic regularly, particularly if, for individuals on antiretroviral therapy, they were able to access drug supplies from other sources. 

The study also suggests the importance of understanding the limitations of different data sources.  While the limitations of self-reported data are well known, the authors also highlight the drawback of using clinic records. The Department of Health re-engagement initiative had found that 57% of the people thought to be out of care were actually receiving care elsewhere. The authors therefore stress the importance of using a combination of data sources in care surveillance. 

Many people considered to be ‘out of care’ by their clinic were surprised to have had this label applied to them. The authors suggest that this finding emphasises the need for better communication between provider and patient so that treatment goals and the importance of regular clinic visits are understood. However, they go on to say that this finding also supports the on-going process of rethinking definitions of ‘engagement in care’ to be more responsive to individual needs and perceptions. Indeed the change in the United States Department of Health and Human Services guidelines to recommend that patients who are virally suppressed can be monitored less-frequently, is in keeping with this suggestion.

Northern America
United States of America
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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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Need for further water, sanitation and hygiene programmes among people living with HIV

The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review.

Yates T, Lantagne D, Mintz E, Quick R. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S318-30. doi: 10.1097/QAI.0000000000000487.

Background: Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

Methods: We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

Results: We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

Conclusions: Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

Abstract access 

Editor’s notes: Researchers, implementers, and policy makers have been examining how to better integrate programmes with overlapping burdens of morbidity and mortality. This paper illustrates how access to clean water and good sanitation practices, or lack thereof, can impact the health of people living with HIV. Water, sanitation, and hygiene (WASH) programmes can improve the negative effects poor water quality and bad sanitation have on people living with HIV. They reduce or even eliminate diarrheal infections, which allow for better absorption of HIV treatment medication that leads to a reduction in viral load and increased CD4 counts. While this systematic review revealed evidence on the reduced burden of morbidity that WASH programmes can confer, little has been done in the way of research linking WASH programmes to mortality in people living with HIV, nor how they may affect adherence or retention in care. Side effects of HIV treatment is a common reason why people stop taking medications, and common side effects are nausea and diarrhoea. It is possible that intestinal issues caused by unsafe drinking water could exacerbate the impact of side effects on people already experiencing them, therefore reducing motivation to continue taking their ARVs. This paper also suggests that synergies in cost sharing and increasing cost effectiveness could be achieved by integrating programmes. However further research is necessary to fully understand the logistical and cost implications.

 

Africa, Asia
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