Rural HIV Research Articles

Factors Influencing Retention in Care after Starting Antiretroviral Therapy in a Rural South African Programme

IntroductionThe prognosis of patients with HIV in Africa has improved with the widespread use of antiretroviral therapy (ART) but these successes are threatened by low rates of long-term retention in care. There are limited data on predictors of retention in care, particularly from rural sites.MethodsProspective cohort analysis of outcome measures in adults from a rural HIV care programme in Madwaleni, Eastern Cape, South Africa. The ART programme operates from Madwaleni hospital and seven primary care feeder clinics with full integration between inpatient and outpatient services. Outreach workers conducted home visits for defaulters.Results1803 adults initiated ART from June 2005 to May 2009. At the end of the study period 82.4% were in active care or had transferred elsewhere, 11.1% had died and 6.5% were lost to follow-up (LTFU). Independent predictors associated with an increased risk of LTFU were CD4 nadir >200, initiating ART as an inpatient or while pregnant, and younger age, while being in care for >6 months before initiating ART was associated with a reduced risk. Independent factors associated with an increased risk of mortality were baseline CD4 count <50 and initiating ART as an inpatient, while being in care for >6 months before initiating ART and initiating ART while pregnant were associated with a reduced risk.ConclusionsServing a socioeconomically deprived rural population is not a barrier to successful ART delivery. Patients initiating ART while pregnant and inpatients may require additional counselling and support to reduce LTFU. Providing HIV care for patients not yet eligible for ART may be protective against being LTFU and dying after ART initiation.

HIV-Infected Children in Rural Zambia Achieve Good Immunologic and Virologic Outcomes Two Years after Initiating Antiretroviral Therapy

BackgroundMany HIV-infected children in sub-Saharan Africa reside in rural areas, yet most research on treatment outcomes has been conducted in urban centers. Rural clinics and residents may face unique barriers to care and treatment.MethodsA prospective cohort study of HIV-infected children was conducted between September 2007 and September 2010 at the rural HIV clinic in Macha, Zambia. HIV-infected children younger than 16 years of age at study enrollment who received antiretroviral therapy (ART) during the study were eligible. Treatment outcomes during the first two years of ART, including mortality, immunologic status, and virologic suppression, were assessed and risk factors for mortality and virologic suppression were evaluated.ResultsA total of 69 children entered the study receiving ART and 198 initiated ART after study enrollment. The cumulative probabilities of death among children starting ART after study enrollment were 9.0% and 14.4% at 6 and 24 months after ART initiation. Younger age, higher viral load, lower CD4+ T-cell percentage and lower weight-for-age z-scores at ART initiation were associated with higher risk of mortality. The mean CD4+ T-cell percentage increased from 16.3% at treatment initiation to 29.3% and 35.0% at 6 and 24 months. The proportion of children with undetectable viral load increased to 88.5% and 77.8% at 6 and 24 months. Children with longer travel times (≥5 hours) and those taking nevirapine at ART initiation, as well as children who were non-adherent, were less likely to achieve virologic suppression after 6 months of ART.ConclusionsHIV-infected children receiving treatment in a rural clinic experienced sustained immunologic and virologic improvements. Children with longer travel times were less likely to achieve virologic suppression, supporting the need for decentralized models of ART delivery.

HIV-related medical service use by rural/urban residents: a multistate perspective

Objective: Geographic location may be related to the receipt of quality HIV health care services. Clinical outcomes and health care utilization were evaluated in rural, urban, and peri-urban patients seen at high-volume US urban-based HIV care sites. Methods: Zip codes for 8773 HIV patients followed in 2005 at seven HIV Research Network sites were categorized as rural (population <10,000), peri-urban (10,000–100,000), and urban (>100,000). Clinical and demographic characteristics, inpatient and outpatient (OP) utilization, AIDS-defining illness rates, receipt of highly active antiretroviral therapy (HAART), opportunistic infection (OI) prophylaxis usage, and virologic suppression were compared among patients, using χ2 tests for categorical variables, t-tests for means, and logistic regression for HAART utilization. Results: HIV-infected rural (n=170) and peri-urban (n=215) patients were less likely to be Black or Hispanic than urban HIV patients. Peri-urban subjects were more likely to report MSM as their HIV risk factor than rural or urban subjects. Age, gender, CD4 or HIV-RNA distribution, virologic suppression, HAART usage, or OI prophylaxis did not differ by geographic location. In multivariate analysis, rural and peri-urban patients were less likely to have four or more annual outpatient visits than urban patients. Rural patients were less likely to receive HAART if they were Black. Overall, geographic location (as defined by home zip code) did not affect receipt of HAART or OI prophylaxis. Conclusion: Although demographic and health care utilization differences were seen among rural, peri-urban, and urban HIV patients, most HIV outcomes and medication use were comparable across geographic areas. As with HIV care for urban-dwelling patients, areas for improvement for non-urban HIV patients include access to HAART among minorities and injection drug users.

Retention in HIV care for individuals not yet eligible for antiretroviral therapy: rural KwaZulu-Natal, South Africa.

To determine retention in HIV care for individuals not yet eligible for antiretroviral therapy (ART) and to explore factors associated with retention in a rural public health HIV program. HIV-infected adults (≥16 years) not yet eligible for ART, with CD4 cell count >200 cells per microliter from January 2007 to December 2007 were included in the analysis. Retention was defined by repeat CD4 count within 13 months. Factors associated with retention were assessed using logistic regression with clustering at clinic level. Four thousand two hundred twenty-three were included in the analysis (83.9% female). Overall retention was 44.9% with median time to return 201 days [interquartile range (IQR): 127-274]. Retention by initial CD4 count 201-350, 351-500, and >500 cells per microliter was 51.6% [95% confidence interval (CI): 49.1 to 54.0], 43.2% (95% CI: 40.5 to 45.9), and 34.9% (95% CI: 32.4 to 37.4), respectively. Compared with CD4 201-350 cells per microliter, higher initial CD4 count was significantly associated with lower odds of retention [CD4: 351-500 cells/μL adjusted odds ratio (aOR): 0.72, 95% CI: 0.62 to 0.84; CD4 >500 cells/μL aOR: 0.51, 95% CI: 0.44 to 0.60]. Male sex was independently associated with lower odds (aOR: 0.80, 95% CI: 0.67 to 0.96), and older age with higher odds of retention (for each additional year of age aOR: 1.03, 95% CI: 1.03 to 1.04). Retention in HIV care before eligibility for ART is poor, particularly for younger individuals and those at an earlier stage of infection. Further work to optimize and evaluate care and monitoring strategies is required to realize the full benefits of the rapid expansion of HIV programs in sub-Saharan Africa.

Decreased sexual risk behavior in the era of HAART among HIV-infected urban and rural South Africans attending primary care clinics.

In light of increasing access to HAART in sub-Saharan Africa, we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIV-infected South Africans in urban and rural primary care clinics. Prospective observational cohort. We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003 to 2010, representing 19703 clinic visits. The primary outcomes were being sexually active, unprotected sex, and more than one sex partner and were evaluated at 6 monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors. Among 6263 HIV-infected men and women, over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up, visits while receiving HAART were associated with a decrease in those reporting being sexually active [adjusted odds ratio: 0.86 (95% confidence interval: 0.78-0.95)]. Unprotected sex and having more than one sex partner were reduced at visits following HAART initiation compared to pre-HAART visits [adjusted odds ratio: 0.40 (95% confidence interval: 0.34-0.46) and adjusted odds ratio: 0.20 (95% confidence interval: 0.14-0.29), respectively]. Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.

HIV status in discordant couples in sub-Saharan Africa: a systematic review and meta-analysis

Most couples affected by HIV/AIDS in sub-Saharan Africa live in discordant relationships. Men are thought to be the index case in most relationships, and most social marketing and awareness campaigns are focused on men. We investigated serodiscordance in stable relationships to establish the gender balance of index-case infections. We did a systematic review, random-effects meta-analysis, and meta-regression of published and unpublished studies enrolling discordant couples and assessed the proportion of men and women that were index cases. We repeated the analysis with data from demographic and health surveys (DHS) from the 14 countries that have documented the HIV status of couples. Our primary outcome was the total number of HIV discordant couples, including the proportion of HIV-positive women. We included data from 27 cohorts of 13,061 couples and DHS data from 14 countries of 1145 couples. The proportion of HIV-positive women in stable heterosexual serodiscordant relationships was 47% (95% CI 43-52), which shows that women are as likely as men to be the index partner in a discordant couple. DHS data (46%, 41-51) and our sensitivity analysis (47%, 43-52) showed similar findings. Meta-regression showed that urban versus rural residence (odds ratio 0.31, 95% CI 0.22-0.39), latitude (β coefficient 0.02, 0.023-0.034), gender equality (β coefficient -0.42, -0.56 to -0.27), HIV prevalence (β coefficient -0.037, -0.04 to -0.030), and older age (β coefficient 0.20, 0.08-0.32) were associated with the proportion of female index cases. Our study shows the need to focus on both sexes in HIV prevention strategies, such as promotion of condom use and mitigation of risk behaviours. None.

Patient referral from nurses to doctors in a nurse-led HIV primary care clinic in South Africa: implications for training and support

Health services in sub-Saharan Africa are under great pressure to provide adequate clinical care due to the continued HIV epidemic, and nurse-driven models of care are one means to address physician shortages. This case–control study examines the reasons for and correlates of patient referral from nurses to physicians at HIV primary care clinics in South Africa prior to initiating antiretroviral treatment. Ninety-seven HIV-infected cases who required physician consolation and 160 controls who did not require physician consultation (matched on gender, age, and date of clinic visit) were consecutively enrolled at both an urban and rural HIV primary care clinic during a 12-month period beginning in March 2006. Univariate and multivariate logistic regression models were used to assess correlates of patient referral to a physician. Cases were more likely to have lower CD4 cell counts and have WHO Stages III and IV disease compared to controls (p<0.05). Predictors of patient referral were a CD4 cell count between 50 and 200 cells/µl (adj OR: 5.27, 95% CI: 2.16–12.88, p<0.0001), a CD4 cell count below 50 cells/µl (adj OR: 3.47, 95% CI: 1.12–10.78, p=0.032), and Stage IV disease (adj OR: 4.58, 95% CI: 1.35–15.60, p=0.015). Additionally, the following ICD-10 clinical diagnoses were associated with patient referral: tuberculosis, aplastic and other anemias, and lower respiratory tract infection (p<0.05). Nurses can provide adequate clinical and diagnostic management for certain clinical conditions to HIV-infected patients. Further studies are needed to examine specifically how HIV healthcare delivery can be scaled-up in resource-limited settings with a high burden of HIV, but with a minimal healthcare infrastructure.

Civic educating rural pregnant mothers to take full nevaripine dose a tool to reducing HIV prevalence in Malawi

Background It is estimated that 600,000 women get pregnant every year in Malawi. Primary health care plays a vital role. Prevention to Child Transmission of HIV education is important in a country like Malawi where prevalence of HIV positive mothers exceeds 20% than normal country prevalence of 12%. In the ultra-partum period Nevaripine has proved to be an effective drug in reducing transmission from mother to Child. Accessibility of essential medicine like nevaripine drug to women and neonates is especially a problem to rural areas where many women deliver at home due to difficulties in accessing health facilities. Objectives This civic education intervention aimed to increase rural HIV+ pregnant mothers uptake of Nevarapine tablets and syrup for infants’ dose for Prevention of mother to child transmission of HIV and to promote hospital delivery. Methods Global Hope Mobilization is providing education and counselling to women in rural setting to access basic medicines such as nevaripine, as well as to promote hospital delivery in Lilongwe district rural setting. Households with pregnant women were included through a random sample and a total of 700 pregnant women were included in a programme to provide civic education materials, including leaflets; local meetings, counselling sessions, and home visits. Nevaripine tablets and syrup were also administered, ANC data were collected and used from the nearest health facility. The intervention was assessed through one to one interviews, focus group discussion, and questionnaires. Results 100% of the pregnant women were sensitized on taking nevaripine, counselled and referred for HIV testing. To date 98% of women have attended pre and post VCT counselling testing and ANC at health facilities and at private clinics referred to. Of these women 66% were found to be HIV positive. Nevaripine tablets and instructions were issued to them when they reached 32 to 34 weeks of gestation. 60% Infants received Nevaripine syrup within 3 days after birth. Of these 6% are not known to have taken syrup and were lost to follow up, while 60% returned for post counselling. The major barriers of the intervention were home delivery, traditional beliefs and lack of knowledge of HIV status and on the course of nevaripine. Discussion

Vital status of pre‐ART and ART patients defaulting from care in rural Malawi

To ascertain the outcome of pre-Antiretroviral therapy (ART) and ART patients defaulting from care and investigate reasons for defaulting. Patients defaulting from HIV care in Chiradzulu between July 2004 and September 2007 were traced at last known home address. Deaths and moves were recorded, and patients found alive were interviewed. Defaulting was defined as missed last appointment by more than 1 month among patients of unknown vital status. A total of 1637 individuals were traced (54%-88% of eligible), 981 pre-ART and 656 ART patients. Of 694 pre-ART patients found, 49% had died (51% of adults and 38% of children), a median of 47 days after defaulting, and 14% had moved away. Of 451 ART patients found, 54% had died (54% of adults and 50% of children), a median of 52 days after defaulting, and 20% had moved away. Overall, 221 patients were interviewed (90% of those found alive), 42% had worked outside the district in the previous year; 49% of pre-ART and 19% of ART patients had not disclosed their HIV status to other household members. Main reasons for defaulting were stigma (43%), care dissatisfaction (34%), improved health (28%) and for ART discontinuation, poor understanding of disease or treatment (56%) and drug side effects (42%). This study in a rural African HIV programme reveals the dynamics related to health service access and use, and it provides information to correct programme mortality estimates for adults and children.

The tuberculosis challenge in a rural South African HIV programme.

BackgroundSouth Africa remains the country with the greatest burden of HIV-infected individuals and the second highest estimated TB incidence per capita worldwide. Within South Africa, KwaZulu-Natal has one of the highest rates of TB incidence and an emerging epidemic of drug-resistant tuberculosis.MethodsReview of records of consecutive HIV-infected people initiated onto ART between 1st January 2005 and 31st March 2006. Patients were screened for TB at initiation and incident episodes recorded. CD4 counts, viral loads and follow-up status were recorded; data was censored on 5th August 2008. Geographic cluster analysis was performed using spatial scanning.Results801 patients were initiated. TB prevalence was 25.3%, associated with lower CD4 (AHR 2.61 p = 0.01 for CD4 <50 cells/μl) and prior TB (AHR 1.58 p = 0.02). Incidence was 6.89 per 100 person-years from 81 cases over 1175 person-years analysis time and was highest in the first 3 months after ART initiation; associated with male sex and higher log HIV RNA. Prevalent and incident TB were significantly associated with mortality (OR 1.81 p = 0.01 and 2.02 p = 0.01 respectively). Incident TB was associated with a non-significant trend towards viral load >25 copies/ml (OR 1.75 p = 0.11). A low-risk cluster for incident TB was identified for patients living near the local hospital in the geospatial analysis.ConclusionThere is a large burden of TB in this population. Rate of incident TB stabilises at a rate higher than that of the overall population. These data highlight the need for greater research on strategies for active case finding in rural settings and the need to focus on strengthening primary health care.

Comparison of Projected and Actual Outcomes of the HIV/AIDS Epidemic in Malawi, 1990–2000

BackgroundIn 1992 Liomba et al used HIV-AIDS prevalence data from 1980 to 1990 and projected the adult HIV prevalence and the impact of AIDS for the years 1991 to 2000, under high and low HIV incidence scenarios, using EpiModel, DemProj and the AIDS Impact Model. This report compares the actual outcomes of the HIV-AIDS epidemic in Malawi from 1991 to 2000 with projections made by Liomba et al.Methods and FindingsDue to the lack of data on rural HIV prevalence in 1992, the prevalence estimates for the years 1980 to 1990 used by Liomba et al were higher than the now published prevalence. We re-estimated the projections for 1991 to 2000 based on more recent estimates of 1980 to 1990 HIV-AIDS prevalence using the Spectrum modeling software, and compared the old and new projections with the actual epidemic figures reported by NAC. The original projections made by Liomba et al and the adjusted projections made in this report are both very similar to the observed course of the AIDS epidemic reported by National AIDS Commission. Unfortunately for Malawi the epidemic seems to have followed the high scenario of HIV incidence.ConclusionThe course of the epidemic in Malawi and the social and economic devastation caused by it, despite the presence of reasonably good projections and prevention recommendations by Liomba et al, highlights the need for better co-ordination between research and practice. It also emphasizes the need to examine the difficulties faced by countries like Malawi to act more rapidly and implement effective prevention measures in the face of an epidemic.

Strategies for gender-equitable HIV services in rural India

The emergence of HIV in rural India has the potential to heighten gender inequity in a context where women already suffer significant health disparities. Recent Indian health policies provide new opportunities to identify and implement gender-equitable rural HIV services. In this review, we adapt Mosley and Chen's conceptual framework of health to outline determinants for HIV health services utilization and outcomes. Examining the framework through a gender lens, we conduct a comprehensive literature review for gender-related gaps in HIV clinical services in rural India, focusing on patient access and outcomes, provider practices, and institutional partnerships. Contextualizing findings from rural India in the broader international literature, we describe potential strategies for gender-equitable HIV services in rural India, as responses to the following three questions: (1) What gender-specific patient needs should be addressed for gender-equitable HIV testing and care? (2) What do health care providers need to deliver HIV services with gender equity? (3) How should institutions enforce and sustain gender-equitable HIV services? Data at this early stage indicate substantial gender-related differences in HIV services in rural India, reflecting prevailing gender norms. Strategies including gender-specific HIV testing and care services would directly address current gender-specific patient needs. Rural care providers urgently need training in gender sensitivity and HIV-related communication and clinical skills. To enforce and sustain gender equity, multi-sectoral institutions must establish gender-equitable medical workplaces, interdisciplinary HIV services partnerships, and oversight methods, including analysis of gender-disaggregated data. A gender-equitable approach to rural India's rapidly evolving HIV services programmes could serve as a foundation for gender equity in the overall health care system.

A Qualitative Analysis of the Economic Impact of HIV and Antiretroviral Therapy on Individuals and Households in Uganda

Despite the acceleration of antiretroviral therapy (ART) scale-up in sub-Saharan Africa, little is known about the social and economic effects of ART on individuals and households. In January 2008, we conducted semistructured interviews with 24 adult ART clients attending urban and rural HIV clinics operated by Joint Clinical Research Center in Uganda. Using content analysis we explored changes in physical health, work activity and asset management from before HIV to after ART. Twenty-one (88%) participants were working prior to HIV (mostly microenterprises and subsistence farming), of whom 18 had to stop work at least temporarily after onset of HIV. After ART, 20 (83% of the sample) were engaged in some type of work, but for many it was not at the same level as before HIV. Also, most that previously had salaried employment were unable to return to the formal labor market. Two thirds of the sample reported having to sell off at least some of their land, capital, or household property after HIV, and few were able to buy it back after ART. A majority (67%) reported that economic support from family was instrumental after the onset of HIV, and for 38% this support continued to be necessary after ART. These findings highlight that while ART helps people to regain a capacity to work, other economic supports are needed to enable individuals and households to reestablish their livelihoods, especially in resource-constrained settings.

The role of in-migrants in the increasing rural HIV-1 epidemic: results from a village population survey in the Kilimanjaro region of Tanzania

To investigate the magnitude of rural in-migration and the role of in-migrants in the observed increase in HIV-1 prevalence in rural Kilimanjaro, Tanzania. A cross-sectional study involving the adult population aged 15-44 years residing in a rural village was conducted from March to May of 2005. Participants were interviewed regarding their risk behaviors and gave blood for HIV-1 and syphilis testing. Overall, the response rate was 73.0% (1528/2093). A total of 699 (48.1%) participants reported having in-migrated to the village at some point during their life. The prevalences of HIV-1 infection were 1.8%, 2.3%, and 3.7% among non-in-migrant, long-term in-migrant, and recent in-migrant men, respectively (p(trend)<0.001). The corresponding prevalences among women were 9.2%, 11.5%, and 14.5%, respectively (p(trend)=0.048). The odds of HIV-1 infection were higher among recent in-migrants as compared to non-in-migrants (men: adjusted odds ratio (AOR) 2.4, 95% CI 1.8-6.6; women: AOR 2.3, 95% CI 1.1-5.0). Risk behaviors were inversely related to years since in-migration for both sexes. The results suggest that rural in-migration is common for both men and women. In-migrants were at higher risk for HIV-1 infection and contributed significantly to increased rural HIV-1 prevalence. More studies to examine the rate and broader causes of rural in-migration in similar communities are called for. These may help in the design of intervention strategies for curbing the rising rural HIV epidemic.

Anaemia in a rural Ugandan HIV cohort: prevalence at enrolment, incidence, diagnosis and associated factors

To determine the prevalence and incidence of anaemia in HIV-positive and negative individuals; to identify risk factors for anaemia, prior to the introduction of HAART; and to determine the validity of the clinical diagnosis of anaemia. Between 1990 and 2003, we followed a rural population based cohort of HIV-infected and uninfected participants. Prevalence and incidence of anaemia were determined clinically and by laboratory measurements. The sensitivity, specificity and predictive values of clinical diagnosis were calculated. The prevalence of anaemia at enrolment was 18.9% among HIV-positive and 12.9% among HIV-negative participants (P = 0.065). Incidence of anaemia increased with HIV disease progression, from 103 per 1000 person-years of observation among those with CD4 counts >500 to 289 per 1000 person-years of observation among those with CD4 counts <200. Compared to laboratory diagnosis, the clinical diagnosis of anaemia had a sensitivity of 17.8%, specificity of 96.8%, a positive predictive value of 50.6% and a negative predictive value of 86.4%. Being female, low CD4 cell counts, HIV-positive, wasting syndrome, WHO stage 3 or 4, malaria, fever, pneumonia and oral candidiasis were associated with prevalent anaemia. Anaemia prevalence and incidence were higher among HIV-positive than negative participants. Compared to laboratory diagnosis, clinical detection of anaemia had a low sensitivity. Clinicians working in settings with limited laboratory support must be conscious of the risk of anaemia when managing HIV/AIDS patients, particularly when using antiretroviral drugs which by themselves may cause anaemia as a side effect. We recommend that haemoglobin should be measured before starting ART and monthly for the first three months.

High HIV incidence in a community with high HIV prevalence in rural South Africa: findings from a prospective population-based study

To measure HIV incidence in a rural area of South Africa with high HIV prevalence and to analyze risk factors for acquisition of HIV using a prospective population-based cohort study. Data from two rounds (2003-2005) of a large prospective population-based HIV survey in rural KwaZulu-Natal were used to calculate HIV incidence by sex and 5-year age group. Multiple imputations (MI) were used to adjust for selection effects and risk factors for acquiring HIV were examined in Weibull multiple regression. During 5253 person-years at risk, 170 individuals became seropositive. The crude HIV incidence rate per 100 person-years was 3.8 [95% confidence interval (CI), 3.2-4.6] in women aged 15-49 years and 2.3 (95% CI, 1.8-3.1) in men aged 15-54 years. MI significantly increased the HIV incidence rates both in women and men [7.9/100 person-years (95% CI, 7.4-8.4) and 5.1/100 person-years (95% CI 4.1-6.2), respectively]. When holding other factors constant in Weibull multiple regression, the hazard of HIV seroconversion was approximately twice as high in people who were currently unmarried but had a partner than among people who were currently married (P < 0.001) and increased with increasing distance from a government health clinic (P = 0.051) and decreasing distance from a primary road (P = 0.002). In this high HIV prevalence community in rural South Africa HIV incidence is very high. The present focus on antiretroviral treatment needs to be balanced with a renewed emphasis on HIV prevention for both sexes.

The Relationship of Stigma to the Sexual Risk Behavior of Rural Men Who Have Sex with Men

Most studies of risky sexual behaviors of men who have sex with men (MSM) have been conducted in cities. Few have documented risky sexual behavior of rural men despite increases in rural HIV. Fewer have addressed stigma and risk. This study explored the effects of stigma on sexual risk behavior among rural MSM. We hypothesized that stigma emanating from families, health care providers, and the communities of rural MSM would indirectly affect their sexual risk behavior through their mental health status, specifically self-esteem and internalized homophobia. A convenience sample of 414 rural MSM obtained through political, health service, and social organizations completed an anonymous self-administered questionnaire. Over half of the men reported high-risk sexual behavior. Sensation seeking directly affected levels of sexual risk while the effects of stigma on sexual risk behavior were mediated by mental health variables. Stigma related to respondents' low self-esteem, and low internalized homophobia increased risk behavior.

China and HIV — A Window of Opportunity

Chinese and international health officials express optimism about controlling the HIV–AIDS epidemic but emphasize the need to move quickly. Bates Gill and Dr. Susan Okie explain that, given China's enormous population, even a small increase in prevalence could be devastating. Bates Gill discusses the largely rural HIV epidemic in China, the turnaround in the central government's approach to HIV–AIDS, and the remaining obstacles to controlling the epidemic. Gill is a China scholar at the Center for Strategic and International Studies, Washington, D.C.

A primary health care intervention to mobilize health workers for HIV prevention in Malawi

For the last 4 years we have implemented a model to mobilize rural health workers as leaders for HIV prevention in Malawi. We use a conceptual framework that integrates the World Health Organization's (WHO) primary health care (PHC) model, the social–cognitive model of behavioural change, and contextual tailoring of the intervention. Health workers are potential rural HIV prevention leaders because they have community trust and respect. However, their leadership potential has been limited by both health system barriers such as inadequate workers, supplies, and training and personal barriers such as risky occupational and personal behaviours. In the first phase of the project, we developed collaborative relationships and conducted qualitative research to adapt a peer group intervention for rural health workers and community members. In the ongoing second phase, we trained the health workers, who then volunteered and provided the intervention to adults in the communities their health centres serve. The intervention was adapted for young people through a community participatory process. Currently the adapted intervention is being offered to young people. As a guide to replication, we discuss barriers encountered in implementing this collaborative project and how we overcame them. This project demonstrates that health workers can be effective leaders for community AIDS prevention in African countries. The primary health care model offers a feasible, cost-effective and sustainable approach to maximizing health worker-community collaboration to reduce the spread of HIV.

Characteristics of HIV-infected adults in the Deep South and their utilization of mental health services: A rural vs. urban comparison

Insufficient utilization of mental health services has been described among HIV-infected individuals in urban areas; however, little is known about utilization of mental health services among rural-living HIV-infected individuals. This article examines use of mental health services by HIV-infected adults in the Southern U.S., where approximately two-thirds of rural HIV cases reside, and compares mental health services use between those in rural and urban areas. Data were obtained from surveys of HIV-infected individuals receiving care at tertiary Infectious Diseases clinics in the Southern U.S. (n = 474). Study findings indicated that participants living in areas with a higher proportion of rural-living individuals were less likely to report seeing a mental health provider (p<.001) in the last year even though there were no differences in level of psychological distress by degree of rurality. Participants living in more rural areas also reported significantly fewer mental health visits in the previous month (p=.025). Furthermore, rural living was significantly associated with being African-American, heterosexual, less educated, and having minor children in the home. Due to differences in characteristics and mental health services use by degree of rurality, efforts are needed to assess and address the specific mental health and other needs of HIV-infected individuals in rural areas.