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How do teenagers located in the KwaZulu-Natal province of South Africa, the epicentre of the HIV pandemic, give meaning to sexuality? This paper examines teenage black Africans investments in sex and sexuality and the gendered dynamics through which sexuality is articulated. Whilst unequal gender relations of power continue to feature prominently within relationship dynamics fuelling the gendering of HIV, attention to the micro-processes through which relationships are forged remain significant in illustrating the complex connections between love, sex and gender. Drawing on empirical findings with teenagers between the ages of 16 and 17 years old, the paper shows how relationships are conceptualised based on discourses of love. Love is inextricably bound up with sex and when teenagers talk about love and sex they also talk about condom use, multiple sexual partners and gender inequalities. What teenagers were interested in for their sexual relationships was not raised in sex education programmes at school. Implications for addressing teenage constructions of sexuality are discussed in the conclusion. [ABSTRACT FROM AUTHOR]

This paper is a response to a growing vision of schools as sites of care and support for vulnerable children in the context of HIV and AIDS. The aim is to interrogate this notion and to raise some key issues in considering the role of schools in the context of the epidemic. The paper is based on two research activities. The first was a desk review of projects working in the area of schools in the context of HIV/AIDS and poverty, including a review of the policies underlying these initiatives. The second was the documentation of a particular project in a province of South Africa. The paper begins by outlining some major education policies in South Africa related to the care and support of vulnerable children in the context of HIV and AIDS. The paper then offers three cautionary notes in relation to the thrust of these policies and those programmes attempting to implement them. The first suggests consideration of the context of implementation - the schooling system. The second recommends consideration for resourcing these policies, which is looked at through a case study. The third note considers the policy visions of schools and teachers: how schools and teachers are conceptualised both in policies and programmes is problematised. The misalignment between the policies around schools and vulnerable children, the resourcing of these policies, and their contexts of implementation is brought into relief, as well as the implications for thinking about expanded roles for schools and teachers. The paper offers possible ways forward in considering the role of schools in the context of HIV and AIDS. These include new ways of thinking about resourcing, proper monitoring and evaluation of projects, and a focus on quality teaching and learning. [ABSTRACT FROM AUTHOR]

Since the end of apartheid, patterns of migration into South Africa have shifted, and South Africa has become a destination for people from across the African continent and beyond - a small but important number of whom are refugees and asylum seekers. While South Africa has a protective, integrative, urban refugee policy, many of these individuals struggle to access the rights to which they are entitled, including healthcare. In addition, many lower-skilled international migrants are unable to legalise their stay in South Africa. As a result, international migrants often become part of the group of 'urban poor,' falling within the periphery of health and social welfare provision and relying on a survivalist livelihood within the informal economy. The health and wellbeing of an individual impact greatly on their ability to maintain a secure livelihood, and this becomes more difficult in the context of an HIV epidemic. This paper presents findings from a case study situated in the City of Johannesburg. The research made use of 1) 2006 survey data on migrant livelihood strategies in Johannesburg, 2) a study investigating non-citizens' access to antiretroviral treatment (ART) in the inner city, which included 3) a set of interviews conducted with migrant ART clients who were working in the city's informal economy. The findings indicate (a) the importance of the informal economy for migrants to Johannesburg; (b) the challenges that non-citizens face in accessing ART in the public sector in South Africa; and (c) the linkages between urban migrants' access to ART and their ability to maintain a survivalist livelihood. The paper argues that upholding people's right to ART for all who need it within South Africa will enable international migrants (including refugees and asylum seekers) to maintain an otherwise fragile survivalist livelihood, and this in turn will assist their self-reliance and integration into urban life. Recommendations are made to ensure that the right to healthcare is upheld for all in South Africa. [ABSTRACT FROM AUTHOR]

Globally, in the last 20 years health has improved. In this generally optimistic setting HIV and AIDS accounts for the fastest growing burden of disease. The data show the bulk of this is experienced in Southern Africa. In this region, HIV and AIDS (and tuberculosis [TB]) peaks among young adults. Women carry the greater proportion of infections and provided most of the care. South Africa has the dubious distinction of having the largest number of people living with HIV in the world, 6.4 million. HIV began spreading from about 1990 and today the prevalence among antenatal clinic attendees is 29.5%. A similar situation exists in other nations of the region. It is an expensive disease, requiring more resources than are available, and it is slipping off the global agenda, both in terms of attention and international funding. Those halcyon days of the decade from 2000 to 2010 are over. This paper explores the concept of three transition points: economic, epidemiological and programmatic. The first two have been developed and written about by others. We add a third transition point, namely programmatic, argue this is an important concept, and show how it can become a powerful tool in the response to the epidemic. The economic transition point assesses HIV incidence and mortality of people infected with HIV. Until the number of newly infected people falls below the number of deaths of people living with HIV, the demand for treatment and costs will increase. This is a concern for the health sector, finance ministry and all working in the field of HIV. Once an economic transition occurs the treatment future is predictable and the number of people living with HIV and AIDS decreases. This paper plots two more lines. These are the number of new people from the HIV infected pool initiated on treatment and the number of people from the HIV infected pool requiring treatment. This introduces new transition points on the graph. The first when the number of people initiated on treatment exceeds the number of people needing treatment. The second when the number initiated on treatment exceeds the new infections. That is the theory. When we applied South African data from the ASSA2008 model, we were able to plot transition points marking progress in the national response. We argue these concepts can and should be applied to any country or HIV epidemic. [ABSTRACT FROM PUBLISHER]

A number of studies have shown strong evidence of the association between HIV testing and an increase in consistent condom use. These studies have shown that HIV testing has contributed to a reduction in risk behaviours, since knowledge of HIV status can motivate both HIV-positive and HIV-negative people to practise safer sex. However, the extent to which knowledge of one's HIV status contributes to behavioural change among people living with HIV (PLHIV) has not been comprehensively documented. Drawing on an analysis of 37 in-depth interviews and five focus group discussions with PLHIV, this paper examines the nature of sexual activity and condom use among PLHIV in Swaziland. The paper explores issues pertaining to behavioural change and safer sex, and how these are influenced by the individual's HIV-positive status and the prevailing social-structural forces. Several factors inhibit the adoption of protective sexual behaviour among HIV-positive sexual partners, some of whom have access to life-saving drug therapy. These factors include a lack of adequate social support structures and prevailing gender power imbalances that deny women control over their sexual lives. To promote behavioural change among PLHIV, the paper proposes the expansion of the scope of information, education and communication strategies to include activities aimed at continually sensitising PLHIV regarding safer sex, as well as activities geared towards improving communication between PLHIV and their health-caregivers with regard to HIV-protective behaviours. [ABSTRACT FROM AUTHOR]

This work explores the connections between gender inequality, HIV/AIDS and women's health in the world of work in South Africa. These connections are located within a context of significant reversals in development, specifically declining life expectancy and premature mortality for South Africans - particularly for women. By relying on the existing literature and interviews with 33 key informants, the paper examines the extent to which South African workplaces are recognising women's social and biological vulnerability to HIV. In particular, the paper considers the potential role of the workplace in responding to growing evidence that links gender and health by establishing targeted HIV/AIDS interventions. The findings suggest that the vast majority of company representatives do not recognise women's social and biological vulnerability and related social norms vis-à-vis HIV and AIDS. Importantly, most workplaces are not initiating programmes that specifically address women's or men's health. The author briefly identifies factors that may help explain the current state of knowledge and practice in the realm of HIV and women's health in the workplace, and puts forward suggestions for future research. [ABSTRACT FROM AUTHOR]

The advent of HIV pre-exposure prophylaxis (PrEP) as a HIV-prevention strategy has received optimistic support among HIV researchers. However, discourse on PrEP trials has tended to be dominated by the disputes arising between some activist groups and researchers about the research methodologies. Instead, this paper discusses other issues oftentimes neglected in discussions relating to PrEP trials. Specifically, I focus on the possible ethical implications and the potential impact of sub-Saharan Africa's socio-economic conditions on the promised benefits of PrEP trials for the region and the continent. I argue that the concept of PrEP as a affordable and practical HIV-prevention intervention presents challenges and questions that urgently need addressing as we await results from several ongoing trials. If research is undertaken with no plans on how the results of specific trials can render actual HIV-prevention-benefits - especially for the world's poor - then such endeavours risk being merely information-acquiring ventures. [ABSTRACT FROM AUTHOR]

Although making a large and rapid impact on our understandings of the interactions between famine and HIV/AIDS, the new variant famine hypothesis has had little critical scrutiny. This paper uses a case study of the Malawian food crisis of 2001/2002 to contribute to understandings of new variant famine (NVF). The critical approach argues that a consideration for gender -- the socially constructed relationship between men and women -- needs to be central to understanding the interactions between HIV/AIDS and famine, which the NVF hypothesis seeks to explain. Evidence from the Malawian crisis is highly suggestive, although not conclusive, that NVF is best understood as mediated by gender inequalities. [ABSTRACT FROM AUTHOR]

The importance of partnerships between marginalised communities and support agencies (from the public sector, private sector and civil society) is a pillar of HIV/AIDS management policy. Such alliances are notoriously difficult to promote and sustain. We present a case study focusing on the first stage of a project seeking to build partnerships to facilitate local responses to HIV/AIDS in a remote rural community in South Africa. To date the Entabeni project has been successful in its goal of training volunteer health workers in home-based care, peer education, project management and procedures for accessing grants and services. The paper focuses on the project's other goal -- to create external support structures for these volunteers (drawing on government departments, local NGOs and private-sector philanthropists). The partnership aims to empower volunteers to lead HIV-prevention and AIDS-care efforts, and to make public services more responsive to local needs. We illustrate how features of the local public-sector environment have actively worked against effective community empowerment. These include a rigid hierarchy, poor communication between senior and junior health professionals, lack of social development skills and the demoralisation and/or exhaustion of public servants dealing with multiple social problems in under-resourced settings. We outline the obstacles that have prevented private-sector involvement, suggesting a degree of scepticism about the potential for private-sector contributions to development in remote areas. We discuss how the project's most effective partners have been two small under-funded NGOs -- run by highly committed individuals with a keen understanding of social-development principles, flexible working styles and a willingness to work hard for small gains. Despite many challenges, the partnership formation process has seen some positive achievements; we outline these and discuss the essential role played by an external change agent, and conclude with a discussion of the possibility of building long-term structures to sustain the project. [ABSTRACT FROM AUTHOR]

This paper explores the nature of HIV/AIDS education and information networks in Malawi, with a focus on Dedza district. We consider the role of institutional and personal actors involved in Malawi's recently instated and decentralised behaviour-change intervention strategy, as well as the form and function of interpersonal social networks that mediate this information. The research reveals that the organisational capacity of actors and the conflicting messages regarding promotion of condom use may prevent Malawi from achieving a coordinated and effective decentralised response to the HIV epidemic. The research shows that individuals draw on complex interpersonal social networks, often processing mixed messages regarding HIV prevention strategies and receiving negative messages regarding condom use. The paper discusses the implications of such inconsistencies and conflicts with actors, interpersonal social networks and the nature of the messages themselves for HIV/AIDS education in Malawi. [ABSTRACT FROM AUTHOR]

Drawing upon ethnographic fieldwork in Sake, a semi-rural area outside Harare, Zimbabwe, this paper explores the social mechanism behind the seeming invisibility of children left on their own and how this form of 'invisibility' challenges established notions of childhood, parenthood, kinship, and community. It argues that the prevailing explanations, such as HIV/AIDS-related stigma, poverty or anomie, are insufficient for understanding the isolation of the child-headed household and situations when children, in what should be a protective relationship, are exploited or abused. Through a detailed case-study, the paper explores the trajectory leading to the isolation of one particular child-headed household. It questions the biological assumptions that guide kinship interpretations and discusses the marriage transactions (the lobola exchange) that secure identity and belonging to the father's kin unit. Finally, it suggests that orphaned children ultimately stand alone because they are left in a specific time, in a specific situation, when the relationships that should surround them still have to be made, recognised and named. [ABSTRACT FROM AUTHOR]

In a particular way, the HIV pandemic exposes the prevailing gender relations and the definitions of male and female gender roles, both in intimate relationships and in the wider society. The HIV pandemic reveals the contradictions between women's legal rights and the persistence of women's cultural and sexual subordination. It reflects the impact of poverty, gender roles, culture and religion. Although HIV and AIDS cuts across class, South African rural black women's infection risk seems particularly high since they suffer notably from subordination and socio-economic hardships. Negotiating safer sex in marriage or intimate partnerships is very difficult for them in view of the traditional spaces in which they find themselves, where patriarchal structures are pervasive. Based on data obtained from a case study, this paper examines socio-cultural constraints to rural women's sexual agency in a patriarchal social order. These rules are based on a patriarchal code of respect, which is still pervasive in many aspects of the community under investigation. In terms of gender relations, the patriarchal code of respect is founded on an assumed 'naturalisation' of the two genders and the natural superiority of the male over the female. In terms of sexuality it is translated into male sex-right. The fear of HIV infection is omnipresent and results in unmarried women engaging in the negotiation of their wants and needs. Owing to the patriarchal code of respect, married women are perceived as having no choice in negotiating safer sex and are forced to put their lives at risk in contracting HIV. Unmarried women have greater although not endless choices in this regard. Although the study participants unexpectedly displayed a rather negative perception of other women, in order to strengthen women in their proximal environment the HIV epidemic may be seen as a vehicle for building solidarity among women in the community. [ABSTRACT FROM AUTHOR]

Recently a few vocal health experts have suggested that some of the billions of dollars currently used to prevent and treat HIV and AIDS be reallocated to address more basic problems such as malnutrition, tuberculosis, malaria, and enteric and diarrheal disease caused by lack of access to clean water. While not universally agreed upon, this reassessment of policy priorities acknowledges that there are multiple other health problems that deserve renewed attention from the international community. It also highlights the fact that the impacts of the HIV pandemic are exacerbated by widespread poverty, food insecurity and malnutrition, and gender inequality. Nowhere is this more evident than in sub-Saharan Africa, where multiple epidemics conflate and seriously compromise the survival of individuals and communities. Given the widespread occurrence of famine in sub-Saharan Africa, issues of food and economic security become of paramount importance in efforts to address the region's HIV epidemics. This paper examines the historical, political-economic, and cultural dimensions of the HIV epidemic in the context of the growing problem of food and economic insecurity. Furthermore, using theoretical frameworks that emphasize the dynamic interrelation between HIV/AIDS and food insecurity, we present suggestions for combining traditional HIV-prevention strategies with food production and nutrition-education programming. In light of the complex interactions between HIV/AIDS and food insecurity and the lack of accessible treatment modalities, such programming could potentially reduce the risk for transmission of HIV through behavioural changes and improved nutritional and immune status, and increase the life expectancy of people living with HIV or AIDS. [ABSTRACT FROM AUTHOR]

In the face of the extreme challenges posed by the South African HIV/AIDS epidemic, collaboration between public and private partners is often called for in an attempt to mobilise additional resources and generate synergies. This paper shows that the ability to successfully use public-private partnerships to address complex challenges, such as an HIV/AIDS epidemic, is influenced by the fabric of society, one important aspect being historical legacies. The first part of the article shows how South Africa's apartheid past affects the ability of public and private partners to collaborate in a response to HIV and AIDS today. It also takes into account how reconciliation and nation-building policies in the immediate post-transformation period have affected the ability to form and sustain partnerships concerning HIV/AIDS issues. The second part of the article analyses more recent developments regarding the information that these hold as to the feasibility of public-private partnerships and whether these continue to be affected by the legacies of the past. Two events with symbolic political value in South Africa, namely the 2010 FIFA World Cup soccer event and the recent changes in government, are systematically examined on the basis of three analytical queries, regarding: the impact of the event on nation-building and transcending cleavages in society; the event's impact on the ability to form public-private partnerships in general; and the role of HIV/AIDS in connection with the event. Conclusions are drawn a propos the influence of historic factors on the ability of South African society to effectively use public-private partnerships in the response to HIV and AIDS, and the continued dynamics and likely future directions of these partnerships. [ABSTRACT FROM AUTHOR]

This paper reviews published quantitative research on the mental health of HIV-infected adults in Africa. Twenty-seven articles published between 1994 and 2008 reported the results of 23 studies. Most studies found that about half of HIV-infected adults sampled had some form of psychiatric disorder, with depression the most common individual problem. People living with HIV or AIDS (PLHIV) tended to have more mental health problems than non-HIV-infected individuals, with those experiencing less problems less likely to be poor and more likely to be employed, educated and receiving antiretroviral treatment (ART). Being female, experiencing poor health, receiving poor-quality health services, and a lack of material and emotional support from family and friends were associated with greater psychiatric morbidity. While some key findings emerged from the studies, the knowledge base was diverse and the methodological quality uneven, thus studies lacked comparability and findings were not equally robust. Furthermore, more rigorous research is needed to put mental health services for PLHIV in Africa on the healthcare agenda. Priorities for future research should include replicating findings regarding common mental health problems among PLHIV, important issues among HIV-infected women, and the longer-term mental health needs of those on ART. Research is also needed into predictors of mental health outcomes and factors associated with adherence to ART, which can be targeted in interventions. [ABSTRACT FROM AUTHOR]

A large portion of HIV transmission in sub-Saharan Africa occurs among married couples, yet the majority of research on safer-sex communication has focused on communication between couples in casual relationships. This paper explores how committed Kamba couples in Machakos District, Kenya, communicate about sensitive relational issues. The findings from focus group discussions with five groups of males and five groups of females are presented. The couples freely shared their thoughts about daily and economic issues and certain aspects of family planning and sexuality. Methods for raising sensitive issues with partners included monitoring the spouse's mood, gradual or indirect revelation, mentioning topics during sex, and use of third-party intermediaries. Interference by extended family members, especially husbands' mothers, and male authoritarian roles emerged as hindrances to effective communication between couples. The implications for HIV prevention regarding gender differences and the role of families in couples' communication are discussed. [ABSTRACT FROM AUTHOR]

This paper reports on a post-intervention qualitative evaluation of the pilot intervention of the AmaQhawe Family Project, in South Africa, which is a cartoon-based, manualised intervention delivered to multiple family groups over 10 sessions, aimed at preventing HIV in adolescents through strengthening the adult protective shield. Semi-structured interviews with nine women who had participated in the pilot intervention were used to understand participants' perceptions of how the family-based HIV-prevention programme had assisted in addressing the issues identified in a pre-intervention exploratory study. Analysis of the data was informed by community health psychology and social capital theory. The findings indicate that at an individual level, the women interviewed had experienced an improved sense of empowerment, both as parents and as women. They also reported increased social support for effective parenting. At a collective level, the women reported that the programme had helped them to exert better informal social controls within the community, as well as to increase their social leverage and participation in community organisations. The findings suggest that HIV interventions involving families can strengthen the adult protective shield to facilitate health-enabling social contexts for youth. [ABSTRACT FROM AUTHOR]

This paper presents epidemiological data from ongoing HIV-prevalence surveillance in a large South African manufacturing company located in various provinces, as well as one location in Swaziland. A survey of the workforce in 12 of the manufacturer's business units (BUs) throughout these locations was carried out in 2001-2003, and each was repeated three years later, in 2004-2006. The company is typical of manufacturing in South Africa, in that it is labour-intensive, male-dominated, and has high proportions of semi-skilled and unskilled employees. The surveys were anonymous, cross-sectional and unlinked. The workforce was stratified at the level of analysis by workplace, geographical location, job status (permanent or contract), job skill level, and age group. In 2001/3 a total of 5 177 permanent employees, representing 76% of those on duty at the time, plus 1 966 contract employees were surveyed. In 2004/6, 5 445 permanent employees, representing 81% of those on duty, and 2 688 contract employees were surveyed. HIV prevalence in the 2004/6 survey ranged from 0.9-30.7% throughout the 12 BUs, with a mean of 15.4%, showing an increase from the previous mean of 13% prevalence in the 2001/3 survey of the same locations (p = 0.0001). Differences in HIV prevalence across the BUs were determined by geographical location and the profile of the workforce. Similar proportions of contract employees were found to be HIV-positive in the initial survey and repeat survey (23% and 24.5%, respectively). HIV prevalence was inversely proportionate to permanent employees' job skill level. The 2004/6 data show lowest HIV prevalence in the upper-management category (3.6%) and highest prevalence in the unskilled category (22.6%). HIV prevalence did not increase in the upper- and middle-management categories but increased significantly in the skilled (p = 0.02), semi-skilled (p < 0.001) and unskilled (p < 0.001) job categories. HIV prevalence was similar among contract employees and unskilled permanent employees. Race (not considered in the study) may in part confound these findings. In both surveys, HIV prevalence was highest in the age group 30-39. Prevalence did not increase between surveys in the age group 18-29; however, significant increases occurred in the age groups 30-39 and 40-49 (p < 0.001), and possibly also in the age 50+ category (p = 0.09). [ABSTRACT FROM AUTHOR]

This paper examines the cultural and structural difficulties surrounding effective prevention of mother-to-child HIV transmission (PMTCT) in rural Lesotho. We argue for three strategies to improve PMTCT interventions: community- based research and outreach, addressing cultural and structural dynamics, and working with the relevant social groups that impact HIV prevention. These conclusions are based on interviews and participant observation conducted within the rural Mokhotlong district and capital city of Maseru, involving women and men of reproductive age, grandmothers serving as primary caretakers, HIV/AIDS programme staff, and medical professionals. Qualitative analysis focused on rural women's soclo-medical experience with the four measures of PMTCT (educational outreach, voluntary counselling and testing, antiretroviral interventions, and safe infant feeding). Based on these results, we conclude that intervention models must move beyond a myopic biomedical 'best-practices' approach to address the social groups and contextual determinants impacting vertical HIV transmission. Given the complexities of effective PMTCT, our results show that it is necessary to consider the biomedical system, women and children, and the community as valuable partners in achieving positive health outcomes. [ABSTRACT FROM AUTHOR]

The ongoing damage that the newer forms of HIV denialism are visiting upon our country is evidenced by the recent firing of Nozizwe Madlala-Routtedge, the South African Deputy Minister of Health. It is widely believed that the underlying reason for her dismissal was her support of orthodox HIV treatment and prevention strategies and her disdain for HIV denialism. This paper seeks to understand the origins, spread and metamorphosis of President Thabo Mbeki's HIV denialism in South Africa. Using the theory of cognitive dissonance, I argue that, given the structural beliefs of the African National Congress (ANC) and the pattern of emergence of HIV in the 1980s, a degree of scepticism around the putative science of HIV was probable in ANC circles. On assuming the Presidency in 1999, Mbeki tapped into this scepticism to formulate his initial biological version of HIV denialism, which claimed that 'a virus can't cause a syndrome.' The steady erosion of support for this flagrant HIV denialism, together with the rise of neoliberal thinking in the ANC, would lead to the evolution of this biological denialism into a form of treatment denialism. This ideology argued against the widespread provision and use of antiretroviral treatment. Empirical evidence is presented to demonstrate the extent to which ongoing HIV denial in the general population is continuing to fuel the spread of HIV. [ABSTRACT FROM AUTHOR]

The study explores and describes South African school children's perspectives of HIM and AIDS, and links this to their respective cognitive developmental stage. The paper highlights developmental differences in the children's perceptions of HIV or AIDS and makes specific recommendations for improving HIV/AIDS education in school. A questionnaire of mainly open-ended questions was used to survey the HIV/AIDS-related perceptions of 1 904 school-going children aged 6 to 19 years. In-depth content analyses as well as basic statistical analyses were performed on the data. Although the school children had a good basic knowledge of HIV/AIDS and generally positive attitudes towards HIV and AIDS, they believed many misconceptions and myths. The children were mostly very afraid of HIV or AIDS and felt extremely vulnerable to HIV infection. The particular developmental phase was the strongest predictor of a child's understanding of HIV/AIDS. The findings have been used to formulate guidelines for the development or enhancement of age-appropriate HIV/AIDS education programmes or curricula in schools. It is hoped that teachers, educators and youth workers will use these findings to re-evaluate and adjust their HIV/AIDS education programmes and messages to fit the needs of the young people in their care. [ABSTRACT FROM AUTHOR]

This paper examines the complex relationship between male circumcision and HIV prevalence and incidence in sub-Saharan African countries that have generalised epidemics. In South Africa, the mean yearly HIV incidence and an estimate of the net reproduction rate of the epidemic (R0) (in this case, the ratio of the number of HIV-infected persons between 1994 and 2004 to the number of persons infected in 1994 from which they were presumed to have become infected) were computed from antenatal clinic data for the period 1994-2004, and then compared, by province, to prevailing levels of male circumcision (high, medium and low). In South Africa, mean yearly HIV incidence and net reproduction rate of the epidemic were not lower in provinces with higher levels of male circumcision. For thirteen other countries where Demographic and Health Survey data were available, male HIV prevalence in circumcised and non-circumcised groups was compared. A meta-analysis of that data, contrasting male HIV seroprevalence according to circumcision status, showed no difference between the two groups (combined risk ratio [RR] = 0.99, 95% CI = 0.94-1.05). Individual case study analysis of eight of those countries showed no significant difference in seroprevalence in circumcised and uncircumcised groups, while two countries (Kenya and Uganda) showed lower HIV prevalence among circumcised groups, and three countries (Cameroon, Lesotho and Malawi) showed higher HIV prevalence among circumcised groups. In most countries with a complex ethnic fabric, the relationship between men's circumcision status and HIV seroprevalence was not straightforward, with the exception of the Luo in Kenya and a few groups in Uganda. These observations put into question the potential long-term effect of voluntary circumcision programmes in countries with generalised HIV epidemics. [ABSTRACT FROM AUTHOR]

Large-scale surveys have reported that about 55% of orphans worldwide are adolescents. In Kenya, the majority of HIV-infected adolescents are females. The current study used the anthropological methods of in-depth case studies to analyse how migratory life situations of individual female adolescent orphans in the Luo community of Western Kenya may increase their exposure to HIV. The study shows that the ability of the female adolescent orphans to adopt risk-preventive behaviour in relation to HIV is determined by a range of factors beyond their control of individual sexual behaviour. Although analysis of a single case study limits generalisation of the findings, the results provide insights into the reason for sex differentials in HIV infection rates among adolescents as reported in some large-scale surveys. The paper recommends that HIV prevention strategies for adolescents should examine the specific life situations of female orphans by focusing on the impacts of HIV and AIDS and poverty on the protective role of the family. It also recommends that keeping female adolescent orphans in school or in vocational training can be an effective HIV prevention strategy for them. [ABSTRACT FROM AUTHOR]

This paper explores the role of the family in caring for orphans and other children in poor urban communities having some of the highest levels of HIV/AIDS prevalence in the world. A range of family forms in Swaziland was found to be caring for orphans. Child-headed households and lone-elderly carers were not the most common; maternal kin played a more important role in orphan care than did paternal kin, indicating both stresses due to AIDS and the dynamic nature of the family. Women of all ages were bearing the brunt of the extra care responsibilities caused by the epidemic. There was limited involvement in children's well-being by agencies of any kind and orphan care remained largely situated within kin structures. The AIDS epidemic was impacting on families in a variety of ways, with a corresponding increase in poverty and vulnerability. Carers did not perceive orphans as a separate category of children requiring assistance over and above any other vulnerable child. Families require assistance at the household, community and national level. Meanwhile, community-based initiatives were poorly developed. Welfare sector policies should strengthen the family model of childcare by increasing support to the poorest families rather than treating orphans as a separate category of vulnerable children and thereby excluding other needy children. [ABSTRACT FROM AUTHOR]

This paper considers the impacts of sexual violence perpetrated while the Eritrean town of Senafe was occupied by the Ethiopian military in 2000, during the second Ethiopia-Eritrea war. It discusses the aftermath for the survivors, all women and girls belonging to the Saho ethnic group, and the responses of other groups in the Saho community. An attempt is made to understand the reasons for the failure of one intervention that sought to provide support to these survivors of sexual violence. The potential repercussions of community denial of the sexual violence are addressed. These include lack of access by survivors to information on HIV, testing and care; refusal to face up to the possible infection of survivors, their husbands and unborn children, and to the psychological, social and economic impacts of HIV/AIDS. [ABSTRACT FROM AUTHOR]

Aim: Women and girls living with or at high risk of acquiring HIV (WGL&RHIV) in Africa are economically vulnerable. This study aims to advance understanding of the economic impact of COVID-19 on WGL&RHIV and to identify the factors associated with this insecurity. Methods: Data were collected from a cross-sectional survey conducted among a convenience sample of WGL&RHIV in Nigeria between May and September 2021. Logistic regressions enabled the study of the role of HIV status, mental health and macrosocial characteristics (people with disability, transgender women, sex workers, persons engaged in transactional sex, substance users, and people on the move) on economic vulnerability, measured by food, financial and housing insecurity, since the COVID-19 pandemic began. The model accounted for the possible interactions between the macrosocial characteristics and controlled for confounders. Results: There were 3 313 (76.1%) of 4 355 respondents facing food insecurity, 3 664 (83.6%) of 4 385 with financial vulnerability and 1 282 (36.2%) of 3 544 with housing insecurity. Being a member of the key and vulnerable groups was strongly associated with food insecurity, financial vulnerability and housing insecurity, regardless of HIV serostatus. For example, WGL&RHIV engaging in transactional sex were more than four times more likely (aOR 4.42; 95% CI 2.57–7.59) to face housing insecurity and more than twice more likely to face food insecurity (aOR 2.47, 95% CI 1.35–4.52) and financial vulnerability (aOR 2.87, 95% CI 1.39–5.93). This economic vulnerability may reduce their negotiating power for safer sex or the use of HIV prevention methods, exposing them to increased risks of HIV infection. Poor mental health was also associated with the three forms of economic vulnerability. Conclusions: As the long-term impact of the COVID-19 crisis on African economies unfolds, HIV programmes at the country level must include economic vulnerability and mental unwellness mitigation activities for WGL&RHIV. [ABSTRACT FROM AUTHOR]

Background: The impact of school closures due to COVID-19 raised widespread concerns about children's health and well-being. We examine the impact on the sexual health needs of learners in the context of COVID-19 related lockdowns in rural KwaZulu-Natal, South Africa. Methods: In july-November 2020 and August-November 2021 we conducted 24 in-depth interviews and 8 group discussions with teachers and learners from 4 schools, community members and key education stakeholders. All interviews were conducted by telephone. We used a thematic analysis approach and Nvivo 12 software to manage the data. Results: Four main themes related to the COVID-19 pandemic emerged from the data: the sexual and reproductive health (SRH) of learners in the lead-up to the pandemic; the impact of COVID-19 on learners' SRH and wellbeing; the opportunities schools provided to support sexual well-being of learners during the pandemic; and the role of schools in supporting SRH for learners during the pandemic. Learners and stakeholders reported that the SRH of young people was affected by alcohol misuse, poor SRH knowledge and few pathways to link learners with services. Stakeholders working with schools reported that a lack of access to biomedical interventions (e.g., contraception) increased learner pregnancies. Gender-based violence in learners' households was reported to have increased during the COVID-19 pandemic related to loss of income. School closures disrupted the provision of a safe space to provide SRH and HIV-education through Life Orientation lessons and school nurse talks. This loss of a safe space also left learners vulnerable to sexual and physical violence. However, once schools re-opened, daily COVID-19 screening in schools provided the opportunity to identify and support vulnerable children who had other social needs (food and uniforms). Conclusion: The COVID-19 pandemic may have increased SRH needs and vulnerability of school-going children in a high HIV-burden rural setting. School shutdowns reduced the opportunity for schools to provide a vital safe space and information to enhance SRH for adolescents. Schools play a vital health promotion and social protection role. [ABSTRACT FROM AUTHOR]

This article examines the association between male circumcision and HIV infection in a national sample. The analysis is based on the 2003 Kenya Demographic and Health Survey (KDHS), a nationally representative household-based population survey of adults, in which male respondents self-reported their circumcision status. In addition, in some households eligible for individual interview, blood samples were subsequently anonymously obtained for HIV testing, making this the first study linking socio-demographic information to HIV status at the national level. The study sample is limited to 3 413 men aged 15-54 years who gave valid information on their circumcision and HIV statuses. Nearly 5% of the men were HIV-positive, and 86% had been circumcised. HIV prevalence was significantly higher among the uncircumcised men (12%) than among the circumcised men (3%). This indication of the protective effect of male circumcision on HIV infection remained statistically significant (OR 0.15; 95%Cl: 0.09-0.23) even after controlling for the effects of socio-demographic variables, age at first sexual intercourse, and use of paid sex. Based on these results, we recommend that HIV-prevention advocates and activists, scholars, bio-medical communities and political leaders find ways to include this oldest surgical procedure in their HIV/AIDS discourses and programmes in sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

The overwhelming rate of HIV-related mortality in the past decades has eroded traditional safety nets for orphans, of which the extended family is the most critical. This has led to the formation of new household structures, i.e. child- and youth-headed households, as children and youths are left to live alone and look after themselves. These types of households are a growing phenomenon in many African countries and are increasingly being recognised as household structures. However, in the absence of an economically active adult, orphans living in these households experience numerous challenges. The socio-economic challenges in Zimbabwe could further exacerbate the conditions of child-headed households. This article discusses findings of an ethnographic inquiry on orphans living in child- and youth-headed households in Zimbabwe. We identified parentification, lack of income and social isolation as risk factors affecting quality of life. Social capital and agency were identified as protective factors enhancing children's quality of life. Our findings suggest that orphans living in child- and youth-headed households are not only victims but are also resilient and can exercise agency. Therefore, interventions to support this vulnerable group should build on their existing resilience and agency. [ABSTRACT FROM AUTHOR]

Background: In Africa, HIV/AIDS research is concentrated in certain countries, particularly South Africa. This distribution may not accurately reflect the disease prevalence or the true research efforts of countries. Objectives: To identify HIV/AIDS research productivity of countries in Africa and the Middle East, in absolute terms and adjusted for people living with HIV, population size and economic development. Methods: We identified all the articles and reviews on HIV and AIDS in the Web of Science Core Collection in which African or Middle Eastern countries had participated. After determining the number of documents produced by each country, we adjusted the findings for the number of people living with HIV, number of inhabitants, gross domestic product and gross national income per capita. Results: African and Middle Eastern countries participated in 21.52% (n = 14 808) of all 68 808 documents analysed. East and Southern Africa produced 17.8% of all documents (n = 12 249), West and Central Africa accounted for only 3.34% (n = 2300), and the Middle East and North Africa, 1.18% (n = 814). South Africa produced 40.94% (n = 6 063) of all publications. Only two other African countries — Uganda (12.97%; n = 1 921) and Kenya (10.71%; n = 1 586) — produced more than 10% of these publications. The indices used for adjusting research productivity revealed the effort and contribution of other countries. Conclusion: Our study confirmed the leading role of South Africa in driving HIV/AIDS research, but also highlighted the contribution of countries such as Uganda, Malawi, Botswana, Zimbabwe and Mozambique. [ABSTRACT FROM AUTHOR]

The article discusses comparison of pandemic publishing with reference of COVID-19 and HIV. Topics discussed include story of the development of COVID-19 vaccines, particularly Oxford–AstraZeneca; lack of research and writing about the long-term impacts of pandemic; and economic effects on people in the developing world from pandemic.

Research on adolescent sexuality, health and parenting has gained much attention in recent years. This growing body of research, however, has arguably limited qualitative outputs on HIV-positive adolescent mothers' sexual and reproductive health choices, needs, and rights in South Africa that could lead to informed policymaking. Through in-depth interviews conducted with a select group of ten HIV-positive adolescents and three key informants, the article explores the sexual, motherhood, risk discourses and reproductive health issues and rights of HIV-positive adolescent mothers as they come to terms with choices they have made and the challenges ahead. The findings highlight the dominant narratives on what are deemed to be the forces that shape these adolescent mothers' new social realities. With existing policies in place for adolescents, it is argued that a "one-size-fits-all" policy approach does not work, especially for HIV-positive adolescent mothers. Drawing on this identified gap and the tensions between individual needs, and the public welfare provision, the article highlights the need for tailored policy that will accommodate and promote the overall well-being of HIV-positive adolescent mothers and their children. [ABSTRACT FROM AUTHOR]

Background: Health care workers play an integral role in the rehabilitation and care of people living with HIV who face multiple impairments and often disabilities. The aim of the article was to understand the perceptions and attitudes of health care workers towards caring for people living with HIV, and experiencing disability. Methods: Fifteen health care workers offering care to people living with HIV were interviewed using a semi-structured guide. These health care workers included doctors, a social worker, a pharmacist, a dietician, an occupational therapist, a physiotherapist, and nurses and HIV couPnsellors who were employed at a public health care facility in KwaZulu-Natal. Data from the interviews were transcribed and analysed using conventional content analysis. Results: Four themes emerged from semi-structured interviews with the health care workers: a holistic disability framework, a multidisciplinary team dynamic, organisational barriers and recommendations by health care workers. Conclusion: Health care workers perceived a shift from a biomedical perspective of disability to a bio-psychosocial interpretation that is influenced by contextual and environmental barriers imposed by communities on people living with HIV. Barriers included stigmatisation that leads to attitudinal barriers and social exclusion of people living with HIV and experiencing disabilities within communities. Lack of resources, including of equipment, and a shortage of health care staff also posed barriers to the care offered to people living with HIV and experiencing disabilities. Participants agreed that improved communication in the multidisciplinary health care team, as well as continuing education and training, would enable health care workers to offer improved, integrated care to people living with HIV who experience disabilities. [ABSTRACT FROM AUTHOR]

Objective: To estimate facility-level average cost for ART services and explore unit cost variations using pooled facility-level cost estimates from four HIV empirical cost studies conducted in five African countries. Methods: Through a literature search we identified studies reporting facility-level costs for ART programmes. We requested the underlying data and standardised the disparate data sources to make them comparable. Subsequently, we estimated the annual cost per patient served and assessed the cost variation among facilities and other service delivery characteristics using descriptive statistics and meta-analysis. All costs were converted to 2017 US dollars ($). Results: We obtained and standardised data from four studies across five African countries and 139 facilities. The weighted average cost per patient on ART was $251 (95% CI: 193–308). On average, 46% of the mean unit cost correspond to antiretroviral (ARVs) costs, 31% to personnel costs, 20% other recurrent costs, and 2% to capital costs. We observed a lot of variation in unit cost and scale levels between countries. We also observed a negative relationship between ART unit cost and the number of patients served in a year. Conclusion: Our approach allowed us to explore unit cost variation across contexts by pooling ART costs from multiple sources. Our research provides an example of how to estimate costs based on heterogeneous sources reconciling methodological differences across studies and contributes by giving an example on how to estimate costs based on heterogeneous sources of data. Also, our study provides additional information on costs for funders, policy-makers, and decision-makers in the process of designing or scaling-up HIV interventions. [ABSTRACT FROM AUTHOR]

Whilst progress has been made, evidence of effective approaches to improve action on addressing the social and structural drivers of the HIV epidemic remains a priority, to meet the 2030 sustainable development agenda, and to achieve key HIV targets, including the 90-90-90 target and the Treatment as Prevention (TasP) intervention. With a focus on the public sector in South Africa, we critically reflect on the HIV mainstreaming approach, assessing its ability to augment multisectoral action on the response to HIV. We reflect on progress made in mainstreaming HIV in non-health sector departments, exploring factors that have enabled and hindered the process. We also highlight limitations in the adopted approach to mainstreaming HIV in non-health sector departments in South Africa; which currently promotes working in silos and does not encourage collaboration and partnerships. We propose a three-step approach to effective mainstreaming of HIV that will augment multisectoral action. The approach also contributes towards realising the sustainable development agenda of "leaving no one behind" and achieving the national and global targets on HIV that are embedded in collaborative efforts. [ABSTRACT FROM AUTHOR]

Background: Overwhelmed, under-trained medical staff working in resource-limited settings need efficient resources for HIV disclosure counselling. The objective of this study was to describe providers’ experiences using tablet computers for disclosure-related counselling with HIV-infected children and their caregivers in western Kenya, with additional perspectives from adolescents. Methods: A qualitative study design was implemented at three HIV clinics in western Kenya (Bumala, Busia and Port Victoria) within the Academic Model Providing Access to Healthcare (AMPATH) partnership. Twenty-one healthcare providers involved with paediatric disclosure were recruited and enrolled in the study. Initial interviews focused on understanding current disclosure practices and barriers. Tablets containing disclosure-related resources were distributed. Resources included short narrative videos created in this context to highlight issues relevant to child HIV disclosure. Results: Providers reported tablets improved disclosure, child participation, and medication adherence. All reported that reviewing materials increased their knowledge and comfort with disclosure. The most frequently used materials were the narrative videos and an animated video explaining the importance of medication adherence. Time was a major barrier for using the tablet. Clinician self-education persisted at one-year follow-up. Adolescents expressed enjoyment from viewing the tablet resources and had a better understanding of the importance of medication adherence. Conclusions: Tablet computers containing resources for disclosure are an acceptable and potentially effective resource to help providers support families with disclosure. Further work is needed to train the clinical providers in using the resources in a developmentally appropriate manner, and to develop new resources on adolescent-specific and HIV-related topics. [ABSTRACT FROM AUTHOR]

We examined the logic that individuals use to account for delaying HIV testing and/or initiating HIV treatment. Our qualitative study, situated within the REALITY trial (Reduction of EArly mortaLITY in HIV infected adults and children starting antiretroviral therapy), was conducted in Uganda and Zimbabwe in 2015. Forty-eight participants (different age groups, sex and viral load/WHO disease stage) were included. Each participant had 2 interviews (1 after 4 weeks of participation in the trial the other after 12 weeks). If a person could manage presenting symptoms, they felt they had “more time” before starting antiretroviral therapy (ART). Their reluctance to have an HIV test (despite deteriorating health) arose from a belief that they were not “sick”, that treatment was “not yet necessary”. People in our study did not consider themselves as presenting “late”, and treatment was not considered urgent as long as they considered their health to be “good enough”. [ABSTRACT FROM AUTHOR]

Although early antiretroviral therapy (ART) reduces HIV-related mortality in children by up to 75%, almost half of HIV-positive children younger than 1 year old in Swaziland do not initiate ART. This study was conducted to identify barriers to early ART initiation among HIV-positive infants. This was a case-control study among HIV-positive infants, aged 2 to 18 months, who either did not initiate ART (cases), or initiated ART (controls), during 18 months after testing. Multivariable logistic regression showed that infants who visited the clinic every month, or every 2 months, were 5.78 and 6.20 times more likely to initiate ART than those who visited less often (OR 5.78, 95% CI 1.82-18.33 and OR 6.20, 95% CI 1.30-29.60 respectively). Children who lived ≤30 and 31-60 minutes from the nearest clinic were 84% and 79% less likely respectively to initiate ART (OR 0.16, 95% CI 0.03-0.78 and OR 0.21, 95% CI 0.04-0.98) compared with those who lived more than 60 minutes away. Children who received immunisation after 6 months were 22.59 times more likely to initiate ART (OR 22.59, 95% CI 7.00-21.72) than those who did not. Infants of caregivers who had excellent or good relationships with their healthcare provider were 4.32 times more likely to initiate ART (OR 4.32, 95% CI 1.01-18.59) than those of caregivers who had average or poor relationships with healthcare providers. The significant predictors of ART initiation identified in this study should be regarded as priority areas for intervention among HIV-positive women in Swaziland. [ABSTRACT FROM AUTHOR]

In South Africa, a lack of integration between sexual and reproductive health (SRH) and HIV services has led to lost opportunities in the treatment cascade. In a context of high HIV, tuberculosis (TB) and unplanned pregnancies, a model for integrating SRH and HIV services was implemented in a hospital and six feeder clinics in KwaZulu-Natal, South Africa. Changes in healthcare provider knowledge, attitudes and understandings were explored following model implementation. Baseline data were collected via focus group discussions (FGDs) and a cross-sectional survey, and were used to inform the development of a model for integrating SRH and HIV services. Following the implementation of the model, an endline survey was conducted to explore any changes. Four FGDs were conducted with healthcare providers at study facilities. A total of 46 providers participated in the baseline survey, and 44 in the endline survey. Qualitative data were thematically analysed using NVivo 11, and quantitative data were descriptively analysed using SPSS 24. The understanding of integration improved by endline. Integration of services was considered important for reducing stigma and increasing access to and improving quality of care. Concerns raised were that integration would increase workload and time per client. Physical structure of facilities was not always conducive to referral or integration. Perceived benefits of integration and actual integration of services improved between baseline and endline. Enhanced understanding of integration and increased levels of reported integration over time imply that providers are more aware, suggesting that the model was effective. Provider perspectives and understandings are important for the successful integration of services. This integration model is relevant and useful to inform training and mentoring of providers, as well as to provide recommendations for policy implementation. [ABSTRACT FROM AUTHOR]

HIV in Mauritius is in a concentrated phase. Most HIV infection is among key populations (KPs) including female sex workers (FSW), people who inject drugs (PWID), men who have sex with men (MSM), and transgender sex workers (TGSW). The objective of this research was to use geographical mapping to determine the precise locations, typologies and population estimates of each KP in Mauritius. From May to July 2014 a programmatic mapping approach determined national estimates and information on the specific locations, “hotspots”, frequented by KPs in Mauritius. Data were collected through multiple levels of activity. Key informants provided information about hotspots where KPs congregated and were actively engaged in risky behaviours. Validation of hotspots was done by engaging KPs. A total of 17 248 KP members were estimated spread over 1 964 hotspots in Mauritius. The largest KP was PWID with an estimate of 7 598 (range: 4 091-6 223), followed by 6 223 (range: 5 090-7 456) FSWs, spread over 694 and 731 hotspots respectively. A total of 2 020 (range: 1 595-2 446) MSM and 294 geographic MSM hotspots, and 1 407 TGSWs (range: 1 165-1 649) distributed over 245 hotspots. This research provided Mauritius with validated KPs size estimations and provided the first national data on KP hotspots and operational dynamics. The use of these data will strengthen HIV prevention, intervention, and programme planning in the country through focusing efforts to systematically target high-risk areas. [ABSTRACT FROM AUTHOR]

The purpose of this article is to provide insights into the demand for pregnancy-related health services by adolescent girls and young women in Mozambique. We analysed the patient registers for the first year of operation (2014) of the Servicios Amigos dos Adolescentes (SAAJ) [Friendly Services for Adolescents] clinics in Beira, Mozambique. These registers provide details of the service demands of, and services provided to the 8 290 adolescent girls and young women who accessed the 6 SAAJ clinics in 2014. Analysis of that record, with disaggregation of the patients according to age (9 years or less; 10-14; 15-19; 20-24; 25 and older), show that 3 021 (36%) were pregnant or had previously been pregnant; most being girls in the 15-19 age band (59%). Being pregnant or having been pregnant previously was associated with dropping out of school. Of all the girls and women, 60% agreed to HIV testing and counselling; the HIV prevalence rate amongst this group was 4-5% amongst adolescents and 25% amongst women 25 years and older. A minority of the girls and women who were pregnant or had been pregnant previously agreed to HIV testing and counselling. Notwithstanding the limitations for analysis, the results were alarming: substantially high HIV prevalence rates were indicated (2% amongst 10-14 year old girls; 8% amongst 15-19 year olds; 10% amongst 20-24 year olds; and 28% amongst >24 year olds). The data from the SAAJ clinics and results pertain only to conditions in Beira. However, as the first empirical assessment of pregnancy-related service demand amongst adolescent girls and young women in the country and involving a relatively large sample, we contend that this study affirms the need for expansion of sexual and reproductive health (SRH) services, including HIV services, for adolescent girls and young women in Mozambique. [ABSTRACT FROM AUTHOR]

Swaziland has the highest HIV prevalence in the world. To mitigate the spread and devastation caused by HIV and to improve the wellbeing of people living with HIV, the country has adopted the latest available HIV prevention campaigns, including “Test and Start”. Because evidence from randomised controlled trials has demonstrated a significant risk reduction in HIV transmission when HIV-positive people start antiretroviral therapy (ART) early, Swaziland aims to find these people and link them to treatment. This study presents findings regarding the perceptions of this promising HIV-prevention intervention among men aged 17–69 years. A combination of qualitative methods including focus group discussions (12), in-depth interviews (17), informal conversations and participant observation (21) were used to collect data in two peri-urban communities in 2013–2014. Findings illustrate that men still fear taking an HIV test because of a relatively high probability of a positive test which some still interpret as a death sentence. Other potential barriers to the effectiveness of Test and Start programmes include lack of hospitality in hospitals, fear of starting treatment early related to side effects of ART, poverty, and lack of trust in the financial stability of the Swazi government. We argue that several social factors need to be considered for the Test and Start programme to be more effective. [ABSTRACT FROM AUTHOR]

HIV/AIDS remains one of the leading causes of death among children under 5 years old in Swaziland. Although studies have shown that early initiation of infants and children diagnosed with HIV on antiretroviral therapy (ART) significantly reduces mortality, many children do not initiate ART until the later stages of disease. This study was designed to collect qualitative data from mothers and caregivers of HIV-positive children to identify the barriers to ART initiation. Focus group discussion (FGD) sessions were conducted in siSwati between July and September 2014 among caregivers of aged children 2–18 months in Swaziland who did or did not initiate ART between January 2011 and December 2012 after HIV DNA PCR-positive diagnosis of the infants. Denial, guilt, lack of knowledge, tuberculosis (TB)/HIV co-infection, HIV-related stigma, lack of money, and distance to clinics were reported by the participants as barriers to ART initiation. The findings further revealed that non-initiation on ART was not linked to a negative perception of the treatment. Findings suggest a need to improve sensitivity among healthcare workers as well as education and counselling services that will facilitate the ART initiation process. [ABSTRACT FROM AUTHOR]

The objective of this review was to provide an overview of behavioural interventions promoting condom use amongst female sex workers (FSW) in sub-Saharan Africa. A search of four electronic bibliographic databases from 1990 to September 2016 was carried out. The search was limited to articles published in English. Studies which evaluated behavioural interventions to increase condom use among FSWs were selected and reviewed. Data were extracted on effectiveness, condom use, intervention content, and process outcomes. A total of 20 eligible articles describing 18 interventions in sub-Saharan Africa on HIV prevention with condom use as an outcome measure were identified. Most of the behavioural interventions incorporated a combination of approaches: health education by peers, health workers and project staff, and activities by brothel owners and brothel managers. Most studies showed effectiveness of these interventions on condom use with paying clients. Five studies measuring condom use with regular non-paying partners recorded less consistent condom use with these partners. This review illustrates the existence of sufficient evidence showing the effectiveness of behavioural interventions targeting correct and consistent condom use by FSWs. [ABSTRACT FROM PUBLISHER]

In the context of the optimism around antiretroviral therapy (ART) as prevention of HIV/AIDS, addressing the barriers to long-term ART adherence is critical. This is particularly important given the tendency to individualise or use a blame discourse when exploring why HIV-infected patients “fail” to adequately adhere to ART, and not sufficiently exploring contextual reasons for poor adherence that may require varying solutions. This study took place at three clinics and one hospital in Khayelitsha, South Africa, to document the contextual factors that challenged ART adherence in this community. Interviews were conducted with 20 HIV-infected patients who had defaulted on their ART and were subsequently admitted to Khayelitsha hospital for clinical complications, and 9 ART service providers including doctors, nurses and HIV counsellors. Interviews assessed the reasons patients defaulted on ART and explored ways this could be prevented. Data from both groups were analysed collectively using thematic analysis. While the interviews revealed a landscape of environmental risks threatening adherence to ART, all patients managed to overcome the identified barriers at some point in their treatment phase, indicating the fluidity of patients’ needs and decision making. Patients reported that distrustful relationships with service providers could inhibit their understanding of ART and/or interrupt their follow-up at clinics. Patients described their rationale and agency underlying non-adherence, such as testing their bodies’ physical limits without ART medication. The study speaks to the need to appreciate contextual social and structural barriers related to ART adherence, and how these are negotiated differently by specific sub-groups, to support an appropriate response. It is imperative to not solely emphasise loss to follow-up but also assess patients’ subjective trajectory of their ART journey, decision making and agency with adhering to ART, their relations with healthcare workers, and how these dynamics are intertwined with broader constraints in health systems. [ABSTRACT FROM AUTHOR]

Hazardous alcohol consumption may compromise optimal antiretroviral therapy (ART) adherence among patients. Adoption of hegemonic notions of masculinity may encourage health-risk behaviours, such as alcohol consumption, and discourage health-enhancing behaviours, such as ART adherence among men. This study aimed to explore linkages between masculinity, alcohol consumption, and taking ART medication among male ART recipients in South Africa. Male facilitators conducted five focus group discussions with 27 black male ART recipients aged between 28 and 65 years at five ART clinics. Eligibility criteria were: 18 years or older, at least three months on ART, and alcohol consumption in the past three months. Data were analysed inductively using thematic content analysis. The men demonstrated a masculinity that fostered commitment to taking ART. However, normative notions of masculinity in the men’s social circles often compromised their timeous taking of medication. Fears of alcohol-ART interactions often led to intentional non-adherence to ART when drinking. Finally, healthcare provider-patient power dynamics seemed to prevent the men from discussing their challenges regarding alcohol use and ART adherence with their healthcare providers. Interventions that focus on addressing harmful hegemonic notions of masculinity among men are needed in community settings such as drinking establishments where men tend to socialise. Patient-centred approaches which enhance men’s sense of involvement in their treatment are needed in healthcare settings. [ABSTRACT FROM PUBLISHER]

Home-based rehabilitation (HBR) has been shown to improve the lives of people living with a wide range of chronic diseases in resource-rich settings. This may also be a particularly effective strategy in resource-poor settings, where access to institution-based rehabilitation is limited. This review aimed to summarise and discuss the evidence related to the effectiveness of home-based rehabilitation (HBR) interventions designed specifically for adults living with HIV. A scoping review methodology was employed, involving systematic search techniques and appraisal of appropriate evidence. English-language journal articles that assessed the quality of life or functional ability outcomes of HBR interventions for adults living with HIV were considered for this review. Out of an initial 1 135 publications retrieved from the search of databases, six articles met this review's inclusion criteria. While this review highlights the scarcity of empirical evidence related to HBR interventions for adults living with HIV, the findings of these six articles are that HBR is a safe management option that may confer a number of physical and psychological benefits for this population. Future research on HBR interventions should include a wider range of assessment measures, including cost-benefit analyses and specific tools designed to assess the functional ability and participation in activities of daily living of participants involved in these programmes. In particular, more research on HBR is required in resource-poor environments, such as sub-Saharan Africa where HIV is endemic, to assess whether this is a feasible strategy that is both effective and practical in the areas that may need it most. [ABSTRACT FROM AUTHOR]

Immense progress has been made in the fight against HIV and AIDS. Achieving and exceeding the AIDS targets for the Millennium Development Goals (MDGs) was accomplished, in large part, due to an unprecedented financial investment from the international community. Following an $800 million dip in donor disbursements in 2010, the discourse has since shifted to the need for greater sustainability of funding. But what does sustainability mean? Current efforts focus heavily on fiscal imperatives such as increasing domestic funding. This is important – needs are increasing at a faster rate than donor funding, especially with increased treatment coverage. The problem is that measures of financial sustainability tell very little about the actual sustainability of specific programmes, disease trajectories or enabling environments. Recognising that current definitions of sustainability lack clarity and depth, we offer a new six-tenet conceptualisation of what sustainability means in the HIV and AIDS response: (1) financial, (2) epidemiological, (3) political, (4) structural, (5) programmatic, and (6) human rights. Based on these, we examine examples of donor transitions for their approach to sustainability, including PEPFAR in South Africa, the Global Fund in Eastern Europe, and the Bill and Melinda Gates Foundation in India (Avahan). We conclude that sustainability must be understood within a broader framework beyond funding stability. We also recommend that certain interventions, such as programming for key populations, may have to continue to receive external support even if affected countries can afford to pay. [ABSTRACT FROM AUTHOR]

The first six months of HIV care and treatment are very important for long-term outcome. Early mortality (within 6 months of care initiation) undermines care and treatment goals. This study assessed the temporal distribution in baseline characteristics and early mortality among HIV patients at the University College Hospital, Ibadan, Nigeria from 2006–2013. Factors associated with early mortality were also investigated. This was a retrospective analysis of data from 14 857 patients enrolled for care and treatment at the adult antiretroviral clinic of the University College Hospital, Ibadan, Nigeria. Effects of factors associated with early mortality were summarised using a hazard ratio with a 95% confidence interval obtained from Cox proportional hazard regression models. The mean age of the subjects was 36.4 (SD=10.2) years with females being in the majority (68.1%). While patients’ demographic characteristics remained virtually the same over time, there was significant decline in the prevalence of baseline opportunistic infections (2006–2007=55.2%; 2011–2013=38.0%). Overall, 460 (3.1%) patients were known to have died within 6 months of enrollment in care/treatment. There was no significant trend in incidence of early mortality. Factors associated with early mortality include: male sex, HIV encephalopathy, low CD4 count (< 50 cells), and anaemia. To reduce early mortality, community education should be promoted, timely access to care and treatment should be facilitated and the health system further strengthened to care for high risk patients. [ABSTRACT FROM PUBLISHER]

This article reviews the methodology of future scenario-building in the context of HIV and AIDS in Africa. It considers three scenario studies conducted in the past decade: UNAIDS (2005), Metropolitan Holdings (2006) and the AIDS Governance scenarios (2015). The article is a critical reflection of Future Studies epistemology which claims to contribute a unique heuristic niche in the study of AIDS. The article offers several methodological insights: (1) despite claims to the contrary, scenario methodology remains profoundly influenced by existing political and research agenda; instead of denying these, scenarists should acknowledge this; (2) the utility of scenario studies is strongly influenced by their unit of analysis and their time frame, which determine their applicability and therefore their policy relevance; and (3) scenario planners should guard against perpetuating the myth that this methodology is a crystal ball into the future because they are powerful tools for strategic planning about the present, rather than the distant future. In addition to these methodological insights, the article finds that future scenario studies are useful in identifying significant discursive and policy shifts in the AIDS response. [ABSTRACT FROM AUTHOR]