HIV Prevention Response Research Articles

A Structured Protocol Model of Depression Care versus Clinical Acumen: A Cluster Randomized Trial of the Effects on Depression Screening, Diagnostic Evaluation, and Treatment Uptake in Ugandan HIV Clinics.

Depression is common among people living with HIV, and it has consequences for both HIV prevention and treatment response, yet depression treatment is rarely integrated into HIV care in sub-Saharan Africa, partly due to the paucity of mental health professionals. We conducted a cluster randomized controlled trial of two task-shifting models to facilitating depression care delivered by medical providers: one that utilized a structured protocol, and one that relied on clinical acumen, in 10 HIV clinics in Uganda. Both models started with routine depression screening of all clients at triage using the 2-item Patient Health Questionnaire (PHQ-2), from which we enrolled 1252 clients (640 at structured protocol clinics, 612 at clinical acumen clinics) who had screened positive over 12 months. We compared the two models on (1) proportion of all client participants, and those clinically depressed (based on survey-administered 9-item PHQ-9>9), who received post-screening evaluation for depression using the PHQ-9; and (2) proportion of clinically depressed who were prescribed antidepressant therapy. Linear probability regression analyses were conducted using a wild cluster bootstrap to control for clustering; patient characteristics, clinic size and time fixed effects were included as covariates. Among all client participants, those in the structured protocol arm were far more likely to have received further evaluation by a medical provider using the PHQ-9 (84% vs. 49%; beta = .33; p = .01). Among the clinically depressed clients (n = 369), the advantage of the structured protocol model over clinical acumen was not statistically significant with regard to PHQ-9 depression evaluation (93% vs. 68%; beta = .21; p = .14) or prescription of antidepressants (69% vs. 58%; beta = .10; p = .50), in part because only 30% of clients who screened positive were clinically depressed. These findings reveal that in both models depression care practices were widely adopted by providers, and depression care reached most depressed clients. The structured protocol model is advantageous for ensuring that positively screened clients receive a depression evaluation, but the two models performed equally well in ensuring the treatment of depressed clients in the context of strong supervision support.Trial Registration: ClinicalTrials.gov NCT02056106

Knowing your HIV/AIDS response: A pilot test of a new service mapping toolkit in Ghana

Background“Knowing” an HIV response in a country is a complex undertaking. This requires knowing what actions key implementers in all sectors (government, non-government, public, and private) are deploying; what populations they serve; what the reach of these programs are, amongst others. AimWe aimed to pilot test a set of newly developed data collection tools referred to as the Know Your Response (KYR) toolkit in Ghana. The KYR toolkit addresses three key concepts that are critical for an improved understanding of the HIV-prevention response in terms of location, scale, and needs. Materials and methodsData were collected on HIV programming being undertaken in each of the 16 metropolitan, municipal, and district assemblies (MMDAs) in the Greater Accra region of Ghana. Analysis and dissemination of data includes the generation of univariate and bivariate tabulations as well as production of maps of HIV services using Geographic Information System (GIS) technology. ResultsThe toolkit was successful in collecting a great deal of data that describe, at the district level, who is working in HIV prevention, what interventions they are providing, where these interventions are being provided, and to whom the interventions are being targeted. The data generated allows for mapping and understanding of the scope and scale of the HIV-prevention response at the district level. It also identifies challenges and opportunities for scaling the exercise nationally. ConclusionsThe study provides information needed to guide prioritization, and/or adjustment of the national HIV-prevention programs and interventions being carried out in the Greater Accra region.

Substance Use and HIV Among Female Sex Workers and Female Prisoners: Risk Environments and Implications for Prevention, Treatment, and Policies.

Female sex workers (FSWs) and female prisoners experience elevated HIV prevalence relative to the general population because of unprotected sex and unsafe drug use practices, but the antecedents of these behaviors are often structural in nature. We review the literature on HIV risk environments for FSWs and female prisoners, highlighting similarities and differences in the physical, social, economic, and policy/legal environments that need to be understood to optimize HIV prevention, treatment, and policy responses. Sex work venues, mobility, gender norms, stigma, debt, and the laws and policies governing sex work are important influences in the HIV risk environment among FSWs, affecting their exposure to violence and ability to practice safer sex and safer drug use behaviors. Female prisoners are much more likely to have a drug problem than do male prisoners and have higher HIV prevalence, yet are much less likely to have access to HIV prevention and treatment and access to drug treatment in prison. Women who trade sex or are imprisoned and engage in substance use should not be considered in separate silos because sex workers have high rates of incarceration and many female prisoners have a history of sex work. Repeated cycles of arrest, incarceration, and release can be socially and economically destabilizing for women, exacerbating their HIV risk. This dynamic interplay requires a multisectoral approach to HIV prevention and treatment that appreciates and respects that not all women are willing, able, or want to stop sex work or drug use. Women who engage in sex work, use drugs, or are imprisoned come from all communities and deserve sustained access to HIV prevention and treatment for substance use and HIV, helping them and their families to lead healthy and satisfying lives.

Young, Online and in the Dark: Scaling Up HIV Testing among MSM in ASEAN.

BackgroundPoor HIV testing uptake by MSM may be attributable to unique challenges that are localized in Southeast Asia.ObjectiveTo characterize MSM who never tested for HIV, to identify correlates of never testing, and to elucidate the perceived barriers to HIV testing.MethodsThe present study used data from the Asian Internet MSM Sex Survey (AIMSS) and restricted the analysis to 4,310 MSM from the ten member countries of the Association of South East Asian Nations (ASEAN).ResultsAmong MSM participants from ASEAN in our sample, 1290 (29.9%) reported having never been tested for HIV, 471 (10.9%) tested for HIV more than 2 years ago, and 2186 (50.7%) reported their last test date was between 6 months and two years ago, with only 363 (8.4%) of these men having been tested in the past 6 months. In multivariable logistic regression, younger MSM (age 15–22 years old [AOR: 4.60, 95% CI: 3.04–6.96]), MSM with lower education (secondary school or lower [AOR: 1.37, 95% CI: 1.03–1.83]), MSM who identify as bisexual or heterosexual (compared to gay-identified) (AOR: 1.94, 95% CI: 1.60–2.35), and MSM who had never used a condom with male partners (AOR: 1.61, 95% CI: 1.32–1.97) had higher odds of never been HIV tested. Main reason for not being tested was a low risk perception of HIV exposure (n = 390, 30.2%).ConclusionCurrent HIV prevention response must not leave MSM “in the dark,” but instead meet them where they are by utilizing the Internet creatively through social media and smart phones. As ASEAN Economic Community (AEC) is quickly becoming a reality, so must there be an equally fast and united response to slowing down the HIV epidemics among MSM in ASEAN.

Curbing the epidemic on both sides of the Atlantic: a public health perspective.

HIV/AIDS continues to place a devastating toll on individuals, families and communities globally, and western industrialized countries are by no means exempt. Today, there are more than 1 million Americans and 100,000 Britons living with HIV, with a disproportionate burden of new and prevalent HIV infections borne by gay, bisexual and other men who have sex with men (MSM), racial/ethnic minorities, migrants and persons who use drugs. Epidemic concentration in urban areas, especially among: population sub-groups with high prevalence of risk behaviours; the socio-economically marginalized; or those with poor access to services, has been well documented. Recent increases in HIV incidence in the rural south US, and in MSM in both countries, reflect the dynamic and evolving nature of these epidemics. New national HIV prevention strategies in both countries have refocused attention on these domestic epidemics, prioritizing HIV testing scaling up, linkage to quality care and tackling long-standing health inequalities. There are also significant differences between the two countries – in part a reflection of the different health and social care systems; historical approaches to the funding and coordination of HIV prevention; and underlying patterns of health inequalities and their social and structural determinants. In addition, the social–political acceptability of using the sexual health frame to guide more holistic and integrated approaches to HIV prevention efforts remains a key difference. This presentation will compare and contrast HIV prevention responses in the US and UK over the past decade, identifying opportunities for enhancing the prevention response in these and other western industrialized countries in the 21st century.

Teaching empowerment? Power and agency in sexuality education discourses in the context of HIV prevention programmes in South Africa

ABSTRACTSexuality education is widely considered a pivotal component for HIV prevention responses for young people and a vehicle for youth empowerment in relation to their sexual identities and behaviours. However, there has been a lack of meaningful engagement between public health discourses and educational theories, and this gap has allowed the educational claims of empowerment discourses to go unquestioned. This conceptual paper, grounded in the South African context, provides a close reading of public health formulations of empowerment discourse through three broad theoretical framings of power and agency and their educational claims: liberal, neo-Marxist and post-structural. This theoretical thinking is applied to educational practice in the South African context in order to encourage discussion about how the promise of education requires making explicit underlying notions of power and agency. It is argued that this educational reading is critical for better responding to the diverse needs of young people as they negotiate their sexual identities and behaviours in the context of a life-threatening disease. The paper offers three potential research directions that could deepen our understanding of the possibilities and limitations of sexuality education as an HIV prevention initiative.

The HIV epidemic and prevention response in Tigrai, Ethiopia: a synthesis at sub-national level.

BackgroundThis study, the first of its kind carried out at sub-national level in Ethiopia, was conducted in order to understand the dynamics of HIV transmission at regional and district level in Tigrai, Ethiopia; and to assess the adequacy of the HIV prevention response.MethodsRoutine data from health centres, data from available published and grey literature and studies, and primary qualitative information were triangulated to draw an updated picture of the HIV epidemic, HIV response and resource allocation in Tigrai.ResultsHIV prevalence in Tigrai was 1.8% in 2011 (EDHS). ANC data show that there has been a continuous decline in the prevalence of HIV in both urban and rural areas (urban: 14.9% in 2001 to 5.0% in 2009; rural: 5.2% in 2001 to 1.3% in 2009, ANC surveillance data). Variability in prevalence by zone and by district was observed. Possible reasons for higher prevalence include the presence of mobile seasonal workers, highly urbanized centres, a high concentration of economic activity and connecting roads and large commercial farms. Sex workers, seasonal farm workers and HIV negative partners in discordant couples were identified as being at higher risk. There is no evidence that programme planning is done on the basis of geographical variations in HIV prevalence and there are gaps in programmes and services for certain high risk population groups.ConclusionConsiderable efforts have been invested in the HIV prevention response in Tigrai however, these efforts do not fully respond to the actual needs. For a more effective and targeted HIV prevention response, studies and data syntheses need to be carried out at sub-national level in order to accurately identify local specificities and plan accordingly. Resources should be targeted towards areas where transmission is linked to sex work, mobility and the mobile labour workforce.

Australia's HIV-prevention response: Introduction to the special issue.

Australia is relatively unique in having, until recently, sustained an effective response to HIV in all of its affected communities. The first case of AIDS was diagnosed in 1982 in a gay man in Sydney, and between 1982 and 1985 HIV spread rapidly, with an estimated 4,500 men being infected, predominantly in the gay community in Sydney and to a lesser extent in Melbourne. The majority of these infections took place at a time when relatively little was known scientifically about HIV (then known as HTLV-III). In consequence, men within the gay community and their friends were forced to look to their own resources—organizing politically and socially, and drawing upon experience both at home and elsewhere in the world, to mount what in retrospect is perhaps best seen as something of a social revolution among gay and other homosexually active men. The difficulty of these early struggles should not be underestimated, especially since homosexual behavior between men remained illegal in many states in Australia until the mid 1980s, and into the 1990s in Queensland and Tasmania. Although there was concern that HIV was also spreading among people who injected drugs (PWID) and that it would be only a matter of time until heterosexual infections became more common, as the pattern of transmission became more established, it was apparent that spread via injecting drug use remained at a very low level (about 5% of the total, but closer to 1% if gay and other homosexually active men who also inject are excluded), that transmission from medical procedures such as the receipt of blood or blood products had declined from about 14% in 1985–1986 to about 1% in 1991–1992, and that onward transmission into the heterosexual community had not occurred to any great extent. The peak in HIV incidence occurred in 1987, and incidence declined year on year until 1999. Over that period, 1987–1999, there was a profound decline in the epidemic. Thereafter, there has been a small but steady increase in incidence. Gay and other homosexually active men remain the largest group affected by HIV in Australia. HIV transmission continues to occur mainly through sexual contact between men and in 2012 accounted for 70% of newly diagnosed HIV infections and 87% of newly acquired infection. The early and relatively sustained success of the Australian response can be attributed to a wide range of actions by communities and networks, supported by government. These include but are not limited to the following measures. Between

The trajectory of methadone maintenance treatment in Nepal

There are about 28,500 people who inject drugs (PWID) in Nepal and HIV prevalence among this group is high. Nepal introduced harm reduction services for PWID much earlier than other countries in South Asia. Methadone maintenance treatment (MMT) was first introduced in Nepal in 1994. This initial small scale MMT programme was closed in 2002 but reopened in 2007 as an emergency HIV prevention response. It has since been scaled up to include three MMT clinics and continuation of MMT is supported by the Ministry of Home Affairs (MOHA; the nodal ministry for drug supply reduction activities) and has been endorsed in the recent National Narcotics policy. Pressure from drug user groups has also helped its reintroduction. Interestingly, these developments have taken place during a period of political instability in Nepal, with the help of strong advocacy from multiple stakeholders. The MMT programme has also had to face resistance from those who were running drug treatment centres. Despite overcoming such troubles, the MMT programme faces a number of challenges. Coverage of MMT is low and high-risk injecting and sexual behaviour among PWID continues. The finance for MMT is largely from external donors and these donations have become scarce with the current global economic problems. With a multitude of developmental challenges for Nepal, the position of MMT in the national priority list is uncertain. Ownership of the programme by government, a cost-effective national MMT scale up plan and rigorous monitoring of its implementation is needed.

Prohibition, stigma and violence against men who have sex with men: effects on HIV in Central Asia

Conscious of a paucity of evidence, and drawing upon a combination of historical documentary material, research literature and surveillance data, this paper offers a commentary on the social, historical and HIV contexts affecting men who have sex with men in Central Asia. The authors describe the history of men who have sex with men in the five Central Asian republics, before, during and after the Soviet-imposed legal prohibition, which continues in Turkmenistan and Uzbekistan, the only nations in the World Health Organization Europe region where sex between men remains illegal. This historical context frames contemporary responses to men who have sex with men. Despite long-established homoerotic traditions, modern attitudes to men who have sex with men are marked by great hostility, generating stigmatization of sex between men and discrimination against men suspected of it. The losses following public exposure can be severe: loss of employment; limited/lack of health-care access; and safety from physical and sexual assault. Such hostility creates an environment of increased HIV risk, and constrains the production of reliable HIV evidence. The authors argue that the generation of HIV risk, HIV-prevention responses and HIV evidence are products of their historical and social contexts, and call attention to the urgent need for HIV prevention and structural reforms to protect the health of men who have sex with men in Central Asia.

In the face of war: examining sexual vulnerabilities of Acholi adolescent girls living in displacement camps in conflict-affected Northern Uganda

BackgroundAdolescent girls are an overlooked group within conflict-affected populations and their sexual health needs are often neglected. Girls are disproportionately at risk of HIV and other STIs in times of conflict, however the lack of recognition of their unique sexual health needs has resulted in a dearth of distinctive HIV protection and prevention responses. Departing from the recognition of a paucity of literature on the distinct vulnerabilities of girls in time of conflict, this study sought to deepen the knowledge base on this issue by qualitatively exploring the sexual vulnerabilities of adolescent girls surviving abduction and displacement in Northern Uganda.MethodsOver a ten-month period between 2004–2005, at the height of the Lord’s Resistance Army insurgency in Northern Uganda, 116 in-depth interviews and 16 focus group discussions were held with adolescent girls and adult women living in three displacement camps in Gulu district, Northern Uganda. The data was transcribed and key themes and common issues were identified. Once all data was coded the ethnographic software programme ATLAS was used to compare and contrast themes and categories generated in the in-depth interviews and focus group discussions.ResultsOur results demonstrated the erosion of traditional Acholi mentoring and belief systems that had previously served to protect adolescent girls’ sexuality. This disintegration combined with: the collapse of livelihoods; being left in camps unsupervised and idle during the day; commuting within camp perimeters at night away from the family hut to sleep in more central locations due to privacy and insecurity issues, and; inadequate access to appropriate sexual health information and services, all contribute to adolescent girls’ heightened sexual vulnerability and subsequent enhanced risk for HIV/AIDS in times of conflict.ConclusionsConflict prevention planners, resettlement programme developers, and policy-makers need to recognize adolescent girls affected by armed conflict as having distinctive needs, which require distinctive responses. More adaptive and sustainable gender-sensitive reproductive health strategies and HIV prevention initiatives for displaced adolescent girls in conflict settings must be developed.

Creative Synergy: Using Community Theatre and Appreciative Inquiry for Young People's Critical Participation in HIV Prevention and Education

This article positions community theatre as an agency for development and education based on the educational principles of Freire and Boal's theatre for development. The article argues that appreciative inquiry can enrich the practice of community theatre by approaching HIV and AIDS education as an asset-based, participatory, inclusive, learner-centered approach. The article hypothesizes that the infusion of the four-D process of appreciative inquiry into community theatre processes aimed at HIV and AIDS education will enhance young people's agency as active participants and agents of change in their communities beyond the didactic notions inherent in ABC education approaches to HIV prevention. The article argues that this approach can encourage meaningful participation and critical consciousness among young people in the HIV prevention response.

Effective HIV prevention: the indispensable role of social science

This paper examines the ways in which HIV prevention is understood including “biomedical”, “behavioural”, “structural”, and “combination” prevention. In it I argue that effective prevention entails developing community capacity and requires that public health addresses people not only as individuals but also as connected members of groups, networks and collectives who interact (talk, negotiate, have sex, use drugs, etc.) together. I also examine the evaluation of prevention programmes or interventions and argue that the distinction between efficacy and effectiveness is often glossed and that, while efficacy can be evaluated by randomized controlled trials, the evaluation of effectiveness requires long-term descriptive strategies and/or modelling. Using examples from a number of countries, including a detailed account of the Australian HIV prevention response, effectiveness is shown to be dependent not only on the efficacy of the prevention technology or tool but also on the responses of people – individuals, communities and governments – to those technologies. Whether a particular HIV prevention technology is adopted and its use sustained depends on a range of social, cultural and political factors. The paper concludes by calling on biomedical and social scientists to work together and describes a “social public health”.

Sex worker-led structural interventions in India: A case study on addressing violence in HIV prevention through the Ashodaya Samithi collective in Mysore

Background & objectives:Structural interventions have the capacity to improve the outcomes of HIV/AIDS interventions by changing the social, economic, political or environmental factors that determine risk and vulnerability. Marginalized groups face disproportionate barriers to health, and sex workers are among those at highest risk of HIV in India. Evidence in India and globally has shown that sex workers face violence in many forms ranging from verbal, psychological and emotional abuse to economic extortion, physical and sexual violence and this is directly linked to lower levels of condom use and higher levels of sexually transmitted infections (STIs), the most critical determinants of HIV risk. We present here a case study of an intervention that mobilized sex workers to lead an HIV prevention response that addresses violence in their daily lives.Methods:This study draws on ethnographic research and project monitoring data from a community-led structural intervention in Mysore, India, implemented by Ashodaya Samithi. Qualitative and quantitative data were used to characterize baseline conditions, community responses and subsequent outcomes related to violence.Results:In 2004, the incidence of reported violence by sex workers was extremely high (> 8 incidents per sex worker, per year) but decreased by 84 per cent over 5 years. Violence by police and anti-social elements, initially most common, decreased substantially after a safe space was established for sex workers to meet and crisis management and advocacy were initiated with different stakeholders. Violence by clients, decreased after working with lodge owners to improve safety. However, initial increases in intimate partner violence were reported, and may be explained by two factors: (i) increased willingness to report such incidents; and (ii) increased violence as a reaction to sex workers’ growing empowerment. Trafficking was addressed through the establishment of a self-regulatory board (SRB). The community's progressive response to violence was enabled by advancing community mobilization, ensuring community ownership of the intervention, and shifting structural vulnerabilities, whereby sex workers increasingly engaged key actors in support of a more enabling environment.Interpretation & conclusions:Ashodaya's community-led response to violence at multiple levels proved highly synergistic and effective in reducing structural violence.

Education, empowerment and community based structural reinforcement: An HIV prevention response to mass incarceration and removal

In the context of US urban jails, incarceration is often seen as an opportune intervention point for prevention interventions in public health. For the detained individual, it is an opportunity to reflect on individual choices and the potential for changes in one's life course. For population focused public health professionals, jail detention facilities represent a concentration of health risks, and an opportunity to have an impact on a significant portion of those at risk for HIV and other health concerns. This paper presents an innovative education and empowerment model that bridges across jail walls, beginning on the inside, and continuing on the outside of jail where individuals continue to be challenged and supported toward positive health and social choices. The intervention also seeks to foment community activism in the communities to which jail detainees return, thus aiming to have a structural impact. This paper examines both the intervention model and the challenges of examining the effectiveness claims for the intervention at multiple levels.

Sex Worker Studies: The Science, Semantics, and Politics of Targeting Our HIV Prevention Response

Sex Worker Studies: The Science, Semantics, and Politics of Targeting Our HIV Prevention Response

Long-term follow up of clients from a community-based opioid substitution therapy programme in Manipur

Long-term follow up of clients from a community-based opioid substitution therapy programme in Manipur

Why HIV/AIDS should be treated as exceptional: arguments from sub-Saharan Africa and Eastern Europe

The idea that HIV and AIDS gets too much attention and funding emerged in 2008 with a call to end 'AIDS exceptionalism.' This article outlines a short history of AIDS exceptionalism — the idea that HIV and AIDS require a response above and beyond 'normal' health interventions and is privileged in terms of attention and resources when compared with other diseases — and the reasons for the backlash to this idea. We argue that in some settings HIV and AIDS must be treated as exceptional. These are the hyperendemic countries of southern Africa, where HIV epidemics have shown substantial and lasting demographic and social impact, and parts of Eastern Europe where the epidemic is augmenting troubling demographic changes, such as declines in fertility rates and population growth, and impacting society in nuanced ways. Also included are resource-poor settings, mostly in Africa, where the combination of the high number of HIV infections and the cost of treatment have created issues concerning donor dependency and sustainable responses. An HIV epidemic must be seen as a long-wave event, with complex challenges to both HIV prevention and treatment responses. The article reviews the available data and literature to provide evidence for our arguments. We conclude that the perception that AIDS exceptionalism is outdated ignores the complexity of different HIV epidemics and obfuscates the challenges to effective responses.

Combination prevention: a deeper understanding of effective HIV prevention

Evidence-informed and human rights-based combination prevention combines behavioural, biomedical, and structural interventions to address both the immediate risks and underlying causes of vulnerability to HIV infection, and the pathways that link them. Because these are context-specific, no single prescription or standard package will apply universally. Anchored in 'know your epidemic' estimates of where the next 1000 infections will occur and 'know your response' analyses of resource allocation and programming gaps, combination prevention strategies seek to realign programme priorities for maximum effect to reduce epidemic reproductive rates at local, regional, and national levels. Effective prevention means tailoring programmes to local epidemics and ensuring that components are delivered with the intensity, quality, and scale necessary to achieve intended effects. Structural interventions, addressing the social, economic, cultural, and legal constraints that create HIV risk environments and undermine the agency of individuals to protect themselves and others, are also public goods in their own right. Applying the principles of combination prevention systematically and consistently in HIV programme planning, with due attention to context, can increase HIV programme effectiveness. Better outcome and impact measurement using multiple methods and data triangulation can build the evidence base on synergies between the components of combination prevention at individual, group, and societal levels, facilitating iterative knowledge translation within and among programmes.

A review of the epidemiology of HIV infection and prevention responses among MSM in Asia

To review the epidemiology of HIV infection and prevention responses among men who have sex with men (MSM) in Asia. A review of the existing scientific literature and governmental and non-governmental reports regarding the epidemiology of HIV infection and prevention responses among MSM in Asia. Data show that HIV infection is now widespread among MSM throughout Asia. With the exception of the Philippines and Timor Leste, all countries for which information is available show epidemics of HIV infection among MSM, particularly in urban areas. Double-digit HIV prevalence among MSM is found in cities in China, Taiwan, India, Myanmar and Thailand. Incidence data, although scarce, confirm the ongoing transmission of HIV among MSM. Reports of new HIV diagnoses in MSM have been increasing in recent years, particularly in the developed economies of East Asia. HIV prevention responses have started in most Asian countries, but while the exact coverage and investment of such responses remain unclear, coverage seems to be far from the 60-80% level needed to have an effect on the HIV epidemic. Both Government and donor investment in prevention programs for MSM remain inadequate, especially when compared with the contribution of male-to-male transmission to the overall burden of the HIV epidemic. Enlarged HIV prevention coverage and increased financial investment are necessary to reduce the spread of HIV infection among MSM in Asia.