Domestic HIV Research Articles

Measuring stigma affecting sex workers (SW) and men who have sex with men (MSM): A systematic review.

BackgroundStigma involves discrediting a person or group based on a perceived attribute, behaviour or reputation associated with them. Sex workers (SW) and men who have sex with men (MSM) are key populations who are often at increased risk for the acquisition and transmission of HIV and who are affected by stigma that can negatively impact their health and well-being. Although stigma was included as an indicator in the US National HIV/AIDS Strategic Plan and there have been consultations focused on adding a stigma indicator within PEPFAR and the Global Fund in relation to potentiating HIV risks among key populations, there remains limited consensus on the appropriate measurement of SW- or MSM-associated stigma. Consequently, this systematic review summarizes studies using quantitative, qualitative, or mixed methods approaches to measure stigma affecting sex workers and men who have sex with men.Methods and findingsThis systematic review included English, French, and Spanish peer-reviewed research of any study design measuring SW- or MSM-associated stigma. Articles were published from January 1, 2004 to March 26, 2014 in PsycINFO, PubMed, EMBASE, CINAHL Plus, Global Health, and World Health Organization Global Health Library Regional Indexes.Of the 541 articles reviewed, the majority measured stigma toward MSM (over 97%), were conducted in North America, used quantitative methods, and focused on internalized stigma.ConclusionsWith the inclusion of addressing stigma in several domestic and international HIV strategies, there is a need to ensure the use of validated metrics for stigma. The field to date has completed limited measurement of stigma affecting sex workers, and limited measurement of stigma affecting MSM outside of higher income settings. Moving forward requires a concerted effort integrating validated metrics of stigma into health-related surveys and programs for key populations.

Women's land rights as a pathway to poverty reduction: Framework and review of available evidence

This paper reviews the literature on women’s land rights (WLR) and poverty reduction. It uses the Gender, Agriculture and Assets Project (GAAP) conceptual framework to identify pathways by which WLR could reduce poverty and increase wellbeing of women and their households in rural areas. It uses a systematic review search methodology to identify papers for inclusion, but adopts a more synthetic approach to assess the level of agreement and the amount of evidence within this literature. The paper examines the evidence from qualitative as well as quantitative studies on each of these pathways. Owing to the scarcity of experimental studies, the review of empirical work is based mostly on observational studies. We find some evidence on these relationships, but many of the key pathways have not been empirically analyzed. The evidence is strong for relationships between WLR and bargaining power and decision-making on consumption, human capital investment, and intergenerational transfers. There is a high level of agreement, but weaker evidence on the relationship between WLR and natural resource management, government services and institutions, empowerment and domestic violence, resilience and HIV risk, and consumption and food security. There is less agreement and insufficient evidence on the associations between WLR and other livelihoods, and a higher level of agreement, but still limited evidence on associations between WLR and credit, technology adoption, and agricultural productivity. Notably, we find no papers that directly investigate the link between WLR and poverty. Many gaps in the evidence arise from a failure to account for the complexity of land rights regimes, the measurement of land rights at the household level, the lack of attention paid to gender roles, and the lack of studies from countries outside Africa. Many studies are limited by small sample sizes, the lack of credible counterfactuals, lack of attention to endogeneity and selection bias, and possible response bias on questions of domestic violence and empowerment. There are very few rigorous evaluations of reforms that strengthened WLR. The paper concludes that gaps in the evidence should not deter the careful design and implementation of programs and policies to strengthen WLR, given the ongoing land tenure reforms in many countries. Different modalities and mechanisms for strengthening WLR could be tested, with appropriate counterfactuals. Program designers and evaluators can strategically identify pathways and outcomes where evidence gaps exist, and deliberately design studies to close those gaps.

Identifying HIV care enrollees at-risk for cannabis use disorder

ABSTRACTIncreased scientific attention given to cannabis in the United States has particular relevance for its domestic HIV care population, given that evidence exists for both cannabis as a therapeutic agent and cannabis use disorder (CUD) as a barrier to antiretroviral medication adherence. It is critical to identify relative risk for CUD among demographic subgroups of HIV patients, as this will inform detection and intervention efforts. A Center For AIDS Research Network of Integrated Clinical Systems cohort (N = 10,652) of HIV-positive adults linked to care at seven United State sites was examined for this purpose. Based on a patient-report instrument with validated diagnostic threshold for CUD, the prevalence of recent cannabis use and corresponding conditional probabilities for CUD were calculated for the aggregate sample and demographic subgroups. Generalized estimating equations then tested models directly examining patient demographic indices as predictors of CUD, while controlling for history and geography. Conditional probability of CUD among cannabis-using patients was 49%, with the highest conditional probabilities among demographic subgroups of young adults and those with non-specified sexual orientation (67–69%) and the lowest conditional probability among females and those 50+ years of age (42% apiece). Similarly, youthful age and male gender emerged as robust multivariate model predictors of CUD. In the context of increasingly lenient policies for use of cannabis as a therapeutic agent for chronic conditions like HIV/AIDS, current study findings offer needed direction in terms of specifying targeted patient groups in HIV care on whom resources for enhanced surveillance and intervention efforts will be most impactful.

The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future.

The HIV care continuum is a framework that models the dynamic stages of HIV care. The continuum consists of five main steps, which, at the population level, are depicted cross-sectionally as the HIV treatment cascade. These steps include diagnosis, linkage to care (LTC), retention in care (RiC), adherence to antiretroviral therapy (ART), and viral suppression. Although the HIV treatment cascade is represented as a linear, unidirectional framework, persons living with HIV (PLWH) often experience the care continuum in a less streamlined fashion, skip steps altogether, or even exit the continuum for a period of time and regress to an earlier stage. The proportion of PLWH decreases at each successive step of the cascade, beginning with an estimated 86% who are diagnosed and dropping dramatically to approximately 30% of PLWH who are virally suppressed in the United States (US). In this current issues review, we describe each step in the cascade, discuss targeted interventions that address weak points in the continuum, review domestic and international policies that help shape and direct HIV care strategies, and conclude with recommendations and future directions for HIV providers and policymakers. While we primarily examine issues related to domestic HIV care in the US, we also discuss international applications of the continuum in order to provide broader context.

Patterns and Correlates of Serostatus Disclosure to Sexual Partners by Perinatally-Infected Adolescents and Young Adults.

Similar to same-age peers, perinatally HIV-infected (PHIV+) youth in the US are engaging in sex, including condomless sex. Understanding decisions about serostatus disclosure to sexual partners is important to domestic and global HIV prevention efforts, since large numbers of PHIV+ children are entering adolescence and becoming sexually active. Using Social Action Theory (SAT) to inform variable selection, we examined correlates of disclosure among 98 PHIV+ adolescents/young adults in New York City. Over half of these youth reported not disclosing to any casual partners (59%) or to any partners when using condoms (55%). In bivariate analyses, increased disclosure was associated with older age; being female; earlier age of learning one's serostatus; and increased STD knowledge, disclosure intentions, and parent-child communication. Multiple regression analyses revealed a strong fit with the SAT model. As with adults, disclosure to sexual partners is difficult for PHIV+ youth and challenges prevention efforts. Effective interventions that help youth with disclosure decisions are needed to curb the epidemic.

Update on the Epidemiology and Prevention of HIV/AIDS in the United States.

This update on the epidemiology and prevention of HIV in the United States is intended to provide contextual background that will help inform an understanding of recent developments in the domestic HIV epidemic. We describe the epidemiology of HIV disease in the US and the HIV continuum of care based on data collected primarily through HIV surveillance systems led by the Centers for Disease Control and Prevention including HIV incidence, prevalence, comorbidities and death. Populations and geographic regions disparately impacted by HIV are also highlighted. The HIV prevention armamentarium is also described including behavioral approaches to prevention, the emerging availability of biomedical prevention interventions such as pre-exposure prophylaxis, and structural and population-level interventions including treatment as prevention. Finally gaps in our understanding of the epidemic are underscored and suggestions for future epidemiologic research are proposed.

Association Between Domestic Violence and HIV Serostatus Among Married and Formerly Married Women in Kenya

Association Between Domestic Violence and HIV Serostatus Among Married and Formerly Married Women in Kenya

Speaking of sex workers: How suppression of research has distorted the United States' domestic HIV response

Sex workers remain a vulnerable population at risk for HIV acquisition and transmission. Research suggests that interventions at the individual level, such as condom distribution, are less effective in preventing HIV among sex workers than structural changes such as allowing safer work settings and reducing the harassment and abuse of sex workers by clients and police. In the US, HIV incidence has not declined in the last decade. This may be due in part to its policy of wilful ignorance about sex work, but the data to resolve the question simply do not exist. Political actions such as PEPFAR's prostitution pledge and a congressional campaign against "waste, fraud and abuse" in research are products of an ideological environment that suppresses research on HIV prevention and treatment needs of sex workers. Even basic prevalence data are missing because there is no "sex worker" category in the US National HIV Behavior Surveillance System. However, international efforts are taking a public health approach and are calling for decriminalization of sex work, as the most effective public health strategy for reducing HIV incidence among sex workers. Although such an approach is not yet politically feasible in the US, some urgent practical policy changes can be implemented to improve data collection and generation of evidence to support HIV prevention and treatment programs targeting sex workers.

Association Between Domestic Violence and HIV Serostatus Among Married and Formerly Married Women in Kenya

The prevalence of both domestic violence (DV) and HIV among Kenyan women is known to be high, but the relationship between them is unknown. Nationally representative cross-sectional data from married and formerly married (MFM) women responding to the Kenya Demographic and Health Survey 2008/2009 were analyzed adjusting for complex survey design. Multivariable logistic regressions were used to assess the covariate-adjusted associations between HIV serostatus and any reported DV as well as four constituent DV measures: physical, emotional, sexual, and aggravated bodily harm, adjusting for covariates entered into each model using a forward stepwise selection process. Covariates of a priori interest included those representing marriage history, risky sexual behavior, substance use, perceived HIV risk, and sociodemographic characteristics. The prevalence of HIV among MFM women was 10.7% (any DV: 13.1%, no DV: 8.6%); overall prevalence of DV was 43.4%. Among all DV measures, only physical DV was associated with HIV (11.9%; adjusted odds ratio: 2.01, p <.05). Efforts by the government and women's groups to monitor and improve policies to reduce DV, such as the Sexual Offences Act of 2006, are urgently needed to curb HIV, as are policies that seek to provide DV counseling and treatment to MFM women.

Spatial Patterns in Domestic Violence and HIV Prevalence in Nigeria

We explore the spatial patterns of domestic violence and HIV prevalence between states in Nigeria using the 2008 Demographic and Health Survey and the 2010 ANC Sentinel Surveillance Survey. The analysis revealed a sizeable number of women in the country suffer physical and sexual violence which occurs across the social strata and ethnic groups in Nigeria. Based on the previous studies that have already established a link between domestic violence and declining in health status of women, the paper examines the linkage between domestic violence and HIV prevalence in Nigeria. We found spatial linkage between the two concepts or variables though we did not establish a causal relationship. We found women in states with a high HIV prevalence rate had either experienced physical and/or sexual violence from their spouses. Based on the results, it shows that there is a need to further explore the causal relationships between domestic violence and health outcomes especially HIV infections. Thus, the spatial linkage between domestic violence and HIV prevalence in Nigeria will be highly context-specific. The study demonstrated a spatial interrelationship between domestic violence and HIV prevalence, thus, planning HIV prevention programming should also design activities or intervention to concurrently address the domestic violent aspects. Since it has been documented and current attempts reveal a connection between domestic violence and HIV infection in Nigeria, there is a need for further research to investigate the relationship between domestic violence and HIV in Nigeria to increase the evidence. Keywords: HIV, domestic violence, Nigeria, spatial analysis, women. Read more →

Financing HIV programming: how much should low- and middle-income countries and their donors pay?

Global HIV control funding falls short of need. To maximize health outcomes, it is critical that national governments sustain reasonable commitments, and that international donor assistance be distributed according to country needs and funding gaps. We develop a country classification framework in terms of actual versus expected national domestic funding, considering resource needs and donor financing. With UNAIDS and World Bank data, we examine domestic and donor HIV program funding in relation to need in 84 low- and middle-income countries. We estimate expected domestic contributions per person living with HIV (PLWH) as a function of per capita income, relative size of the health sector, and per capita foreign debt service. Countries are categorized according to levels of actual versus expected domestic contributions, and resource gap. Compared to national resource needs (UNAIDS Investment Framework), we identify imbalances among countries in actual versus expected domestic and donor contributions: 17 countries, with relatively high HIV prevalence and GNI per capita, have domestic funding below expected (median per PLWH $143 and $376, respectively), yet total available funding including from donors would exceed the need ($368 and $305, respectively) if domestic contribution equaled expected. Conversely, 27 countries have actual domestic funding above the expected (medians $294 and $149) but total (domestic+donor) funding does not meet estimated need ($685 and $1,173). Across the 84 countries, in 2009, estimated resource need totaled $10.3 billion, actual domestic contributions $5.1 billion and actual donor contributions $3.7 billion. If domestic contributions would increase to the expected level in countries where the actual was below expected, total domestic contributions would increase to $7.4 billion, turning a funding gap of $1.5 billion into a surplus of $0.8 billion. Even with imperfect funding and resource-need data, the proposed country classification could help improve coherence and efficiency in domestic and international allocations.

Risk Factors for Physical Domestic Violence in a High-Prevalence HIV Setting: Findings from Project Accept Baseline Data (HPTN-043).

Zimbabwe faces an acute generalized HIV/AIDS epidemic combined with rapidly deteriorating economic and political conditions, under which levels of domestic violence are on the rise. We aimed to determine possible demographic and behavioral factors associated with physical domestic violence in a rural setting in order to better inform both national and local domestic violence and HIV prevention policies. Using the Project Accept baseline data set, we selected demographic, socio-economic, and behavioral variables that might be associated with physical domestic violence based on a review of the literature. Univariate and multivariate analyses were carried out, and odds ratios (OR) were computed using logistic regression. Women reporting physical domestic violence were significantly more likely to report (i) a history of childhood domestic violence (OR=2.96, P<0.001), (ii) two or more lifetime partners (OR=1.94, P<0.001), (iii) some form of sexual abuse as a child (OR=1.82, not significant), and (iv) low or medium socio-economic status as measured by type of homestead (OR=1.4, P=0.04) than women who reported no experience of physical domestic violence. Married women were less likely to experience physical domestic violence than unmarried women (OR=0.65, P=0.011). Women at greatest risk of domestic violence include those with a personal history of violence or sexual abuse, multiple lifetime partners, and low or medium socio-economic status. Risk assessments and joint interventions for both domestic violence reduction and HIV prevention should target these population groups, which are effective both on the public health and global heath diplomacy levels.

Operational research to improve HIV prevention in the United States.

The HIV/AIDS epidemic in the United States continues despite several recent noteworthy advances in HIV prevention. Contemporary approaches to HIV prevention involve implementing combinations of biomedical, behavioral, and structural interventions in novel ways to achieve high levels of impact on the epidemic. Methods are needed to develop optimal combinations of approaches for improving efficiency, effectiveness, and scalability. This article argues that operational research offers promise as a valuable tool for addressing these issues. We define operational research relative to domestic HIV prevention, identify and illustrate how operational research can improve HIV prevention, and pose a series of questions to guide future operational research. Operational research can help achieve national HIV prevention goals of reducing new infections, improving access to care and optimization of health outcomes of people living with HIV, and reducing HIV-related health disparities.

Levels of Spending and Resource Allocation to HIV Programs and Services in Latin America and the Caribbean

BackgroundAn estimated 1.86 million people are living with HIV in Latin America and the Caribbean (LAC). The region is comprised of mainly middle-income countries with steady economic growth while simultaneously there are enormous social inequalities and several concentrated AIDS epidemics. This paper describes HIV spending patterns in LAC countries including analysis of the levels and patterns of domestic HIV spending from both public and international sources.Methods and FindingsWe conducted an extensive analysis of the most recently available data from LAC countries using the National AIDS Spending Assessment tool. The LAC countries spent a total of US$ 1.59 billion on HIV programs and services during the latest reported year. Countries providing detailed information on spending showed that high percentages are allocated to treatment and care (75.1%) and prevention (15.0%). Domestic sources accounted for 93.6 percent of overall spending and 79 percent of domestic funds were directed to treatment and care. International funds represented 5.4 percent of total HIV funding in the region, but they supplied the majority of the effort to reach most-at-risk-populations (MARPs). However, prevalence rates among men who have sex with men (MSM) still reached over 25 percent in some countries.ConclusionsAlthough countries in the region have increasingly sustained their response from domestic sources, still there are future challenges: 1) The growing number of new HIV infections and more people-living-with-HIV (PLWH) eligible to receive antiretroviral treatment (ART); 2) Increasing ART coverage along with high prices of antiretroviral drugs; and 3) The funding for prevention activities among MARPs rely almost exclusively on external donors. These threats call for strengthened actions by civil society and governments to protect and advance gains against HIV in LAC.

Battling AIDS in America: An Evaluation of the National HIV/AIDS Strategy

Thirty years ago, the Centers for Disease Control and Prevention reported the first cases of AIDS in the United States. Since then, more than half a million Americans have died of AIDS, and 1.1 million people are currently living with HIV in the United States. In an attempt to reinvigorate the domestic response to the HIV epidemic, the Obama administration developed and released the National HIV/AIDS Strategy for the United States (NHAS). The NHAS has 3 focus areas: reducing new infections, improving access to care and health outcomes, and reducing HIV-related disparities. With ambitious five-year targets set for each goal, the NHAS requires significant fiscal investment to achieve its desired impact on the domestic HIV epidemic.

The HIV Epidemic in the United States: A Time for Action

It is not uncommon to encounter in a hospital emergency room in San Francisco, Atlanta, New York City, or Washington, DC, a young man or woman with the diagnosis of life-threatening cryptococcal meningitis or pneumonia caused by Pneumocystis jirovecii as the first manifestation of HIV infection. How could this be possible in 2010, fully 3 decades into the epidemic in the United States? How could this be possible in a country that prides itself on the widespread availability of HIV testing and treatment options? How could this be possible in a country with broad access to health messages and a plethora of communication tools? How could this be possible in one of the richest countries on earth? The answers to these questions are sobering. HIV in the United States is currently an invisible epidemic, largely confined to vulnerable and disenfranchised populations. It has disappeared from the public discourse. The prevailing perception is that HIV is a problem of the past, with few new infections and with miracle drugs available for all those living with HIV. Yet, beside the tragic anecdotes cited above, data indicate that there are an estimated 56,000 new infections per year in the United States, with an alarming impact on men who have sex with men and African American men and women. Great disparities remain in access to care and treatment for racial/ethnic minorities with HIV. How to address these disparities is the immediate challenge. The articles included in this supplement focus on some of the populations who have been most heavily impacted by the domestic HIV epidemic, including disenfranchised women of color, men who have sex with men, transgender persons, and substance users. Some of the articles describe specific venues, both physical and virtual, that are common in the lives of people living with, and at increased risk for, HIV, such as prisons, bathhouses, and the Internet; others discuss some of the factors that potentiate susceptibility to infection, such as substance use and depression. This supplement also features a wide array of approaches designed to slow the tide of the epidemic, ranging from culturally nuanced social, behavioral, and structural approaches to biomedical interventions, such as HIV testing, vaccines, and the use of antiretroviral drugs for prevention. Another paper describes lessons from Africa that could inform the response to the US HIV epidemic. The underlying theme is that HIV is spread in diverse communities, influenced by multiple biological, behavioral, cultural, societal, economic, and structural factors, and that curbing the epidemic will require an extensive variety of tactics carefully titrated to the needs of communities and individuals. The newly released National HIV/AIDS Strategic Plan, the first in the history of the epidemic in the United States, offers a fitting framework for action. This supplement to the Journal of Acquired Immunodeficiency Syndrome is an attempt at articulating a path ahead. Yet, substantial progress will not be achieved unless there is a concerted effort by the breadth of stakeholders to work together tirelessly and selflessly to reach defined priority goals. From policy makers to funders, researchers, providers, community organizations, and individuals living with HIV, all must be fully engaged in a united front to confront this epidemic in our midst. The time for action is now.

A Prevention Response That Fits America's Epidemic: Community Perspectives on the Status of HIV Prevention in the United States

HIV prevention services have succeeded in limiting HIV incidence in the United States but have not prevented HIV from becoming a devastating epidemic in the communities most affected. The National HIV/AIDS Strategy represents an important opportunity to improve domestic HIV prevention efforts and to begin to reduce HIV incidence over time. Elements that are essential to improving HIV incidence outcomes include greater transparency and accountability in use of HIV prevention funds; scaling up programming for those most at risk; fostering and evaluating community-based HIV prevention efforts; and looking beyond individual behavior change programming by putting a greater emphasis on structural, network, and policy interventions. To overcome years of stagnation on HIV prevention outcomes, we need a response characterized by accountability, appropriate targeting, and sufficient scale.

A Way Forward: The National HIV/AIDS Strategy and Reducing HIV Incidence in the United States

In July 2010, the Obama Administration released a National HIV/AIDS Strategy for the United States to refocus national attention on responding to the domestic HIV epidemic. The goals of the strategy are to reduce HIV incidence; to increase access to care and optimize health outcomes among people living with HIV; and to reduce HIV-related disparities. The strategy identifies a small number of action steps that will align efforts across federal, state, local, and tribal levels of government, and maximally impact the domestic HIV epidemic. In this article, we outline key programmatic and research issues that must be addressed to accomplish the prevention goals of the National HIV/AIDS Strategy.

Domestic Violence Screening: Prevalence and Outcomes in a Canadian HIV Population

There is a strong association between domestic violence victimization and HIV infection. This may lead to poor health outcomes including mental health disorders and reduced access to care. A standardized domestic violence screening interview was incorporated into ongoing care in the large and diverse population living with HIV in Southern Alberta, Canada. Results from May through December 2009 are reported, including the prevalence and outcomes of abuse. Thirty-four percent of 853 patients screened reported abuse. Of these, 16% reported abuse in their current relationship, 58% in a previous relationship, and 57% reported a history of childhood abuse. High-risk groups for abuse included females (43%), gay/bisexual males (35%), and Aboriginals (61%). We found an association between a history of domestic violence and delayed access to care (p < 0.05), missed appointments (p < 0.001), and an increased use of clinic resources such as social work (p < 0.0001) and psychiatry (p < 0.001). Mental health conditions prior to HIV diagnosis, including depression (p < 0.0001), suicidal ideation (p < 0.0001), and anxiety disorder (p < 0.0001) were associated with abuse at any time, while a history of adjustment disorder was associated with childhood abuse (p < 0.05). A simple domestic violence screening tool was helpful for identifying patients experiencing abuse in our diverse HIV-infected population. This high prevalence of domestic violence among our HIV patients was associated with poor outcomes and an increased use of medical resources. HIV caregivers should be aware of domestic violence in order to optimize care and refer patients to appropriate support professionals as needed.

Substantive equality and women’s rights to sexual and reproductive health in Cameroon

Substantive equality is a very important phenomenon in the promotion of the reproductive health rights of citizens in the developing world in general and Cameroon in particular. The multiplicity of ethnic groups coupled with diverse cultural beliefs and practices impact negatively on the promotion of the notion of substantive equality in Cameroon. Although the preamble to the Cameroonian Constitution recognizes the idea of equal rights for all, the country’s record on promotion of rights associated with reproductive health is below expectations. Hence, it is worth reviewing Cameroon’s achievements, gaps and prospects in regard to the promotion of the doctrine of substantive equality in relation to the reproductive health of women in the country. In this paper, the aspects of domestic violence, abortion, and HIV and AIDS are used as examples in an attempt to analyse the extent to which the notion of substantive equality as provided for under the Cameroonian Constitution, has been implemented, particularly in regard to the reproductive health rights of women.KEYWORDS: Reproductive health, HIV and AIDS, Cameroon, domestic violence, equality, women