Multisectoral Responses Research Articles

Simulating system dynamics of the HIV care continuum to achieve treatment as prevention.

The continuing HIV pandemic calls for broad, multi-sectoral responses that foster community control of local prevention and care services, with the goal of leveraging high quality treatment as a means of reducing HIV incidence. Service system improvements require stakeholder input from across the care continuum to identify gaps and to inform strategic plans that improve HIV service integration and delivery. System dynamics modeling offers a participatory research approach through which stakeholders learn about system complexity and about ways to achieve sustainable system-level improvements. Via an intensive group model building process with a task force of community stakeholders with diverse roles and responsibilities for HIV service implementation, delivery and surveillance, we designed and validated a multi-module system dynamics model of the HIV care continuum, in relation to local prevention and care service capacities. Multiple sources of data were used to calibrate the model for a three-county catchment area of central Connecticut. We feature a core module of the model for the purpose of illustrating its utility in understanding the dynamics of treatment as prevention at the community level. We also describe the methods used to validate the model and support its underlying assumptions to improve confidence in its use by stakeholders for systems understanding and decision making. The model’s generalizability and implications of using it for future community-driven strategic planning and implementation efforts are discussed.

Implementation Strategies to Increase PrEP Uptake in the South.

Seven years after TDF/FTC was approved for pre-exposure prophylaxis to reduce risks of HIV infection, there have been large increases in the number of persons using PrEP in the USA. However, recent data on pre-exposure prophylaxis (PrEP) use at the state level indicate that people living in the Southern United States are underserved by PrEP relative to their epidemic need. We sought to review possible reasons for inequitable uptake of PrEP in the South and identify implementation approaches to increase PrEP uptake in the South. Published literature, data on the locations of PrEP service providers, recent data on PrEP utilization from pharmacy prescription databases, HIV surveillance data and government data on healthcare providers, and health literacy indicate a confluence of factors in the South that are likely limiting PrEP uptake. A variety of approaches are needed to address the complex challenges to PrEP implementation in the South. These include considering alternative PrEP provision strategies (e.g., pharmacy-based PrEP, telemedicine-delivered PrEP), conducting gain-based stigma-reduction campaigns, increasing capacity for reimbursement for PrEP medications and services through policy change to expand Medicaid and to preserve access to Affordable Care Act-compliant health plans, expanding STI screening programs and improving integration of PrEP offering with delivery of positive STI results, using mHealth tools to screen groups at highest risk for HIV (e.g., men who have sex with men) periodically to increase correct perception of risk, and streamlining clinical procedures to allow same-day PrEP starts for patients without obvious medical contraindications. Overcoming the structural, capacity, and policy challenges to increasing PrEP uptake in the South will require innovations in clinical approaches, leveraging technologies, and policy changes. The South has unique challenges to achieving equitable PrEP uptake, and addressing key barriers to expanded PrEP use will require multisectoral responses.

Dual-harm, complex needs, and the challenges of multisectoral service coordination

The risk of premature death from suicide and other causes is elevated in people with a history of self-harm1 and people with a history of violence against others.2 Despite overlap in these two populations,3 the study by Sarah Steeg and colleagues4 in The Lancet Public Health is the first to examine the risk of unnatural death in people who have engaged in both behaviours—ie, those with a history of so-called dual-harm. By using linked administrative data (an important method for examining health outcomes in marginalised, inclusion health populations),5 the authors found that although the risk of unnatural death is elevated among people with a history of violence (incidence rate ratio [IRR] 5·19, 95% CI 4·45–6·06) or self-harm (12·65, 10·84–14·77), the risk is considerably higher among people with both behaviours (29·37, 23·08–37·38). Although this outcome might be expected, the magnitude of the elevation in risk of unnatural death in the dual-harm group is marked, and highlights a need for targeted, multisectoral responses for this complex group.

Climate change and human health: Risks and responses

Climate change is one of the biggest global health threats of the 21st century. Sensitive to shifts in weather and climate patterns, all human populations are affected by the direct and indirect health impacts of climate change. These impacts include exposure to extreme weather events, environmental and ecological disruptions, and even the social responses to climate change and variability. Some groups may be more vulnerable than others due to their high levels of exposure and sensitivity, poverty, and the weaknesses of public health systems in their region. Because climate change is complex and place-specific, vulnerable populations experience health challenges for different reasons. Some factors act as generic causes of vulnerability, such as age, gender, education, current health status, geographic location and environment, physical infrastructure and socioeconomic condition. Given the severity of these risks, the health effects of rapidly changing climate are commanding greater policy attention and government action. A public health response to climate change refers to any short- or long-term strategies that can reduce adverse health impacts or enhance resilience to observed or expected changes in climate and associated extremes. Generally, it operates on two levels: Building climate resilience and implementing adaptation actions. However, any public health response must first overcome the uncertainties of future climate and socioeconomic conditions as well as financial constraints, institutional arrangements, and individual cognitive limits. The current research on climate change and human health shows the scientific community is deepening our understanding the possible health effects and risks of our changing climate. In China, multisectoral and multidisciplinary responses to address the health impacts of climate change are necessary. This will require the close collaboration of individuals, communities, governments, and the research community. In particular, key research projects and methods will need to be developed. First, the regional health risks of climate change should be estimated with a focus on how the geographic range and disease burdens will change with changing weather patterns. Second, the thresholds and the time of emergence of dangerous health consequences caused by climate change should be calculated. Third, a method of detecting and attributing the health effects caused by climate change and variability should be adopted. Fourth, a forecast of how climate change may affect the functioning of health systems and infrastructure should be envisioned. And finally, a method for integrating the uneven patterns of climate change into adaptation planning. The international community has begun addressing some of these issues. Launched at the UN conference on Sustainable Development (Rio+20) in 2012, Future Earth is an international research programme that will develop comprehensive knowledge for responding to challenges posed by global environmental change and create transformative opportunities toward global sustainability. The Chinese National Committee for Future Earth (CNC-FE) should make full use of international resources and facilitate collaboration between domestic health sectors and meteorological departments. The governments response should include estimating the health implications of mitigation and adaptation measures when designing government policies, conducting climate change and health impact, vulnerability and adaptation assessments, tracking the progress of health and climate change, identifying opportunities to address the adaptation gap in the nations public health sector, and finally, building climate resilience into Chinas health systems.

Harnessing the Differentiated Model of HIV-AIDS Care as an Enabling Factor for Successful HIV-AIDS Programme Management

UNAIDS estimates that 37million individuals are infected with HIV-AIDS6. Traditional modes of service delivery cannot meet the needs of those infected and affected by HIV-AIDS. This has led to the development of several service delivery care models of care. One such model is Differentiated care. “Differentiated care is a responsive, client-centred approach that simplifies and adapts HIV services across the cascade to better serve individual needs and reduce unnecessary burdens on the health system”1. This is fast growing concept that is being utilised in both the developed and developing world allowing better care, wellness and treatment to HIV-AIDS sufferers across the globe. This paper explores the use of the differentiated care model across the various multi sectoral responses to HIV-AIDS and assesses the benefits of the model as an enabling factor for successful HIV-AIDS programme management both locally and globally.

Nutrition and the governance of agri-food systems in South Asia: A systematic review

Malnutrition is a multicausal challenge that requires multisectoral responses to make comprehensive and sustainable progress, over the long term. How is agriculture and the wider agri-food system positioned within the constellation of factors and processes that determine nutrition outcomes in different contexts and countries? What is known about the role of enabling environments and the governance of agri-food systems in driving nutrition outcomes, for better or worse? In this paper we will highlight the findings of a systematic review that focuses on this question, drawing on work from the South Asian region including research undertaken by LANSA. We conclude with a discussion of the major implications and recommendations for future policy and practice.

Sexual violence against children in South Africa: a nationally representative cross-sectional study of prevalence and correlates

We aimed to complete a nationally representative study of sexual violence against children in South Africa, and its correlates, since we could identify no other such study. For this nationally representative, cross-sectional study in South Africa, households were selected by use of a multistage sampling frame, stratified by province, urban or rural setting, and race group, and schools were selected on the basis that they were closest to the area in which households were selected. Interviews and self-administered questionnaires in each location inquired into lifetime and last-year prevalence of sexual abuse, and its correlates among children aged 15-17 years, whose parents gave informed consent and they themselves gave informed assent. The final household sample was 5631 (94·6% participation rate). 9·99% (95% CI 8·65-11·47) of boys and 14·61% (95% CI 12·83-16·56) of girls reported some lifetime sexual victimisation. Physical abuse, emotional abuse, neglect, family violence, and other victimisations were all strongly associated with sexual victimisation. The following were associated with greater risk of sexual abuse (adjusted odds ratio [OR]); school enrolment (OR 2·12, 95% CI 1·29-3·48); rural dwelling (0·59; 0·43-0·80); having a flush toilet (1·43, 1·04-1·96); parental substance misuse (2·37, 1·67-3·36); being disabled (1·42, 1·10-1·82); female (but not male) caregivers' poor knowledge of the child's whereabouts, friends, and activities (1·07, 0·75-1·53) and poor quality of the relationship with the child (ie, poor acceptance; 1·20, 0·55-2·60). The child's own substance misuse (4·72, 3·73-5·98) and high-risk sexual behaviour (3·71, 2·99-4·61) were the behaviours most frequently associated with sexual abuse, with mental health conditions found to be less prevalent than these factors but still strongly associated with sexual victimisation (post-traumatic stress disorder 2·81, 1·65-4·78; depression 3·43, 2·26-5·19; anxiety 2·48, 1·61-3·81). Sexual violence is widespread among both girls and boys, and is associated with serious health problems. Associated factors require multisectoral responses to prevent sexual violence or mitigate consequences. UBS Optimus Foundation.

Marriage, violence and HIV: the shifting policy context in Uganda

The policy environment for vulnerable women in Uganda is rapidly changing, with the aim of introducing more punitive measures for violent offenders and more options for women seeking help. This paper examines HIV-positive women who experienced intimate partner violence in two regions of Uganda prior to the enactment of the Domestic Violence Act of 2010. Based on in-depth interviews and observations, it reports on women’s views of marriage and relationships, and their strategies for help seeking to show the interaction between the two phenomena within the local cultural and political context. HIV-positive women in Uganda reshape their notions of marriage and love based on experiences of violence, illness management and broader social factors. Their narratives of relationships and conflict reveal an ambivalence toward formal marriage because of both its security and rights and its potential to inhibit leaving, as well as a reluctance to seek help through formal means. This construction of marriage is intertwined with the shifting social backdrop in Uganda, in particular the increasing rollout of antiretroviral treatment for HIV and the development of new policies surrounding violence, marriage and divorce. Women’s experiences show potential points of intervention and the need for multi-sectoral responses to violence.

Going somewhere slowly? An assessment of the pace of local government HIV/AIDs multisectoral responses in African cities

Sub-Saharan African (SSA) countries have the highest rates of HIV prevalence in the world accounting for an estimated 71% of all new infections (UNAIDS 2010). HIV prevalence is greatest in urban informal areas, caused largely by the proliferation of a variety of risk environments that facilitate the rapid spread of HIV/AIDS. As a strategic response to the complex nature of the HIV/AIDs epidemic in urban areas, decentralised multisectoral HIV/AIDs responses at the local government level have been adopted. These are seen as a sustainable way of dealing with the spread of HIV/AIDs in a number of African cities, in line with internationally accepted recommendations. Now that a number of local governments in African cities have adopted HIV/AIDS multisectoral responses, the question can be asked to what degree is this is this response being implemented in these countries, and what challenges are faced by cities as they adopt this approach? This article reviews HIV/AIDS multisectoral responses in African cities, and discusses the challenges that face urban local governments as they implement these responses.

Selected factors in predisposition to HIV and AIDS: Implications for educational policy and practice

The purpose of this paper is to illuminate a gendered view of the importance of biological age and gender inequality in predisposition to the Human Immune Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), and implications for requisite educational policies and best practice. Cognizant of the increasing age-based and gender inequality as factors in vulnerability women and girls face in Botswana. This paper is based on a critical review of deliberations and expressed opinions of workshop participants of a qualitative methodological workshop in a series of four sensitization workshops conducted in four areas in Botswana, namely the capital city of Gaborone, Lobatse town and two villages of Tsabong and Serowe between November 2007 and February 2008. Using Botswana as a point of contact, and informed by a combined epistemological base of age and gender inequality, and the PEN 3 model as analytical tools, and the author argues that age and gender inequality are some of the global factors that predispose women, and to a lessor extent, men, to the adverse prevalence, incidence and effects of HIV and AIDS. A conclusion drawn from the workshop series is that educators and policy makers need to periodically revisit administration practices and policies and ensure that they promote best practice in the global multi-sectoral responses to HIV and AIDS. Context specific formal and non-formal educational administration, formulation and enforcement of policies that promote best practice are very important in the global management of HIV and AIDS. Key words: Selected factors, predisposition to HIV/AIDS in Botswana.

Talking past each other: Towards HIV/AIDS prevention in Nigeria

This study investigates the relationship between HIV/AIDS prevention programmes and the lived realities of people most ‘at risk’ in the poor community of Ajegunle in Nigeria’s Lagos State. While providers, international NGOs and their client NGOs, emphasize Western medical models for HIV/ AIDS intervention and prevention, ‘at-risk’ groups expressed strong feelings of powerlessness over socio-cultural and political conditions affecting them. We suggest that multi-sectoral responses with full community participation are necessary in order to engage in more effective preventive action. This requires a major power shift, whereby local people are fully involved in decision-making about policies and their implementation.

Multisectoral responses to HIV/AIDS: applying research to policy and practice.

The KwaZulu-Natal Enhancing Care Initiative is a program developed by a consortium of members who represent 4 sectors: academia, government, nongovernmental and community-based organizations, and the business sector. The Initiative was formed to develop a plan for improved care and support for people with HIV/AIDS and who live in resource-constrained settings in the province of KwaZulu-Natal, South Africa. A needs analysis helped to determine the following priorities in prevention, treatment, care, and support: training, grant-seeking, prevention, and care and treatment, including provision of antiretroviral therapy. A partnership approach resulted in better access to a wider community of people, information, and resources, and facilitated rapid program implementation. Creative approaches promptly translated research into policy and practice.

Multi-sectoral responses to HIV/AIDS: constraints and opportunities for technical co-operation

The magnitude of the HIV/AIDS epidemic, the severity of its impact and the inadequacy of purely health-based responses have prompted national, bilateral and international organizations alike to adopt multi-sectoral responses to contain the spread and mitigate the effects of HIV/AIDS. So far, the implementation of multi-sectoral responses has been hampered by a host of structural, logistical and policy constraints. This article examines the operational status, implications and constraints of multi-sectoral responses to HIV/AIDS for technical co-operation programmes, focusing on agricultural and rural development projects supported by GTZ (GTZ is the acronym for German Technical Co-operation (Deutsche Gesellschaft für Technische Zusammenarbeit) in sub-Saharan Africa. The paper proposes a conceptual framework on the relevance of HIV/AIDS to non-health technical cooperation programmes, highlighting factors of susceptibility (The term ‘susceptibility’ describes factors that increase the likelihood that the epidemic will be propagated more rapidly) and vulnerability (The term ‘vulnerability’ describes factors that result in greater costs, financial or otherwise, as a consequence of increased morbidity and mortality associated with the epidemic) to the epidemic. It is argued that as HIV/AIDS is rooted in problems of underdevelopment, such as poverty, food and livelihood insecurity, socio-cultural inequalities and poor support services and infrastructure, AIDS-specific responses alone are unlikely to contain the spread or mitigate the impact of the epidemic. What is needed is a shift from AIDS-specific responses to what are oft-perceived to be AIDS-specific problems to an approach that addresses broader development problems across sectors, highlighting the specificity of HIV where necessary. Copyright © 2000 John Wiley & Sons, Ltd.