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Ministers are anxious to see shorter hospital waiting lists. Instead of buying services from the private sector, health authorities may do better by trading with each other. But, if the full potential of trading is to be realised, the financing and management of the NHS will have to alter.

From November 1987 to October 1988, numbers of clients, visits made and syringes dispensed and returned were monitored at the needle exchange of the Middlesex Hospital, London, UK. A sample of clients were interviewed 1 month after entry to the scheme and again 3 months later to evaluate changes in injecting and sexual risk behaviours for HIV infection. Clients were asked to donate saliva for anti-HIV immunoglobulin G (IgG) antibody capture radioimmunoassay (GACRIA). The rate of lending and borrowing used injecting equipment fell, both compared with rates prior to entry to the scheme and during the period of study. Frequency of injecting did not increase and there was reduced incidence of abscesses. There was a highly significant correlation between multiple sexual partners and condom use and a reduction in the proportion of clients with multiple partners. On entry to the study, seven out of 121 (6%) clients were anti-HIV positive; after 3 months, a further two clients tested were found to be anti-HIV positive. Anti-HIV positivity prevalence for the year of study was nine out of 121 (7%). The scheme attracts clients, reduces injecting-related risk for HIV infection and has high equipment return rates. Saliva testing is acceptable to clients. Continued monitoring of anti-HIV in saliva is indicated.

SummaryBackgroundCombination antiretroviral therapy has substantially increased life-expectancy in people living with HIV, but the effects of chronic infection on health-related quality of life (HRQoL) are unclear. We aimed to compare HRQoL in people with HIV and the general population.MethodsWe merged two UK cross-sectional surveys: the ASTRA study, which recruited participants aged 18 years or older with HIV from eight outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012; and the Health Survey for England (HSE) 2011, which measures health and health-related behaviours in individuals living in a random sample of private households in England. The ASTRA study has data for 3258 people (response rate 64%) and HSE for 8503 people aged 18 years or older (response rate 66%). HRQoL was assessed with the Euroqol 5D questionnaire 3 level (EQ-5D-3L) instrument that measures health on five domains, each with three levels. The responses are scored on a scale where a value of 1 represents perfect health and a value of 0 represents death, known as the utility score. We used multivariable models to compare utility scores between the HIV and general population samples with adjustment for several sociodemographic factors.Findings3151 (97%) of 3258 of participants in ASTRA and 7424 (87%) of 8503 participants in HSE had complete EQ-5D-3L data. The EQ-5D-3L utility score was lower for people with HIV compared with that in the general population (marginal effect in utility score adjusted for age, and sex/sexuality −0·11; 95% CI −0·13 to −0·10; p0·05).InterpretationPeople living with HIV have significantly lower HRQoL than do the general population, despite most HIV positive individuals in this study being virologically and immunologically stable. Although this difference could in part be due to factors other than HIV, this study provides additional evidence of the loss of health that can be avoided through prevention of further HIV infections.FundingUK National Institute for Health Research.

IN the recent past, health education has understand ably focused on sexual behaviour, particularly unprotected anal sex, that is most risky in terms of HIV in relation to gay and homosexual behaviour. Other aspects of the health-related life-styles of gay men have been neglected. Three hundred and fifty six gay and homosexual men were interviewed about health behaviour. Levels of alcohol use, aspects of diet and drug use were found to be very similar to other young adult males. Forty per cent of men were currently smokers. Use of nitrites and high levels of alcohol consumption in relation to risky sex consti tute specific problems of health behaviour which may not be reached by conventional health edu cation interventions.

Despite a large number of needle-exchange schemes in the U.K., there are few accounts of how particular agencies attract injecting drug users. This paper describes a busy scheme in London, the take-up of services by clients, and the operating philosophy of the staff. From November 1987 to October 1988 The Exchange saw a mean of 257 clients per month, making an average three visits per client each month. An average of 8,950 needles and syringes were dispensed and 6,918 returned monthly, giving an average return rate of 77%. The Exchange also served as a referral agency to clients; 533 referrals were made, 63.4% of which were to drug and non-medical services, 36.6% to health services, and 9.2% to HIV services. To account for the take-up of services the paper describes The Exchange's open access policy, the staff's communication strategies and their adoption of the philosophy of harm-minimization in relation to injecting drug use. It is argued that these must be seen as integral to needle-exchange if it is to succeed as a comprehensive service.

Three hundred and fifty six homosexually active men were recruited in 1988 for a study by interview of sexual behaviour. Thirty two per cent had homosexual passive anal sex in the previous month and 60% in the year before interview. Anal sex and unprotected anal sex were more common with regular than non-regular partners. Heterosexual sex was reported by 4% of men in the last month and 10% for the last year. Sixteen per cent of heterosexually active men reported anal sex with a female partner. Fewer men described themselves as bisexual than would be expected from the sample's recent sexual histories. More attention is needed to the definition and measurement of "bisexuality" to understand its role in HIV transmission.

One-hundred and nine injecting drug users entering a methadone detoxification programme underwent HIV antibody test counselling. Approximately 80% of men and women were concerned because of sharing injection equipment (‘works’) in the previous year, although other reasons for considering an HIV antibody test, such as sexual contact with drug users and concern for sexual partners, was also given. Two-thirds of both men and women decided to be tested. Reasons for declining or deferring an HIV antibody test included an inability to cope with a positive result, recent sharing of ‘works’, and intoxication with drugs or alcohol at the time of counselling. Of the 74 clients tested, two were HIV antibody positive. Only 55% of clients reattended for results. Testing drug users for evidence of HIV infection requires careful pre-test counselling and adequate support should be readily available when results are given.

OBJECTIVE: To investigate current risk factors for HIV seroconversion among homo/bisexual men. DESIGN: Matched case control study in a large STD clinic in central London. Data on risk factors were obtained by case note review. METHODS: Fifty-six cases who had at least one negative HIV test followed by a positive test between June 1988 and July 1993, and two homo/bisexual controls (having two or more negative HIV tests) matched to each case on age, total number of HIV tests and test interval period were identified. Univariate and multivariate odds ratio were calculated for acute STD, ano-genital intercourse, condom use and HIV status of sexual partners. RESULTS: Adjusted odds ratios (95% confidence intervals) for HIV seroconversion were 4.1 (1.3-13.3) for having an acute interval STD and 4.6 (1.4-15.4) for having a known HIV infected sexual partner. Compared with men who always used condoms, odds ratios for men who sometimes or never used condoms were 7.9 (2.2-28.9) and 16.2 (3.0-86.0) respectively. Unprotected ano-genital intercourse was commonly reported by both cases and controls, and reported condom use was no greater with a known HIV infected partner than with a partner of unknown HIV status. CONCLUSION: HIV seroconversion among homo/bisexual men attending STD clinics is strongly related to having an acute STD, a known HIV infected partner and not using condoms. Although consistent use of condoms is highly protective, knowing that a partner is HIV infected does not ensure condom use between serodiscordant men. More effective, well-evaluated interventions are needed to reduce sexual risk-taking in this population.

Objectives: To examine changes in sexual behaviour among London homosexual men between 1998 and 2003 by type and HIV status of partner. Methods: Homosexual men (n = 4264) using London gyms were surveyed annually between 1998 and 2003 (range 498–834 per year). Information was collected on HIV status, unprotected anal intercourse (UAI) in the previous 3 months, and type of partner for UAI. High risk sexual behaviour was defined as UAI with a partner of unknown or discordant HIV status. Results: Between 1998 and 2003, the percentage of men reporting high risk sexual behaviour with a casual partner increased from 6.7% to 16.1% (adjusted odds ratio (AOR) 1.36 per year, 95% confidence interval (CI) 1.26 to 1.46, p

Interventions are unlikely to achieve their desired aims unless they are implemented as intended. This paper focuses on factors that impeded or facilitated the implementation of a specially designed sex education programme, SHARE, which 13 Scottish schools were allocated to deliver in a randomized trial. Drawing on qualitative and quantitative data provided by teachers, we describe how this intervention was not fully implemented by all teachers or in all schools. Fidelity to the programme was aided by intensive teacher training, compatibility with existing Personal and Social Education (PSE) provision, and senior management support. It was hindered by competition for curriculum time, brevity of lessons, low priority accorded to PSE by senior management, particularly in relation to timetabling, and teachers' limited experience and ability in use of role-play. The nature of the adoption process, staff absence and turnover, theoretical understanding of the package, and commitment to the research were also factors influencing the extent of implementation across and within schools. The lessons learned may be useful for those involved in designing and/or implementing other teacher-delivered school-based health promotion initiatives.

Objective: To compare the characteristics of men who have sex with men (MSM) surveyed online (through gay Internet chat rooms and profiles) and offline (in community venues) in London, UK. Methods: In February and March 2002, 879 MSM completed a self-administered pen-and-paper questionnaire distributed in central London gyms (offline sample). In May and June 2002, 1218 London MSM completed a self-administered questionnaire online, accessed through Internet chat rooms and profiles on gaydar and gay.com. Results: Compared with men surveyed offline, those surveyed online were significantly less likely to only have sex with men (89 vs. 94%), to be in a relationship with a man (44 vs. 52%), or to have been tested for HIV (68 vs. 80%) (P < 0.001). Men recruited online were also younger (mean age, 34 vs. 36 years) and less likely to have had a higher education (67 vs. 79%) (P < 0.001). However, differences between online and offline samples were less pronounced for HIV-positive men and more pronounced for HIV-negative men and those who had never been tested for HIV. Regardless of HIV status, men recruited online were more likely to report high-risk sexual behavior (i.e., unprotected anal intercourse with a partner of unknown or discordant HIV status) than men surveyed offline (32 vs. 22%, P < 0.001). Men recruited online were also significantly more likely to have used the Internet to look for sex (85 vs. 45%, P < 0.001); for HIV-positive and negative men, seeking sex on the Internet was associated with high-risk sexual behavior (P < 0.01). In multivariate analysis, after controlling for confounding factors, being surveyed online was independently associated with high-risk sexual behavior for HIV-negative and never-tested men (HIV-negative men, adjusted odds ratio for online vs. offline samples, 1.73; 95% CI, 1.23, 2.42; P < 0.01; never-tested men adjusted odds ratio 2.45; 95% CI, 1.40, 4.29; P < 0.01). This was not the case for HIV-positive men (adjusted odds ratio for online vs. offline samples, 1.32; 95% CI, 0.69, 2.50; P = 0.4). Conclusion: The Internet offers valuable opportunities for conducting behavioral surveillance among MSM because it reaches some men who may not be easily accessed in the community yet who are at high risk for HIV and sexually transmitted diseases. Comparisons of the social, demographic, and behavioral characteristics of online and offline samples must, however, take into account the confounding effects of HIV status and seeking sex on the Internet.

In response to a recent expert advisory group report to the chief medical officer, the government has announced the setting up of two pilot schemes to assess the feasibility of a Chlamydia trachomatis screening programme in the United Kingdom.1–3 Chlamydia is the most common, curable, sexually transmitted infection in the Western world. Chlamydia infection is largely asymptomatic, but if it is left untreated it can have particularly severe long term consequences for women. These sequelae include pelvic inflammatory disease, ectopic pregnancy, and infertility.4 The expert advisory group has recommended that the following groups be targeted for screening: everyone with symptoms of chlamydia infection, all those attending genitourinary medicine clinics, and women seeking termination of pregnancy.1 There should also be opportunistic screening of young sexually active women under 25 years and of women over 25 with a new sexual partner or two or more sexual partners in the past year. The report identifies family planning clinics and general practice as key sites for screening. It also emphasises the importance of follow up management of infected individuals, which should be carried out in conjunction with genitourinary medicine clinics. #### Summary points The rationale behind targeting women for this screening programme is based on health benefits, cost effectiveness, and accessibility. Firstly, and most importantly, the purpose of the programme is to reduce the morbidity associated with pelvic inflammatory disease. Evidence from countries …

BACKGROUND--Predictors of chlamydia and gonorrhoea can be used to increase the cost-effectiveness and acceptability of screening programmes, and allow targeting of control strategies. METHOD--All men attending an STD clinic in 1988-1990 were offered screening for chlamydia and gonorrhoea, and the test results correlated with a wide range of potential predictors using multiple logistic regression. RESULTS--Of 9622 attenders, 7992 (82.3%) were tested over a total of 10,110 episodes for chlamydia and 10,090 episodes for gonorrhoea, yielding 729 (7.2%) chlamydial and 123 (1.2%) gonococcal infections. Having urethral discharge and/or dysuria, being heterosexual, and STD contact, unmarried, uncircumcised, tattooed and not having had an STD previously were independently associated with chlamydial infection. Having urethral discharge and/or dysuria, being Aboriginal, an STD contact, homosexual, uncircumcised, tattooed and having sex outside the state in the past three months, no steady partner in the past three months and multiple partners in the past month were associated with urethral gonococcal infection. Selective screening criteria for gonorrhoea provided 90% of positives, eliminated the need for 58% of tests and resulted in an increased yield ratio of 2.2 whereas the corresponding outcomes for screening criteria for chlamydia were 93% 20% and 1.2 respectively. CONCLUSIONS--The widespread influence of confounding on potential predictors for both gonorrhoea and chlamydia may provide misleading indicators of risk factors by univariate analysis. In the setting studied the benefits of selective screening for gonorrhoea in men would be substantial, whereas satisfactory criteria for selective screening for chlamydia could not be identified.

To describe the sexual risk behaviour of and HIV and hepatitis B antibody prevalence in gay men in England.Cross-sectional.Gay men recruited from community settings (bars, clubs, gay organizations) and genito-urinary clinics in London, Manchester, the Midlands and Bristol; men who participated in an earlier study.Interview including demographic information, sexual behaviour, partner type and health service use. Subjects donated saliva, which was screened for antibodies to HIV-1 by immunoglobulin G (IgG) antibody capture enzyme-linked immunosorbent assay (GACELISA) and to hepatitis B core (HBc) antigen by IgG antibody capture radioimmunoassay (GACRIA).Ninety-four out of 580 (16.2%) men were HIV-antibody-positive; 6.2% of men agedor = 25 years were positive versus 19.5% of men agedor = 26 years. HIV-antibody prevalence was highest in London (21.1%), and twice that previously reported outside London (10.5%). Ninety-four out of 568 (16.5%) men were HBc-antibody-positive; 6.9% of men agedor = 25 years were positive versus 19.7% of men agedor = 26 years. Anti-HBc prevalence was highest in London (19.8 versus 12.7% outside London). Manual workers were more likely to be anti-HBc-positive, as were men who reported recent high-risk intercourse. Sexually transmitted diseases associated with frequent partner change (gonorrhoea, non-specific urethritis) were reported.The HIV epidemic in gay men in England continues, particularly outside London, where prevalence was double that of previous studies. We found relatively high rates of infection in young men whose main sexual experience has been in a time of unprecedented awareness of AIDS. Our data on hepatitis B suggests that further pro-active immunization programmes are urgently required. These findings add to concerns about provision of interventions targeting gay men.

The objective was to examine how many young men who have sex with men (MSM) meet their first sexual partner through the Internet and whether this has increased over time. In 2003, 2505 MSM surveyed on UK Internet sites completed a self-administered questionnaire. Data were analysed for 810 MSM who were under 30 years old at the time of the survey and who first had sex with another man between 1993-2002. During this period there was a significant increase in the percentage of MSM who met their first male sexual partner through the Internet (2.6-61.0%). There was a corresponding decrease in the percentage who met their first sexual partner at a gay venue (34.2-16.9%), school (23.7-1.3%), a public sex environment, through small ads or telephone chatlines (10.5-1.3%). An increasing number of young MSM appear to meet their first sexual partner through the Internet. Online sexual health interventions should be developed targeting men early in their sexual careers.

OBJECTIVE: To determine whether a theoretically based sex education programme for adolescents (SHARE) delivered by teachers reduced unsafe sexual intercourse compared with current practice. DESIGN: Cluster randomised trial with follow up two years after baseline (six months after intervention). A process evaluation investigated the delivery of sex education and broader features of each school. SETTING: Twenty five secondary schools in east Scotland. PARTICIPANTS: 8430 pupils aged 13-15 years; 7616 completed the baseline questionnaire and 5854 completed the two year follow up questionnaire. INTERVENTION: SHARE programme (intervention group) versus existing sex education (control programme). MAIN OUTCOME MEASURES: Self reported exposure to sexually transmitted disease, use of condoms and contraceptives at first and most recent sexual intercourse, and unwanted pregnancies. RESULTS: When the intervention group was compared with the conventional sex education group in an intention to treat analysis there were no differences in sexual activity or sexual risk taking by the age of 16 years. However, those in the intervention group reported less regret of first sexual intercourse with most recent partner (young men 9.9% difference, 95% confidence interval -18.7 to -1.0; young women 7.7% difference, -16.6 to 1.2). Pupils evaluated the intervention programme more positively, and their knowledge of sexual health improved. Lack of behavioural effect could not be linked to differential quality of delivery of intervention. CONCLUSIONS: Compared with conventional sex education this specially designed intervention did not reduce sexual risk taking in adolescents.

A sample of 502 homosexually active men were recruited from genitourinary medicine clinics and non clinic sources and interviewed in relation to their sexual behaviour and factors that might influence their use of condoms. Three hundred and eighty three men (76%) reported penetrative anal sex in the previous year. Ninety four (25%) had not used condoms in penetrative sex. Failure to use condoms was associated with unfavourable attitudes to them, not knowing close friends or partners who had HIV-related health problems, having fewer sexual partners and being in a closed monogamous relationship. On the other hand levels of awareness about the risks of unprotected anal sex and involvement in gay networks and social groups were not predictors of condom use.A sample of 502 homosexually active men were recruited from genitourinary medicine clinics and nonclinic sources and interviewed in relation to their sexual behavior and factors that might influence their use of condoms. 383 men (76%) reported penetrative anal sex in the previous year. 94 (25%) had not used condoms in penetrative sex. Failure to use condoms was associated with unfavorable attitudes towards the method, not having close friends or sex partners who had HIV-related health problems, having fewer sex partners who had HIV-related health problems, having fewer sex partners, and being in a closed monogamous relationship. Likewise, levels of awareness about the risks of unprotected anal sex and involvement in gay networks and social groups were not predictors of condom use.

BACKGROUND: Men's healthcare-seeking delay results in higher mortality while on HIV or tuberculosis (TB) treatment, and implies contribution to ongoing community-level TB transmission before initiating treatment. We investigated masculinity's role in healthcare-seeking delay for men with TB-suggestive symptoms, with a view to developing potential interventions for men. METHODS: Data were collected during March 2011- March 2012 in three high-density suburbs in urban Blantyre. Ten focus group discussions were carried out of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers. Individual interviews were done with 20 TB patients (female =14) and 20 un-investigated chronic coughers (female = eight), and a three-day workshop was held with 27 health stakeholder representatives. RESULTS: An expectation to provide for and lead their families, and to control various aspects of their lives while facing limited employment opportunities and small incomes leaves men feeling inadequate, devoid of control, and anxious about being marginalised as men. Men were fearful about being looked at as less than men, and about their wives engaging in extramarital sex without ability to detect or monitor them. Control was a key defining feature of adequate manhood, and efforts to achieve it also led men into side-lining their health. Articulate and consistent concepts of men's bodily strength or appropriate illness responses were absent from the accounts. CONCLUSIONS: Facilitating men to seek care early is an urgent public health imperative, given the contexts of high HIV/AIDS prevalence but increasingly available treatment, and the role of care-seeking delay in TB transmission. Men's struggles trying to achieve ideal images seem to influence their engagement with their health. Ambiguous views regarding some key masculinity representations and the embrace of less harmful masculinities raise questions about some common assumptions that guide work with men. Apparent 'emergent masculinities' might be a useful platform from which to support the transformation of harmful masculinity. Finally, the complex manifestations of masculinity indicate the need for interventions targeting men in health and TB control to assume supportive, multidimensional and long-term outlooks.

There is widespread demand for the development of female controlled methods of protection against sexually transmitted diseases and HIV. The success of such methods will depend on their acceptability to women and their male partners. Currently, the only form of HIV prevention under women's control is the female condom. This paper reports on men's attitudes to female controlled methods in southwest Uganda. Data were collected in individual interviews with 50 men and 7 focus group discussions with 42 men. The men's attitudes to male condoms, female condoms and female controlled methods of protection generally were characterized by ambiguity and anxiety. Though men liked the male condom because it protects against infection and unwanted pregnancy, they were worried by rumors that it was unreliable. The central theme in the discussions was the anxiety of men about retaining control over their female partners. While men wanted women to be protected, they also wanted to remain in control, at least to some extent, of the means of protection. Once suitable female controlled methods have been identified, it will be necessary to use education and social marketing in a manner that men can be reassured of the positive benefits of these products to them as well as to women.

Objective: To assess risk factors for infection and to determine HIV prevalence in a sample of international travellers.Design: A cross-sectional survey of new patients attending a hospital outpatient clinic, and self-completion of an anonymous questionnaire on sexual behaviour prior to and during travel. Urine samples were tested for the presence of antibodies to HIV.Setting: The Hospital for Tropical Diseases, London, UK.Subjects: All new patients over a 6-month period.Results: Of 782 people approached, 757 (97%) agreed to participate: 141 (18.6%) had had new sexual partners during their most recent trip abroad. Almost two-thirds of those having sex abroad did not use condoms on every occasion with a new partner, and 5.7% contracted a sexually transmitted disease (STD) during their most recent trip; 26% of men from World Health Organization Pattern I countries who had new sexual partners abroad paid for sex. Sixteen out of 731 (2.2%) participants were HIV-antibody-positive. HIV positivity was associated with being born in east, central or southern Africa, having symptoms of an STD since arriving in the United Kingdom and being treated for an STD since arrival.Conclusion: The rates of unsafe sex and payment for sex abroad reported by these international travellers indicate the potential for contracting and transmitting STD, including HIV, in both their foreign and domestic sexual partnerships. With the increasing HIV incidence in Asia (the most common destination for UK travellers after sub-Saharan Africa), the number of cases of HIV contracted abroad may rise in the future.

In May-June 2002, 4,974 men who have sex with men (MSM), average age 31 years, completed a self-administered questionnaire online accessed through two popular gay Internet sites in the UK (gaydar and gay.com UK). Most men were white (95%), employed (83%), lived in the UK (91%) and self-identified as gay (85%). Nearly half (46%) had not been tested for HIV, while 6% said they were HIV-positive. One-third (31%) reported high-risk sexual behaviour in the previous three months, i.e. unprotected anal intercourse with a partner of unknown or discordant HIV status. Nearly all the men (82%) had looked for a sexual partner on the Internet and three-quarters had been doing so for more than a year. Almost half the men (47%) said they preferred to meet men through the Internet rather than in bars or other 'offline' venues. Although nearly 40% of men said the most important reason for using these Internet sites was to find sexual partners, a further 17% said they primarily used them to have contact with other men, 16% because they were bored, 12% for entertainment, 4% because they were lonely and 3% because they were addicted to it. The majority of men in this survey had favourable attitudes towards online health promotion. Most men thought that Internet sites should allow health workers into chat-rooms (75%); would click on a banner to find out about sexual health (78%); and said if they met a health worker in a chat-room they would find out what they had to say (84%). In multivariate analysis, being HIV-positive, older age and high-risk sexual behaviour were all independently associated with an increased frequency of using the Internet to look for sex (p < 0.05). The Internet has emerged as an important meeting place for men who have sex with men. As online HIV prevention initiatives are developed it will be important to monitor the extent to which the favourable attitudes seen here are reflected in preventive behaviours.

In this research note we begin to develop ideas drawn from studies concerned with the social context of sex work, and contribute to the literature on the sociology of risk, by investi- gating the social organisation and conditions of work of a group of female sex workers whose work has not so far been described in any detail - fiat-working women. These are preliminary findings from an ongoing empirical study comparing occupational risk of violence between women working in flats and street-working women in central London. Here we report on the flat-working women's employment of protective strategies, such as co-working with ‘maids’ who serve as gatekeepers, allowing clients access to the women and monitoring the time clients spend in the flats. Rather than focus on women's self-efficacy or health beliefs, we argue that it is through the social organisation of their work that we are best able to understand the nature of their risk exposure, and their strategies for managing risk and safety in relation to their occupational health.

Individual in-depth, semi-structured interviews with 30 HIV positive Black Africans were conducted in London, UK. The interviews focused upon experiential accounts of living with HIV. The interviews were transcribed and analysed for recurrent themes using interpretative phenomenological analysis. The social context of being a Black African living in the UK emerged as an important framework within which the experience of being HIV positive was positioned. In terms of people's accounts of their own experiences of living with HIV, diagnosis figured as an important moment in people's lives. The majority of participants were surprised and upset upon receiving their positive antibody test results. Many reported a period of depression and social isolation. Stigma and prejudice associated with HIV also emerged as a major force shaping the daily lives of the participants. We discuss the role of identity and social context in disrupting the medical meaning of diagnostic tests.