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Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Copyright © 2018 The Author(s). Published by Elsevier Ltd. Background A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle- SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view - and subsequent provision - of quality health care for all populations.

INTRODUCTION Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state. OBJECTIVE To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016. DESIGN AND SETTING A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year. MAIN OUTCOMES AND MEASURES Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed. RESULTS Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states). CONCLUSIONS AND RELEVANCE There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.

Importance Cardiovascular disease (CVD) is the leading cause of death in the United States, but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously. Objective To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 as well as risk factors driving these changes. Design, Setting, and Participants Using the Global Burden of Disease methodology, cardiovascular disease mortality, nonfatal health outcomes, and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 for all residents in the United States using standardized approaches for data processing and statistical modeling. Burden of disease was estimated for 10 groupings of CVD, and comparative risk analysis was performed. Data were analyzed from August 2016 to July 2017. Exposures Residing in the United States. Main Outcomes and Measures Cardiovascular disease disability-adjusted life-years (DALYs). Results Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. Cardiovascular disease DALYs remained twice as large among men compared with women. Ischemic heart disease was the leading cause of CVD DALYs in all states, but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggest additional unmeasured risks beyond these traditional factors. Conclusions and Relevance Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures.

GBD 2016 SDG Collaborators. Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016. Lancet 2017; 390: 1423–59—In figure 8B of this Article (published Online First on Sept 12, 2017), the number of indicator targets has been changed from 1 to 9 for Turkmenistan, from 0 to 1 for Afghanistan, and from 1 to 2 for Yemen. Ettore Beghi, Neeraj Bhala, Hélène Carabin, Raimundas Lunevicius, Donald H Silberberg, and Caitlyn Steiner have been added to the list of GBD 2016 SDG Collaborators. Their affiliations, along with the affiliation of Soumya Swaminathan, have been added to the Affiliations section. These corrections have been made to the online version as of Sept 18, 2017, and the printed Article is correct.

GBD 2016 SDG Collaborators. Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016. Lancet 2017; 390: 1423–59—The full-text version of this Article has been updated so that the list of authors is displayed in the correct order, in line with the pdf version, rather than in alphabetical order. This correction has been made to the online version as of Oct 12, 2017.

BACKGROUND: Timely assessment of the burden of HIV/AIDS is essential for policy setting and programme evaluation. In this report from the Global Burden of Disease Study 2015 (GBD 2015), we provide national estimates of levels and trends of HIV/AIDS incidence, prevalence, coverage of antiretroviral therapy (ART), and mortality for 195 countries and territories from 1980 to 2015. METHODS: For countries without high-quality vital registration data, we estimated prevalence and incidence with data from antenatal care clinics and population-based seroprevalence surveys, and with assumptions by age and sex on initial CD4 distribution at infection, CD4 progression rates (probability of progression from higher to lower CD4 cell-count category), on and off antiretroviral therapy (ART) mortality, and mortality from all other causes. Our estimation strategy links the GBD 2015 assessment of all-cause mortality and estimation of incidence and prevalence so that for each draw from the uncertainty distribution all assumptions used in each step are internally consistent. We estimated incidence, prevalence, and death with GBD versions of the Estimation and Projection Package (EPP) and Spectrum software originally developed by the Joint United Nations Programme on HIV/AIDS (UNAIDS). We used an open-source version of EPP and recoded Spectrum for speed, and used updated assumptions from systematic reviews of the literature and GBD demographic data. For countries with high-quality vital registration data, we developed the cohort incidence bias adjustment model to estimate HIV incidence and prevalence largely from the number of deaths caused by HIV recorded in cause-of-death statistics. We corrected these statistics for garbage coding and HIV misclassification. FINDINGS: Global HIV incidence reached its peak in 1997, at 3·3 million new infections (95% uncertainty interval [UI] 3·1-3·4 million). Annual incidence has stayed relatively constant at about 2·6 million per year (range 2·5-2·8 million) since 2005, after a period of fast decline between 1997 and 2005. The number of people living with HIV/AIDS has been steadily increasing and reached 38·8 million (95% UI 37·6-40·4 million) in 2015. At the same time, HIV/AIDS mortality has been declining at a steady pace, from a peak of 1·8 million deaths (95% UI 1·7-1·9 million) in 2005, to 1·2 million deaths (1·1-1·3 million) in 2015. We recorded substantial heterogeneity in the levels and trends of HIV/AIDS across countries. Although many countries have experienced decreases in HIV/AIDS mortality and in annual new infections, other countries have had slowdowns or increases in rates of change in annual new infections. INTERPRETATION: Scale-up of ART and prevention of mother-to-child transmission has been one of the great successes of global health in the past two decades. However, in the past decade, progress in reducing new infections has been slow, development assistance for health devoted to HIV has stagnated, and resources for health in low-income countries have grown slowly. Achievement of the new ambitious goals for HIV enshrined in Sustainable Development Goal 3 and the 90-90-90 UNAIDS targets will be challenging, and will need continued efforts from governments and international agencies in the next 15 years to end AIDS by 2030. Funding: We thank the countless individuals who have contributed to the Global Burden of Disease (GBD) Study 2015 in various capacities. We specifically thank Jeffrey Eaton and John Stover. HW and CJLM received funding for this study from the Bill & Melinda Gates Foundation; the National Institute of Mental Health, National Institutes of Health (NIH; R01MH110163); and the National Institute on Aging, NIH (P30AG047845). LJAR acknowledges the support of Qatar National Research Fund (NPRP 04-924-3-251) who provided the main funding for generating the data provided to the GBD-Institute for Health Metrics and Evaluation effort. BPAQ acknowledges institutional support from PRONABEC (National Program of Scholarship and Educational Loan), provided by the Peruvian government. DB is supported by the Bill & Melinda Gates Foundation (grant number OPP1068048). JDN was supported in his contribution to this work by a Fellowship from Fundacao para a Ciencia e a Tecnologia, Portugal (SFRH/BPD/92934/2013). KD is supported by a Wellcome Trust Fellowship in Public Health and Tropical Medicine (grant number 099876). TF received financial support from the Swiss National Science Foundation (SNSF; project number P300P3-154634). AG acknowledges funding from Sistema Nacional de Investigadores de Panama-SNI. PJ is supported by Wellcome Trust-DBT India Alliance Clinical and Public Health Intermediate Fellowship. MK receives research support from the Academy of Finland, the Swedish Research Council, Alzheimerfonden, Alzheimer's Research & Prevention Foundation, Center for Innovative Medicine (CIMED) at Karolinska Institutet South Campus, AXA Research Fund, Wallenberg Clinical Scholars Award from the Knut och Alice Wallenbergs Foundation, and the Sheika Salama Bint Hamdan Al Nahyan Foundation. AK's work was supported by the Miguel Servet contract financed by the CP13/00150 and PI15/00862 projects, integrated into the National R&D&I and funded by the ISCIII (General Branch Evaluation and Promotion of Health Research), and the European Regional Development Fund (ERDF-FEDER). SML is funded by a National Institute for Health Research (NIHR) Clinician Scientist Fellowship (grant number NIHR/CS/010/014). HJL reports grants from the NIHR, EU Innovative Medicines Initiative, Centre for Strategic & International Studies, and WHO. WM is Program analyst, Population and Development, in the Peru Country Office of the United Nations Population Fund, which does not necessarily endorse this study. For UOM, funding from the German National Cohort Consortium (O1ER1511D) is gratefully acknowledged. KR reports grants from NIHR Oxford Biomedical Research Centre, NIHR Career Development Fellowship, and Oxford Martin School during the conduct of the study. GR acknowledges that work related to this paper has been done on the behalf of the GBD Genitourinary Disease Expert Group supported by the International Society of Nephrology (ISN). ISS reports grants from FAPESP (Brazilian public agency). RSS receives institutional support from Universidad de Ciencias Aplicadas y Ambientales, UDCA, Bogota Colombia. SS receives postdoctoral funding from the Fonds de la recherche en sante du Quebec (FRSQ), including its renewal. RTS was supported in part by grant number PROMETEOII/2015/021 from Generalitat Valenciana and the national grant PI14/00894 from ISCIII-FEDER. PY acknowledges support from Strategic Public Policy Research (HKU7003-SPPR-12).

Introduction: HIV testing is a cornerstone of efforts to combat the HIV epidemic, and testing conducted as part of surveillance sites provides invaluable data on the spread of infection and the effectiveness of campaigns to reduce the transmission of HIV. However, participation rates can be low, and if respondents systematically select into not testing because they know or suspect they are HIV positive (and fear disclosure), prevalence estimates may be biased. We implement Heckman-type selection models which can be used to adjust for missing data which are not missing at random, and establish the extent of selection bias in a population-based study of a hyperendemic community in rural South Africa.\ud - Methods: Using data from residents of the 2009 Africa Centre Surveillance cohort in KwaZulu-Natal, where 5,565\ud women (35%) and 2,567 men (27%) provided blood for an HIV test, we account for missing data using interviewer identity as a selection variable which predicts testing participation but not HIV status. Our approach involves using our selection variable to examine the HIV status of residents who would ordinarily refuse to test, except they were allocated a persuasive interviewer. Our copula model relaxes a key parametric assumption typically used to implement this method.\ud - Results: Our selection model HIV prevalence estimate of 33% (95% CI 27-40) for women compares to 24% from respondents who participated in testing, or 27% using imputation analysis to predict missing data on HIV status. For men, we find 25% HIV prevalence (95% CI 15-35) using the selection model, compared to 16% among those who participated in testing and 18% with imputation. We provide new confidence intervals which correct for the fact that relationship between testing and HIV status is unknown and requires estimation.\ud - Conclusions: We confirm the feasibility and value of adopting selection models to account for missing data in Demographic Surveillance Systems. This approach should be routinely used in HIV prevalence estimation to assess potential selection bias. Elements of survey design, such as interviewer identity, present the opportunity to adopt this approach. Where non-participation is high, confidence intervals are much wider than standard approaches to dealing with missing data suggest.

Background We evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad Juarez (CJ) Mexico during 2008-2010, when harm reduction was expanding in TJ, but not CJ. Methods FSW-IDUs≥18 years reporting recently sharing injection equipment and unprotected sex with clients participated in a randomized factorial trial comparing four brief, single-session combinations of active motivational-interviewing and didactic interventions focused on negotiating safer-sex in the context of drug use and safer-injection skills. The injection intervention included a video made by FSW-IDUs. Women underwent quarterly interviews and testing for HIV, syphilis, gonorrhea, Chlamydia and Trichomonas. Poisson regression with robust variance estimation and repeated measures ordinal logistic regression via GEE examined effects on HIV/STI incidence and receptive needle sharing frequency, respectively. Results Of 599 initially HIV-negative FSW-IDUs (TJ: N=296; CJ: N=303), quarterly retention was≥90%. After 12 months, HIV/STI incidence decreased >50% in the active vs. didactic sex intervention (TJ: AdjRR:0.41, 95%CI: 0.18–0.91, p=0.03; CJ: AdjRR: 0.44, 95%CI: 0.19–0.99, p=0.05)-see tables. In CJ, women receiving active vs. didactic injection risk interventions decreased receptive needle-sharing by 84% vs. 71%, respectively (p=0.05); in TJ, receptive needle-sharing declined by 95%, but was similar in active vs. didactic groups (p=0.54). TJ women reported significant increases in access to syringes and condoms, but CJ women did not-see figure. Conclusion In both cities, a 30-minute intervention promoting safer-sex in the context of drug use significantly reduced HIV/STI incidence with sustained effects at 12 months. Expanding free access to sterile syringes coupled with brief, didactic education on safer injectionwas both necessary and sufficient in achieving dramatic, sustained injection risk reductions in TJ. In the absence of expanding syringe access in CJ, the injection risk intervention still achieved significant, albeit more modest reductions, suggesting that community-level interventions incorporating harm reduction are more powerful than individual-level interventions for reducing injection risks. Figure 1Plot of proportional odds of higher receptive needle sharing for intervention group by visit. Table 1Intervention effects on HIV/STI incidence after 12 months, excluding women who were HIV-positive or had active STIs at enrollment, TiujanaPredictorAdjusted Relative Risk95% CIIntervention Group (ref-Didactic Sex Rick intervention-Diadactic injection Risk intervention)Active Sex Risk Intervention and Didactic Injection Risk Intervention0.410.18, 0.91Active Injection Risk and Didactic Sex Risk Inetevention0.840.38, 1.84Active Sex Risk Intervention+Active Injection Risk Intervention0.360.15, 0.85=of unprotected sex acts with non-regular clients for month poor to enrollment1.011.01, 1.02Anested during the six months poor to enrollment2.611.38, 4.91 Table 2Intervention effects on HIV/STI incidence after 12 months, excluding women who were HIV-positive or had active STIs at enrollment, Ciudad JuarezPredictorAdjusted Relative Risk95% CIIntervention Group (ref-Didactic Sex Rick intervention+Diadactic injection Risk)Active Sex Risk Intervention and Didactic Injection Risk Intervention0.440.19, 0.99Active Injection Risk and Didactic Sex Risk Inetevention1.150.58, 2.28Active Sex Risk Intervention+Active Injection Risk Intervention1.120.56, 2.25Amount earned per unprotected sex act (USD)1.021.00, 1.05Used cocaine the months poor to enrollment1.660.98, 2.80, Background The results of the HPTN 052 study, which showed antiretroviral treatment (ART) is highly effective in reducing HIV transmission, have been hailed as a “game-changer” in the fight against HIV, leading to calls for significant scaling up of treatment-as-prevention (TasP). But it is unclear how TasP could be financed, given flat-lining support for global HIV programs. We assess if TasP is indeed a game-changer against HIV, or if comparable benefits can be obtained at a lower cost by scaling up existing interventions such medical male circumcision (MMC). We also assess the impact of TasP in combination with MMC. Since MMC is currently being scaled up in many countries in sub-Saharan Africa, the effectiveness of TasP in conjunction with MMC is a highly policy-relevant question. Methods We formulate a new mathematical model to overcome challenges in predicting the effectiveness of untried mass interventions (lack of a historical epidemic trajectory) and in predicting the combined effectiveness of different prevention interventions. Our model uses simple behavioral assumptions to estimate new HIV infections instead of estimating parameters by fitting a curve to a disease history. Results For South Africa, a combination of high ART coverage at CD4< 350/ml and circumcision coverage provides approximately the same HIV incidence reduction as TasP (defined as universal ART for all HIV-infected persons) at a cost ~ $5 billion less over 2009–2020. Circumcision outperforms high ART coverage at CD4, Background The Total Control of Epidemic (TCE) Program of Humana People to People aims to reduce spread of HIV and its impact by systematically engaging individuals and communities to take control of their own risk factors, while increasing access to prevention, treatment and support services. Implemented in close partnership with respective Ministries of Health and National AIDS Councils across Sub-Saharan Africa and Asia, TCE has made major impact in HIV control. Methods The TCE model works through two primary strategies: a) Individual HIV Counselling to Prevent New Infections: Every person in target areas was provided with counselling for behaviour change and was assisted to develop individual risk reduction plans. Home-based testing consistent with country guidelines was conducted as an integrated part of the process. b) Community Mobilization to Change Social Norms: To change social norms across the full range of HIV related issues (stigma, discrimination etc.), community-wide mobilization was carried out with local leaders, activists, PLHIV to project them as role models for others along with intensified promotion of existing services. Results Since the first TCE pilot in Zimbabwe in 2000, 11 million people were covered in 11 countries. 28 million individual HIV counselling sessions were delivered. As a result, 2 million people were tested for HIV and received their results. Over 500,000 women attended PMTCT services. More than 600,000 community activists were trained and engaged in community mobilization activities. In Blantyre District of Malawi, 4 times increase of PMTCT utilization within 3 years and in Ehlanzeni District of South Africa, 6 times increase of PMTCT utilization within 4 years after TCE implementation were observed. Conclusion With an average cost of U$ 2/person/year, the TCE model represents a cost effective community-based intervention for HIV control and care with proven results, that should be replicated across the most HIV affected countries., Background Traditional HIV Prevention Programs have not adequately addressed the issues of women in substance abuse recovery. In response, Greenhope Services for Women, Inc developed “Phenomenal Woman”, an HIV prevention program for women recently released from prison and/or mandated to receive residential substance abuse treatment. Methods The target population for “Phenomenal Woman” is African-American and Latina women demonstrating relatively high HIV risk behaviors receiving residential substance abuse treatment at Greenhope. The development of “Phenomenal Women” involved incorporating key components from “SISTA”, other HIV prevention programs, the “Helping Women Recover” curriculum, and newly created components. Formative research including: three focus groups, one key informant interview and two pilot cohorts were conducted to identify and pretest curriculum components and participant retention strategies. Results “Phenomenal Woman” is comprised of 5 group sessions and a booster session held 45 days after program completion. Its primary aims include: enhancing women's sense of self, increasing HIV/STI knowledge, as well as attitudes, self-efficacy, and behaviors related to sexuality, safe and sober sex practices, and spirituality. Utilizing the formative feedback received (n=42 participants), the program creatively uses tangible objects (music, affirmation sheets, and meditation rocks) to reinforce the key messages of strength, resilience, and making healthy decisions regarding safe and sober sex behaviors. The program was implemented with 76 participants with retention rate of 100% across the five initial sessions and 72% at the booster session. Conclusion Greenhope's “Phenomenal Woman” is an example of effectively developing and delivering curricula through the adaptation of evidence-based curricula and the creation of new components to address a target population's needs for HIV prevention and substance abuse relapse prevention. Through high levels of administrative support, participant retention rates were maximized. Accordingly, “Phenomenal Woman” holds considerable promise for dissemination to other agencies with similar target populations., Background Research among transgender persons is rare in Serbia. The emergence of HIV infection led to an increase in stigma and discrimination, but not to an increase in professional interest. Sex work in Serbia is illegal and sex workers are highly discriminated against, especially those of ‘different sexual orientation’. This paper presents research of HIV prevention needs of transgender sex workers in Serbia. The research study is meant to be a baseline study for designing special prevention strategies for this population group. Methods By snowball sampling methodology, 250 sex workers were incorporated into the research study, of those 40 were transgender, 55 male and 155 female. Results A high level of multiple stigmatization and marginalization is the result of a combination of the following characteristics: gender, ethnicity (mainly Roma), very low education levels and high levels of auto-stigma. Moreover there is a statistically significant difference between transgender sex workers and male/female sex workers in terms of being victims of violence much more frequently, perpetrated by their peers, clients, police and citizens. Transgender persons differ also in terms of low levels of prevention knowledge, the presence of misconcepotions about HIV and inadequte assessments of risk to themselves. Clearly, the preventive needs of this group cannot fully be met through programs designed for sex workers in general (such as outreach work, drop-in centers, mobile medical units, etc). Conclusion It is necessary to develop additional preventive strategies, such as:Behavior Change commmunication interventions, which are aimed at increasing self-efficacy, self-confidence which should result in an increase in visibility and affirmation of the transgender identity.raising public awareness about human rights regardless of gender differences.education of health care workers about the needs of this group., Background Initiatives aimed at behaviour change of key populations such as the female sex workers (FSWs) are pivotal in reducing the transmission of HIV. A 5-year implementation research to establish the predictor factors of behaviour change among FSWs in Kenya was initiated by the African Medical Research Foundation (AMREF) with Sida and DfID support, whose follow up results are presented in this paper. Methods This cross-sectional survey interviewed 156 female sex workers (FSWs) identified through snowball sampling. The measurement of behaviour change was based on: the consistent use of condoms with both regular and non regular clients, reduced number of clients, routine checks for STIs, and involvement in alternative income generating activities. The adjusted odds ratios at 95% confidence interval computed during binary logistic regression analysis was used to determine the behaviour change predictor factors. Results Most FSWs (84%) had participated in AMREF's integrated intervention programme for at least one year, with 4.4 years as the average duration. The results indicated that 59.1% had gone through behaviour change during the project's life cycle. The adjusted odds ratio showed that the FSWs with secondary education or more were 2.23 times likely to change behaviour, protestants were 4.61 times, being in sex work for>4 years were 2.36 times, FSWs with good HIV prevention knowledge were 4.37 times, and those engaged in alternative income generating activities were 2.30 times more likely to change their behaviour compared to respective counterparts. Conclusion Behaviour change among FSWs was possible and is associated with the level of education, religious affiliation, number of years in sex work and one's level of HIV prevention knowledge. A re-orientation on the peer education programme to focus on HIV preventive measures beyond use of condoms is emphasized., Background Condom use as a means to prevent HIV infection has significantly increased over the past decade among all age groups in South Africa. However, little is known about what motivates the behaviour in South Africa. This study investigated the prevalence and demographic, psychosocial, and behavioural determinants of condom use among people aged 15 years and older in South Africa who were sexually active over the 12 months prior to the survey. Methods Data from the 2008 national HIV population-based survey was used. This was a cross-sectional survey which was conducted using a multi-stage stratified sampling approach. Univariate analysis and multiple logistic regression were used to identify factors associated with condom use at last sexual intercourse. A total of 5072 respondents, 46.0% males and 54.0% females, who indicated having had sex in the last 12 months were involved in the study. Results Overall, there was no gender difference found in condom use: males (64.6%) vs females (60.4%). The multiple logistic regression analyses indicated that youth aged 15–24 years and students’ learners were more likely to use condoms at last sex. (AOR=2.2528, AOR=2.4358, p< 0.05). Whites, Coloureds and Indians were less likely than Africans to use condoms (AOR=0.2125, AOR=0.3000, AOR=0.4511, p< 0.05). Likewise, married people and those whose current relationships exceeded a year were less likely to use condoms (AOR=0.2782, AOR=0.3239, p=0.00). Finally, having only one regular sexual partner significantly reduces the odds of condom use (AOR=0.2855, p=0.021). Conclusion It is important to understand more about the nuances of condom use so that programmes can target those at greatest risk of infection such as African adults and people in stable relationships, especially those that might also be involved in other risky behaviours such as multiple concurrent sexual relationships., Background Given their epidemiological and socio-ecological differences, urban and rural contexts may require differently designed prevention messages. Utilizing messages framed in terms of the benefits (gains) or costs (losses) associated with a particular HIV/AIDS-related behavior could be one viable strategy to address urban-rural differences. Methods Based on relevant literature, urbanity vs. rurality, experience with HIV testing and concern about and information needs on HIV/AIDS were tested as moderators of framed HIV testing messages’ effectiveness. Gain- vs. loss-framed brochures were distributed to 394 participants (199 Urban: 46.2% male, 53.8% female; 195 Rural: 79% male, 21% female). Through pretest-posttest measures of intention to test for HIV, the relative persuasiveness of gain- and loss-framed messages was determined. Results Urbanity vs. rurality, experience with HIV testing and concern about and information needs on HIV/AIDS significantly moderated the effects of gain- vs. loss-framing on Intention to Test for HIV, F(1, 385)=9.28, p, Background Botswana's HIV prevalence is 17.6% among the general population and the incidence rate is 2.9%. In 2009, Botswana's Tertiary Education Council, recognizing that HIV interventions for College/University (tertiary) students were few/fragmented, conducted a study to understand student behaviours, needs and gaps in services. Born in the 1990s, this generation of youth is the first of its kind-a generation who has grown up with HIV-infected, heavily affected and message-fatigued. Methods Between 2009–2010, TEC conducted a study of 10% of tertiary students using self-administered surveys (N=4312). Classes were randomly selected from 32 institutions and surveys were augmented by 28 post-survey FGDs. Participation was voluntary, anonymous and counselling was offered. Survey questions were qualitative and quantitative. Results 57.0% of participants were female and 63.0% were aged 20–24. HIV knowledge was high (over 90% responded correctly to 9/11 knowledge questions) but satisfaction with current HIV interventions was low (44.9%) and 38.5% said condoms are never available on campus. 82.5% were sexually active and 45.0% had already engaged in unprotected sex. 53.9% knew their HIV status and 49.4% knew their partner′s status. 33.7% reported that they were engaging in MCP. Key findings from the FGDs include: a) campuses are sexualized spaces b) students are involved in transactional relationships c) students do not perceive themselves to be at risk for HIV and d) campus interventions are few and irrelevant. Conclusion Irrespective of increased knowledge and impact from AIDS deaths within their families while they were young children, the sexual practices that gave rise to the current HIV epidemic in Botswana persist among tertiary youth. The study raises serious reservations about the assumption that youth are making behaviour changes. It also exposes gaps in service provision and questions the strength and relevance of current interventions to youth in a country with a staggering incidence rate., Background Cash transfer programs may reduce the risk of HIV transmission among young people from poor households by providing economic security. The Cash Transfer for Orphans and Vulnerable Children (CT-OVC) is the Government of Kenya's flagship social protection program, reaching 150,000 poor families with OVC age 17 or below. Households are provided a flat unconditional cash transfer of US$25 per month. The objective of this study is to assess whether the CT-OVC reduces HIV related behavioral risk among adolescents. Methods We use data from the third wave of the impact evaluation of the CT-OVC collected in 2011. The design is a cluster-randomized trial. 1912 households in seven districts across Kenya were part of wave three; two-thirds were in the program and the remaining third were randomized out at baseline in 2007. Data on sexual behavior and other risk related behaviors were collected in wave 3 only for residents age 15-25. We analyze data for residents age 21 and below who had not had sexual intercourse at baseline (N=1516, Females=41%). We use multivariate analysis with controls for age, sex, Nairobi residence, and relationship to household head. Results Main study findings indicate that the CT-OVC has reduced the probability of sexual debut by 6.73 percentage points off a proportion of 0.37 who had ever had sex after the program began in 2007. This result appears to be driven by males. The program has also reduced the proportion of adolescents with 2 or more partners in the last 12 months, by 7.2 percentage points , and reduced the probability of 2 or more unprotected sex acts in the last 3 months for females (p=0.10). Conclusion A large scale, national cash transfer program may prevent HIV among adolescents by postponing sexual debut, reducing the number of partners and reducing the number of unprotected sex acts.Table 1Main Results Age, Background In South Africa, adolescents are at high HIV risk, yet few prevention interventions have been effective. Parents can play a pivotal role in youths’ healthy sexual development. We tested whether Let's Talk!, a pilot worksite-based parenting program, could improve parent-child communication about HIV and sexual health. Methods A small randomized pilot test was conducted at a large public worksite in Cape Town. The intervention consisted of five weekly two-hour group sessions for parents of children aged 11–15. Sixty-six parents [64% female, mean age 43 years (SD=7), range 23–59] and their 64 children [41% girls; mean age 13 years (SD=1)] completed surveys before and immediately after the intervention; surveys assessed HIV knowledge, comfort with talking about sex, communication about 16 HIV- and sex-related topics (e.g., steps of condom use, how to prevent HIV), and condom use self-efficacy. Thirty-four Black-African (Xhosa-language) and 32 Coloured (mixed-race; Afrikaans-language) parent-child dyads participated. Thirty-four parents were randomized to one of two intervention groups stratified by language, and 32 to one of two control groups. Results Multivariate regressions indicated that the intervention significantly increased parents’ comfort with talking to their child about sex, b(SE)=0.98 (0.39), p=0.02, and the number of sex- and HIV-related topics discussed with their child, b(SE)=3.26(1.12), p=0.005 (Table 1). Compared to control parents, intervention parents were more likely to discuss new sex- and HIV-related topics that had not been discussed before the intervention, b(SE)=2.85(0.80), p< .001. The intervention also significantly increased parents’ self-efficacy for condom use, b(SE)=0.60(0.21), p=0.007, and showed marginally significant effects on parent and child HIV knowledge [b(SE)=0.60(0.32), p=.066, b(SE)=0.85(0.43), p=0.052, respectively].Table 1Effects of Intervention on Parent & Child OutcomesAdjusted CoefficientsIntervention Pre M (SD)Intervention Post M (SD)Control Pre M (SD)Control Post M (SD)Comfort Talking to Child about Sex (Parent)0.98 (0.39), p=.203.39 (1.84)5.01 (1.70)4.07 (2.15)4.32 (1.91)Number of Sex & HIV Topics Discussed (Parent)3.26 (1.12), p=.0057.79 (4.84)12.38 (4.27)8.34 (5.75)9.28 (5.68)Number of New Sex & HIV Topics Discussed Since Baseline (Parent)2.85 (0.80), p, Background There is a general consensus that people with severe mental illness(SMI) are more likely to have a history of childhood sexual abuse and are at increased risk for HIV. For this study, we hypothesized that our homeless, mentally ill participants reporting CSA would be more likely to report current engagement in HIV-risky behaviors, history of STI's, and associated psychopathology than their non-CSA counterparts. Furthermore, we hypothesized that those who had experienced CSA in early to middle childhood (EMCSA) would be more likely to report these challenges than those who had experienced CSA in adolescence (ACSA). Methods As part of a NIH-funded RCT(1R01MH084696-01A2 PI Brady) primary and secondary prevention trial for adults with SMI at-risk for HIV transmission, ninety participants were administered an assessment battery which included the Structured Clinical Interview for DSM-IV, Demographic Inventory, and Timeline Followback. Chi-square analyses were used to test our hypotheses and analyze the relation between our variables of interest. Results There were no significant differences in current HIV-risky behaviors between CSA/non-CSA participants nor for EMCSA/ACSA participants. However, CSA participants were more likely to present with PTSD{χ2(1, 90)=12.95, p, Background The numbers of street children vary from 30,000 to 100,000 in Ukraine. Their vulnerability to health-related risks, including HIV/AIDS, substance and drug abuse, was a subject of the baseline study in 2008. Based on its findings, UNICEF implemented a comprehensive approach to HIV-service delivery in four pilot cities and repeated the survey to assess the effectiveness of interventions in 2011. Methods Behavioral survey among street-based adolescents (N=805, age 10–19, 565 boys, 240 girls) was conducted using location-based network and convenience sampling. Data were disaggregated by age and gender. Comparative data analysis was applied to learn the behavioral and knowledge changes. The client satisfaction questionnaire was used to define the service access barriers. Results Street adolescents are highly vulnerable to HIV-infection: 22% injected drugs, 65% of girls provided commercial sex services; 7% of boys had sex with men; only 13% always used condom with casual sexual partners. Social vulnerability factors hinder access to medical and social services: two-thirds of respondents didn't have a permanent place of residence and were not covered by medical services. 46% didn't have an ID, 54% didn't have an education certificate. The piloted interventions caused the positive behavioral change and knowledge increase: a share of those, who correctly identified the ways of HIV transmission, has increased for 10%; a share of those, who were tested for HIV during the last year and received the result, has almost doubled. The biggest increase in HIV-testing is among girls: every sixth tested in 2008, every third in 2011. Conclusion Study confirmed effectiveness and sustainability of implemented interventions and suggested a roll-out-strategy to the country. This is of critical importance as a significant number of street children remains uncovered by services and has a low level of knowledge about HIV/AIDS, HIV-service organizations and places, where support is provided and testing is available., Background This study investigated how gender, multicultural and multi-religious factors influenced the teaching and learning of HIV/AIDS education. Methods The qualitative case study utilised 6 primary schools from Kakuma Refugee Camp and its host community. The sample had 617 respondents from 9 nationalities, including 356 male and 160 female pupils. Interviews, observation, FGDs, documentary analysis and drawings generated data. The research proposal and tools underwent ethical review. Results Cultural and religious tendencies of same gender clustering denied Muslim Somali pupils an opportunity to work together as partners in addressing pertinent and effective strategies in HIV/AIDS education. Unlike the Christian Turkana and Ugandan girls who seemed open and outgoing in HIV/AIDS education activities, Somali and Ethiopian Muslim girls remained quiet, reserved and shy as a way of showing respect to the male, a behaviour that jeopardised HIV/AIDS education. Christian Sudanese and Turkana boys and girls interacted more freely, hence learnt better. Gender influenced perceptions of pupils on HIV/AIDS education content and pedagogy. While boys seemed vocal, uncontrolled and eager to discuss sex and condoms, girls preferred discussing love and care of people living with HIV/AIDS. Refugee boys produced culturally and linguistically diverse resource materials that were easily understood across the cultural groups while portraying males as innocent victims and females as potentially responsible for the spread of HIV. Notably, pupils received different and conflicting messages on similar topics depending on the teacher's religious background. While older teachers were perceived as ‘parents’, young male teachers were seen as having a hidden ‘sex agenda’. Conclusion In conclusion, gender, culture and religion, influence the learning of HIV/AIDS education in refugee schools in a complex manner, which if not understood and controlled could have negative implications. The study recommends pre-service multicultural teacher education and training on how to make HIV/AIDS education gender-responsive., Background From 2005, the Québec Ministry of Education cut what was five (5) hours of sex education (STIs, HIV/AIDS, gender, sexual diversity, etc.) per year from the secondary school curriculum. Consequently, in the context of the education reform, teachers holding specializations in English and Art, Science & Technology and Moral and Religious Education were persuaded to integrate sexuality in their course. Methods Being highly sexualized sites, high schools act as a channel for sexual initiation and exploration. Thus, teachers can be catalysts to providing valuable and life altering information around HIV/AIDS to their students. Through a qualitative case study, teacher narratives were collected to identify their classroom structure; strategies; awareness of HIV/AIDS; and the challenges encountered when discussing the subject in their classroom. Overall, implicating communication processes were an essential factor in uncovering the subtle, yet, uncomfortable silences found in this study. Results The surface-level understanding around HIV/AIDS and a lack of consistent training and access to accurate resources identified how teachers understood and valued HIV/AIDS information. Ultimately, such familiarity corresponded to how their students comprehended the virus and viewed the marginalized communities most affected. Conclusion Theoretical frameworks connected to Paulo Freire's Engaged Pedagogy and Nel Noddings's Pedagogy of Care, were considered as tools for empowering teachers when imparting knowledge on HIV/AIDS., Background School-based, teacher led Sexuality Education (SE) is effective in promoting and protecting young people's sexual health. In sub-Saharan Africa, much of SE is provided through school-based, teacher-led programmes. The aim of this study was to find out what topics in Comprehensive Sexuality Education (CSE) were acceptable and not acceptable to the teachers. Methods This study was part of an assessment of the status of Sexual and Reproductive Health and Rights in three regions (Tanga, Singida and Iringa) in Tanzania. Respondents were purposively obtained from 6 purposively selected primary and secondary schools in three purposively selected wards. A total of 45 teachers participated in Focus Group Discussions and Group Interviews. Data were analyzed using Nvivo software. Results Six topics in CSE were consistently rejected by teachers. These are homosexuality, masturbation as an alternative to sexual intercourse, condom use, sexual pleasure and enjoyment, sexual behavours other than intercourse and appropriate and inappropriate touching. Three major reasons were given to why they rejected these topics. First, they explained that if students are taught about these topics, they may practice them and that would fuel sexual activity among them. Second, since they have to teach practically, teachers explained that demonstrating these topics would be an embarrassment to them and to the students. Third, they reported that these topics are against sexual norms of the communities where they (teachers) and students come from. Conclusion With these findings, it is important to rethink the position of teachers in the delivery of CSE. Being “teachers” does not exclude individuals from abiding by sexual norms of their community. The rejection of these topics indicates that teachers still adhere to sexual norms of their communities. In order to strengthen CSE programmes, programmes need to work on sexual norms that may hinder the delivery and success of CSE in schools., Background Coastal people of Tanzania practice a rite of passage (unyago) for girls when they enter puberty (wali). Unyago is conducted by respected, mature women (manyakanga) who use local art forms and idioms to address family life and sex education. Unyago is sometimes faulted for encouraging early sex, teenage marriage, early child-bearing, and multiple concurrent partnerships (MCP). Methods We conducted a participatory learning-and-action exercise with manyakanga in the Coast region. We assessed: 1) manyakanga's knowledge of SRH and 2) manyakanga′s potential to serve as promoters of SRH. In 2011, 28 manyakanga (who were involved in small-scale pilot activities since 2008; about 50% of the manyakanga at the program sites) received a five-day training. PAYODE (a community-based organization) conducted eight monthly forums, and FHI 360 provided 28 person-days of on-site technical assistance. Results Training improved manyakanga's knowledge of SRH.Pre-training testPost-training test Score Persons Score Persons Difference (+/−) 100%4100%12+8>50%17>50%14−3, Background Interpersonal communication has been implicated as a key factor in HIV declines in Zimbabwe (Halperin et al., 2011), but little is known about the social networks through which it might have taken place. In the quantitative component of a World Bank sponsored study, Gregson (2012) found associations between community group memberships and HIV avoidance. Our qualitative component elaborates on these findings through mapping out possible psycho-social pathways between group participation and more effective community responses to HIV/AIDS. Methods We used Nhamo's (2010) conceptualisation of the ‘HIV competent community' to frame thematic analysis of the Manicaland Project's qualitative dataset. 481 people participated in 30 children's draw-and-write, 100 interviews and 55 focus groups exploring local responses to HIV/AIDS. These included people on ART; healthcare workers; workers; community group members; sex workers and clients; and participants in cash transfers, home-based care, support groups and peer education. Results Community group memberships are often associated with lower HIV incidence amongst women, and higher incidence amongst men. Group memberships impact directly through facilitating or hindering healthy behaviours, and indirectly through impacting service access, and the effects of peer education, home-based care and cash transfers. Gendered group communication styles often make women more likely to engage in positive health-related dialogue, and to entrench macho stereotypes and health-damaging behaviours in men, although this is not always the case. Conclusion Growing evidence suggests indigenous community groups could become a useful focus for enhanced HIV/AIDS prevention, care, treatment and impact mitigation. Efforts might focus on enhancing the beneficial effects of groups (mostly on women) and limiting their damaging effects on men. Parallel efforts should facilitate contexts that are supportive of beneficial group effects, including a wider comprehensive response with empowering support from funders and community partnerships with supportive service providers., Background In Western Uganda, high HIV prevalence, poverty, and abuse/exploitation threaten children's wellbeing and can contribute to high HIV transmission risk for vulnerable children. A comprehensive approach is needed to address the key drivers of vulnerability and improve child welfare for highly vulnerable children. World Education (WEI)'s Western Uganda Bantwana Program (WUBP) builds the capacity of nine community-based organizations (CBOs) to provide comprehensive services and referrals strengthening to 3,100 vulnerable children and their families to improve child welfare. Methods Using the following methods, Bantwana and local partners gathered evidence suggesting that an integrated package of psychosocial support (PSS), livelihoods, and child protection (CP) interventions can effectively contribute to reducing child vulnerability and improve children's overall wellbeing: Child profiling baseline and follow-on survey: of 132 children, measuring child wellbeing across a range of internationally accepted vulnerability indicators;CP case study: focus group discussions with districts, children, schools, and other protection stakeholders to assess school and community child protection interventions;PSS assessment: interviews/focus group discussions with volunteers, caregivers, CBO partners and children, exploring effects of a household approach to PSS on child wellbeing; andQualitative evaluation study (with Columbia University): of 247 households, to determine benefits of livelihoods/protection interventions on child wellbeing. Results Preliminary results from the Columbia study suggest that an integrated protection/livelihood intervention can improve outcomes in child wellbeing. The CP case study and PSS assessments reveal that strengthening linkages among CP stakeholders (school, community, government and household)—improves child protection outcomes, while the child profiling survey reinforces the importance of a household approach. Conclusion Preliminary evidence suggests that an integrated package of PSS, livelihoods, and CP intervention may reduce vulnerability and improve child wellbeing which could have implications for HIV prevention approaches for vulnerable children in regions with high HIV prevalence., Background The Center of Excellence for Transgender Health (CoE) has been mobilizing transgender (trans) community throughout the United States utilizing a coalition building approach since 2007. The CoE along with its National Advisory Board (NAB) has identified and supported community leaders, health departments and key stakeholders in engaging the transgender community, identifying gaps and developing strategies for addressing identified unmet needs in the U.S. The CoE supports local community efforts in organizing conferences, symposiums, and summits that are focused on transgender specific health and well being. Methods In the CATCH model, with support from staff of the CoE, local coalitions guide the community mobilization process and lead data collection and analysis efforts, prioritize HIV prevention and health care needs, develop a comprehensive plan to strengthen community access to and utilization of HIV prevention and health care services, and decide how to evaluate these efforts. Results Community mobilization is a very empowering process that can provide participants with a sense of control, self esteem, self determination and increased capacity for changing systems to be transgender inclusive.Both providers and community members are able to create meaningful, sustainable linkages for capacity building and increasing access to services.Social networks created through CATCH are sustainable and increasingly multiplying.CATCH is a groundbreaking national network that ensures that community members have a voice in the transgender HIV and human rights movement through a coordinated effort. Conclusion CATCH increases transgender community capacity to access services by supporting advocacy efforts, creating networking opportunities, and increasing visibility of trans HIV prevention and health care needs., Background The dilemma of infant feeding in HIV context of poor resource setting remains unresolved and the practice of replacement feeding may happen to be a curse by lowering child survival. Appropriate infant feeding counseling can reverse such risk as well as limiting spill-over (WHO, 2010.) Objective to describe infant feeding intents of HIV positive women and determine the appropriateness of choice of those opting for formula-feeding after the counseling process. Methods Routine infant feeding counseling of HIV positive mother offered by short-course trained counselors during the pregnancy or in the early-post partum. Intents were assessed using a generic acceptable, feasible, affordable sustainable, secure (AFASS) score composed of 7 variables grading from 0 to 2:type of energy, source of water, kind of latrines, disclosure to the partner, monthly income, ability to prepare bottle feeding and to give a reason for non breastfeeding. An AFASS score above 10/14 was considered as appropriate for formula feeding. Results 950 women were included for cohort characteristic. Among 924 women counseled, 63% intended to formula feed their babies while 37% planned to breastfeed. The AFASS criteria>10 was met by 87% who intent to practice formula-feeding compared to 57% of those who intent to breastfeed. Women counseled during post-partum were more likely than others to opt for artificial feeding (p< 0.001). Formula-feeding choice was more appropriate in women counseled during pregnancy vs after delivery (p=0.02). The determinants of choosing replacement feeding were tertiary education (p< 0.001), no previous exclusive-breastfeeding, HIV-status disclosure (p< 0.001) and AFASS score>10 (OR: 5; 95% CI: 3–6). Conclusion in Djoungolo, after infant feeding counseling, replacement feeding intent is mostly appropriate fitting mother's environment and livelihood. In addition, the desire to breastfeed remains real as more than 1/2 women who choose to breastfeed met the conditions to practice formula feeding., Background Although evidence reveals that most heterosexual HIV transmission in sub-Saharan Africa takes place within marriage or cohabitation, approaches for people living with HIV (PLHIV) focus primarily on individuals. The Faithful House (TFH) is a couples-based, skills-building curriculum used with 45,000 couples in twelve countries, recently modified to address PLHIV issues. Research examined the effect of TFH on attitudes and behaviors to provide evidence for a couples-based approach for more holistic PLHIV programming. Methods Participants, using convenience sampling, from HIV programs in four regions of Ethiopia were randomly distributed between intervention and control groups. The intervention group participated in TFH workshop for PLHIV. Both groups completed surveys at baseline and three months post-intervention which was analyzed using STATA. Results The study surveyed 378 individuals with a mean age of 35.2. Most couples (88%) were either married or cohabitating. All participants had been tested for HIV with 90% testing positive. Intervention participants (193) reported significant changes (p< 0.01) in the quality of their relationship, including improved communication and joint decision-making about child care, finances and sexual negotiation. Intervention participants had statistically significant improvements in medication adherence (18% non-adherent at baseline versus 10% at three-months) and percentage diagnosed with sexually transmitted infections in the past three months (7.3% decreased to 4.7%). Of males with pregnant partners, 94% in the intervention group attended antenatal care visits compared with 36% in the control. Intervention participants also reported statistically significant decreases (p, Background As part of a government-sponsored pilot initiative of ‘treatment as prevention’, recent efforts have been made to improve access to HIV prevention and care, including HIV testing, to vulnerable sub-populations in Vancouver, Canada. This study assessed the association between geographic factors measuring access to HIV testing sites and having a recent HIV test among hidden street- and off-street sex workers(SWs) in Vancouver. Methods Baseline data were used, including an interviewer-administered questionnaire, HIV/STI testing and geographic location data, from an open prospective cohort of SWs recruited in 2010 in Metropolitan Vancouver (“An Evaluation of Sex Workers’ Health Access”[AESHA]). Access was measured by density of testing sites within a catchment surrounding SWs’ place of solicitation (radius=distance travelled in 15 minutes of combined bus/walking) and time to travel to nearest testing site. Bivariate and multivariable logistic regression was used to identify if density and time were independently associated with recent HIV testing (in the last year). Adjusted odds ratios and 95% confidence intervals were reported (AOR:[95% CIs]). Results In total, 291 seronegative SWs from Vancouver City were included, with 69.4% (202) reporting a recent HIV test. In bivariate analysis, having a recent HIV test was significantly associated with a higher density of testing sites (p< 0.001) and time to nearest testing site (p=0.05). After adjusting for key confounders (recent injection drug use, age and sexual identity), having a recent HIV test was significantly associated with increased density of HIV testing sites: the probability of having a recent HIV test increased by 2% for each increase in one testing site (1.02[1.01–1.04]). Conclusion Our results highlight the importance of physical availability of HIV testing sites within sex work environments to facilitate use of HIV prevention and care among SWs. Increased mobile and safer-environment interventions that facilitate access to voluntary and confidential HIV testing at outdoor and indoor sex work venues remain a critical priority., Background HIV/AIDS is a leading cause of death for African-American women in the United States between the ages of 25 and 34 years. Studies have suggested that HIV-related stigma impacts morbidity and mortality rates because it contributes to poor treatment utilization for various groups of people with HIV. Despite these findings, there are no intervention studies investigating stigma reduction strategies for African-American women living with HIV. Methods We implemented an adapted version of the International Center for Research on Women's HIV Stigma Toolkit for African-American women living with HIV, with intervention modules led by an African-American woman living with HIV. Twenty-four participants attended workshop sessions split across 2 weekday afternoons, discussed issues “triggered” by videos that were produced specifically for the intervention, learned stigma reducing mechanisms from each other, and practiced using these mechanisms in role plays. Participants completed a measure of internalized stigma before, immediately after, and 1-week after workshop participation. Results The intervention demonstrated feasibility and the women enthusiastically accepted the intervention. The women reported decreased stigma from the start of the workshop to immediately after (p=0.05) and 1 week after workshop participation (p=0.07). Conclusion Findings suggest that the Unity workshop holds promise for reducing internalized stigma for African-American women living with HIV., Background This study examined the effectiveness of psycho-education in Family-to-Family Project on family relationship and emotional quotient (EQ) of adolescents in HIV families in two representative provinces in Thailand, Chiangrai and Nakorn Ratchasima. The intervention included core elements identified by Thai Ministry of Public Health and University of California, Los Angles, USA for improving physical and mental health, family relationship, and social outcomes for HIV-affected families. Methods The sample consisted of 194 adolescents (aged 12–17 years) in 402 HIV-affected families. A randomized controlled trial with pre-test and post-test was performed during December 2006 - January 2009. Adolescents were randomly assigned into 2 groups: (a) adolescents whose parent and caregiver(s) attended psycho-education and (b) adolescents whose parent and caregiver(s) did not attend psycho-education. The instrument was a set of questionnaire including: family relationship and EQ. Data were collected prior to the beginning of the program, and at 24-month follow-up. They were analyzed using t-test and logistic regression statistics. Results The study findings suggested, when controlled sex, age and education, family relationship and EQ of adolescents before and after the intervention in each group did not vary significantly. Family relationship had significantly positive relationship with EQ on the “happy” subscale [adjusted Odds Ratio (OR)=12.03, 95% Confidence Interval(CI)=3.21–45.02] and total EQ [adjusted OR=9.57, 95% CI=2.28–40.17]. However, it did not relate to EQ on the “good” subscale [adjusted OR=3.13, 95% CI=0.57–17.12] or the “competence” subscale [adjusted OR=1.41, 95% CI=0.158–12.57]. Conclusion Family relationship is a protective asset in happiness and total EQ of adolescents in HIV-affected families. However, larger and robust trials are needed to further determine the effectiveness of psycho-education for Thai HIV families. This study was funded by the National Institute of Nursing Research (grant NINR R01-NR009922)., Background Mental disorders are highly prevalent among individuals with HIV and are consistently associated with negative health outcomes. These disorders are often not adequately treated due to significant individual and community level barriers. Innovative approaches are needed to engage and effectively treat mental health problems among individuals with HIV. Methods The NIH-funded Collaborative HIV/AIDS Mental Health Program (CHAMP) assessed the feasibility and preliminary outcomes associated with providing 9 months of in-home mental health counseling for 40 individuals with HIV and a Major Axis I mental disorder living in Mecklenburg County North Carolina. The CHAMP treatment was guided by the HIV/AIDS Illness Management and Recovery Model (HAIMR), which was adapted from the evidence-based Illness Management and Recovery treatment model using a Community Based Participatory Research approach. Study participants were surveyed at baseline, 5 and 9 months to assess psychiatric symptoms (using the Brief Symptom Inventory (BSI)), social support, coping, and medication adherence. Results The CHAMP study participants were reflective of the HIV population in the region with respect to race (80% African-American) and gender (35% female).DEMOGRAPHIC CHARACTERISTICS Female35% African-American80% Average Age43.1 Less than High School Education28%PROBABLE MENTAL DISORDERS (Mini-International Neuropsychiatric Interview (MINI)) Depression55% Bipolar30% PTSD38%Baseline Characteristics of Study Subjects (N=40). Statistically significant decreases in the global BSI score and a number of BSI symptoms dimensions including anxiety, depression, obsessive compulsive, and hostility were detected. The sample means for anxiety, hostility, and phobia dropped below the BSI clinical significance level and the proportion of participants meeting the BSI case definition based on having a BSI Global Score of 63 or above decreased from 85% of participants to 54% of participants (p=.018). Statistically significant improvement was also found for the SF-12 mental health scale, adaptive coping, overall social support and emotional support. Baseline Survey (prior to treatment entry) Survey at 9 months (after treatment completion); **p, Background Perceived racial (PRD) and gender discrimination (PGD) relate to poorer health in African American (AA) women (Kreiger, 1990; Borell et al., 2006). Critical consciousness (CC), the awareness of social oppression, has been found to moderate the effects of discrimination stress (Kelso et al., submitted 2012). The present study explored PRD, PGD, and CC in AA women, examining their relationships to age, education, employment, and HIV status. Methods Participants were 98 AA women (73 HIV-positive, 25 HIV-negative) from the Chicago Women's Interagency HIV Study. Table 1 displays demographic information. Self-report questionnaires measured CC and its dimensions Power Discontent, Rejection of System Legitimacy (RSL), and Belief in the Need for Social Change (BNSC) on behalf of AAs, and PGD, and PRD. Pearson correlations examined age, education, employment and HIV status in relation to CC. Partial correlations examined CC in relation to PGD and PRD. T-tests examined HIV status differences in PGD, PRD, and CC. Variable Age Education Employment Identification with Women.04.19.30**Identification with African Americans.06.15.24*Power Discontent.10.21*.20*Rejection of System Legitimacy.25*.22*.17Belief in need for social change on behalf of African Americans.03.26*.27**Total Critical Consciousness.17.29**.25*Perceived Gender Discrimination.23*.04.17Perceived Racial Discrimination.22*−.20−.14*Note. p, Background Human rights approaches to managing HIV globally offer hope to vulnerable persons living with HIV (PLHIV), but structural challenges impede achievement of this goal. Little is known about the relationship between structural challenges and health promoting behavior among PLHIV. Our purpose was to describe associations between national level democracy ranking, HIV criminalization, perceived social capital, and antiretroviral therapy (ART) adherence among an international sample of PLHIV. Methods We recruited PLHIV at 16 sites in Canada, China, Namibia, Thailand, and the United States. Participants (n=2,149) completed a cross-sectional survey of demographics, social capital, and ART adherence. Data were collected between August, 2009 and March, 2012. HIV criminalization was assessed by reviewing site specific state/provincial or national laws and policies. Five aspects of a country's democracy and freedom were obtained from the World Audit (www.worldaudit.org) international database. Data analysis included descriptive statistics, correlational and regression analyses. Results Participants were primarily male (68%) with an average age of approximately 47 years. Overall, mean 3-day self-reported ART adherence was 82.6%. Strong associations were observed between medication adherence and overall democracy ranking (0.66, p< 0.01) and degree of limitation to political rights (−0.68, p< 0.01). In the final model, overall democracy ranking; HIV criminalization (e.g., HIV specific enhancements for other crimes, HIV reporting laws), and number of HIV-related prosecutions; and total social capital score were significantly associated with self-reported ART adherence after controlling for site, gender, age, time since HIV diagnosis, and adherence self-efficacy (F=132.05, p< 0.01, adjusted R 2=0.56). Conclusion Our results demonstrate the interconnectedness of the political, social and biomedical spheres in addressing PLHIV health care needs. Decontextualized biomedical advances and models of intervention efficacy are insufficient for future HIV management. Our results provide evidence for the importance of using intersectoral human rights based approaches to the management of HIV and its intersecting vulnerabilities globally., Background Across sub-Saharan Africa, the HIV pandemic has orphaned millions of children. Evidence from high-income settings on complicated grief, which precipitates psychologically and medically debilitating symptoms, is growing. However research on how orphans in rural Africa cope with their loss remains scarce. We report on prevalence and predictors of complicated grief among a rural Zambian cohort. Methods 376 rural Zambian orphans 10-18 years, (46.3%=female, 44.1%=orphaned by AIDS) were interviewed five times. Respondents were included if they had lost their parent(s) at least two years prior to the final survey. Validated scales from Western settings were translated and culturally adapted. Complicated grief was defined as experiencing above average levels of grief symptoms in the last four weeks. Cross-sectional data assessed prevalence of complicated grief and tested multiple regression models. Bootstrapping supported robust regression coefficients estimates. Results Approximately one-third (30.3%; n=114) of these orphans reported complicated grief symptoms. Independent predictors (p< 0.05) included peer bullying, daily stress (e.g. excessive household chores, looking after ill family) poor primary-caregiver relations, within household discrimination, number of primary caregiver losses, and time since loss. Together these explain a fifth of the grief found two or more years after parental death ( Radj2 =0.21). Other theoretical predictors of complicated grief including age, sex, sudden or violent death, living with the deceased parent or experiencing their prolonged illness prior to death were not associated. Expected comorbidities with depression, suicidal thoughts, PTSD, and functional impairment in everyday tasks were confirmed, underscoring construct validity. Conclusion One-third of orphans exhibit debilitating grief two or more years after parent death. While these data highlight the centrality of community-based initiatives that sensitise caregivers of orphans to alleviate stigma and discrimination, additional research on children with complicated grief suggests benefits from more focussed interventions. Screening tools and effective counselling interventions adapted for this rural African population are urgently needed., Background There is mixed evidence on the association between HIV prevalence and poverty, but an increasing number of studies have found a positive association between HIV prevalence and income inequality, especially among countries with generalized epidemics. Less is known about the association between income inequality and HIV prevalence in concentrated epidemics, such as among injection drug users in Vietnam, or whether this association holds at the community level. Methods 1674 male IDUs, and 1349 community members (40% male) living in physical proximity, were recruited throughout Thai Nguyen. Both IDUs and community members completed cross-sectional surveys. IDUs were tested for HIV. The GINI coefficient for income inequality was calculated for each commune from the self-reported incomes of non-IDU community members. Scatterplots of the communes were then constructed to compare community-level income inequality and HIV prevalence among IDU. Results The HIV prevalence among IDU in 32 communes in Thai Nguyen is 31.2% (4.3%–63.6%). There is a statistically significant positive correlation of 0.59 (p, Background A controversial aspect of HIV/AIDS epidemiology has been whether it is relative wealth or relative poverty that is a key driver of the epidemic in sub-Saharan Africa. We hypothesised that the social epidemiology of HIV in Africa is changing from a situation where more new infections are acquired by those of relatively high socioeconomic position (SEP), to one where those of relatively low SEP are at greater risk. We suggested this pattern is compatible with the inverse equity hypothesis from child heath that suggests those of higher socioeconomic position benefit first from new health interventions. Methods We analysed Demographic and Health Survey (DHS) data from sub-Saharan African countries with two surveys measuring HIV prevalence or with a second expected in the next two years. We inspected the pattern of HIV prevalence by SEP, indicated by education status. In the countries with two surveys we calculated the percentage risk difference for HIV prevalence stratified by education and sex. Results Data were available for eleven countries: four with two surveys and seven expecting a second survey within two years. In the first/only survey, higher SEP is broadly associated with higher HIV prevalence. In countries with two surveys, HIV prevalence has risen in the no education group in all cases except among women from Lesotho, and fallen among those with secondary education in all cases except women from Malawi. Conclusion Available evidence strongly suggests that in the early phase of the epidemic HIV infections were concentrated among those of higher SEP. Our analysis supports the inverse equity hypothesis that new infections will increasingly concentrate in people of lower SEP because of lower access to public health interventions. Data that will be available within the next two years will further test this hypothesis. The inverse equity hypothesis has important implications for policy and resource allocation., Background Swaziland has the highest HIV prevalence in the world. Many Swazis are chronically food insecure. Globally and within southern Africa, food insecurity has been linked to high-risk sexual behaviors, difficulty with antiretroviral (ARV) adherence, higher rates of mother-to-child transmission, and more rapid HIV progression. Methods In-depth interviews were conducted with 20 HIV+ female sex workers (SWs) in Swaziland. Interviews took place in four different regions of the country, and were designed to learn about context, experiences, and health service needs amongst Swazi sex workers. Interviews were coded in Atlas.ti. Results Hunger was a consistent, major theme in our informants' lives. Women cited their own hunger or that of their children as the impetus to begin sex work, and as a primary force in continuing to sell sex. Nearly all informants requested food-related services (parcels, grants, or education) when asked about desired programming. Good nutrition and the ability to eat “healthy” or ”balanced“ foods was seen as an important means of controlling HIV disease progression. Informants discussed difficulty in adhering to ARVs when faced with taking pills on an empty stomach. Across interviews, discussions of CD4 counts and ARV adherence intertwined with discussions of poverty, hunger and healthy foods. Food security and food sharing were also seen as important expressions of social networks, which many SWs felt they had trouble accessing as a result of both their HIV status and profession. Conclusion Informants described a risk cycle of hunger driving sex work driving HIV infection. The two latter in turn drive an increased need for ‘healthy foods' and an alienation from social networks which offer material and emotional support against hunger. Poverty and food security are concrete, vital issues in the lives of SWs living with HIV in Swaziland, issues that cannot be ignored when conceptualizing risk or designing services., Background Despite recent efforts to increase HIV testing in sub-Saharan Africa, poor testing availability and limited uptake in refugee populations persists. Refugees require additional focused efforts because many have suffered human rights violations putting them at increased HIV- risk. Our objective was to qualitatively study refugees' utilization of services in a refugee settlement where HIV/AIDS services are available. Methods Open-ended interviews were conducted with HIV-infected refugees living in Nakivale Refugee Settlement in southwest Uganda. Interviews focused on: (1) accessibility of HIV/AIDS-related testing and care; (2) experiences of ART adherence; and (3) perspectives on how to improve access to testing and care, adherence, and retention. Data were collected at the Nakivale HIV/AIDS Clinic from March to July of 2011 and included patient (N=73) and staff (N=4) interviews, and observations of clinical activities. For this analysis, category construction methods were used to analyze the data relating to HIV testing. Results Refugees, because of competing daily hardships, do not prioritize HIV testing. Refugees living with HIV/AIDS often present to clinic for testing and initial evaluation with very advanced disease. Reported barriers to HIV testing for Nakivale refugees reflected in the data include: difficulty physically accessing testing facilities; fear of stigma associated with HIV+ diagnosis; low self-perceived risk of disease, and lack of knowledge regarding the potential benefits of medical therapy. Given the competing priorities for survival, HIV tests are not obtained until special circumstances lead to temporary priority shifting. Conclusion Understanding how HIV testing fits among the survival priorities of refugees will help in designing effective interventions. To increase HIV testing for refugees, efforts should aim to intervene in the survival cycle to encourage priority-shifting. Intervention approaches may include improving accessibility, providing incentives and increasing HIV-related education., Background There is paucity of published data on ways in which HIV in children receiving Highly Active Antiretroviral Therapy (HAART) impacts other children living within the same households. We investigated the psychosocial impact of HIV on the siblings of HIV infected children. Methods Data were collected using pre-tested interviewer administered questionnaires and focus group discussions. Twelve 12 HIV treatment sites which account for over 90% of children receiving HAART in Botswana participated. HIV affected children were defined as those aged 6-18 years who were living in the same household as documented HIV-infected children. Ethical approval was obtained from the Botswana Ministry of Health and Baylor College of Medicine. Results Of the 258 HIV affected children, 251 (97.3%) were attending school; 206 (79.8%) and 52 (20.2%) had been fully or partially disclosed to respectively. 153 (59.3%) were siblings of the HIV-infected children, 79 (30.6%) were cousins and 26 (10%) were related in other ways. 223 (86.4%) had lived together with the HIV-infected children for longer than 5 years. 11 (4.3%) said that living with an HIV-infected child made them feel different because of stigma, playing caregiver roles, fear of contracting HIV, and feeling sad. 65 (25.4%) faced various problems, including: worrying about the HIV infected child; receiving less attention from caregivers; and experiencing stress due to adherence-related issues, stigma, and family disharmony. They coped by crying, talking to an adult relative, talking to the HIV-infected child or isolating themselves from others. 230 (89%) felt sad or scared/anxious whenever the HIV-infected child was sick. 254 (98.4%) reported playing caregiver roles, such as reminding or giving medications to the infected children. Conclusion Although HIV affected children are not the prime targets of paediatric HIV interventions, they face many psychosocial challenges. Programs and policies aimed at ameliorating the impact of HIV should take these findings into account., Background The last century's economic and political upheavals are widely believed to have reduced African and particularly South African families' cohesion and ability to function collectively. AIDS has compounded this threat to the resilience of households and wider family networks. We explore the resilience of families to AIDS and demonstrate that theories of social capital, family obligation and reciprocity can help to explain access to familial support in rural KwaZulu-Natal, South Africa. Methods Data were collected over a 7-month period from a small sample of households dealing with AIDS illness or death using in-depth interviews and participant observation. Retrospective and prospective data about households' experiences were analysed using framework analysis and the development of household case studies for comparisons. Results Affected households and individuals drew on family relationships for financial and material support and physical care. Close family members, often sharing a common sense of home and family, were the most important source of care and support. Their greatest motivation was a strong moral obligation to family, associated with norms of familial assistance. Support from other family varied depending on whether levels of mutual trust, investment in social capital and physical proximity, enabled negotiated reciprocal exchange. Families suffering from conflicting obligations, conflict, severe poverty or extreme illness were more likely to be excluded from these networks and suffered because of their inability to secure familial support. Conclusion Despite examples of exclusion, we demonstrate that social capital, reciprocity and a sense of family obligation persist in families responding to the impacts of AIDS, contributing to them maintaining cohesion, collective functioning and ultimately ensuring their resilience. Interventions to support the treatment, care and well-being of sick individuals need the flexibility to be able to both support families in their efforts to provide these services and address the needs of people without access to supportive family networks., Background Black men who have sex with men (BMSM) have the highest rates of HIV in the United States. Despite increased attention to social and sexual networks as a framework for biomedical intervention, the role of family in these networks and their relationship to HIV prevention has received limited attention. Methods A network sample of BMSM and their family members (N=380) was generated through respondent driven sampling of BMSM and elicitation of their personal networks. The proportion of personal networks that were family was calculated and weighted logistic regression was used to assess the relationship between this proportion and unprotected anal intercourse (UAI), sex-drug use (SDU) and group sex (GS); as well as intravention efforts to discourage these risk behaviors among their MSM social networks. Results 45.3% of respondents listed at least one family member in their close personal network. Greater family network proportion (having 2 or more family members in the close network) was associated with less SDU [adjusted odds ratio (AOR 0.38(0.17–0.87))] and participation in GS (AOR 0.25(0.10–0.67)). For intravention, BMSM with greater family proportion were more likely to discourage GS (AOR 3.83(1.56–9.43)) and SDU (AOR 2.18(1.35–3.54)) among their MSM friend network. Moreover, increased male family network proportion was associated with lower HIV-risk and greater intravention than increased female network proportion. Network Proportion* N(%) UAI AOR (95% CI) Sex-drug use AOR (95% CI) Group Sex AOR (95% CI) Discourages UAI AOR (95% CI) Discourages sex-drug use AOR (95% CI) Discourages group sex AOR (95% CI) Family Network (%) 0%111 (54.7)refrefrefrefrefref20–39%40 (19.7)1.48 (0.67–3.27)0.51 (0.24–1.05)†0.51 (0.14–1.84)1.05 (0.34–3.20)0.89 (0.42–1.90)2.12 (0.88–5.11)†>40%52 (25.6)0.68 (0.34–1.36)0.38 (0.17–0.87)‡0.25 (0.10–0.67)§1.66 (0.55–4.99)2.18 (1.35–3.54)§3.83 (1.56–9.43)§ Male Family Network 0%150 (73.9)refrefrefrefrefref20–39%33 (16.3)1.26 (0.52–3.03)0.55 (0.25–1.22)0.53 (0.14–2.02)1.07 (0.34–3.39)1.37 (0.74–2.55)1.33 (0.57–3.09)>40%20 (9.9)0.37 (0.11–1.21)†0.26 (0.06–1.22)†‖1.54 (0.39–6.10)2.98 (1.17–7.61)‡3.37 (0.95–11.9)†Black men who have sex with men (BMSM) family netw.*Proportion of close network members who are family. This is further limited to male family network proportion.Models are weighted and control for age, education, employment status, HIV status, network size and site of participant recruitment.†p, Background In Zambia, HIV prevalence in women (15–24) is twice that of same aged men. A gender perspective is critical for designing interventions that recognize gendered-risks to HIV. The Zambia-led Prevention Initiative (ZPI) is initiating community-level interventions through targeted approaches that address gender disparities and power imbalances. The baseline survey, part of the ZPI evaluation plan, identifies key areas for targeting. Methods A total of 1,060 men (aged 15–59) and 1,700 women (aged 15–49) participated in a survey conducted in 4 provinces. Provinces and districts were purposively selected; households and individuals were randomly selected. The survey included questions related to gender-based violence, rape myths that blame women for rape (i.e., If a woman doesn't physically fight back, you can't really say it was rape), and attitudes towards gender norms (measured using the Gender Equitable Men scale) and contraception. Results 68% of females ever experienced either or both physical (35%) or sexual abuse (39%); only 15% sought help. 62% of all respondents endorsed at least 1 of 4 rape myths and 37% supported inequitable gender norms. Those with 2+ partners (46%) in the last 12 months were more likely to support inequitable norms than those with 1 partner (39%) or no partners (26%) (p< 0.001). Nearly 20% of men think that contraception is women's business; 32% think women who use contraception are promiscuous. When women were asked about their last birth, 50% indicated they wanted to wait or did not want the pregnancy at all. Unintended pregnancies were highest among unmarried younger females (77–85%) compared to married women aged 25+ (50%). Conclusion Inequitable gender norms are pervasive and may affect women's vulnerability to HIV and gender-based violence. ZPI is addressing power imbalances between men and women that contribute to HIV risk and focusing on male norms and behaviors that contribute to gender-based violence., Background Gender based violence (GBV) is a human rights violation and public health problem impacting women's health globally and is interconnected with the HIV epidemic. GBV is associated with reduced adherence, poor treatment outcomes, and mortality in women with HIV. Methods Using marginal structural survival models (MSMs) we evaluated the effect of sexual, physical, or emotional abuse in the past 12 months on mortality among 2,222 (1,642 HIV-infected and 580 seronegative) participants in the Women's Interagency HIV Study (WIHS), an ongoing cohort study. Mortality data were confirmed by National Death Index Plus registry match. MSMs were used to estimate the mortality hazard ratio and survival curves from baseline (1994/95 or 2001/02) through 2007, controlling for sociodemographic, behavioral, and clinical factors. Results Overall, 437 (19.7%) women died between 1994 and 2007 and had abuse data available in the year prior to death. Compared to survivors, women who died were more likely to be older, HIV-infected and not treated with highly active antiretroviral therapy; have lower nadir and current CD4; to have engaged in transactional sex and used drugs and tobacco; be depressed, report lower cognitive function, and have a history of pre-study abuse including childhood sexual abuse. Accounting for these fixed and time-varying confounders, recent abuse was independently associated with all cause mortality (HR 1.54; CI 1.18, 2.02); findings remained significant in analyses stratified by pre-baseline abuse history, and by HIV serostatus. This effect was greater in uninfected (HR 4.39; CI 1.78, 10.82) than HIV infected women (HR 1.42; CI 1.07, 1.89). Conclusion Mortality risk is significantly elevated for women exposed to GBV and appreciable even in the context of a high death rate due to HIV infection. Interventions to address GBV should remain a public health priority. Further research is needed to identify possible biologic pathways underlying abuse related sequelae., Background Links between experience of sexual violence and HIV risk behavior among women are well established, as is the fact that male perpetrators of sexual violence against women report high levels of risk behavior. Links between sexual violence victimization and HIV risk have also been reported for MSM. However, little data has explored links between male-on-male sexual violence and HIV risk among men in the general population, and almost no such data exists from developing countries. Methods We conducted a population-based household survey of 1,738 men aged 18–45 across two provinces in South Africa. Information on sexual behavior, and experience and perpetration of male-on-male sexual violence was collected using audio-enhanced personal digital assistants. Male SV Victims Non-Victims P-Value 2+ casual partners in the past year55.9%40.6%, Background As northern Uganda emerges from decades of war and displacement, a growing number of young women engage in sex work (SW) for survival. With the escalating rates of HIV, the normalization of violence in northern Uganda creates a high occupational risk environment for young SWs. We aim to investigate the prevalence of client violence and associations with HIV risks among a cohort of SWs in Gulu, northern Uganda. Methods We conducted an analysis of baseline data (questionnaire and HIV screening) of SWs enrolled in a prospective cohort. Young women (≥14 years) who exchanged sex for resources in the last 30 days were recruited through ethnographic mapping, time-location sampling and peer outreach (current SWs) to SW venues. Bivariate and multivariate logistic regression modeled associations with physical and/or sexual violence by clients among SWs. Results Of 400 SWs, the median age was 21 (IQR: 19–25). The majority were Acholi (92.3%) with 66.5% (266) having formerly lived in displacement camps, 34.0% (136) living with HIV. In the last six months, 83.7% (335) had experienced violence by clients: 69.0% (276) forced unsafe sex, 28.8% (115) stabbed, and 18.8% (75) raped. In multivariate logistic regression, client violence was independently associated with rushing negotiations with a client due to police presence (a-OR: 3.58, 95% CI: 1.68–7.64), inconsistent condom use by regular and one time clients (a-OR: 3.53, 95% CI: 1.89–6.86), and older age (a-OR:1.08, 95% CI: 1.01–1.17). Conclusion The SW risk environment in northern Uganda is characterized by extreme occupational violence directly associated with a 3.5-fold increase risk of non-condom use. The criminalization of sex work in Uganda contributes to 3.5-fold increased odds of client violence from rushing negotiation due to police presence. Structural interventions (decriminalization and enforcement-based approaches) must be integrated into the HIV response, both as a human rights and public health imperative., Background The Population and Community Development Association implemented the Positive Partnership Program (PPP), which pairs HIV positive and HIV negative individuals and provided pairs loans for income generating businesses. Pairs also collaborated to disseminate HIV/AIDS knowledge to their community, with the objective of reducing community-level stigma and discrimination. Interventions included monthly HIV campaign events, funfairs, and production of three IEC materials (radio dramas, posters, and slips of paper with HIV messaging). Figure 1Change of HIV Knowledge Among Community Members. Characteristics Baseline (N=560) Endline (N=560) GENDER - Female 58.658.8 - Male 41.441.3 AGE - 15–29 22.520.0 - 30–39 17.919.5 - 40–49 23.023.2 - 50+ 37.137.3Community Respondent Profile, Baseline and Endline. The study goal is to evaluate the effect of interventions on reducing community-level stigma. Methods Randomly selected households and individuals were interviewed at baseline (N=560) and endline (N=560). We conducted t-tests on three stigma domains: fear of HIV infection through daily activity; shame associated with having HIV; and blame towards people with HIV. We developed three scales using confirmatory factor analysis and regressed each stigma scale on demographic characteristics, HIV knowledge, and exposure to intervention activities. B Coefficient (95% Confidence Interval) CHARACTERISTICS - Female (ref=male) 1.37(−0.36: 3.10) - Personally know a PLHIV (ref=does not know) −2.42(−4.34: −0.51) - 4–9 correct HIV knowledge responses (ref= 0–3 correct responses) −4.71(−6.35: −3.07) INTERVENTION EXPOSURES - None or one ref - Two −0.98(−2.95: 0.98) - Campaign/VDB or PPP club/IEC −2.86(−6.82: 1.10) - Campaign/Funfair/IEC −4.18(−7.74: −0.63) - Four −1.70(−6.44: 3.04)Results of Linear Regression on Fear-Driven Stigma. Results No differences were observed in respondent characteristics at baseline and endline. Significant changes were observed in HIV transmission knowledge and fear of HIV infection from baseline to endline. Respondents exposed to the monthly campaign, funfair and IEC materials were less likely to exhibit stigma along the dimensions of fear (4.2 points lower on average compared to respondents exposed to none or only one intervention; 95% CI: −7.4 to −0.6) and shame (4.7 points lower; 95% CI: −8.4 to −1.1), net of demographic controls and baseline levels of stigma. Personally knowing someone with HIV is associated with low fear and shame, and females are less likely to possess attitudes of shame compared to males. B Coefficient (95% Confidence Interval) CHARACTERISTICS - Female (ref=male) −2.17(−3.92: −0.41) - Personally know a PLHIV (ref= does not know) −1.78(−3.72: 0.15) - 4 to 9 correct HIV knowledge responses (ref= 0–3 correct responses) −3.73(−5.40: −2.06) INTERVENTION EXPOSURES - None or one ref - Two −0.88(−2.98: 1.14) - Funfair/Campaign/ VDB or PPP club 0.60(−7.84: 9.04) - Campaign/VDB or PPP/ IEC −1.11(−5.13: 2.90) - Funfair/Campaign/IEC −4.73(−8.35: −1.11) - Four −5.76(−10.59: −0.94)Results of Linear Regression on Shame Stigma. Conclusion Results suggest that a combination of three interventions is critical in shifting community-level stigma in Thailand: monthly campaigns, funfairs, and exposure to IEC materials. Knowing which interventions to invest in for maximum impact is crucial for country-wide expansion and scale-up of interventions., Background Disclosure of seropositivity within a partnership is a pre-requisite for couples counseling and the tailoring of prevention interventions, such as the use of treatment as prevention. In this study, we used a mixed methods approach to describe the rates and determinants of disclosure within partnerships. Methods The Multi-Country African Testing and Counseling for HIV study was a cross-sectional study designed to compare clients’ experiences of HIV testing services in Burkina Faso, Kenya, Malawi, and Uganda. Face-to-face questionnaires were administered and included multiple-choice and open-ended questions. Our analysis focuses on a sub-set of married/cohabiting participants reporting awareness of their seropositive status. We explore the influence of stigma through a multilevel logistic regression model. Results Of the 477 participants, 85.3% [95%CI 82.1–88.5] reported ever disclosing their serostatus. However, only 52.6% [95%CI 48.1–57.1] reported disclosing to their partners. We observed a significant variation between countries-participants in Kenya and Burkina Faso disclose at similar levels, while lower levels of disclosure were reported in Malawi and Uganda. Analysis of the open-ended responses among HIV positives who did divorce, revealed that disclosure can create serious rifts with partners. Perceived community stigma was approximately reported at same levels across the four countries, but levels of self-stigma differed. Patients were more likely to report self-stigma in Burkina Faso, while they were the least likely to report self-stigma in Malawi. However, none of our stigma indicators was associated with disclosure. At individual level, those with a lower education and member of a support group disclose less than the rest. Conclusion Seropositive patients tend to disclose to people in their support network. However, disclosure within the partnership is less common. We found no relationship between stigma and disclosure to partners. A tailored disclosure support and advice will be essential for programs looking at implementing treatment as prevention in serodiscordant couples., Background Internal stigma or self-stigmatization is a critical problem among PLHIV as it usually leads to low self-esteem, a sense of worthlessness and depression, etc. The objective of this study is to assess the level of internal stigma among HIV-positive adults in Ethiopia Methods This study utilized a nationally representative two-stage cluster sampling method to collect data from 3360 PLHIV (68% of them women) sample cases. Results More than half of the PLHIV blamed themselves and reported to have low self-esteem. More than 40 percent of the PLHIV feel ashamed and guilty because of their HIV status. PLHIV residing in rural areas have higher likelihood of feeling guilty than PLHIV residing in urban areas. One out of five of the PLHIV felt suicidal, in connection with their HIV positive status. Abandoning aspirations/life goals, in connection to their HIV-positive status was reported by substantial proportion of PLHIV. For instance, the proportion of PLHIV who took the decision not to have (any more) children was 59 percent,), not to have sex was 40 percent and not to get married 37 percent. Significantly higher proportion of female PLHIV were noted to have taken all these decisions compared to males (P=0.000). Almost one-quarter of PLHIV revealed that they have isolated themselves from their family and/or friends as a result of their being HIV-positive. Nearly equal proportion of PLHIV have decided to withdraw from their education/training and stopped working (12 percent) because of their HIV-status. Conclusion Internal stigma and its negative consequences are very common among PLHIV in Ethiopia. This may deter PLHIV from active participation in socio-economic activities of the community out of a fear of having their status revealed or being discriminated against. In order to address the problem, peer-to-peer support groups, skills building, network building, counselling, training, should be given attention., Background Previous research has revealed a negative impact of orphanhood and HIV-related stigma on the psychological well-being of children affected by HIV/AIDS. Little is known about psychological protective factors that can mitigate the effect of orphanhood and HIV-related stigma on psychological well-being. This research examines the relationships among several risk and protective factors for depression symptoms using structural equation modeling. Methods Cross-sectional data were collected from 755 AIDS orphans and 466 children of HIV-positive parents aged 6–18 years in 2006–2007 in rural central China. Participants reported their experiences of traumatic events, perceived HIV-related stigma, perceived social support, future orientation, trusting relationships with current caregivers, and depression symptoms. Results We found that the experience of traumatic events and HIV-related stigma had a direct contributory effect on depression among children affected by HIV/AIDS. Trusting relationships together with future orientation and perceived social support mediated the effects of traumatic events and HIV-related stigma on depression. The final model demonstrated a dynamic interplay among future orientation, perceived social support and trusting relationships. Trusting relationships was the most proximate protective factor for depression. Perceived social support and future orientation were positively related to trusting relationships. Conclusion We conclude that perceived social support, trusting relationships, and future orientation offer multiple levels of protection that can mitigate the effect of traumatic events and HIV-related stigma on depression. Trusting relationships with caregivers provides the most immediate source of psychological support. Future prevention interventions seeking to improve psychological well-being among children affected by HIV/AIDS should attend to these factors., Background The deleterious impacts of racism, sexism and HIV-related stigma on well-being are widely documented, yet most research has examined these forms of stigma separately. Rising HIV infection rates among Black African Caribbean women in Canada underscore the importance of understanding factors associated with quality of life (QOL). We used a feminist intersectional approach to examine the influence of racism, sexism and HIV-related stigma on QOL among HIV-positive Black African Caribbean women in Ontario, Canada. Methods We conducted a community-based multi-method study triangulating qualitative and quantitative methods. Building on qualitative findings regarding stigma from 15 focus groups with HIV-positive women (n=104) in Ontario, we implemented a cross-sectional survey with HIV-positive Black African Caribbean women in three Ontario cities. Multiple linear regression (MLR) analyses were conducted to measure associations between independent (block 1: racism, sexism, HIV-related stigma; block 2: resilient coping, social support) and dependent (total QOL; QOL domains: physical; psychological; level of independence; social relationships; environment; personal beliefs) variables. Results Survey participants (n=163; mean age=40.7 years, SD=8.8) reported frequent/everyday experiences of racism (29.4%) and sexism (22.6%) and high HIV-related stigma (disclosure: 84.4%; personalized: 54.7%; public attitudes 40.4%; negative self-image: 27.6%). In MLR analyses, racism, sexism and HIV-related stigma were associated with lower QOL scores (total; psychological; level of independence; social relationships; environment; personal beliefs). Resilient coping and social support accounted for a significant variance of higher QOL scores (total; psychological; social relationships; environment) after controlling for the effects of racism, sexism and HIV-related stigma. Conclusion HIV-positive Black African Caribbean women experience pervasive racism, sexism and HIV-related stigma associated with reduced QOL; social support and resilient coping were associated with higher QOL. Interventions tailored for HIV-positive Black African Caribbean women should aim to strengthen protective factors, such as resilient coping and social support, and challenge stigma and discrimination associated with HIV, race/ethnicity and gender., Background Female bar/spa workers in the Philippines face continued risk of sexually transmitted infections (STIs), yet Philippine Congress recently rejected a Reproductive Health Bill. Little is known about differences in condom attitudes among workers in different venues and the effects of social support on their condom attitudes. This study assesses socio-structural and individual factors associated with condom attitudes among female bar/spa workers in the Greater Metro Manila Area, Philippines. Methods Female bar/spa workers (N=498) from 54 venues underwent interview-led surveys as part of a larger intervention study. Multiple hierarchical linear regression analyses, adjusted for individuals nested within venues, were conducted to assess socio-behavioral (age, education, length of time employed as an entertainer, alcohol, and substance use) and socio-structural (venue type, manager support, peer support, establishment condom rule, condom availability at establishment, and social support) factors associated with condom attitudes. Results Participants were aged 18–60 years. Over 90% indicated using condoms every time while having vaginal and anal sex could lower their chances of contracting HIV/AIDS. However, nearly 70% considered condoms too expensive to use regularly. Over 60% said condom usage depended on males in their culture. Over half thought condoms caused pain or discomfort. A like proportion indicated that condom usage never or only occasionally went against their religion. In multivariate analyses, positive attitudes toward condoms were associated with co-worker peer support (0.35, p, Background In the third decade of the HIV epidemic in the United States, the population of persons living with HIV/AIDS (PLHIV) has aged. While 50 and older was initially created as the “older age” category, that cut-point is no longer informative. Understanding the health status of different adult age-groups of PLHIV will assist in providing the types of healthcare services needed by an aging population. Methods A convenience sample of 2,182 PLHIV was enrolled from HIV clinics and service organizations in the United States, Canada, Puerto Rico, Namibia, China, and Thailand from February 2010 to July, 2011. This subanalysis of U.S. participants (N=1293) assessed differences in PLHIV in three adult age groups: 40–49 (n=687, 53%); 50–59 (514, 40%); and 60 and older (n=92, 7%). Results Participants' mean ages were 44.7, 53.4, & 63.9 years; 71%, 73% & 79% male, no differences in race/ethnicity, 64%, 71% & 87% reported other medical conditions, 81%, 82% & 91% were taking HIV medications, and 52%, 46% & 40% were diagnosed with AIDS. No differences were found in social capital (measured by the Social Capital scale, Onyx & Bullen) or physical functioning (measured by SF-12); there were significant differences in mental functioning (measured by SF-12) in that mental health improved with age (means=43.6, 45.4, & 50.8), depressive symptoms (measured on CES-D) declined with age (means=22.2, 20.5, & 14.8) and treatment self-efficacy (measured on the HIV-ASES) improved with age (means =91.3, 96.8, & 100.5). Conclusion The oldest group of PLHIV has better mental health although they are living with multiple comorbidities, perhaps because they view themselves as survivors. Although fewer older persons have AIDS, 91% are taking HIV medications and their treatment self-efficacy is significantly higher than the younger age group (F=9.091, p=.000). It might be time to reexamine the possibility of creating peer groups between middle and older aged PLHIV., Background In 2010–2011 we conducted a HIV and non-communicable disease (NCD) prevalence and risk behavior survey (“Ha Nakekela” study) within the Agincourt Health and Demographic Surveillance System site (AHDSS) in Mpumalanga Province, South Africa (Menken P.I). We found surprisingly high levels of HIV prevalence at older ages, given in Table 1. 40–49 50–59 60–69 70–79 80–89 Women34%25.5%12.4%8%1%Men34%33%17%6%1%HIV Prevalence of Older Adults in Agincourt, SA. Older adults are either contracting HIV at earlier ages and surviving for a long period or they are contracting HIV at older ages. In this study we examine the sexual behavior and HIV risk for older adults in the two years previous to the study visit. Methods The Ha Nakekela study was based on a probability sample of 7,428 individuals aged 15 years and above. We analyze the sexual behavior survey for the 2,051 adults over age 39 in the study to investigate the prevalence of sexual behavior risk factors for acquiring HIV. Results We find evidence suggesting that older adults are at risk of acquiring HIV through unprotected sex and by having multiple partners. Fifteen percent of men over 39 report multiple partners, the majority of whom are significantly younger. Very few men (9.5%) and women (11.5%) reported condom use at last sex. We also find that older adults are not likely to know their or their partner's HIV status: only 5% of sexually active older adults said they knew the HIV status of their sexual partner. Of those that are HIV positive, 31% had never been tested and only 40% of those that had ever tested reported being on ART. Conclusion The high HIV prevalence, lack of condom use, lack of testing, and low ART uptake of known positives suggests that older adults are an over-looked but critical population for both HIV prevention and treatment programs., Background HIV/AIDS among adults 50 and older in Uganda is on the increase partly due to newly diagnosed infections in this age group as well as improved survival owing to antiretroviral therapy, for many HIV infected persons. Although national programmes are in place to ensure access to medical services, older people living with HIV have unique unmet healthcare needs. The objectives of this study were to identify the healthcare needs of older Ugandans living with HIV and to gather recommendations for improvements by health service providers. Methods Data regarding healthcare needs were collected from HIV positive adults aged 50 years and older attending two large non-governmental outpatient clinics in Kampala and Masaka districts, Uganda between March 2011 and June 2011. Individual in-depth open-ended qualitative interviews focus group discussions were conducted. Observations of clinic interactions were also recorded. Interview transcripts were analyzed using thematic content analysis. Results The mean age of the respondents was 65 years, 50% were female, (n=40). Respondents expressed multiple age-related healthcare needs that may differ from their younger counterparts. Needs increased with higher age. Both men and women attributed double stigma from HIV and old age as a major factor affecting disclosure and seeking healthcare for HIV. 60% of the respondents expressed anxiety about their future access to healthcare, the lack of social services and end of life care. Lack of transport and food access issues compromised respondents’ adherence to antiretroviral therapy. Conclusion Older people living with HIV have unique healthcare needs which health promotion programmes should consider meeting through appropriate and innovative approaches such as preventing and managing age-related chronic illnesses, palliative care, developing age-friendly services and settings. Research to further explore the impact of these healthcare needs on the quality of life of older PLWHA is required., Background The health of prisoners is an issue of global concern. Increased socio-demographic and behavioural risk factors prior to incarceration and poor prison living conditions contribute to increased prevalence of transmissible infections. Little is known about the health of prisoners in Mexico City. This study sought to establish prevalence data and risk factors to identify those currently needing healthcare and to inform future policy. Methods This cross-sectional study was carried out in 4 Mexico City prisons, June to December 2010. Ethical approval was granted prior to starting; participation was voluntary, confidential and based on informed consent. Participants were offered HIV, Hepatitis B, C and Syphilis testing. A representative sample completed a questionnaire on socio-demographic characteristics and risk behaviours. Positive results were delivered with counselling and treatment or referral with consent. Data was analysed using Stata. Results 76.8% (15,517/20,196) men and 92.9% (1,779/1914) women participated. Complete data sets were available for 98.8%. Prevalence of HIV (0.7%), syphilis (Anti-TP Ab 4.1%; VDRL 2.0%), Hepatitis B (HBcAb 3.0%; HBsAg 0.2%) and Hepatitis C (3.2%) was higher in the study population compared with national data. The relative increase was greater for HIV and syphilis amongst women, Hepatitis C in men, and all infections in younger participants. Questionnaire data (1934 men, 520 women) demonstrated lower educational levels, increased smoking and substance use compared to national data. High levels of unsterile tattoing, physical abuse and a history of sexual violence were found. Conclusion The study identified that health screening is acceptable to Mexico City prisoners and feasible on a large-scale. It demonstrated increased prevalence of HIV and other infections compared to national data, though low rates compared to international data. Individual participants benefited from earlier diagnosis, treatment and support. The data collected will also enable the formation of improved policy for this vulnerable group of individuals., Background After two decades of living with HIV a generation of around 7,000 children from Romania nosocomially infected in communist era, turned into young adults. Hyper protection from the family, combined with discrimination in education services, developing social services, and a focus on medical aspects represented the environment these children grew. Between 2004 and 2010 the Global Fund financed social programs for their professional integration, increasing the percentage of those availing of cash benefits from 30% to 66%. In 2010 people living with HIV (PLHIV) and NGOs protested over ARV treatment interruptions and budgetary cuts due to economic crisis, although WHO estimated the treatment coverage at 83% in 2009. Methods A nationally representative clinic-based research among PLHIV was carried out in 2011 (March–June) to determine their access to treatment, care and support (N=618, ±4%). Measures of treatment interruptions, adherence and access to services were included, as well as demographics variables. Sample was weighted according to subjects’ surveillance center registration. Results The vast majority of the sample (71.7%) is young (18–24 years), with more than 6 years of known seropositivity (82.1%), receiving ARV for more than 6 years (78.7%), with more than 2 changes in their treatment plan (80.1%), and with their main source of income as cash benefits (80.5%). Unintended treatment interruptions were spread (65.2%, average interruption lasting 38 days), resulting in more visits to regional center (49.2% more than once a month), higher expenses and the need for new combinations of ARV. Discontinuous adherence was reported by 42.2%. Access to social services was high (over 80%). Conclusion While Romania is a low prevalence country, and ensures high coverage of ARV treatment, authorities must pay attention at continuous treatment access for PLHIV, and support of treatment adherence to prevent deterioration of the health status and ensure universal access for PLHIV., Background Despite evidence that a significant number of children infected and affected by HIV (uninfected, but have HIV+family member) reside with caregivers who are not their birth parent, few studies have examined the psychological functioning of these alternate caregivers. The majority are women, typically ethnic minorities, often from impoverished communities. This study compares mental health and substance use problems in birth-mothers, and non-birth female caregivers of HIV-infected, affected, and unaffected children in the US. Methods Data come from the baseline caregiver interviews of two longitudinal studies of urban youth perinatally-HIV infected, HIV-affected, and unaffected by HIV. Caregivers (n=451) included HIV+ and HIV− birth-mothers and other HIV− female caregivers primarily of African American and Latina ethnicity. Measures of depression and anxiety symptoms and substance use problems were completed. Results Birth-mothers reported more symptoms of depression (p< .001) and anxiety (p< .001) than non-birth caregivers. Non-birth caregivers were less likely (3%) to report substance use than HIV+ (13%) or HIV− (12%) birth-mothers (p=.006) (Table 1). In multiple regression analyses, HIV+birth-mothers, but not HIV−birth mothers were significantly more depressed and anxious than non-birth caregivers, after adjusting for age, race, number of children under 18-years, and having a partner in home (Table 2). Both birth-mother groups (HIV+ and HIV−) had more substance use problems than non-birth caregivers even after adjusting for covariates. Among all caregivers in the study, those who reported either substance use or Latina ethnicity had significantly higher depression and anxiety scores (each p≤.01; data not shown).Table 1Caregiver characteristics HIV+ Birth Mother HIV− Birth Mother HIV− Non-birth Caregiver Chi-square/Anova p-value N (%)209 (46)120 (27)122 (27)Age (mean)39.238.354.4.000African-American (%)553757.006Latina (%)334835Children, Background Women's low or unpaid role in providing care for people living with HIV in the form of home-based care while central to the response to HIV been has increasingly been recognised as entrenching unequal gender relationships. Frameworks to map out the pathways have suggested that this process occurs in three domains: financial costs, opportunity costs and physical and emotional costs. Yet such a framework has a tendency to ignore the broader conceptualisation of gender inequalities that include violence against women. Methods We undertook 5 focus groups with 45 home-based carers in South Africa as part of a larger study focused on how to transform home-based care organisations from spaces of reproducing inequalities to transforming gender relationships. We conducted thematic analysis on the data exploring factors that could support or hinder gender equality. Results As with other studies, our data showed home-based carers suffered economic costs related to their work, often spending their own money to provide for their patients. In addition, few received stipends or other financial support either from donors, government or NGOs. Many carers also related the extreme physical and emotional costs of the work they did; again reflecting what is already known about providing care. However, home-based carers also spoke about the central role of gender-based and sexual violence that they feared, risked and experienced both while working and sometimes within the organisations they worked in. Such relationships of violence undermined their ability to envision their work as spaces for women's empowerment and transformation. Conclusion To move women's participation in home-based care from one of reinforcing gender inequalities to empowering women requires those supporting home-based carers to envision a wider conceptualisation of the gender inequalities home-based carers face, that includes the centrality of gender- and sexual-violence, and actively work to programme and tackle these., Background Psychiatric disorders are prevalent among HIV-infected individuals and may have deleterious effects on HIV care and outcomes. We sought to examine the impact of depression on retention in care and viral suppression among racial/ethnical diverse HIV-infected patients in a large managed care organization. Methods We evaluated a cohort of HIV- infected adults who received care and had at least 8 months' membership in health care plan in 2010 in Kaiser Permanente Southern California. History of depression prior to 2010 was identified by International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9 CM) codes for depressive symptoms. Retention in care was defined as ≥ 2 CD4 and/or HIV-1 RNA tests at least 90 days apart in 2010. Viral suppression was defined as undetectable viral load or HIV-1 RNA, Background Previous research (amongst others our own published in AIDS and Social Science & Medicine) has demonstrated gender differences in various antiretroviral treatment (ART) outcomes including, adherence, quality-of-life, disclosure and retention. However, little longitudinal, in-depth research has been done to investigate the why and how of these differences. The current study firstly aims to explore the impact of masculinity and femininity on ART experiences, in both a longitudinal and in-depth manner. In addition, the study investigates the complex interrelationships between gender constructs whereby males and females potentially influence-through intricate household dynamics- the ART experiences of the other gender. Methods Based on a previous explorative quantitative study, we conducted a longitudinal qualitative study whereby 12 male and 12 female ART patients were repeatedly interviewed >over the course of 1 year in the Free State province of South Africa. Results Despite several cases of lipodystrophy and other side-effects among women due to ART, they seem to adhere and lead healthy lifestyles, often in the absence of a male partner. Male patients reported a clear notion of masculinity that required males to be in control and act strong, highly sexual and economically productive, thus conflicting with the role of ‘good patient’ that is expected to accept being HIV-positive, take instructions, and engage in health-enabling behaviors. The majority of men interviewed overcame these barriers and internalized their treatment, albeit with fewer side-effects and more support in terms of reminding and accompanying them to the clinic (mostly by females). Conclusion The study findings have both theoretical and practical relevance. Theoretically, the longitudinal impact of gender and household dynamics on the ART career draws attention to the sociological processes influencing ART outcomes. Practically, the study demonstrates that policy interventions aimed at improving long-term ART outcomes should incorporate the (interactions between) gender-specific illness and treatment experiences., Background Asian gay men make up the highest group in MSM/gay HIV notification after Anglo background, constituting a priority group for HIV health promotion in Australia (MHAHS, 2011). Multiple challenges exist as issues of stigma, migration, isolation, in addition to sexual stereotyping and homophobia within the gay and ethnic communities respectively, complicates this work.The immediacy of these issues renders HIV health promotion a second order issue. Underrepresentation in HIV health promotion work, research and general media also contributes to their invisibility. Multicultural HIV & Hepatitis C Service (MHAHS). Trends in NSW HIV notifications 1999–2010. (unpublished). Methods The “A-Men” publication was developed with an aim to engage lived experiences and visibility of Asian gay identities as an entry point to promoting sexual health and wellbeing. The approach was two-pronged: a resource production engaging broader issues facing Asian gay men - the person-centric approach; and the developmental process that involves and builds community ownership - ‘for the community, by the community'. With $5000 community arts funding from Sydney city council, the resource was developed and distributed in-print and online. Results A total of 70 volunteers from 9 different Asian ethnicities were involved in the production.1000 hard-copies were launched in March and distributed through community and service providers. 1600 users accessed the online version to date. Volunteer feedback (n=58) showed increased social-connectedness, self-esteem, pride, HIV awareness and knowledge of services. 2 community focus groups (n=62)reported similar trends: greater community engagement and dialogue around wellbeing and self-esteem. Conclusion A broader exploration of lived realities was effective in enlivening HIV messaging with Asian gay men. Through engaging intersections of identity, art and community building, a ‘biggest bang for your buck' can be achieved in a resource limited setting. Through cultural change, "A-Men" addressed the barriers to HIV awareness and wellbeing, in the process building a more resilient and empowered community., Background Evidence suggests that men who have sex with men (MSM) account for most new HIV infections in Lebanon and act as a bridge to transmission in the general population. In a region where same-sex sexual activity is highly stigmatized, a better understanding of the psychosocial factors that influence sexual risk behavior and HIV testing in MSM is essential for HIV prevention initiatives to be effective. Methods An exploratory, qualitative study was conducted with a sample of 31 MSM living in Beirut. Semi-structured interviews examined relationships with family and friends, comfort with and disclosure of sexual orientation, sexual behavior, and HIV testing. All interviews were recorded, transcribed, and coded in Atlas-ti to identify themes and extract counts. Results All men self-identified as homosexual (77.4%) or bisexual (22.6%), although 32.3% also have sex with women, and a majority (64.5%) reported some discomfort with their sexual orientation. The men described a strong heterosexual social norm, causing some to feel guilty and lead a “double life” where they conceal their sexual orientation by publically feigning attraction or dating women, or dissociating from effeminate men. Comfort with and disclosure about sexual orientation appeared to be linked with sexual risk behaviors and HIV testing. As compared to the remaining sample (n=18), the 13 participants who were both uncomfortable with their sexual orientation and had not disclosed to either parent reported higher rates of unsafe sex (69.2% versus 33.3%), more annual sexual partners (mean=36.7 versus 17.0), and lower rates of being HIV-tested (53.8% versus 88.9%) and discussing HIV risk with their sex partners (38.5% versus 88.9%). Conclusion These findings reveal the influence of sexual identity acceptance and disclosure on condom use and HIV testing in the context of high societal stigma, and suggest the need for HIV prevention interventions to facilitate progression through these psychosocial processes of sexual development., Background Evidence indicates that MSM experience higher rates of intimate partner violence (IPV) than non-MSM; however, no study has examined what defines IPV among MSM, or the associations between MSM-specific IPV and sexual risk-taking Methods Seven focus group discussions were held with 84 MSM, generating 30 types of IPV, including HIV-specific IPV. These were tested using a cross-sectional survey of 1,074 MSM. Factor analysis generated five domains of MSM-specific IPV, including a domain of HIV-related IPV. Six logistic regression models for unprotected anal intercourse (UAI) were created (n=626). Models controlled for age, race, education, employment, HIV status, and gay identity, with the key covariate being receipt or perpetration of three different IPV measurements: MSM-specific, Conflict Tactics Scale (CTS), and World Health Organization (WHO). Results The MSM-specific IPV definition included HIV-specific typologies of violence not currently included in any definition of IPV, e.g., not disclosing HIV-positivity to a partner, and captured significantly higher reporting of IPV compared to WHO (46.2% v. 13.5% receipt of IPV; 31.9% v. 8.5% perpetration of IPV). Reporting receipt of neither WHO-defined IPV nor CTS-defined IPV was significantly associated with UAI, but reporting receipt of MSM-specific IPV significantly increased odds of UAI (OR: 1.80, 95% CI: 1.27, 2.54). Two models demonstrated a significantly increased risk of UAI among men reporting IPV perpetration (WHO OR: 1.74, 95% CI: 0.91, 3.31; CTS OR: 1.67, 95% CI: 1.06, 2.63; MSM-specific OR: 1.82, 95% CI: 1.26, 2.64). Conclusion This study provides for the first time a MSM-specific definition of IPV that captures HIV-related violence not represented in standard definitions. MSM who reported MSM-specific IPV had increased odds of UAI at last sex. These findings suggest that MSM experiencing IPV are at higher risk for HIV seroconversion, although this association may not be recognized by using non-MSM-specific definitions of IPV that do not include HIV-related violence., Background HIV prevalence among MSM in India remains disproportionately high at 7.4% as compared with overall national prevalence of 0.3%. India HIV/AIDS Alliance in consortium with five other organizations implements the five-year Global Fund-supported Pehchān program in 17 Indian states to build the capacity of 200 CBOs to serve as effective HIV prevention partners with the National AIDS Control Program and reach 453,750 MSM, transgenders and hijras using a community-driven and rights-based approach. Non-disclosure of identity and low self-esteem due to internalized stigma are known to be associated with vulnerabilities that place these populations at greater risk of HIV infection. Methods A cross-sectional baseline study sampled 2,762 MSM, transgenders and hijras (TG/H: 16%) in 55 districts across 10 states to understand demographics, behavior and needs of target populations. Time and Location Cluster Sampling (TLCS) was used to identify these often hard-to-reach and relatively mobile populations. Data were analyzed using SPSS. Results Self-disclosure of sexual identity occurred least with parents (21%) for reasons ranging from fear of being rejected and rendered homeless to adverse legal consequences. Self-disclosure with siblings was also low (22%), for fear of being neglect, isolation, and verbal/physical abuse. Disclosure was highest amongst community peers (67%). Feelings of shame (33%), self-blame (28%) and feelings of guilt (26%) were associated with sexual identity among study subjects. 30% of respondents have actively attempted to avoid disclosure of their sexual identity. Conclusion Low self-esteem among MSM, transgenders and hijras and fear of rejection leads to non-disclosure of sexual identity. Based on the insights from the baseline, Pehchān developed a life skills training module that places greater emphasis on coping, communication and interpersonal skills to address sexual identity. The program plans messaging to change attitudes about homosexuality and gender identity within families and communities in India to strengthen support structures and manage conflicts more successfully., Background Globally, YMSM are uniquely vulnerable to HIV. Many are dependent on family that may not understand or accept their sexuality, forcing them to hide their sexual behavior or risk losing housing and financial support. YMSM also may have limited access to information regarding sexual health and legal rights. Despite this vulnerability, YMSM's distinct needs are often overlooked by efforts to address HIV among general youth and general MSM. Methods In 2010, the Global Forum on MSM & HIV (MSMGF) conducted a global online survey of MSM and their service providers. Among 5,066 survey participants, 1,488 were YMSM (age 30/younger). YMSM respondents were from: Asia (65%), Latin America (10%), Australasia (9%), North America (6%), Europe (4%), and Africa (3%). Chi-square and Wilcoxon rank-sum were used to evaluate differences between YMSM and other MSM. Multivariable regression was used to identify predictors of access to HIV prevention services. Results HIV-prevalence among YMSM was 14%. Most YMSM (67%) had two or more sexual partners in the past year; 33% were homeless/unstably housed. Compared to other MSM, YMSM reported lower “easy access” to evidence-based HIV prevention strategies: free HIV testing (53% vs. 37%[p, Background In India, many MSM either are married or expect to marry. The present study aimed to identify strategies for the national HIV programme to promote the health of women partners of MSM both in terms of preventing HIV transmission and in promoting early HIV diagnosis and treatment. Methods Qualitative field research used a collective case study design to collect data in 2010/11 from 11 sites in seven states among 401 MSM (HIV prevention outreach workers and beneficiaries) through 57 focus groups (n=364; 46% married) and 37 key informant interviews. Women partners of MSM could not be recruited for the study. Potential interventions proposed are based on the inferences drawn by synthesising both the literature review and qualitative data (thematic analysis). Results Both literature review and qualitative data showed that women partners of MSM can include wives, casual, regular, paid or paying partners, and they may be at higher risk of HIV due to their male partners' high-risk sexual behaviours, which include having a large number of male and/or female partners combined with inconsistent condom use. Field data revealed that self-identified MSM may enter into heterosexual marriage with willingness, under compulsion (e.g., family pressure) or with indifference. Importantly, qualitative data offer new insights into whether disclosure of sexuality and/or HIV status among MSM is significant in preventing HIV transmission to female partners. Conclusion HIV prevention messages aimed at MSM ought to explicitly promote awareness of the risks/vulnerabilities faced by female partners. Such strategies ought to particularly include counselling and HIV testing approaches that address the complexities of safer sex practices with both male and female sexual partners. Developing interventions for single MSM that raises awareness of the HIV risks faced by their women partners and implementing interventions that explicitly target married MSM and their wives are key to effective, future HIV prevention programming., Background Social network analysis has been widely used as a tool to describe and explain HIV prevalence and risk behaviors. However, the network of male sex workers is understudied. This study provided a description and graphical presentation of the social network structure of male sex workers with HIV status in Houston, Texas. Methods The study used network data from a cross-sectional network study derived from male sex workers in Houston, Texas. A convenience sampling plan was used wherein male sex workers were identified first and then were asked to refer their social, drug, or sex partners (both male and female) to the study. Netdraw, UCINET version 6, and Stata version 11 were used. Results The analysis consisted of 395 participants; with a mean age 33.1 years old (SD=9.7); 84.3% male; 31.4% gay, 44.3% bisexual, and 24.3% straight. There were 81 (20.5%) HIV positive, 253 (64.1%) HIV negative, and 61 (15.4%) unknown HIV status. Two thirds of the participants traded sex for money or drugs in the last 30 days. The network had 17 components and 32 isolates. The largest component of the network consisted of 155 people (39.2%), and the second largest consisted of 16 people. The graph below indicates that HIV positive and HIV negative people tended to be clustered together. The mean sexual network size in the last 30 days was 35.1 (SD=64.4). There was no difference in the sexual network size among HIV positive, HIV negative, and unknown HIV status.Figure 2Change in Fear of HIV Transmission Among Community Members. Conclusion Our network data showed that most network participants were connected with each other in 17 separate components, and more than a third were connected in the same network. HIV positive and HIV negative participants tended to be clustered together. These findings indicate high potential for network-level HIV interventions for HIV positive and HIV negative people., Background Northern Uganda hosts one of the highest prevalences of HIV and teenage pregnancy in the country. The Gender Roles Equality and Transformations (GREAT) Project conducted ethnographic research to understand the processes through which social norms about gender, SRH, and violence, which underlie HIV vulnerability, are transmitted in this post-conflict setting. Methods Forty life histories were collected from adolescents across the life course: very young adolescence, older adolescence, newly married, and pregnant with or parenting a first child. Forty in-depth interviews were also conducted with adults who significantly influence adolescents in study communities. Data were analyzed using AtlasTI software. Results Data reveal efforts to destigmatize HIV have been largely successful as evidenced by widespread support for youth access to HIV services, including education, testing, condoms, and treatment, as well as by the ritualization of HIV testing among young unmarried couples. The need for young people to “test their blood” before beginning sexual activity appears to have become a cultural norm, viewed by adults and adolescents as a rite of passage into sexual relationships. These efforts, however, have not translated to other aspects of adolescent SRH, namely, pregnancy prevention. Respondent Category # of Males # of Females Very Young Adolescents (ages 10–14 years)55Older Adolescents (ages 15–19 years)53Newly Married Adolescents (ages 16–19 years)56Parenting Adolescents (ages 16–19 years)56Total2020Life History Interviews (ages 10–19 years). Respondent Category # of Males # of Females Parent of adolescent girl or boy27Relative of adolescent girl or boy44Community Member (e.g. teacher, religious leader, elder)83Peer of adolescent girl or boy63Total2020In-Depth Interviews (ages 20 years and above). Results show that most respondents do not acknowledge the link between HIV prevention and family planning (FP) and oppose adolescent use of FP products. Condoms are viewed as acceptable only in the context of HIV prevention but not for pregnancy prevention. Opposition to adolescent FP use is primarily due to fear of compromised future fertility or increased promiscuity. Conclusion Severe social, economic, and medical consequences resulting from early pregnancy, particularly in low-resource settings, have been globally recognized. Efforts are needed to build on successes in HIV prevention efforts to address adolescent SRH in a more comprehensive manner., Background Few studies have documented female sex workers' (FSWs) efforts to engage in safe behaviors in the context of their multiple identities with sexual partners in India. Recognizing the intricacies of women's perceptions of risks and benefits within diverse relationships and moving beyond condom promotion are crucial for HIV prevention. Methods An exploratory qualitative study was conducted with female sex workers in India. Sixty FSWs participated in 5 focus groups and 25 semi-structured in-depth interviews in addition to completing a short questionnaire that captured basic socio-demographic information. Results The majority (60%) of FSWs was based in rural areas and was Hindu (90.3%). Respondents' mean age was 30.2 years, with an average of 6.4 years of education. Only 28% reported being legally married or living with a partner and 82% had at least one child. Further, for 58%, sex work was the main income source. Findings implied a complex interplay of factors that determined FSWs' abilities and willingness to avoid unsafe sexual behaviors with paying clients, regular/trusted clients, and non-paying intimate partners. Often, this was dictated largely by economic hardships, emotional attachments, social norms, perceived lack of power as well as the threat of violence and to a less extent by the knowledge of HIV risk. Further, discrimination and exploitation by community members including police combined with the need to hide their sex worker identities often put FSWs in situations that compromised their efforts to avoid risky behaviors. Conclusion A deeper understanding of the multifaceted exchanges between the various partner types that heighten FSWs' vulnerabilities is critical when planning HIV prevention interventions in addition to adopting a human-rights framework and recognizing women's agency in safeguarding health. Challenging popular notions of sex workers as undeserving of substantive support and individual rights would go a long way in ensuring the effectiveness of HIV prevention efforts., Background Male partners of female sex workers (FSW) have traditionally been viewed as holding power and decision-making authority regarding condom use due to the transactional nature of their relationships. The aim of this study is to explore relationship and gender dynamics between FSW and their regular partners and consider how these dynamics influence HIV vulnerability. Methods We conducted qualitative interviews with FSW (n=20) and regular partners (n=20). FSW were recruited from an ongoing cohort study and regular partners were referred by non-participating FSW in the cohort. Regular partners were defined as trusted and/or intimate partners with whom the referring FSW reported sex with at least 4 times in the last 3 months. We used narrative and thematic analysis to describe the relationship history and identify emergent themes. Results Both FSW and regular partners described emotional, sexual, and economic attachments to each other. Regular partners, however, described greater emotional and sexual attachment. While most men provided some economic support to their FSW partner, they were aware that due to their limited economic resources, they were not able to provide for all of their partner's needs. In contrast, FSW displayed more pragmatic attitudes, emphasizing the importance of both the material and emotional support provided by regular partners. Some FSW clearly stated that while they had the strongest emotional attachment to their regular partner, they had to maintain other partnerships in order to survive. Conclusion Findings challenge hegemonic norms of masculinity between FSW and their regular partners and highlight the intersection between socio-economic position and relationship power. HIV prevention efforts targeting FSW and regular partners must address both emotional and socio-economic dimensions of relationships and their influence on HIV protective behaviors., Background For some women who engage in female sex work (FSW) life remains bound up in the work as they age. We explored the reasons for entering and staying in FSW through life histories of older women (35 years and above) at high risk of HIV in Kampala, Uganda. Methods 100 women were purposively selected from a cohort of 1027 high-risk women. Life history interviews and in-depth interviews on their life and work, including sexual practices, were conducted with each woman. Data were analyzed using thematic content analysis. Informed consent and ethical clearance were obtained. Results Sixteenwomen were aged over 35, and had joined sex work as young adults usually because of financial need. They continued to take an active part in sex work. These women perceived sex work to be addictive, because of the quick access it could give to cash. Some women confided that they found their continued sex work humiliating and they really wanted to give up because they were too old and they feared that their children might find out what they did. However, faced with recurrent economic demands, paying children's school fees and buying food, these women had few alternatives. Most wished for a ‘husband’ who could help them. In the absence of such support or alternative livelihoods, giving up FSW was not an option. As they aged, they commanded lower rates from clients. Some augmented their living by selling alcohol and providing labour in the community, including child care to younger sex workers. All these women were at risk of HIV, STIs and sexual violence. Conclusion Sex work remains a key structural driver of HIV among some vulnerable older women. Sexual violence and high risk behaviour characterized sexual relations. There is an urgent need for interventions to support such middle-aged and older women., Background Findings from recent clinical trials evaluating the efficacy of antiretrovirals for pre-exposure prophylaxis (PrEP) against HIV among women are mixed, and none has included U.S. women. In addition, there is a dearth of research on knowledge, attitudes, and likelihood of use of PrEP among women in the U.S., who comprise 27% of new infections in the country. Thus PrEP′s potential as an HIV prevention strategy for American women is unknown. Methods We conducted a focus group study with 92 women in 4 U.S. cities between March and April 2012. Participants were recruited by local, woman-serving CBOs that also hosted the groups, which were led by trained facilitators. Participants completed a questionnaire with demographic and behavioral information. Focus group questions elicited basic understanding of PrEP, attitudes about its administration and uptake, barriers to use, and targeting and marketing. All sessions were digitally recorded and transcribed, and transcripts were analyzed to identify predominant themes and any demographic or site differences. Results Across sites, almost no women had heard of PrEP prior to the study; but once informed about it, nearly all found it an important option. Key considerations in deciding to take PrEP were cost (including who would pay), efficacy (most wanted 85–99%), and side effects (including interaction with contraceptives). PrEP was seen as "additional," not substitute, protection to condoms. Young women were the most commonly named target population, and schools the best venue for informing them. Mistrust of men was a main motivator for PrEP among women in Oakland and Washington; and churches were seen as a key barrier to PrEP in Memphis. Conclusion Women at risk for HIV in the U.S. are likely to use PrEP if it is known to be highly effective, doesn′t cost too much, doesn′t have significant side effects, and is promoted by peers and CBOs., Background HIV prevalence among fishermen in Malaysia is ten times that of the general population. Combining Rhodes' “risk environment” framework to assess contextual features influencing HIV risk and Berkman et al.'s comprehensive model of the mediating effects of social networks on health, this paper assesses the social relationships among drug-using fishermen in Malaysia as a key axis along which HIV risk decision-making occurs. Methods Data were collected in Kuantan, one of the busiest fishing ports on the East coast of Malaysia and from two nearby fishing villages. Twenty-eight fishermen reporting drug use during their last fishing trip or upon returning to shore participated in in-depth interviews. Fishermen were selected based on the type of fishing vessel they worked on (traditional vs. commercial) and gear used (hook/line vs. trawlers/purse seiners) to draw upon different social networks and spheres of influence. Data were coded thematically and analyzed to inform key research questions around drug use and aspects of social networks. Results Economics, occupational culture, punitive policies and stigma shaped the social networks of drug-using fishermen. Social networks, in turn, shaped HIV risk perceptions and behavior through the following pathways: 1) social influence - through the introduction to drugs, male homosociality, and peer pressure; 2) social support - drug users relied on other drug users for information and emotional needs; 3) social engagement - other drug users provided a sense of community and shared identity; and 4) access to resources and goods, like drugs. Conclusion These results suggest that aspects of social networks both constrain and enable HIV risk behavior among Malaysian fishermen by mediating the relationships between social structures and individual behaviors. Understanding the role of network influence in drug use and HIV risk among fishermen is essential to developing HIV prevention interventions that are appropriate for the unique needs of this highly interconnected population., Background Drug users often use multiple substances and are involved in sexual risk behaviors, and thus are at high risk of sexually acquiring or transmitting HIV. Studies on typologies of drug use are limited, especially those that examine the relationship between typologies of polydrug use and unsafe sex practices. Methods Using respondent driven sampling, 248 rural drug users were recruited in rural areas of the Midwest. They participated in a longitudinal, natural history study of illicit drug use and health service utilization. Latent Class Analysis was used to identify a typology of poly-drug use and assess differences in sexual risk for HIV transmission between these classes. Results All stimulant users consumed multiple drugs in the previous 30 days and many (63.7%) reported unsafe sex (condomless sex). Three latent classes were identified: Class 1 (N=107): all used powder cocaine, 90% used marijuana, 42.2% used crack-cocaine, 23.0% used heroin, and few used other stimulants and methamphetamine; Class 2 (N=67): all used crack-cocaine, 72.3% used marijuana, 20.8% used powder cocaine, 90.0% used heroin, few used other stimulants, and no methamphetamine; Class 3 (N=74): all used methamphetamine, 92.6% used marijuana, 74.2% used crack-cocaine, 88.1% used power-cocaine, 17.7% used heroin, and 49.1% used other stimulants. Although the patterns of drug use practice among the classes vary, the prevalence (64.5%, 67.2% and 59.5%, for Classes 1, 2, and 3, respectively) of unsafe sex practices was not significantly different across the classes (p=0.6213). Conclusion Rural stimulant users can be classified into three latent classes: primary cocaine users, primary crack users, and heavy multiple stimulant users. High prevalence of unsafe sex practices was reported across all classes. While much attention has been given to HIV risk reduction efforts among urban stimulant users, HIV prevention and intervention efforts for rural stimulant user are still greatly needed., Background Since 1985, research has shown that some gay/bisexual men combine specific sex-drugs and heavy alcohol use (SDA), resulting in high risk for HIV infection. Recently, we demonstrated that 2/3rds of incident HIV infections among men in the Multicenter AIDS Cohort Study (MACS) were associated with use of ≥1 sex-drug classes. However, there is little data on current prevalence and long-term SDA trajectories of MSM. Using data from 1,551 MSM in the MACS, we examined vulnerability and resilience factors (V&R) that predict adult SDA use trajectories and associated morbidities. Methods We used Latent Class Trajectory Analysis (LCTA) to assess statistically reliable patterns of SDA use over time. Classifying each participant into a distinct trajectory, we used MLR and LCTA including potential covariates to determine pre-existing V&R factors predicting SDA trajectories. Results The best fitting model yielded 5 distinct SDA use trajectories (Figure). While 10% of men were classified as high-sustained users of two SDA, the largest group (40%) never used SDAs. The next largest group (29%) used moderate (, Background Bangladesh is thus far regarded as a low HIV prevalence country with increased vulnerability due to several risk factors including high demand for commercial sex. Male clients of female sex workers (FSWs) are considered to be a potential bridge population to transmit HIV and other sexually transmitted infections (STIs) to the general population. The objectives of this paper are to describe the correlation between illicit substances (ISs), unsafe sexual behavior and self-reported symptoms suggesting STIs among male clients of FSWs in Bangladesh. Methods A cross-sectional study was conducted among 1565 male clients of FSWs during November 2005 to July 2006 in three sex trade settings (streets, hotels, and brothels) in Bangladesh. No personal identification of the clients was recorded and only verbal consent was taken in the structured questionnaire administered by male interviewers. Bivariate and multivariate data analysis was performed. Results Among the male clients of FSWs, 36.2% aged ≤24 years, nearly 30% never attended school, and above one-half (54.6%) of them were never-married. Nearly one-third (30%) used ISs. Cannabis (60.6%), alcohol (51.9%), heroin (6.8%), sleeping pills (5.7%), and injecting drugs (1.5%) were used by these clients. Consistent condom use with non-marital sexual partners in the last one month from the interview date was reported by only 13.2% of those who used ISs. Almost one-half(45%) of the IS-users experienced the symptom of STIs in the last 12 months prior to the interview date. The IS-users were 1.7 times more likely to have symptom of STIs than the non-users (adj. OR=1.70, 95% CI: 1.29–2.20). Conclusion Use of ISs was a significant risk factor for having symptom of STIs among the male clients of FSWs and they are less likely to use condoms consistently during non-marital sexual relationship. There is an urgent need to implement targeted intervention to promote safer sex behavior for male clients of FSWs in Bangladesh, especially those who use ISs., Background Injecting drug use has emerged as an important route for HIV transmission in India. The Government of India currently estimates that there are 200,000 PWID (or IDUs) in India (NACO, 2010), though other studies indicate the numbers could be much higher. Surveillance studies estimate HIV prevalence among PWID at 9.2% (NACO, 2010). Understanding the patterns of drug use and other behaviors by PWID is critical to successful intervention design. India HIV/AIDS Alliance conducted a baseline with PWID in three states (Delhi, Manipur and Haryana) on drug use and behavior patterns, as part of the Hridaya project, the India component of the five-country, Dutch government-funded Community Action on Harm Reduction program. Methods A cross sectional survey was conducted with PWID in three states. 181 respondents were selected through systematic random sampling using client information made available by partner NGOs at selected sites. Data were analyzed using SPSS software. Results 60% of PWID interviewed have injected drugs for more than 5 years; 32% inject daily and 33% at least once a week in the last 30 days. 22% of PWID have injected using needles or syringes previously used by another person. In the last 12 months, 55% of respondents had sexual intercourse with regular partners; 22.9% with casual partners; and 26.6% with commercial sex partners. During last sexual contact, 70% used condoms with regular partners; 64% with casual partners; and 51.7% with commercial sex partners respectively. Of the 100 respondents who disclosed their HIV status, 21% reported being HIV-positive. Conclusion Unsafe injection practices along with low condom usage are putting PWID at dual HIV risk. These findings support the development of focused prevention strategies that address both injection drug use and sexual behavior as part of Hridaya's harm reduction approach., Background Substance use is associated with high-risk sexual behaviors and HIV-seroconversion among MSM. Most MSM use substances episodically but research does not usually distinguish between episodic (less than weekly) and high-frequency (at least weekly) users when evaluating HIV risk. We sought to assess the relationship between engaging in serodiscordant unprotected anal intercourse with a partner of unknown or HIV-positive status (SDUA) and varying frequencies of use for different substances. Methods We screened 640 substance-using HIV-negative individuals for a qualitative study to adapt the Personalized Cognitive Counseling HIV prevention intervention for SUMSM in San Francisco from March 2009-January 2010. Data on substance use and sexual risk behaviors were collected via structured telephone interviews. We examined the association between SDUA and different frequency (episodic or high-frequency) of use for methamphetamine, cocaine, and poppers, using multivariable logistic regression, adjusting for age and race. Results Episodic use was more prevalent than high-frequency use for methamphetamine (13% vs. 6%), cocaine(26% vs. 5%) and poppers (25% vs. 9%). We observed significant dose-response relationships (i.e., greater risk with more frequent use) between episodic use and high-frequency use of methamphetamine, cocaine, and poppers; and having SDUA. Compared to non-users, the adjusted odds ratios (AOR) for SDUA among episodic and high-frequency methamphetamine users were 6.6 and 7.2, respectively. AORs for episodic and high-frequency cocaine users were 2.0 and 4.4, respectively. For poppers, AORs for episodic and high-frequency users was 1.7 and 2.8, respectively (all AORs p< 0.01; see Table 1). Substance Frequency of Use N Percent Adjusted Odds Ratio* 95% CI P-value Methamphetamineepisodic (less than weekly)80136.6(4.0–11.0), Background Thailand continues to experience dual epidemics of injection drug use and HIV/AIDS. In response, Thailand has relied on heavy-handed enforcement-based approaches. Although policing is known to contribute to the production of drug-related harm among people who inject drugs (IDU), the impact of police violence on HIV risks among IDU has not been fully characterized. Methods Using multivariate logistic regression, we identified the prevalence and correlates of experiencing police violence among IDU who participated in the Mitsampan Community Research Project (Bangkok) in 2009 and 2011. Results Among the 637 unique IDU who enrolled in the study between June 2009 and October 2011, 153 (24.0%) were female, and the median age was 37 years. In total, 239 (37.5%) participants reported having ever been beaten by police. In multivariate analyses, exposure to police beatings was independently associated with male gender (Adjusted Odds Ratio [AOR]=9.25), younger age (AOR=1.65), study enrollment in 2011 (AOR=1.95), obtaining income from illegal sources (AOR=2.12), a history of imprisonment (AOR=4.52), syringe sharing (AOR=1.91) and overdose (AOR=1.73) (all p< 0.05). Seventy percent of participants reported experiencing police violence during the interrogation process. Conclusion A high proportion of community-recruited IDU participating in this study reported being beaten by police, and this form of police violence appears to have increased in recent years. Further, experiencing police violence was independently associated with indicators of drug-related harm, including syringe sharing and overdose. These findings suggest that the over-reliance on enforcement-based approaches is contributing to ongoing human rights violations at the hands of police and the perpetuation of the HIV epidemic among Thai IDU. These findings indicate the need for greater police oversight and a shift toward the implementation of evidence-based programs focused on the HIV- and addiction-related needs of IDU., Background Injecting drug use has been documented in 158 countries and is a major contributor to HIV epidemics. People who inject drugs have poor and inequitable access to HIV services. The Global Fund to Fight AIDS, Tuberculosis and Malaria is the leading multilateral donor for HIV programmes and a major funder of harm reduction interventions. This presentation will discuss findings from the first detailed analysis of Global Fund investments in harm reduction (which is being published in the International Journal of Drug Policy during the conference, as well as in the Global State of Harm Reduction 2012 report). Methods The full list of over 1,000 Global Fund grants was analysed to identify HIV grants that contain activities for people who inject drugs. Data were collected from the detailed budgets agreed between the Global Fund and grant recipients. Relevant budget lines were recorded and analysed in terms of the resources allocated to different interventions. Results 120 grants from 55 countries and territories contained activities for people who inject drugs worth a total of US$ 361 million, increasing to US$ 430 million after projections were made for grants that had yet to enter their final phase of funding. Two-thirds of the budgeted US$ 361 million was allocated to core harm reduction activities as defined by the United Nations. Thirty-nine of the 55 countries were in Eastern Europe and Asia. Only three countries with generalised HIV epidemics had grants that included harm reduction activities. Conclusion This study represents the most comprehensive assessment of Global Fund investments in harm reduction, data which are important for policy-makers, advocates and researchers alike. This funding, while substantial, falls short of the estimated needs. Investments in harm reduction must increase if HIV transmission among people who inject drugs is to be halved by 2015., Background According to the latest update on the global state of harm reduction published in 2010, OST is available in 70 countries and territories around the world. The global coverage is estimated at the level of between 6 and 12 OST clients per 100 PWID. However, in most countries of Central and Eastern Europe and Central Asia coverage is limited due to long-term pilots and lack of systematic scale-up. The purpose of this study is to provide an up-to-date overview of the state of OST service provision in Eurasia, with a particular focus on access and quality issues. Methods Data were collected in 28 countries between August and November 2011 in order to capture some of the most recent developments related to OST service provision in Eurasia. We conducted an on-line survey using a semi-structured questionnaire in Russian and English, reviewed available literature and interviewed key stakeholders. Results Essential OST-related data including year of OST introduction, OST medications, number of clients, number of sites in prison and community settings, geographic coverage, and availability of take-home doses were analysed for all 28 countries. Based on this analysis, countries were divided into three groups: i) countries with sustained availability of OST programmes; ii) countries with limited availability and sustainability of OST programmes; and iii) countries with no OST programmes. Within each of the three groups, we identified challenges and opportunities for scaling up OST services, improving their quality and/or strategies for overcoming existing opposition. Conclusion While some progress has been made and more countries introduced OST over the past three years, numerous challenges still exist. The opportunities for increasing access to and improving quality of OST programmes are related to six areas, ranging from national ownership of OST service provision to protection from police harassment and violation of human rights of OST clients and service providers., Background Since 2004, China has rapidly scaled up Methadone Maintenance Treatment (MMT) from 8 to 716 clinics with 332,996 cumulatively enrolled drug users by September 2011. The average methadone dose is lower than the minimum recommended dose (60mg) in Chinese national guidelines. Lower methadone dosing may result in higher drop-out and continued HIV risk behavior. On average, 7.8% of MMT clients are HIV-infected. Methods A qualitative study was conducted in 2011 to determine reasons behind current dosing practices. Key informant interviews were conducted in 10 MMT clinics in 3 provinces (Guangdong, Guangxi, and Guizhou) among current and former MMT clients, their family members, and service providers. All interviews were conducted using a field guide and each interview lasted around 45 minutes. Interviews were recorded and transcripts were analyzed using a coding scheme and thematic sorting. Results Interviews with clients and their family members revealed that they did not view drug users as patients with a chronic disease in need of long-term treatment; they expected MMT to end drug use in a short time. They also thought that methadone was more addictive than heroin and that methadone withdrawal was more severe and long-lasting. This contributed to their preference for lower and tapering methadone dosing. Interviews with MMT providers revealed that many doctors did not have previous experience in drug use treatment. Lack of experience and insufficient training led to client-dominated, lower methadone dosing and the common misperception “the lower dose, the safer and better for patients.” Conclusion Factors contributing to lower methadone dosing include clients and their families’ misperceptions as well as providers’ limited experience and training in MMT. To improve the performance of MMT in China, it is recommended that capacity building for providers be improved and education and counseling of clients and their family members be strengthened., Background Rates of HIV are increasing among youth throughout Kenya. Research regarding how these youth have coped with their diagnosis and remained resilient is critical to the development of interventions that promote their health and well-being. The purpose of this study was to explore resilience among urban/slum youth newly diagnosed with HIV in Kenya. Methods Adolescents (ages 18–25) who were diagnosed with HIV within the past two years were recruited from ten villages in the Kibera informal settlement in Nairobi, Kenya. Six gender-specific focus groups (N=53; 26 female, 27 male) were conducted. Questions elicited specific and contextual data regarding participants' experiences, beliefs, and behaviors as youth newly diagnosed with HIV. Results Qualitative data were analyzed first separately, and then collaboratively, by two teams of analysts in Kenya and U.S.A. using a phenomenological framework. Seven primary thematic areas of active coping strategies were reported: 1) accepting a new HIV+ identity; 2) disclosing HIV+ status to supportive others; 3) engaging in holistic self care; 4) participating in formal support and health promotion programs; 5) advocating for other HIV+ individuals; 6) finding HIV+ role models; and 7) re-engaging with friends for social activities. Seven primary sources of social support were also revealed: 1) romantic partners; 2) friends; 3) healthcare workers/counselors; 4) people living with HIV; 5) co-workers/employers; 6) religious colleagues; and 7) affirming HIV+ media figures. Conclusion These data demonstrate that Kenyan youth who are newly diagnosed with HIV demonstrate resilience across multiple dimensions. In addition to intrapersonal-level resilience related to individual cognitions and behaviors, they also reported interpersonal-level resilience related to both seeking support and providing advocacy/support for others. Future interventions for Kenyan youth newly diagnosed with HIV should work to enhance the coping and social support of these young people through the use of creative strategies focused on developing and maintaining varying types of resilience., Background Adults caring for AIDS-orphaned children face poor psychosocial outcomes. However, we have little understanding of whether living with HIV exacerbates psychosocial outcomes. We assessed prevalence of depression and anxiety among caregivers of AIDS-orphaned children; compared prevalence among caregivers living with HIV and those not living with HIV; and tested whether social support serves as a protective factor. Methods A cross-sectional survey of 4,954 participants (2,477 children 10–17 years and 2,477 of their primary adult caregivers) was conducted in 2010 in KwaZulu-Natal Province (HIV prevalence 36.3–41.6%). Depression and anxiety were assessed using the Center for Epidemiologic Studies Depression Scale and the Beck Anxiety Inventory. HIV status was based on self-report and the verbal autopsy method. Social support was assessed using the MOS-SSS. Chi-square tested whether outcomes differed among caregivers living with HIV versus those without HIV. Multivariate logistic regressions identified whether social support was a protective factor and controlled for sociodemographic differences. Results Among caregivers, 35.6% met criteria for depression and 49.4% met criteria for anxiety. Caregivers of AIDS-orphaned children were more likely to report depression or anxiety than caregivers of other children (p, Background Evidence from India suggests that a comprehensive approach to SRHR has been lacking and that current responses have not sufficiently decreased vulnerability and sexual and reproductive ill-health among PLHIV. Previous studies with PLHIV have shown high rates of unmet contraceptive needs, untreated STIs and lack of knowledge and skills on safer sex and broader positive prevention. Methods 803 people living with HIV aged 15–49 (352 men; 401 women; 50 transgender/hijra) were interviewed in five districts in four states of India (Andhra Pradesh, Gujarat, Maharashtra and Tamilnadu). Lists of PLHIV covered by local CBOs were used as the sampling frame for the selection of respondents. The required number of respondent households was arrived at using systematic random sampling. Results Approximately one quarter of all respondents reported STI-related symptoms in the previous three months which is a cause of concern. Also, a relatively small proportion of mothers reported seeking maternal health advice during their last pregnancy (12% in Andhra Pradesh; 21% in Gujarat; 44% in Maharashtra; 27% in Tamilnadu). 10% of respondents reported having been advised against having children because of their HIV status indicating a lack of accurate or comprehensive information available at health facilities. Awareness of contraceptive methods ranged between 55% and 98%; similarly, STI-related knowledge levels ranged between 56% and 91%. Reported condom use with non-regular partners ranged between 56% and 91%. Conclusion The study highlighted unmet SRHR needs of PLHIV in the four states. While most subjects reported frequent condom use, STI-related symptoms indicate unsafe sexual behavior. SRH and HIV-related knowledge levels are low, and respondents also reported SRH-related rights violations. This study confirms the need for interventions for positive prevention along with specific SRH programming for PLHIV as part of India's HIV response., Background There is a dearth of literature on the challenges and coping mechanisms of school-age HIV infected children. The purpose of this study was to investigate challenges faced by HIV infected children in Botswana and to assess the coping mechanisms they employ to cope and survive. Methods The study was conducted among HIV-infected children and adolescents aged 6–18 years, using a cross-sectional design, in 12 antiretroviral therapy sites accounting for over 90% of all HIV-infected children receiving Highly-Active Antiretroviral Therapy in Botswana. Data were gathered using a structured pretested interviewer administered questionnaire and focus group discussions. Focus group discussions were held until saturation was achieved. Quantitative data were analyzed using descriptive statistics and cross-tabulations. Qualitative data were grouped into mutually exclusive categories according to themes emerging from the data. Ethical approval was obtained from the Botswana Ministry of Education & Skills Development, the Botswana Ministry of Health's Health and Research Development Committee and Baylor College of Medicine's Institutional Review Board. Results 984 HIV infected children participated between August 2010 and February 2011. The children were confronted with various challenges, including: poor school grades; poor school attendance due to medical appointments; poor nutrition; unanswered questions of how they became infected; and stigma or altered relationships with other children and teachers. In response to these challenges HIV infected children developed or adopted various coping mechanisms including: non-disclosure of HIV status, self-isolation; non-participation in school trips; attempting to treat HIV like any other disease; talking to close relatives or friends; and adoption of positive attitudes toward life. Conclusion HIV infected children faced many serious psychological and social challenges in living with HIV. These challenges elicit both positive and negative coping and survival strategies. Support systems for the children should aim to build on the positive coping strategies while ameliorating the negative ones., Background Approximately 70000 people are living with HIV (PLH) in Peru. Over half live in Lima-Callao and one half are gay/bisexual men and transgender people. While they are the focus of care and prevention services, not much is known about their sexuality, sexual and reproductive health (SRH) needs and access. A community-based collaborative study involving the Peru Positive Network took place to assess sexuality and SRH status and access of PLH in Peru. Methods Trained PLH volunteers in Lima-Callao and 6 inner cities conducted 814 structured interviews in 2011 (48.7% in Lima-Callao, 72% biological males). This analysis focuses on 273 males reporting being gay and bisexual (40.8%) and compares Lima-Callao (n=134) with other cities (n=139). Results Participants in Lima-Callao were slightly older; 40% in Lima-Callao and 60% elsewhere lacked health insurance. Overall 32% had regular partners-in Lima-Callao 95% of partners were men, while elsewhere 21% of those were women and 17% trans; 42% of regular partners were seropositive, but serostatus of another 20% was reported as unknown outside Lima. Participants had disclosed serostatus to 82% in Lima-Callao but 60% elsewhere. 88% reported penetrative sex in last 6 months-up to 40% unprotected outside Lima; condom use was unrelated to partner serostatus. Among those with only casual partners, 28% reported unprotected sex in prior month; disclosure was negligible. Participants recognized a shared responsibility in prevention, including through treatment adherence. 21% and 8% had heard about barebacking and serosorting, respectively, but few had practiced them. 15% had been diagnosed STIs in prior year, primarily herpes and syphilis. Sexual health advice received by participants often encouraged abstinence (30%). Conclusion HIV+ gay/bisexual men in Peru remain sexually active; serostatus disclosure is limited, particularly with casual partners; unprotected sex and STIs are common. Often sexual health services inappropriately advise abstinence and insufficiently address prevention and disclosure., Background An increasing number of children living with HIV are growing into adolescence where they face new sets of challenges. In resource constrained settings, few psychosocial and sexual and reproductive health (SRH) services provide age-appropriate support for these adolescents. Methods A large multi-country cross-sectional observational study was conducted in Malawi, Mozambique, Zambia and Zimbabwe, looking at the experience of adolescents aged 10-19 [n=1600 (boys=790, girls=810)]. Gender specific experiences from rural and urban settings were explored in each country. Data was collected using in-depth interviews with adolescents (n=150) and guardian/parents (n=46), focus group discussions (n=68), participant observation (3 months) and a knowledge, attitude and practice survey (n=1498). Data was analysed through a triangulation approach. Results Preliminary analyses reveal that key challenges for adolescents living with HIV include accessing information on SRH; disclosing their status to peers; talking about sex and HIV in the context of a relationship, within families and with health service providers; planning to have children; and emotional well-being. HIV represents a complex challenge for adolescents who lack safe and non-judgemental environments to talk about safer-sex options and pregnancy, whilst it is assumed by families and health providers that sexual activities should not start before adulthood. Few health services provide support tailored to adolescents; health providers give out inappropriate information and frequently breach confidentiality, resulting in further marginalising adolescents living with HIV. Conclusion Despite variations between the four countries and in rural vs. urban settings, the attitude of health care providers and the lack of family-centred approach result in inadequate support for adolescents when they first experience sexual and love relationships. The study provides evidence that new policies and funding for HIV in low income settings must include safer-sex advice and SRH interventions, training for health-workers and families in order to provide adolescents with skills to make choices about relationships, safer-sex and HIV disclosure., Background As HIV treatment extends the lives of people with HIV, we are learning about social as well as clinical drawbacks for the current generation over 50 with HIV. Many people with HIV express fears about the future but what is the reality and how can it be managed? Methods 410 UK-based people with HIV aged 50+were surveyed online and on paper. PLHIV were involved throughout the process advising, managing and administering the survey. Results were analysed in comparison to data on general population aged 50+ and data on all PLHIV. Results This group is highly diverse in terms of sexuality, ethnicity, gender, length of diagnosis. Compared with their peers theyReport twice as many other long term medical conditions in addition to HIV, many linked to lifestyle issues such as smoking and exerciseReport greater mobility problems and difficulty with everyday tasksAre less economically active, less likely to have savings or a pension and more reliant on state benefitsAre less likely to be homeowners, more likely to live in social or rented accommodation Many, particularly gay men, report social isolation due to age or HIV stigma, death of peers or concerns about disclosure. They also report difficulties getting primary healthcare, particularly from dentists and GPs, which are more heavily used by older people. Full results can be obtained from www.tht.org.uk/50Plus. Conclusion HIV appears to systematically disadvantage people in health, social and financial terms over a lifetime. Attention must be paid to healthcare and financial and social inclusion of older PLHIV, but also to informing long term condition management for younger and future generations of PLHIV about the greater importance of healthy lifestyle and financial planning. Work must be done to inform geriatric and generic healtcare providers about the needs of older PLHIV., Background Treatment advances and HIV transmission feed a growing population of older adults with HIV. Little attention has been given to differences within this group. Methods One in twenty UK-based over 50s with HIV (n=410) surveyed. Sample was accurate for demographics of wider group. Data from 106 heterosexual over 50s, comprised of 51 HW and 55 HBME. Results Health: HW 3x as likely be recently diagnosed. HBME diagnosed in last 6-9 years 5x HW (51.0/10.0%). HBME twice as likely to have low CD4 count when first diagnosed. HW have higher count generally. HW♂ /HBME♀ most likely to have low CD4 count now, or not know count. HW♂ more than twice as likely not to be attending a treatment centre, despite reporting significantly higher occurrence of extreme pain/discomfort. HW less likely to be taking medication for HIV (84.3/98.1%), have higher pill burden, find it harder to remember to take HIV treatment (15.5/5.7%), have side-effects from medication (20.8/13.3%) and more problems with walking, (56.0/42.6%), taking care of themselves (27.5/18.8%) and performing everyday activities (56.0/39.2%). HBME♀ have more other long-term health conditions (HBME♂ have the least), but only 50% are taking medication for these (70% HW♂ are). HBME higher levels of depression (28.8/21.6%), particularly HBME♀ (34.2%), but HW three times as likely to rate emotional/psychological health as poor. Financial/Social Exclusion: HBME all of those with no income and 3x not enough income for basic needs (45.3/15.7%). HW more likely to own their own home (47.1/18.2%). HBME more likely to be homeless, living in asylum support housing or renting council flat/house. Socially, HW more likely to disclose to Partner (16.4/4.5%), family members (16.4/12.7%) or friends (16.4/12.7%). HBME more likely to seek support from non-family. Conclusion There are major health, financial and social differences between HW and HBME. These factors need to be considered when targeting support for these groups., Background In communities severely affected by HIV many children are growing-up without their parents in skipped-generation households. Often these are headed by their grandparents. This research aims to critically examine what it means for children to grow-up in these households and which roles and responsibilities they assume. Methods The data for this qualitative and quantitative study were collected in Misangwa, a small community in the rural part of the Copperbelt Province in Zambia. Data collection was conducted by means of household surveys, in-depth interviews, Focus Group Discussions, and observational techniques. Respondents were members of the younger and the older generation found in 65 skipped-generation households. Their lives were followed over the course of thirteen months. Results Between 2001 and 2009 the number of skipped-generation households in Misangwa has increased. The proportion of children living in these households also increased significantly. The experiences and roles these children have are complex. It was found that especially older children actively impact the situation in their homes and are often wholly responsible for many aspects of daily life in the households. They work on the fields and are engaged in income-generation. Given the social isolation of many skipped-generation households a focus on households, rather than families, can be justified. Conclusion Literature often characterizes fostering as one-directional. This research examined skipped-generation households using ecological theories of child development. It found that that it is often children, and not guardians, who care for others in the households. Depending on age, personal characteristics and granted freedoms the older children provide care and support to the members of their households. In a sense these people assumes the roles and are associated with the missing middle generation. The research has brought to the surface a complexity that calls a different focus on kinship and caring with attention for diversity, historicity and experience., Background There is a high demand from donors to predict which NGOs are able to improve the health outcomes of their populations and ensure an adequate return on social investment. The principal drivers of capacity development for NGOs are often those of the donor, and promote the development of organizations contrary to achieving sustainability. This stems from insufficient knowledge of the predictors of organizational sustainability, and how to measure and prioritize capacity building efforts. These gaps must be filled since local NGOs are the backbone for services in HIV care, support, and treatment. Methods We studied three NGOs providing community based/residential care to OVC. An instrument was developed, consisting of 14 organizational domains, to enable a quantifiable and replicable assessment of an organization's level of development. Data was collected from key informants, staff surveys, record review and abstraction of routine program data. Domains were weighted in order to ascertain their relative importance in a “healthy” organization, and individual NGO performance was measured against this standard. Results The profiles generated were those of well-managed but unsustainable organizations. Financial and pharmaceutical management scored highly, while governance structures and strategic and business planning were weak. When graphed, the output revealed that only one organization's capacity was balanced while the other two curves were asymmetrical, indicating uneven capacities and ability to deliver services (Figure 1).Demographic Characteristics. Conclusion The quantitative instrument is the first tool enabling consistent, repeated assessments on the organizational capacities of NGOs providing HIV services. It guides donors on which NGOs to invest in and which capacities to build. It also enables donors to rigorously evaluate capacity building efforts of international organizations and hold them accountable. This is vital as resources for HIV/AIDS are in jeopardy and as PEPFAR increasingly emphasizes the delivery of HIV services through local organizations, investment in organizational development and country-owned capacity building., Background HIV-related stigma and discrimination is widespread in health care settings and poses a barrier for HIV prevention and control. The objective of the intervention was to reduce service providers' stigmatizing attitudes and behaviors toward people living with HIV (PLH). Methods The study was conducted in 2008-2011 in 40 county-level hospitals in two provinces of China. The hospitals were matched into pairs, with one hospital in each pair randomly assigned to the intervention condition after the baseline assessment. For intervention hospitals, we identified and trained about 20% of the popular opinion leasers (POL) among service providers to disseminate stigma reduction messages within their hospital. At the same time, universal precaution supplies were provided to all participating hospitals. A total of 1,760 participants, 44 from each hospital, were assessed at baseline, 6, and 12 months. Main outcomes of the intervention included general prejudicial attitude towards PLH, avoidance intent to treat PLH, and perceived institutional support in the hospitals. Results Significant improvements for the intervention group were observed in reducing prejudicial attitude (Estimate 2.401, SE=0.220; P, Background AIDS stigma inflicts hardship and suffering on People-Living-with-HIV (PLHIV), reducing the likelihood of HIV testing, treatment and disclosure. Stigma can be particularly harmful in health care settings. This study was designed to examine and reduce AIDS stigma among nurses and nursing students in India. Methods We interviewed 369 nurses in Mumbai and Bangalore, assessing stigma, endorsement of coercive measures and discrimination toward PLHIV. Based on these results, we developed, implemented and evaluated a 2-session stigma reduction intervention, co-facilitated by PLHIV, for 50 intervention and 50 control nursing students. Results Casual transmission misconceptions were common, with 28% of nurses believing HIV could be transmitted by sharing a glass and 26% HIV by sharing toilets with PLHIV. 70% agreed that people who were infected via sex/drugs deserved their infections. Almost all (96–99%) endorsed mandatory testing for sex workers and surgery patients and most stated that HIV-infected men (77%) and women (73%) should not be allowed to get married and that HIV-infected women should not be allowed to have children (76%). 88% said they would treat PLHIV differently from other patients, taking unnecessary precautions when drawing blood. significantly more participants worried about acquiring HIV at work (41%) than in their personal lives (14%, p, Background Stigma is a hindrance to care for people living with HIV (PLHA) in Egypt. To understand how gender affects stigma among healthcare workers (HCWs), a study was conducted to identify the differences in HIV related misconceptions and attitudes of male (M) and female (F) doctors. Methods A cross-sectional study was conducted in two tertiary care hospitals in Cairo from October–December 2010. All doctors working in surgical departments were invited to participate; three hundred thirty two accepted (210 males, 122 females). Data was collected on socio-demographic information and HIV related misconceptions and attitudes. A chi square test was used to examine the differences between male and female doctors. Results Both male and female doctors had misconceptions about HIV modes of transmission. Significant differences (p, Background Studies indicate that stigma and discrimination among health workers is higher than in other sectors. This subsequently affects service delivery and access to care and treatment for health workers living with HIV. This study aimed to determine the impact of HIV, including stigma and discrimination, on demand and supply of service delivery in order to develop health sector specific mitigation policies. Methods Data was collected from key informant interviews with 35 health facility managers and 6 focus group discussions with various cadres of facility and community based health workers in both public and faith based health facilities drawn from eight provinces in Kenya over the period June-August 2011. Content analysis of the key informant interviews and focus group discussions was done to determine health worker perceptions on the impact of stigma and discrimination on demand and supply of HIV services. Results Although stigma in the general community was reported to be reducing, the majority of the key informants felt that stigma amongst health workers was of significant concern. Stigma contributed to a high tendency of health workers to self test for HIV, avoid uptake of post exposure prophylaxis, and seek counselling and antiretroviral therapy in distant facilities. Disclosure of HIV status among health workers remained low particularly in lower level facilities. Despite high level of knowledge on HIV, it emerged from the FGDs that health workers living with HIV are discriminated against by other health workers. This manifested as a refusal to shake hands, share utensils and bias in the allocation of duties. Conclusion Policy and programmatic interventions, to support health workers living with HIV and to eliminate stigma and discrimination, are required within a comprehensive HIV workplace programme for all health workers in the country., Background Abandoned children in Russia, particularly those affected by HIV, face a grim life or death in a government institution. HealthRight and local partners developed a comprehensive MAMA+® model that includes early identification of women at risk of abandoning their children, home visits, child daycare and halfway house. Implementation of this model reduced the child abandonment rate in St. Petersburg, Russia, from 27% in 2004 to 6% in 2009. This project aimed to improve access to psychosocial services for women at-risk of child abandonment, including HIV-positive women, and reduce child abandonment in Yekaterinburg, another high HIV-prevalence city.Behavioral Characteristics. Methods In 2010–2011, HealthRight and partners replicated the MAMA+ model in Yekaterinburg, the capital of Sverdlovsk region, which leads the country in absolute number of HIV cases. The replication involved 10 training events and 12 supervision sessions; 67 government and 30 NGO service providers were trained on case management, HIV basics, psychosocial counseling, reproductive health counseling and other topics. Data were collected on the uptake of services for at-risk women delivered by the trained providers using case management records.5-Class Model fof SDA Use. Results A cross-sectoral referral network between government healthcare, social services and non-government agencies was established. An interagency referral guide was published, and an interagency protocol is being developed. A government-NGO risk screening, home visiting and case management service was institutionalized in five government social service centers, with 249 women screened and 159 (63.9%) enrolled as high risk. These women, their children and other family members received 1,201 services over 1,126 service encounters. The rate of child abandonment by HIV-positive mothers in Yekaterinburg decreased from 6.3% in 2009 to 1.9% in 2011. Conclusion Replication of the MAMA+ model offers a promising approach for decreasing child abandonment by HIV-positive mothers in urban settings. Institutionalization of psychosocial services within government agencies is key for sustainability of the MAMA+ model in Russia., Background People living with HIV (PLHIV) face various problems dealing with their relatives. Most often PLHIV in Armenia do not disclose their status to anyone. The disclosure of a childs HIV status or the parents to their children is a particularly sensative issue often leading to pshycological and interpersonal tensions, which leave influence on the health and child-parent relationships. To prevent the above “Positive People Armenian Network” NGO (PPAN) has carried psychological work with PLHIV and their children. Methods 10 trainings with HIV affected children were conducted. It was aimed at extension of the emotional and volitional spheres. 10 children 8–13 years old were selected (8 parents were HIV+, 2 HIV-). The age group was selected as the middle childhood years are significant in reviewing children-parents relationship. Children in middle childhood years are emotionally less active than teenagers. Design of meetings was planned (fables-discussions, games, art-therapeutic exercises). They were aimed at decreasing emotional tension, empathy development, value system identification, emotional harmony. Parenting works were also carried out. Results During 10 group meetings it was possible to establish psychological intimacy. Group thinking was strengthened through art-therapeutic techniques “the group tree”. Subsequent works have focused on skill development. Through discussion of Fables and art-therapy childrens vision was enlarged and turned versatile, developing the moral values. Children learned to understand their emotions properly, see themselves on the underside for understanding others’ reactions through. Parents noted the positive change in children-parents relations with and in school environment. Conclusion The values and skills obtained during the meetings will help the children for further disclosure and acceptance of parents’ status, to manage their emotions and feelings not allowing the parents illness to cause pshycological problems in themselves. Currently individual work with parents and children is still ongoing. More similar and parent-children mixed group meetings are planned for the future., Background HIV care and treatment services in Ethiopia are mostly facility based and, services are not extended to or followed up at community level. To address this challenge, AIDSRelief introduced the Community-Based Treatment Support Services (CBTS) based on the principle of continuous patient and family engagement in care and treatment to assist HIV patients achieve optimal anti-retroviral therapy (ART) adherence and maintain low rates of loss to follow-up (LTFU) at St. Luke hospital in Oromia. Methods The CBTS model is composed of adherence counselor, case managers, community nurses and community volunteers (CVs) with distinct responsibilities. This team, established at the facility level, was trained to assist establishment of community level support for HIV patients. At the facility, the team leads patients through structured treatment preparation prior to ART initiation; conduct home visits; sets up appointment system and same day follow-up for patients who miss clinic appointments; and provides supportive counseling to assist status disclosure and stigma reduction. CVs focus on providing home visits, LTFU tracing, awareness raising, early identification and counseling for OIs, and referring pregnant mothers for prevention-of-mother-to-child-transmission (PMTCT) programs. Results Following CBTS start-up in St. Luke hospital, the LTFU rate declined rapidly from 53.1 LTFU/1,000 patient months of follow-up (PMFU) in December 2010 to 47.3 LTFU/ 1,000 PMFU in March 2011. The retention rate has also shown statistically significant increase from 74.8% in March 2009 to 79.6% in March 2011.In addition, the overall patient crude retention rate has increased from 34.4% to 47.5%. Moreover, cross-directional linkages to other community-based programs supporting PLHIV have improved and community-wide disclosure among pregnant women has been promoted. Conclusion This experience proves that higher adherence rates can be attained through the CBTS model structured care programs. Such innovative community programs could to be scaled up and replicated for substantial country wide results., Background Community support systems are effective structures to provide care and support to most vulnerable children and PLWHA. However, sustainability of such initiatives can be weak. The purpose of this study was to get insight into sustainability issues of World Vision's community based care and support programming in Eastern and Southern Africa. Methods A qualitative review has recently been conducted, including 13 key informant interviews and 54 focus group discussions with community initiative members, non-governmental organization staff and government representatives in Ethiopia, Kenya, Mozambique, Uganda and Zambia. Results The study results indicate that the sustainability of community based organizations depends on several issues, one of the key factors being vertical linking to government structures. These links can take different shapes, ranging from loose cooperation between government officers and community organizations to government representatives becoming members of community organizations’ executive or coordinating boards. Such cooperation can even lead to a full adoption and institutionalization of community care and support initiatives into regional or national government structures, including further roll-out of such systems. The findings further indicate that any form of government structure cooperation with community based care and support systems can improve the community organizations’ sustainability and increase the service delivery of both sides. Conclusion As it seems, the stronger the link to government structures, the higher the community groups’ sustainability. However, sustainability also depends on the quality and availability of resources within such cooperation, as well as on the individual commitment of the partners. And finally there is also need to consider the possible pitfalls in government structure co-option, like the loss of access to external NGO funding and a politicization or restructuring of community groups, which can change their initial focus or even undermine and end volunteers’ efforts in providing care and support to vulnerable children and PLWHA., Background TB/HIV twin epidemics should be addressed jointly at community level. PLAN Foundation engaged community volunteers (CVs) for improving access to TB/HIV prevention, treatment and care services in 5 Local Government Areas (LGAs) of Ibadan, Nigeria. Methods 24 communities were selected from high TB-prone areas, high density areas and hardly-reached communities. A consensus meeting involving various community stakeholders was held during which 50 CVs were selected to facilitate active referral of TB suspects to DOTS centres and linkage with HIV testing services in ART clinics and other healthcare facilities in the areas. The CVs were trained on the basics of TB, suspects’ identification, defaulter tracing, adherence support and TB/HIV relationships. They were involved in providing support and follow-up services for smear-positive cases, linkage with HIV testing and treatment for dually-infected persons; and organizing community mobilization. Monthly CVs review meetings were held while PLAN Foundation staff provided supportive supervision to the CVs in communities. Results There were steady and significant increases in number of TB suspects referred by CVs between project onset in June 2011 and October 2011. TB clients referred to DOTS centres for screening were: June-47; July-56; August-118; September-274; October-238 totaling 733 for the period. Of these, 78 of the suspects were smear positive cases while 25 were dual infected with TB and HIV. Conclusion Engaging CVs is effective in identifying, referring, supporting and following up TB suspects and persons infected with TB and HIV. There is the need for linkage of TB and HIV services as a strategy for detecting HIV infection among people with TB. Community mobilization through CVs helps to increase awareness about TB and HIV in communities. There should be improved support and motivation for CVs as vital linkages to communities TB/HIV interventions., Background Effectively reaching PLHIV in rural, hard-to-reach areas is considered critical to improving access to health services and enrolment in care and treatment, which are needed to improve PLHIV's quality of life. Health facilities are located at least 20 kilometers from a farming population in Lamu District, Kenya. Infrastructure is poor and transport is unavailable; therefore, access to information and health services is an uphill battle. PLHIV there have had no option but to default treatment or share drugs. Methods Through Ministry of Health (MOH) structures, community sensitization was undertaken and trained clinical staff made available. Technical and financial support to conduct monthly mobile clinics was provided through AIDS, Population, and Health Integrated Assistance (APHIAplus). Comprehensive services for PLHIV were provided, including education on secondary prevention, HIV counseling and testing, provision of Septrin and HAART, adherence and support counseling, prevention with positives package, and treatment of opportunistic infections during monthly clinic days. Service delivery data was collected and summarized using standard MOH tools. Results From June 2010 to December 2011, 304 people were tested for HIV and 6% were found positive. Cumulatively 52 (48 active) patients have received HIV care (18 new) and 37 of them are actively on HAART (20 new). Patient retention is 92% and 87% have disclosed their serostatus to their sexual partners. All patients have had a CD4 test and 6-month monitoring is regularly conducted. The patients have formed a vibrant support group for psychosocial support and economic empowerment. Conclusion With structured links to health systems and community involvement, sustainable models of outreach clinics for remote and hard-to-reach areas can be developed to achieve universal access to HIV prevention, care, and treatment. The approach has the potential to promote ART adherence, patient retention on care and treatment, and stigma reduction in the community., Background There is a sense of urgency to identify instruments that can promote the health and development of children in poor resource and high HIV prevalence areas of sub-Saharan Africa. This has led to a surge in technical programmes, such as cash transfers, whose new ideas and resources may not necessarily resonate with local support structures. This paper describes the effects of a community-led cash transfer programme in Manicaland Province, Zimbabwe, and explores how community members appropriated ‘techno-fixes’ in ways that benefits them and achieve buy-in. Methods We report on data from 35 individual interviews and three focus group discussions, involving 24 key informants, 24 cash transfer beneficiaries, of which four are children, and 14 non-beneficiaries. Results A thematic network analysis found the cash transfer programme to have had a substantial effect on children's schooling and education, mainly through improved access, concentration and ultimately performance, but also on their health and well-being, primarily through improved food intake, access to healthcare and reduced levels of stress and worry at a household-level. The programme was also said to provide the beneficiaries with an important platform to reduce levels of poverty, primarily through investment opportunities arising from having greater disposable income. Encouraged by local participation in the programme, conditionalities and witnessing its positive effects, both benefiting and non-benefiting community members spoke enthusiastically about the programme and highlighted their preference for conditional cash transfers-indicating community-wide buy-in and involvement. Conclusion We conclude that despite their invasiveness, cash transfer programmes can, if implemented through local community structures, be appropriated at a community-level in ways that facilitate health-enabling and supportive social environments for vulnerable children and youth in sub-Saharan Africa., Background The advent of UNAIDS “Treatment as Prevention” policy of global antiretroviral (ARV) scale-up is not only life-saving for HIV-positive health care users, but may also hold significant potential to improve health care worker clinical practices, professionalism, and workplace morale. This research investigates the impact of ARV service delivery programming on health care workers′ clinical practices and personal and workplace morale in a rural western Ugandan setting. Methods As part of a larger community study (N=142, 48% female), individual qualitative interviews were conducted with health care workers (n=15, 47% female) from Rwimi clinic in Kabarole District, during a four-month period. Clinic practices were also assessed through 40 hours of participant observation. Findings were coded and analyzed using Attride-Stirling′s Thematic Network Analysis, and further mapped for discussion using the Social World Triad, a conceptual model developed for this study. Results ARVs are seen as being a positive, helpful force which allows health care workers to re-frame their clinical practice and professional identity to one of mastery over the illness. Their representations of HIV/AIDS are correspondingly beginning to change, to that of an illness which is manageable and controllable with drugs, thereby providing health care workers with renewed hope and a sense of clinical competence not felt since before the HIV/AIDS era. Professional practice is improving through more positive clinical interactions between health care workers and clients, which could lead to improved health service programming uptake by the community. Conclusion The clinical use of ARVs has also improved the personal coping strategies, workplace morale, and professionalism of health care workers at this clinic. Such findings encourage increased advocacy and community outreach efforts regarding ARV service provsion, and suggest that ARVs could be utilized in concert with broader social and biomedical interventions and programming, as a social change agent to reduce stigma and improve health service uptake., Background As the efforts to tackle the HIV/AIDS pandemic have become increasingly more refined, the dialogue about the ways in which the local understandings of gender and sexualities and dynamics of stigma shape the success or failure of treatment and prevention efforts has come to the fore. This presentation examines one such example in which the complex social, political, and health entanglements affect—in differing and often unexpected ways—the efforts to provide HIV-related prevention and treatment services. Specifically, it provides a qualitative socio-political analysis of the debates around the emergence of an HIV-focused clinic in Mexico City, where after the approval of a local law more comprehensive health care services for trans individuals were also to be delivered. Methods It is based on fourteen months of ethnographic research in Mexico City conducted in two phases spanning 2009–2011. It draws on qualitative interviews, observations and analysis of relevant textual documents, and provides a qualitative “bottom-up” analytical approach to the gathered data. Results The results show that the emergence of a transgender health program delivered in what is known as the HIV clinic sparked a heated controversy between supporters and detractors. Due to the intersections between structural vulnerabilities and existing dynamics of stigma around HIV, many trans women—and particularly sex workers—prevented themselves from accessing HIV-related and other health care services available to them in this hospital. Many of them did not want to be seen as potentially HIV positive individuals, as this may have brought both negative social and labour consequences into their lives. Conclusion The predicament between accessing or not health services in a clinic tainted with stigma had direct implications for the successful prevention and treatment of HIV and other illnesses. This study supports the view that local sociocultural and political dimensions need to be fully considered when envisioning HIV-specific programs., Background The Division of HIV/AIDS Prevention (DHAP), Centers for Disease Control and Prevention (CDC) Legal Assessment Project is developing interdisciplinary public health law research (PHLR) methods to assess legal frameworks that can be barriers or facilitators to effective HIV prevention. Rigorous, reproducible methodology focusing on interpreting legal data and using epidemiologic research methods can facilitate translation of legal text into data useful for making structural programmatic decisions. Methods In the U.S., state law plays a preeminent role in shaping local HIV prevention environments. We conduct 50-state legal surveys across numerous legal domains. For each domain, preliminary research identifies existing legal data from academic and legal research institutions. Research protocols (search parameters, coding schemes, codebook, pilot phase, reliability/validity checks) are developed, followed by systematic data collection (typically WestlawNext™.) Periodic legislative tracking assesses policy diffusion across states over time. These data can be combined with secondary data (census, HIV incidence, etc.) for further quantitative analysis. Results We present results from three domains. 1) Reimbursement for HIV screening: 18 states reimburse for HIV screening in all populations, and 15 reimburse in some populations (August 2011) (Map 1). 2) Reporting of all CD4 and viral load laboratory results to state HIV surveillance programs for monitoring access to care and quality of care: 26 states plus D.C. specifically require reporting of all CD4 and viral load data (January 2012) ( Map 2). 3) Previous research on consistency of state laws with CDC HIV testing recommendations was updated: 46 states plus D.C. had laws consistent with CDC recommendations (January 2012) ( Map 3).Figure 1Deviations from Norm and Prioritised Areas for Capacity Building [Prioritized areas for capacity building]. MAMA+ Model Components. MAMA+ Case Management. Conclusion PHLR data characterize important structural barriers or facilitators to effective HIV prevention environments. Methods development is ongoing and may be translatable internationally or for cross-country comparisons where countries share a regional identity and where policy diffusion across state/national lines may be expected., Background Systematic efforts to develop a national GIPA policy can help change the HIV landscape towards improving the quality of life for PLHIV in Malawi. The GIPA Report Card, a measurement tool, which assesses the application of the GIPA principle in the national response to HIV, was conducted in Malawi to identify specific barriers and opportunities to involving PLHIV in the development of policies and delivery of programmes. Methods The Malawian Network of People Living with HIV conducted a nationwide assessment. The study included knowledge about the principle, PLHIV involvement in policy development at district level, inclusion of GIPA in the National Action Framework, universal access targets, and the involvement of PLHIV in research. The data collectors, all PLHIV, also visited institutions that have HIV workplace programmes. Results The respondents represented varied institutions: 33% PLHIV; 27% Civil Society Organisations, 14% government departments or other public institutions; 5% UN agencies; 9% International NGOs, 5% parastatal organisations; and 5% private sector. Respondents stated there were fewer efforts in ensuring that the principle is practiced at local and community levels. Inclusion of GIPA in the Malawi HIV Extended National Action Framework signals the increase in efforts by the government to embrace the principle. However, there is no proactive communication and outreach campaign regarding the principle. Stigma and discrimination remain the greatest barrier to the GIPA. Conclusion Malawi must increase awareness and funding to support activities highlighting the meaningful involvement of PLHIV and to address the barriers to the effective application of the GIPA. A multi-sectoral communication's strategy and systematic efforts to develop national GIPA guidelines would help to promote the involvement of PLHIV and contribute to the quality of Malawi's HIV response., Background HIV prevention in women is a priority identified in the National Strategic Plan for STIs, HIV and AIDS 2006–2010 and the Country Programme agreed between the Government of Nicaragua and the Population Fund United Nations taking note that Nicaraguan women are being increasingly affected by HIV. In order to contribute to the national response has developed an initiative to visualize this situation and promote the active participation of women with HIV in the national response to the increased incidence departments to advocate for the promotion and defense of human rights, including reducing the stigma and discrimination, and develop preventive actions to prevent other women from acquiring HIV. Methods Qualitative evaluation. Results 6 departments have women′s organizations and local references with HIV prevention and support for the capture and defense of human rights including access to treatment, care and support.Women with HIV at 3 CONISIDA integrated departmental and national CONISIDA, 5 Commissions to Fight AIDS, from civil society (CNLCSSC) and 6 Multidisciplinary Care Teams departmental hospitals.Coordination with various stakeholders and mobilizing key social sectors, around HIV prevention in women and the promotion and defense and guarantee of the rights of women with HIV enhancing hardly a social response is obtained as quickly and effectively with other actors. Conclusion The initiative developed has been proposed as a successful model to be incorporated in the national response to HIV. Their strategies: i) Strengthening the organization of women with HIV in their communities, ii) development of their capacities in advocacy, communication and addressing HIV with other women affected by the epidemic; iii) public advocacy decision makers to influence the reduction of stigma and discrimination and vi) the exchange of experience can be replicated and adapted to different contexts to be feasible to develop successfully., Background Despite the growing number of women infected with HIV/AIDS in China, insufficient attention to women living with HIV/AIDS in the Global Fund's strategy and structure continue to increase the vulnerability and participation of women. No expenses in the budget are designated for projects focused on women, and all 11 NGO representatives in the Country Coordinating Mechanism (CCM) are men. Methods The Henan Women's Network works to mainstream gender-based approaches into China's national AIDS strategy in order to help women gain improved access to HIV/AIDS prevention, treatment and care services. The Network used three major strategies to advocate within the national Global Fund mechanism as entry point for broader national advocacy: working with female PLWHA to conduct needs assessment, and strengthen collaboration between women's health organizations; submit recommendations and mobilize international organizations including UNWOMEN and UNAIDS to incorporate gender concepts into the revision of CCM regulations; and cooperate with the All China Women's Federation on gender rights awareness trainings for health departments, the Federation and female PLWHA. Results After incorporation of a gender strategy into the CCM regulations and a targeted call for applications from women, 40% of 2011 CCM NGO consultants are women. Their increased participation in decision-making process will further the development of gender-based approaches in budget and strategy. Conclusion Actual needs of women living with HIV/AIDS have been successfully passed on through a local grassroots network. Integrated support from international organizations, the government, scholars, experts and community organizations was instrumental in achieving consensus in a gender-based strategy. Moving forward, capacity-building for women living with HIV/AIDS need to enable greater participation, and needs assessments will need to clarify suitable targets for women. Budgets promulgated by the CCM need to define specific expenses to implement gender-based strategies., Background Rwandan women and girls are disproportionately impacted by HIV and comprise the largest percentage of those infected. Progress has been made to promote gender equality and women's participation in decision-making. However, women living with HIV (WLHIV) remain underrepresented in the national HIV response. Experience shows that HIV policies and programs often fail when women are excluded from shaping their content and direction. Methods The authors examined three case studies to determine best practices for ensuring meaningful involvement of WLHIV (MIWA): (1) National Accelerated Plan for Women, Girls, Gender Equality and HIV (2010–2014); (2) EC-UN Women “Supporting Gender Equality in the Context of HIV/AIDS” program; and (3) National Strategic Plan for the Elimination of Mother-to-Child Transmission of HIV (2011–2015). Results Participatory processes (workshops, focus groups, and in-depth interviews) involving women, including WLHIV, were used to identify key priorities, activities, and HIV strategies for the National Accelerated Plan (2010) and eMTCT Strategy (2012). The EC-UN Women project fostered HIV-positive women's leadership through training, technical assistance, advocacy planning sessions, and the development of formal mechanisms within national AIDS coordinating bodies that include women. These case studies demonstrate that WLHIV's active participation in national HIV policies and strategies development increases their visibility and ensures that their needs and rights are prioritized (e.g. requirement of future participation of women and girls in national HIV decision-making). Such practices enable WLHIV to be directly involved in implementation, monitoring, and evaluation of strategies they helped to develop (e.g. by aligning their own programs and budgets to the National Accelerated Plan). Conclusion These Rwandan cases highlight MIWA's positive impact and the need for concentrated commitment to actively involve WLHIV in decision-making. Deliberate programming is needed to ensure that women and girls are empowered and equipped to transform national agendas to protect and promote their needs and rights in the HIV context in all countries., Background The UK is currently reforming its benefits system to encourage people with health conditions to return to work. However, research indicates that unscrupulous employers were using pre-employment health questionnaires to discriminate against people with health conditions in the recruitment process. Research from 2006 found that when a non-disabled person and a disabled person who disclosed their disability applied for the same job, non-disabled applicants were invited to twice as many interviews. Research also shows that fewer than 50% of people diagnosed with HIV in the UK are in employment. Methods NAT brought together a coalition of organisations including mental health and HIV charities, to campaign to prohibit the use of health questionnaires before a job offer. The Equality Bill was identified as an appropriate piece of legislation to outlaw the use of these questionnaires. Media coverage of the impact of discrimination on people living with HIV and mental health conditions raised the profile of the campaign. The coalition submitted evidence to Parliamentary Select Committees including international examples and secured cross party support for the campaign in the House of Commons. After initially rejecting the idea, the Government met with the coalition and representatives living with HIV to listen to our concerns. Results The Government accepted the evidence presented by the coalition and tabled an amendment to the Equality Bill prohibiting the use of pre-employment health questionnaires. The Equality Act came into force in October 2010 and it is now unlawful for employers to ask health related questionnaires before a job offer. This is a significant step forward in ending discrimination in recruitment for people living with HIV. Conclusion There are significant gains to be made in building coalitions with organisations supporting people with other health conditions that face similar stigma and discrimination to campaign to reform legislation., Background The crises of preventable maternal death and HIV are interrelated. In Uganda, a country with HIV treatment coverage rates of 47%, 16 women die unnecessarily in childbirth daily, one in five new HIV infections is through vertical transmission, and untreated HIV contributes to 25% of preventable maternal deaths. In addition, stigma as well as lack of basic health equipment such as gloves for midwives contributes to reluctance of health professionals to attend to HIV positive mothers, particularly in remote areas. Methods Civil society networks in Uganda formed a diverse coalition to implement a legal and advocacy strategy to challenge the epidemic of preventable maternal death in Uganda. Combining a Constitutional Court challenge with a challenge in the court of public opinion, the coalition used grassroots mobilization, media work, budget monitoring and advocacy in Parliament to create a common platform for health justice advocacy, prioritizing issues ranging from HIV treatment access to the shortage of nurses. The multiple factors that contribute to preventable maternal death, including HIV, created multiple opportunities for high impact civil society advocacy. Results This new civil society coalition has been able to break down walls between disease- and condition-specific advocacy and implement bold campaigns to scale up access to essential health services in Uganda. In one year, the coalition has supported an historic legal challenge on the right to health and preventable maternal death; has successfully advocated for increased investments in increased professional health worker recruitment, remuneration and equitable deployment; and has generated national and international press attention to the human right to health in Uganda. Conclusion We have developed an approach to advocacy in Uganda that joins civil society focusing on a wide range of diseases and conditions in synergy. Uniting around key policy opportunities has resulted in important progress in the struggle for health for all., Background The purpose of the study was to identify barriers to and opportunities for evidence-based policy on illicit drugs in four sub-Saharan African countries-Tanzania, South Africa, Nigeria and Ghana. Small-scale studies indicate that HIV transmission is linked to injection and non-injection drug use in all of these countries. Methods A policy case study for each country was developed through in-person semi-structured interviews with key informants, including policy-makers, academic experts, NGO representatives and representatives of international organizations. Results The lack of population-based data and trend data on the extent of drug use and drug injection is an impediment to policy-making, leading to denial at policy levels. In all four countries, the law allows the police wide latitude in search, seizure and arrest of people accused or suspected of committing minor drug crimes, who can receive long prison sentences. Except in Tanzania, there are very limited affordable options for evidence-based drug treatment, especially of opioid dependence. Pressure from the US and other external actors to demonstrate interdiction successes may contribute to the domination of the policing-based drug policy. South Africa's drug policy-making has been walled off from HIV policy-making bodies. Ghana is seeking to generate population-based data on the extent of drug injection as health authorities bemoan the weakness of mental health and drug treatment services. Conclusion Criminalization and policing dominate drug policy in most of these countries, impeding evidence-based responses to HIV. There is an urgent need to build capacity among policy-makers and civil society to rethink entrenched policing-based approaches to drug use and to raise awareness of affordable evidence-based services for people who use drugs. The advances made in Tanzania's methadone program, including new awareness by the police of the importance of public health approaches, should be an occasion for learning across the continent., Background Cameroon is among the 22 countries with the highest burden of PMTCT unmet needs. In response to the global commitment to eliminate new infections among children and keep their mothers alive, Cameroon decided to develop a bold PMTCT scale-up plan aligned with the global MTCT elimination targets. To develop an evidence based plan, the MoH with support from its partners conducted an analysis of programme bottlenecks, disparities using an innovative tool based on marginal bottleneck budgeting (MBB). Methods The tool was used to analyze bottlenecks and disparities on the demand and supply of MNCH and PMTC services. Key steps included: advocacy and consensus building on the methodology, key tracer interventions; consensus on bottlenecks and disparities, causal analysis and identification of corrective actions. Results Key bottlenecks are presented in table 1. Geographical, socio-cultural and economic disparities were also observed between and within regions (see fig 1 and 2). Strategies and interventions to address these bottlenecks include: 1) capacity building of community actors for the promotion of integrated PMTCT/SMNI, 2) strengthening procurement and supply management system, 3) quality assurance of PMTCT service delivery, 4) strengthening monitoring and evaluation. Conclusion The bottleneck analysis has proven to be a powerful method for identifying and analyzing disparities and factors impeding the performance of MNCH and PMTCT programmes. To generate accurate information and draw relevant conclusions quality data are a prerequisite. This was one of the major challenges which were addressed by actively collecting data by field actors. Choices and decisions on key bottlenecks should be based on their potential impact on programme performance, relevance and feasibility of corrective strategies, and availability of resources for action. Participation of all level-stakeholders from the onset of the process increases ownership, and recognition of findings. Results from the analysis were precious inputs for the development of the national mother to child transmission elimination Plan. The plan provides a framework for strategic vision and coordination for all actors and is therefore a structured road map to achieving the set targets for PMTCT by 2015., Background The demand for effectiveness swept through the international community raising expectations about results and their impact. None has been more affected than CSOs. Despite being at the front-lines of the international response to HIV/AIDS, these efforts were not always evaluated. This evaluation of the community response asked: Do communities with a strong community engagement show: (i) better knowledge, attitudes, perceptions and behavior, (ii) greater access to and utilization of HIV/AIDS services, and (iii) social transformation? Methods Given the complexity/variety of community responses, the approach selected involved several countries, studies and methods. Experimental and quasi-experimental methods measure community results looking for changes in knowledge, behaviors, utilization of services and health outcomes with indicators related to prevention, treatment, care, support and mitigation. Quantitative and qualitative data from CBO/NGOs/households were collected and analyzed to better understand social transformation and the findings. Results Eleven studies were conducted in 8 countries (2009–2011) (Burkina Faso, Kenya, India, Lesotho, Nigeria, Senegal, South Africa, Zimbabwe). Strong casual evidence shows that specific community interventions can affect the course of the HIV epidemic through increased HIV knowledge and reduced stigma, and increased condom use, testing uptake, treatment adherence and use of services. Example: (i) community empowerment increased services utilization among FSWs in India (p, Background The U.S. Food & Drug Administration prohibits men who have sex with other men (MSM) from donating blood. The policy does not consider the potential donor′s HIV status, sexual activity, or relationship status. The current policy allows other populations at elevated risk of HIV to less restrictive deferrals, or no deferral at all. This type of policy reinforces incorrect information about the spread of HIV. Most countries have permanent deferrals of MSM blood donors despite chronic blood shortages. Reform of U.S. blood donation guidelines is necessary to maximize blood donations and improve blood safety protocols. Methods Advocates, including public health and blood bank communities, blood product recipients, and NGOs, have pushed for a more equitable policy. In May 2010, GMHC joined with leading hemophilia advocates, who also represent a population disproportionately impacted by HIV, to raise awareness of blood donation guidelines in agreement that: the current deferral of all MSM results in a large number of potentially eligible blood donations; and that there are some high-risk activities permissible from heterosexual donors under the current policy. Both perspectives were presented to the Advisory Committee on Blood Safety and Availability (ACBSA) in June 2010. Results The ACBSA recommended that sufficient data were not present at that time to change the policy banning MSM, that current blood donation guidelines are “suboptimal”, and that a robust research agenda be pursued in order to carefully examine alternative policies. Government agencies are now implementing the ACBSA's recommendations to identify a subset of low-risk MSM blood donors. In tandem with U.S. momentum for reform, a number of other countries, including the United Kingdom, have made reforms to their policies to allow MSM to become blood donors. Conclusion International momentum to revise blood donation guidelines for MSM advances efforts to maximize blood safety, increases blood donation, and decreases stigma of MSM., Background Political leadership is known to affect HIV prevention and treatment. In this presentation, we aim to show the dimensions of political governance that are associated with ART coverage using country-level data. Methods Percentage of ART coverage from 2004 to 2009 as estimated by UNAIDS is analysed as the outcome measure. High-income countries as defined by the World Bank in 2009 are excluded from the analyses. Measures of political governance and GDP per capita (log-transformed) from the World Bank, adult literacy rate (UNESCO, reflected and log-transformed), gender inequality index from World Development Report 2011, skilled birth attendance at delivery compiled by World Bank (reflected and log-transformed) and disability adjusted life years (DALY) due to non-HIV causes and international (HIV and non-HIV) health funding per capita from the Institute of Health Metrics and Evaluation were fitted separately as predictors in multi-level linear models, in which year of reporting or estimation and HIV prevalence from UNAIDS are included. Missing data were imputed for fitting a final model that includes year, HIV prevalence and variables that remained statistically significant. Results Higher levels of ART coverage are significantly associated with higher GDP per capita (p< 0.001), lower gender inequality (p=0.003), higher literacy rate (p=0.011), higher percentage of births attended by skilled attendants (p=0.002) and less DALY due to non-HIV causes (p=0.033). It is also highly significantly associated with better political governance in all six dimensions( political stability, voice and accountability, control of corruption, rule of law, government effectiveness and regulatory quality) (p< 0.001). In the final model, only political stability and voice and accountability remained as statistically significantly associated with higher levels of ART coverage. Conclusion The analyses indicate that better political governance are crucial determinants of ART coverage in a country., Background The HIV and tuberculosis (TB) epidemics present unprecedented public health challenges. Antiretroviral therapy (ART) and the Three I′s for HIV/TB (isoniazid preventive treatment (IPT), intensified TB case finding (ICF), and TB infection control) are key interventions to prevent TB in people living with HIV (PLHIV). This article reviews the extent to which national HIV and TB guidelines for high HIV/TB burden African countries are consistent with current World Health Organization (WHO) guidelines. Methods The 14 African countries with 62% of the estimated global HIV/TB burden were identified from WHO estimates. Recommendations on ART initiation criteria and the Three I's for HIV/TB from national HIV, TB and HIV/TB guidelines were reviewed and compared with current WHO recommendations. Results Of the 14 countries, eight (57%) and ten (71%) follow WHO′s recommendation to provide ART at CD4 counts≤350 cells/mm3 in asymptomatic people and pregnant women, respectively. Seven (50%) countries recommend ART in people with HIV and TB irrespective of CD4 count. All countries have guidelines on the Three I's for HIV/TB. All 14 countries except Zimbabwe recommend IPT for six months, and ten of them follow symptom-based screening to rule out active TB. However, the WHO four-symptom screening algorithm is not yet widely recommended. Nine, eight and five countries have monitoring and evaluation indicators for ICF, IPT, and TB infection control, respectively. In the 14 countries, 38% of 8.4 million people eligible for ART were receiving it and 61,997 people without active TB were on IPT. Conclusion WHO and country guidelines on ART and the Three I′s for HIV/TB are largely consistent and reflect a common approach to addressing HIV and TB. However, there is a significant gap in implementation of the guidelines. Further scale-up of existing programmes and implementation of policy recommendations are required to address the HIV/TB syndemics in the countries examined., Background Gender inequalities are a key driver of the epidemic, yet despite this being recognised for many years, global policies to change these often have had little effect. Using the UNAIDS’ Agenda for Country Level Accelerated Action on Women, Girls, Gender Equality and HIV which is its flagship gender and HIV policy as a case study, we explore the barriers and facilitators of the Agenda's development and implementation, to understand the strengths and limitations of gender policy better. Methods We conducted semi-structured interviews with 16 southern African and global gender and HIV/AIDS policy makers, researchers and activists who had been involved in the development or implementation of the Agenda. We analyse their responses using thematic analysis. Results Barriers to the development and implementation of the Agenda included the lack of resources and tools to development and implement the policy; the lack of participation of women in grassroots organisations, despite this being a pillar of HIV and gender policy; and a lack of political will to see the policy translate into meaningful programmes and change on the ground, despite significant visible support from key actors in UNAIDS. Yet positively, the Agenda also provided a collaborative platform for women's organisations to develop and common language to prioritise women and girls and ensured consistent and strong language around this emerged. Conclusion Our study suggests that despite the Agenda being the ‘flagship’ policy on women and girls in the context of HIV championed by UNAIDS, there remain significant weaknesses in how the Agenda was developed and is being implemented. These challenges are reflective of the wider field of gender and HIV and reflect the limited real commitment that is often placed around challenging gender inequalities in the response to HIV., Background We reviewed the laws of the 50 states and compiled those vocational and professional licensing laws (e.g. for licensure to be an acupuncturist, barber, massage therapist, midwife, cosmetologist, nurse practitioner, doctor, dentist, etc.) that discriminate against people living with HIV/AIDS and/or those with a communicable, contagious, or infectious disease. Methods The statutes, regulations, and cases were identified in Westlaw using the following search terms: “HIV,” “Human immunodeficiency virus,” “communicable,” “contagious,” “infectious,” and “disease.” The volume includes laws that explicitly discriminate against people living with HIV/AIDS (PLWHA) as well as laws that do so implicitly through restrictions concerning communicable, contagious, or infectious diseases. While we did attempt to include all relevant state law, this does not promise to be an exhaustive list. Results The results of this survey reveal a deeply rooted HIV stigma that has been embraced by policy makers in a majority of the states. Thirty-five of the fifty states have licensing requirements that explicitly discriminate against people living with HIV/AIDS for one or more of the fifteen vocations considered here, and forty-four states have requirements that either discriminate against PLWHA or discriminate against people living with infectious, communicable, or contagious diseases. These laws lack any basis in the science of HIV transmission, and maintaining them only validates the ignorance and bias that spawned them. Conclusion Licensing criteria that discriminate against people living with HIV/AIDS violate federal law. States that allow these discriminatory laws to remain on the books are ignoring scientific consensus and promoting HIV stigma. If PLWHA in the United States are to enjoy the same employment opportunities that other individuals enjoy, then states must examine their licensing procedures and alter or remove any discriminatory requirements until all licensing practices are in compliance with the Americans with Disabilities Act and guidance from the Department of Justice., Background The southern United States has the highest numbers of adults and adolescents living with HIV and the highest death rates from AIDS. Numerous southern cities are in the top ten for HIV infection rates. Yet state laws and policies fuel the epidemic and exacerbate pervasive stigma and discrimination. Methods This long-term, multi-method investigation is based on hundreds of interviews with people living with HIV and AIDS, their advocates, public health officials, legislators, judges and medical providers, as well as extensive legal and policy analysis. Results Multiple state laws and policies create an ‘environment of risk’ that has made the South the nation′s leading region for both HIV infection and deaths from AIDS. In the South, where poverty levels are the highest in the nation and fewer people have access to health insurance state policies are contributing to the disproportionate impact of HIV on minority communities. The failure to invest in public health, Medicaid and HIV-specific programs, particularly housing and transportation for a rural population; insistence on failed abstinence-based education; criminalization of HIV exposure; homophobic laws that drive MSM and transgender people underground and away from essential health services and the highest incarceration rates in the nation are some of the human rights violations that undermine public health efforts and fuel the epidemic in southern states. Conclusion Laws and policies in the southern U.S. are undermining human rights and conflict with the goals and objectives of the National HIV/AIDS Strategy. This interactive session will identify strategies for challenging these policies at the federal, state and local level., Background Ukrainian National HIV/AIDS Prevention Program (NAPP) envisages 20,000 people on opioid substitution treatment (OST) by the end of 2013. WHO estimates 53,000 IDUs shall be placed on OST to provide adequate response to HIV/AIDS epidemic. Ministry of Health (MOH) is only organization regulating number of OST patients. MOH determines number of OST patients in its distribution orders (DO). OST targets set by MOH DO are much lower than annual NAPP indicators and indicator of GFATM Rd 6 funded Program run by ICF “HIV/AIDS Alliance in Ukraine” (AU) for 2012 as it shown on Diagram #1. Map 3. Methods 6650 patients were getting OST in 133 healthcare institutions in all regions in January, 2012. All patients receive treatment and psychosocial support for free within GFATM Rd 6 funded Program. Though OST procurement is budgeted in NAPP OST medications have never been bought from state budget. OST is regulated by MOH and other executive bodies in clumsy manner. It takes up to 7 months to issue new OST DO. State Service on narcotic control (SSNC) allowed importation of only 55% of methadone envisaged by MOH DO in 2011. SSNC is intended impose lower domestic methadone quota for 2012 than needed for OST scale up under NAPP.FigureVillages in Zimbabwe with more people in community groups have greater HCT update. 2003–2008 (N=184). Results Ukrainian State demonstrates double standard policies towards scaling up of OST. Ambitious OST NAPP targets were proclaimed but MOH applies inadequate efforts to achieve those targets. Diagram#2 demonstrates that OST expanded on 10% only over 2011 comparatively to 303% in 2008 and 131% in 2009. Conclusion AU is overcoming double standard policies towards OST scale up. AU collaborates with National AIDS Center (NAC) which is one of MOH compartments and our implementation partner within GFATM Rd 10 funded Program. This partnership is aimed to build NAC capacity for OST provision, ensure OST scale up and sustainability., Background This study examines how HIV/AIDS funds, including vertical Global Public Goods for Health (GPGH), might be leveraged to contribute to production of horizontal GPGH through health system strengthening. Specifically, it addresses the following questions: 1)How can vertical (disease-specific funds) be used to decrease the impact of funding asymmetries between vertical and horizontal GPGH and support the production of horizontal GPGH? 2)How would complementary activities be evaluated with regard to their contribution to health system strengthening? Methods Global Fund grant information was used to examine the extent to which HIV/AIDS grants are currently contributing to system strengthening and capacity building at the national level beyond their disease-specific areas and if the inclusion of health system strengthening components influences grant performance. In addition, a framework is developed to evaluate the contribution of HIV/AIDS programs to the production of GPGH through the horizontal strengthening of national health systems. Results In the bivariate analysis, the number of health system strengthening components was significantly related to performance. However, as more variables were added the significant disappears. The grant characteristics significant across the models were grant duration and region. While the results regarding the positive association between health system strengthening components and grant performance are inconclusive, the inclusion of health system strengthening components doesn′t appear to interfere with a grants ability to meet its disease specific performance targets. Conclusion The results from this analysis indicate the need for additional research to examine the relationship between health systems, health system strengthening, and HIV/AIDS program performance. The critical step would be to examine how the national subsystems are contributing to the international level through governance, financing or provision of goods and services related to GPGH. Diagram#1. Diagram#2., Background In most of the three decades since HIV appeared in Central America resource scarcity have limited the response. The HIV spending analysis it's been used for advocacy to mobilize international and public resources. National aids expenditure assessments (NASA) 2010 sheds evidence on the need to review the political agenda of resources in pursuit of higher levels of sustainability, equity and effectiveness.FigureSignificant use of prevention and any HIV Services by study communities as compared to ‘comparison’ communities. Methods NASA is a technique based on health accounting principles, extended to multi-sectoral responses to HIV, according to the resource needs model (RNM). With USAID PASCA support and by Health Ministers Council Agreement, six Central American countries developed NASA 2010, with a harmonization strategy based on research questions guiding design, data analysis and interpretation; tabular and graphical outputs, both relevant and feasible for all countries, and guidelines for data validation and participatory discussion of results.National AIDS Spending in Central American Countries. Results Except Belize, countries with higher HIV per capita spending in Central America are not those with higher HIV prevalence but those who have: a) health systems with mainly public financing, or b) large Global Fund grants. In both cases, most of the funding goes to medical interventions, people living with AIDS and general population. Spending on key populations at higher risk for HIV exposure is minimal, although the epidemics are concentrated, with high prevalence among gay men, sex workers and Trans. Antiretroviral spending is about U.S. $ 26 million, with few countries monitoring length of survival and quality of life since treatment initiation.National Aids financing by source in selected countries. Conclusion There are sharp contrasts in financial position of the response to HIV in Central America. NASA 2010 showed evidence that will put these issues on the political agenda of countries and define an updated and more effective financial strategy., Background PEPFAR South Africa saw a 2008 government policy shift in HIV opening doors to more formal collaborative planning and greater transparency in implementation of donor-supported programs. In 2010, PEPFAR commissioned a national survey to catalog i) geographic location of partners and sites and ii) human and financial resources used for implementation. This dynamic online reporting, graphing and mapping tool is called the PEPFAR Inventory and is accessible freely on the Internet. Its purpose is to provide strategic information to monitor implementation of the PEPFAR Partnership Framework between the United States and South African Governments.National Aids spending by Beneficiary Population. Methods Data were captured into a single database and 6,600 sites were geocoded using open source tools. Sites were then assigned to sub-districts, municipalities and provinces using additional open source proprietary software. A combination of open source software was used to create searchable maps. Results The Inventory is integrated with results and budget data which will be linked to targets. This will make it possible for the PEPFAR Inventory to monitor achievement and US Government investment across the country. Cluster maps enable program managers to view program coverage. MapGuide software provides an interface to display various data sets comparatively, such as population and HIV prevalence, pin-maps per agency, prime partner, site type, site ownership and program area. Viewing which partners are working in the same geographical and programme area helps to avoid duplication of effort. Conclusion The Inventory, developed by the USAID-funded Enhancing Strategic Information Project implemented by John Snow Inc., is a critical tool for monitoring the Partnership Framework. Aggregated provincial data can be integrated with other datasets at similar geographical levels to determine if PEPFAR resources are distributed to respond to the needs of the epidemic. It is envisaged that HIV/AIDS activities of other donors will eventually be linked to allow better coordination and more effective targetting., Background Since 2004, the HIV Vaccines and Microbicides Resource Tracking Working Group has employed a comprehensive methodology to track trends in R&D investments and expenditures for biomedical HIV prevention options, including HIV vaccines, microbicides, PrEP, treatment as prevention and adult voluntary medical male circumcision. Methods R&D data were collected on annual disbursements by public, private and philanthropic funders for product development, clinical trials and trial preparation, community education and policy advocacy efforts in order to estimate annual investment in HIV prevention R&D. Investment trends were assessed and compared by year, prevention technology type, funder category and geographic location. Results The period from 2000 through 2010 saw significant growth in funding support for HIV prevention research and development. However, in 2011 HIV prevention research began to see increased funding pressures as governments worldwide decreased or flat-lined budgets in global health and as philanthropic donors worked to revise their investment strategies. Funders also had to deal with greater competition among funding priorities within the field of HIV prevention and with other major global disease needs. Despite various pressures, HIV prevention research progressed significantly in 2011, with new findings and promising new trials. Conclusion Monitoring funding trends for HIV prevention research is particularly important in this time of economic uncertainty, especially as the scientific community has articulated a clear path to the end of the HIV epidemic. Such monitoring permits identification of investment needs, prioritization of research areas and assessment of the impact of public policies that increase or decrease investment. It also provides the fact base for advocacy around spending levels and allocations that will sustain investments in the research required to build on the success of recent trials; bring novel HIV prevention candidates into the pipeline; and, support follow-on clinical trials needed to assure the safety, immunogenicity, efficacy and acceptability of new HIV prevention products. Map 3., Background Sao Huang (elimination of prostitution) in China is an important public security effort to eliminate prostitution by imposing harder punishments on FSWs. Despite of the growingly intensive intervention from health department, HIV infection among female sex workers in Kunming remains high, at the level between 1.6 and 4.0% in 2009, syphilis infection at 12% and other STIs at 51% in 2006. Convincing evidences are needed to concert policies from public security and health departments. Methods The research was carried out jointly by the Kunming CDC, FSW peer workers and university volunteers, in four populated urban districts in Kunming China. In the initial phase, an estimation of FSWs was conducted. The second phase included literature review of policies, laws, regulations and practices related to Sao Huang, with special attentions drawn to Women's Education Center, a facility created under the public security system to detain FSWs arrested in Sao Huang. The third phase was a study on the lives of FSW and impact from Sao Huang particularly related to health service accessibility. Face-to-face interviews, focus group discussions and questionnaires were carried out to cover 561 FSWs. Results Extensive discrimination already hampers FSWs’ rights to health information and services. Sao Huang efforts have furthered such obstacles. Sao Huang is also a main driving factor for FSWs to move to ‘safer’ locations, increasing FSWs’ invisibility thus weakening service accessibility. Sao Huang promotes distrustful relationship and tension between FSWs and public service departments, including that of health provision, which makes it even more difficult for health department to access FSWs. Conclusion Sao Huang is a wide-spread national policy which needs to be restructured in order to adapt to the growing needs for HIV response in China. The research group is organizing evidences from the research to draft a paper advocating for changes in this particular policy., Background The enabling legal environment has long been identified as critical to rights-based responses to HIV. In the 2011 Political Declaration on HIV/AIDS, UN Member States committed to supporting legal services as well as monitoring the impact of the legal environment on HIV prevention, treatment, care and support. Research shows that legal services in developing countries remain under-resourced, of variable quality, ad hoc and reactive, often with poor case documentation and weak links with the Health and Justice Ministries. Methods A study on HIV and legal empowerment was commissioned to place the program in a broader access to justice paradigm. In each country, a comprehensive needs analysis or an environmental scan was undertaken to determine the needs, available services and gaps in HIV-related legal services. A local organization already providing legal services was given technical and financial support to improve quality and scale up, including documentation of their work. Regional and international consultations were held to promote sharing on management challenges, and substantive issues such as criminal law, needs of women and girls, and access to treatments for HIV. An independent end of program evaluation was undertaken in early 2012. Results A review of results in program countries and other contexts revealed success factors such as: engagement of outreach workers to create demand for services; women friendly and child friendly services can increase uptake; opportunities exist to mainstream HIV-related legal services into existing government services; service (such as child care) can increase access and assist sustainability, particularly for female clients; technical assistance can improve case documentation and hence advocacy for science-based policy and law reform. Conclusion Legal empowerment and access to justice approaches are essential elements of the enabling legal and policy environment for the response to HIV. They are needed to help take prevention, care, treatment and support to scale., Background Existing prostitution policies directly affect an individual's ability to protect oneself from risk of HIV/AIDS in terms of access of services and ability to negotiate safety. We examine the policies as they are written, but also from the perspectives of those they are directed toward. This panel offers an explicit analysis of policy related to sex work, prostitution, and trafficking through the perspectives of sex workers, including the criminalization of prostitution in general as well as specific policies and practices (i.e., Condoms as Evidence (DC), Prostitution Free Zones (DC), and End Demand (Chicago). Methods Our goal is to analyze policy through direct communication (in-depth interviews, surveys and case studies) related to criminalization of prostitution in general with a focus on specific policies including Condoms as Evidence, Prostitution Free Zones, and End Demand Campaigns. Our research includes 34 in-depth interviews, 50 surveys, and 6 case studies and is representative of Washington, DC, the southwest and northeast areas of the country. Results Trafficking and prostitution policies undermine HIV programs and the health of those individuals toward whom they are targeted becauseStigma and fear discourage sex workers from seeking out health services, which can further endanger the worker as well as his/her clients and partners.Quick and risky negotiations with clients because of criminalization leads a worker to operate from a less empowered place from which to negotiate specific sexual activities safelyNew anti-trafficking legislation criminalizes organizations if they provide certain services to a person they believe is trafficked but don't take the person to the police Conclusion Existing policies must be analyzed with these questions in mind and revised/reframed to place individuals' safety and health at the forefrontSex worker and sex worker rights activists must be at the forefront and integral to these discussions and reworking of policies., Background In many countries police practices are dramatically out of sync with declared government policies to prevent HIV by promoting access to condoms. Police confiscation and destruction of condoms held by sex workers and outreach workers impair sex workers’ access to condoms. Police treatment of condoms as evidence of criminal activity and as tools for extortion threatens sex workers’ ability to safely carry condoms and negotiate their use with clients. Methods In a joint research effort, community groups in Kenya, Namibia, Russia, South Africa, the United States, and Zimbabwe administered detailed questionnaires to 139 sex workers and 40 outreach workers. Results Research revealed that police routinely stop and search sex workers and confiscate their condoms. In some locations, police destroy sex workers’ condoms by burning them, cutting them up, driving on them, or throwing them in the garbage. Police confiscation and destruction of sex workers’ condoms increases their vulnerability to HIV. Sex workers reported having unprotected sex with clients after police took their condoms. In some cases, police use condom possession as justification to detain or arrest a person on charges of engaging in sex work, or as leverage to extort bribes or sexual favors. Sex workers sometimes do not carry condoms or refuse condoms from health care providers because they fear condoms will get them in trouble with police. Police further impede sex workers’ access to condoms by surveilling and harassing outreach workers and taking or destroying condoms meant for distribution. Conclusion Policing practices are undermining messages of condom accessibility and acceptability crucial for disease prevention and the promotion of individual and public health. Policing tactics and guidelines must be brought into alignment with international best practices to prevent HIV. As a first step, governments should eliminate laws that criminalize sex work and other structural obstacles to police reform., Background Due to the current legal frame work of sex work in Bangladesh sustainable HIV prevention interventions among Female Sex workers (FSWs) is a major challenge. It is clear from experience gained so far that social marginalization & disempowerment that characterize FSWs community are the key vulnerabilities that need to be addressed before any interventions related to HIV can be successfully adopted by them with ownership. Methods The first ever national congress of FSWs in Bangladesh organized by Save the Children was participated in by 1000 FSW around the country from 29 FSWs networks. They discussed legal and policy issues related to sex work and its consequences. This allowed an opportunity for shared experience from leading national, international organizations working with FSWs for last 20 years to have an analysis of the legal framework of sex work among Bangladesh. Results Hotel or Street, in any settings FSWs are not in a legal position to say no and or insist client for negotiating safe sex. According to anti- prostitution law two or more FSWs cannot work together which interferes with the ability to form collective resistance to violence, abuse & unsafe sex. On the other hand Police and Municipality law creates fear of Arrest hinders community outreach and FSW is hidden: this means it is difficult to identify, contact & build trust and avoiding arrest prevails over safer sex. Also Police powers harasses peer educators, carrying condoms seen as ‘promoting', ‘soliciting' & ‘carrying on' sex work. Due to criminalization of Brothels prevention program cannot ensure 100% condom use, frequent raids disrupt HIV services. Conclusion The legal and policy framework requires radical restructuring to reduce legal sanctions and social marginalization and allow capacity building will work for sex workers community to build a sustainable HIV AIDS program in partnership with other stakeholders including government in Bangladesh., Background In the past several years FTA negotiations have proliferated across the developing world. Why have PLHIV been protesting these FTAs and what provisions do they contain that could really impact access to medicines? Is this all conjecture or is there evidence to show the impact? Methods FTAs negotiated by the EU, US and Japan were examined. Chapters on intellectual property have been analysed. Evidence from FTAs already in existence and their impact on access to medicines was collected. FTA negotiations with India, Malaysia, Vietnam, Thailand, Brazil and South Africa were covered. Results Although there are some variations in the intellectual property provisions demanded in FTAs by the EU and US their primary aim is to decrease the space for generic production of medicines including ARVs. Provisions like data exclusivity (a new monopoly on off-patent medicines), extention of patent terms beyond 20 years, enforcement measures that will have a chilling effect on generic production, interfere with judicial independence and put shipments of medicines at risk of being seized feature in these FTAs. In addition the investment chapter puts government actions to ensure access to medicines or provision of healthcare at risk of MNC's legal cases filed in private, international arbitration. Conclusion In 2001 the price of ARVs crashed from $10,000 per person per year to $350. In 2001, governments around the world signed the Doha Declaration stating that international trade rules on intellectual property should not come in the way of providing access to medicines for all. FTAs go well beyond these international trade rules that are already resulting in higher prices of newer ARVs and medicines for Hepatitis C. Understanding the nitty gritty of the demands made in these FTAs is crucial to effective advocacy on the FTAs and for the proper involvement and consultation of PLHIV and health groups by their governments., Background There has been widespread concern about the impact of patents on access to low-cost generic antiretroviral (ARV) drugs in low- and middle-income countries (LMIC). Patents can hinder competition, which has provided sustainable price reductions for the older generation, less-widely-patented ARVs. However, until recently, limited data on patent status in developing countries hampered a full understanding of the implications of pharmaceutical patenting in these countries. Methods We compared patenting trends for 12 molecules invented pre-1995 and 12 invented post-1995, the year the WTO TRIPS Agreement came into force. We used data from the Medicines Patent Pool ARV Patent Database, the most comprehensive and regularly updated source of such information, providing information on 69 countries accounting for 84% of PLHIV in LMICs. We analyzed trends regarding: the number of molecules for which patents were applied for in a given territory, the number of LMICs with ARV patents, the expected date of patent expiration, and the implications for the development of and access to fixed-dose combinations (FDCs). Results Since 1995, pharmaceutical companies are filing for patents in a greater number of LMICs and for a greater number of molecules, such that newer ARVs are more widely-patented than older drugs. A patent on just one drug in a 2- or 3-drug FDC can pose barriers for accessing the entire FDC, and such patents can pose problems in up to 80% of territories for which data was available. Conclusion Since 1995, pharmaceutical companies are filing for patents in a greater number of LMICs and for a greater number of molecules, such that newer ARVs are more widely-patented than older drugs. A patent on just one drug in a 2- or 3-drug FDC can pose barriers for accessing the entire FDC, and such patents can pose problems in up to 80% of territories for which data was available., Background The french speaking countries of African ‘have been struck the hard by the pandemic. In recent years, however, the governments have made concerted efforts in combating the disease. With the support of international organisations programs on treatment, care and education have increased. However, a recurrent problem has been the difficulties of making HIV/AIDS medicines accessible. Stringent intellectual property laws act as a stumbling block to access to HIV/AIDS medicines. Methods Presentation of a panoramic view of the problems created by stringent intellectual property laws and how they affect access to HIV/AIDS medicines. Analysis of various approaches to facilitate access to HIV/AIDS medicines. Proffering recommendations for reforms. Results Demonstrating that the patent regime of the Bangui Agreement to which most Francophone African countries have signed is hampering access to HIV/IADS medicines and that there is an urgent need for reform. Conclusion Though the coming into force of the WTO and the TRIPS Agreement ushered in a new dynamic on when and how countries had to use certain measures to provide, promote and protect access to HIV/AIDS medicines, french speaking African countries still have certain limited policy spaces for which to manoeuver and improve access to medicines. Most of them are signatories to international and regional treaties which creates rights to health obligations. Subsequent developments after coming into force of TRIPS have tended to tilt towards supporting access to medicines. The sad problem though is regional policy incoherence and countries’ entering into treaties with TRIPS plus provisions. Fortunately, international law provides enough justification for enacting access to medicines pieces of legislation. Making maximum use of TRIPS flexibilities, incorporating human rights perspectives in intellectual property treaties, forging a strong alliance with civil society are just some of the measures needed by french African countries in increasing access to HIV/AIDS medicines., Background Over the past decade, the issue of counterfeit medicines has been seen as a burgeoning public health concern, requiring immediate action. Some decisionmakers have advocated for addressing the counterfeit issue through legislative measures targeting intellectual property enforcement. During this process, the term “counterfeit medicine” has been defined in ambiguous and confusing ways that have numerous legal interpretations, and thus intended and unintended consequences. One particular issue is the conflating of counterfeit medicine with generic drugs, which has and will continue to impede access to generic ARVs in developing countries. Methods My study consists of a political and legal analysis of three anti-counterfeiting efforts and their impacts on access to generic ARVs in developing countries, with a particular focus on East Africa. Results My analysis begins with a brief discussion and overview of some definitions of counterfeit medicine used by WHO and under the TRIPS agreement. The analysis will then explore anti-counterfeiting efforts in Kenya, in the East African Community, and in Anti-counterfeiting Trade Agreement (ACTA). I then explore an example in each context of how these measures have or will impede access to generic ARVs in developing countries. Conclusion Based on this analysis, the anti-counterfeiting measures examined pose a real and dangerous threat to accessing generic ARVs in developing countries. The counterfeit definitions used conflate generics with counterfeit medicines. Thus, a clearer and more concise definition of counterfeit is needed to avoid negative implications for generic ARVs. Finally, the real public health concern at issue here is addressing the safety quality and efficacy of medicines, and anti-counterfeiting measures do not adequately address these concerns. Therefore, rather than trying to deal with substandard medicines through intellectual property rights enforcement, other policies need to be developed that not only address the real issue, but also do not pose a threat to accessing generic ARVs., Background Since 2006, Brazil has attempted to negotiate lower prices with the patentee of Efavirenz in two grounds: a) EFZ was being sold at more affordable prices in countries with the same level of development and with less people in need of treatment than Brazil; b) generic versions were much cheaper. Considering the Brazilian policy of universal access of ART for PLWH, the offer of reducing 30% on the drug cost was still unsatisfactory (US$ 1,14 per pill). Methods Comparison of prices and case study aproach. The reference price of comparison was the last proposed by Merck for Brazil in 2007 of US$ 1,14 per pill. The total savings presented exclude the 1,5% of royalties that Brazil paid due to the Compulsory Licence. Results The government strategies to maintain a sustainable coverage of treament for those in need allowed firstly to issue a compulsory licence to import generic versions of EFZ, and thereafter to estimulate local production by the government industries. The savings with EFZ 200mg, purchased of international generic supliers, were of US$ 1.042.568,99; with EFZ 600mg, imported of international generic suplies, of US$ 63.992.537,16 and with EFZ 600mg locally manufactured of US$ 29.763.749,72. Amounting to a total saving of US$ 94.798.855,87 from 2007–2011. Conclusion The economic savings that were enabled with the compulsory licence were essential for the increased access to Efavirenz in Brazil. It is important to emphasize that the adoption of mechanism also boosts the strenght of the government to negotiate prices of other medicines and to stimulate the capacity of national pharmaceutical production and the transferring of technology., Background Morocco is facing a rising HIV epidemic among people using drugs (PUD). HIV prevalence among PUD ranks from 7% to 38% according to recent studies as HIV prevalence in general population is estimated to be 0.1%. This major change in epidemic pattern led Moroccan stakeholders to pay more attention to PUD. A first national harm reduction (HR) strategic plan (2008–2011) has allowed some needles and syringes programs as well as methadone for 80 people out of other HR services. But PUD are facing legal and social barriers acting as potential barriers for access to HIV prevention, care and treatment. Country is in need to assess those barriers in order to design a more comprehensive approach to mitigate and reverse HIV among PUD. Methods National HIV/AIDS community based organization ALCS has managed a cross sectional study in 3 North cities. 300 PUD recruited through outreach programs were asked to answer a questionnaire including 9 questions designed to assess human right violation from police officers, health professional and closed environment. Human right violation was defined as a break in national endorsed civil rights or break in national health good practices. Results 99.8% of PUD have been victims of at least one of those 9 violations with following sub scores: 87% from police officers (eg. non legal custody) and 49% from health professional (eg. non access to emergency hospital units). 60% has faced situation closed to human exploitation with drug smugglers or other PUD (including sexual intercourse against drug). Famility is also a major cause of human right violations. Conclusion Human Right should be considered as a central component of HR interventions in Morocco. At a time the country is designing HR scaling up it could improve PUD access to health services and alleviate family burden., Background In Macedonia, sex workers are among the most discriminated communities. Due to self stigma and no trust in the system, our experience shows that SWs almost never report perpetrators or demand protection via litigation. This made us aware about the complexity of raising awareness to litigate cases of human rights breaches. In November 2008 a systematic human rights violation by state happened when 23 SWs were unlawfully arrested and forcibly tested for HIV/HepC. Seven SWs were found HCV positive and criminally charged. Encouraging sex workers to demand justice, HOPS developed a complex model of legal, psycho-social and media support. Methods After the incident, HOPS created intervention team of lawyer, outreach worker, social worker and psychologist for free information and support for emotional trauma and possible lawsuits. For the first time 13 SWs raised 2 court cases against institutions and media, and defended themselves in the criminal case. 3 years after, 2 cases finished, 1 is ongoing, but the SWs successfully resisted fears and remained motivated to follow through. Consequently, 7 criminally charged SWs were sentenced on parole, and the civil suit against state institutions was won. Results SW in Macedonia are at risk for rights violation. Strategic litigation is a powerful protection tool, and while free legal aid is crucial, effective support should address emotional and other aspects of marginalization and resisting the state without fearing victimization. Trusted outreach and social workers, skilled psychologists and peer support must be part of the supportive model, involving the media and allies to create supportive environment. Conclusion Promoting the success of this model nationally and regionally, in order for organizations working with marginalized groups to adopt it in motivating them to report violence and use disposable mechanisms, including litigation. These positive outcomes will empower SWs in our country to seek justice., Background HIV criminalization laws are championed as protecting women. But HIV-positive women are increasingly prosecuted under these laws, resulting in unique violations of their sexual, reproductive and parental rights. 38 U.S. states and territories have criminal HIV exposure and transmission laws that increase HIV stigma and hinder HIV testing. Yet few tools exist to support anti-HIV-criminalization advocates, especially women. Methods In 2011, the Positive Justice Project (PJP) - a consortium working to end abuses of the criminal law against HIV-positive people - conducted community forums focused on HIV-positive women in four states with active HIV-specific criminal law prosecutions: Louisiana, Kansas, Missouri, and Illinois. HIV-positive advocates, public health officials, and attorneys attended. Local advocates, especially HIV-positive women, engaged to reframe the HIV criminalization conversation. Panels of local and national experts opened each forum and provided legal advocacy tools - fact sheets, model legislation, and “know your rights” cards - to eliminate local HIV criminal laws. Participants then developed advocacy strategies. Result Since October 2011, 125 people have been reached through PJP forums; thousands more through PJP and partner websites. PJP forums increased community knowledge of the impact of HIV criminalization laws on women, and provided general and women-specific advocacy tools to build an infrastructure at the state level to monitor and challenge existing laws. With technical assistance from PJP, HIV-positive women founded local advocacy groups in the four forum states to eliminate state criminalization laws; began monitoring criminal prosecutions and discriminatory practices; and put a woman's face to the consequences of HIV criminal laws. Conclusion HIV-positive women's engagement in turning the tide of the epidemic by personally advocating for elimination of criminal HIV exposure and transmission laws has increased awareness of the breadth of the laws' harms. Further policy research and political will is needed to support advocates to fight discriminatory criminal laws., Background The established critique of criminalizing HIV exposure/transmission focuses on issues of public health impact and human rights. Although important, this critique offers little guidance on how to practically oppose criminalization in local settings. Successful advocacy requires developing a literature on the impacts of strategies undertaken by advocates in various jurisdictions. This paper contributes to that literature through an analysis of the social organization of criminal law reform in Ontario, the centre of Canadian HIV-related prosecutions. Methods This paper is based on the experiences of members of the Ontario Working Group on Criminal Law and HIV Exposure (CLHE), a key participant in advocacy against criminalization in the province. Drawing on a studies in the social organization of knowledge perspective (Smith, 1990), it systematically identifies the key factors shaping CLHE's activities and reflects on the outcomes of CLHE's principal strategies. Results CLHE has emphasized the dissemination of research and political lobbying to create a stronger presence, in the criminal justice system, of scientific evidence on factors that reduce HIV transmission risk (a key element of the legal test in cases of HIV non-disclosure). Four initiatives have been key: (1) The mobilization of criminal defence lawyers and the identification of qualified expert witnesses have resulted in favourable judicial decisions; (2) a campaign to establish prosecutorial guidelines has been an effective community mobilization tool, but has stalled at implementation due to lack of provincial buy-in; (3) a proactive media campaign has, for the first time in Canada, generated widespread favourable mainstream media coverage of opposition to criminalization; (4) political lobbying has helped prevent harmful interventions in 2 cases recently heard by the Supreme Court of Canada. Conclusion Science-based criminal law reform led by a community organization can enhance legal defense, mobilize allies and impact media coverage, but faces challenges of engagement with provincial criminal justice authorities., Background The HIV epidemic has raised new and complex legal challenges, leading to a wide range of judgements on HIV-related matters. Given the diversity of issues and the quickly evolving science, judges need more opportunities to take stock of developments relevant to the cases before them. If properly informed and supported, the judiciary can help create the legal and social environment necessary to roll back the HIV epidemic. Methods An advisory committee of sitting and retired judges, judicial trainers, and legal experts from around the world was constituted to inform the scope, format and content of the handbook. Issue experts prepared chapter outlines and draft texts which were shared with the advisory committee for detailed feedback. The final text includes case summaries, key principles, plain language explanations of the science and treatment of HIV, statistics, and factors to consider when adjudicating cases. Results The result is a comprehensive and user-friendly handbook for the judiciary, suitable for use as a reference manual and in judicial training sessions throughout the world. Issues addressed include: discrimination, criminalization of HIV exposure, sexual assault and domestic violence, drug policy and the rights of people who use drugs, women's rights in family and property law, HIV-related treatment and healthcare, key populations at higher risk of HIV exposure, and judging during the HIV epidemic. Conclusion The handbook for judges is a unique resource with significant potential to provide judges with a contextualized understanding of key HIV-related issues, and thus improve rights protections for people living with and affected by HIV. This potential will be maximized through judicial training sessions and commitment by governments to include the judicial sector in strategies to attain universal access. The tools and training needed by judges are distinct from existing HIV-related resources therefore targeted, sensitive approaches are needed., Background It is well-documented that discrimination in women's access to property and inheritance hinders an effective response to HIV. However, in southern Africa, where HIV prevalence still remains high, numerous laws on property and inheritance rights explicitly discriminate against women. Law reform efforts are slow and in many cases have been ineffective resulting in discriminatory laws remaining in place. Approaching courts through litigation as a means of striking down such laws is underutilized in southern Africa. Methods In an attempt to accelerate the revision and/or striking down of laws discriminating against women in property and inheritance rights, we are using litigation before domestic courts to effectively strike down laws that discriminate against women with respect to property and inheritance in southern Africa. Results A number of cases have been filed. A case challenging a customary law rule denying women the opportunity to inherit from their father's estate is in the Botswana High Court; the Lesotho Constitutional Court will hear a challenge to a law denying women the right to succeed to chieftainship; and the Malawi Constitutional Court is expected to issue a decision on whether courts are permitted to only take monetary contribution to property into account when determining property distribution at the time of divorce. In each of these cases, the relief sought is a change in the discriminatory law. In all cases, the countries have constitutional provisions protecting women from discrimination. Decisions in the cases are expected by June 2012. Conclusion Law reform measures are critical to revise laws that facially discriminate against women with respect to property and inheritance rights. However, for relatively fast and effective reform, more advocates should approach courts asking them to strike down discriminatory laws., Background The HPTN 052 study authors randomized 1763 HIV-serodiscordant couples ( HIV infected partner CD4 count of 350–550/mm3) in 9 countries (8 LMIC) from June,2007–May, 2010 into an “early-therapy group” (median CD4=442, treatment started at enrollment,) and a “delayed-therapy group”(median CD4=428, treatment delayed until CD4 count ≤250 or development of AIDS).Subjects with a current/previous AIDS defining illness were excluded.WHO Stage 3 subjects were eligible; baseline viral load was not an exclusion criterion. Results were released, based on data collection to February 21, 2011 with 90% of couples enrolled a median 1.7 years. The study was designed and occurred while ARV initiation guidelines were evolving giving rise to 2 questions: researchers′ duty to offer subjects treatment at trial onset or mid-trial according to current guidelines and use of the word “early” to describe the study results. Methods The dates and recommendations of country /international guidelines for ARV initiation were cross checked against the study period, inclusion /exclusion criteria and triggers for “delayed-therapy group” treatment. The 052 study protocol was assessed against recognized international research guidelines. Results Tables 1 and 2 show that during the 052 study period, contemporaneous country/international guidelines for ARV initiation recommended substantially earlier triggers for treatment than those used in the 052 “delayed-therapy group”. The use of the 052 word “Early” relative to recommended treatment triggers is not reflective of those contemporaneous guidelines. Table 3 shows that the 052 study protocol may be inconsistent with international research ethics guidelines.Table 1ARV Country Guidelines052 Country GuidelineYearARV Initiation RecommendationGuideline Met for 052 “Delayed-Therapy Group”Botswana2008WHO Stage 3NoBrazil2008Clinically significant symptoms suggestive of advanced disease (not AIDS) or CD4 200–350 when VL > 100,000NoIndia2007WHO Stage 3 with no CD4 Consider if WHO Stage 3 and CD4 < 350NoKenya2005WHO Stage 3 and CD4 < 350NoMalawi2008WHO Stage 3 regardless of CD4NoSouth Africa2010CD4 < 350 + TBCannot DetermineThailand2010Asymptomatic with CD4 < 350 HIV-related symptomatic (not AIDS) with CD4 of any valueNoUnited States-DHHS2009All patients with CD4 < 350NoZimbabwe2007WHO Stage 3 with no CD4 Consider treatment with WHO Stage 3 and CD4 < 350No Table 2ARV International GuidelinesInternational GuidelineYearARV Initiation RecommendationGuideline Met for 052 “Delayed-Therapy Group”International AIDS Society-USA20082010All patients CD4 < 350All patients CD4 < 500NoNoWHO/UNAIDS2010All patients CD4 < 350No Table 3Research Ethics GuidelinesReseach Ethics GuidelinesEthics Guidelines/Recommendations052 Compliance with Guidelines/RecommendationsWMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects (2008)- Research subject wellbeing takes precedence over all other interests.- When research combined with medical care, research study will not adversely affect health of research subjects.NoUNAIDS/WHO Guidance Document: Ethical Considerations in Biomedical HIV Prevention Trials (2007)Internationally recogznized treatment regimens, including ARVs, must be accessible to subjects who become HIV-infected during a trial.Cannot determine treatment availability and follow-up of 052 subjects who sero-converted during trial.UNAIDS Guidelines for Biomedical HIV Prevention Trials (2010 Draft and 2011 Final Version)Research teams may need to modify their HIV care and treatment access plans in line with updated national guidelines.No Conclusion The 052 “delayed-therapy group” did not receive ARVs in accordance with national/international guidelines. The 052 descriptor “Early” is inaccurate relative to standard ARV initiation guidelines. According to contemporary research ethics standards the wellbeing of subjects should be paramount, requiring provision of the current standard of treatment to clinical trial subjects-in this case to the “delayed-therapy group”., Background HIV testing is a major part of HIV prevention efforts across the globe. In US and World Health Organization (WHO) HIV testing guidelines, opt-out testing has replaced voluntary confidential testing as a means of combating low rates of HIV testing. The success of opt-out testing is not assured, particularly due to financial, legal, operational, and cultural barriers, such as limited reimbursements for testing, obstructive laws that require written consent, limited access to healthcare, and poor compliance by care providers in testing patients perceived to be low-risk for HIV infection. Alternative methods of promoting HIV testing warrant analysis in comparison to opt-out testing. Methods HIV testing policies were hypothesized empirically and identified in the scientific and popular press. Each method was analyzed for consistency with WHO policy on HIV testing, which emphasizes the '3 Cs' of proper human rights-centered HIV testing. These conditions require that HIV testing must be: confidential, complemented by counseling, and informed, voluntary consent. Results We identified incentivized testing, anonymous mandatory testing, and names-based mandatory testing as alternatives to voluntary confidential and opt-out testing. Incentivized testing, in which a person's “willingness” to be tested is rewarded, e.g., with money, is voluntary but potentially coercive to those of lower socioeconomic status. Incentivized testing is in limited use but large-scale implementation would need to be names-based in order to avoid significant fraud. Anonymous mandatory testing using de-identified codes that allow verification that a person has undergone HIV testing preserves confidentiality but is involuntary. Names-based mandatory testing violates confidentiality and volition. Conclusion Though each HIV testing policy provides counseling, opt-out testing remains the only ethical approach for the promotion of HIV testing as it avoids coercion and loss of privacy. Financial, legal, operational, and cultural barriers to greater uptake of opt-out testing must be removed so that ethically unacceptable HIV testing policies are avoided., Background Study participants are reimbursed for transport costs incurred when travelling for clinic visits. Reimbursement also compensates for time spent in the clinic and is important for participant motivation and retention. In impoverished communities, determining adequate reimbursement is challenging. Under-compensation leads to low recruitment/retention rates, high mortality and missed trial endpoints. Ethical Committees cap reimbursements as overcompensation leads to undue influence. We sought to examine reimbursement practices, their impacts on costs and study participation in an ongoing tuberculosis vaccine trial. Methods Mothers in rural Western Kenya were approached to recruit their infants. Once enrolled, they come for seven scheduled visits and an average of two unscheduled/sick visits in a span of two months. Reimbursement was set at a rate of $4 per visit regardless of distance and cost incurred. Distances to clinic were measured by study staff. Furthest distance covered is 30km costing $6. Where the reimbursement rate was unacceptable to the mother given cost or critical study visits would be missed, mothers were ferried to clinic by designated vehicles at a cost of $18 per subject. Results Of 144 participants enrolled after 7 months, 57(40%) were under-compensated when compared to the costs incurred in attending study visits and expressed dissatisfaction with amounts reimbursed. Of these, retention rate was 99%.118 of sick participants attended clinic and 30(20%) sought care elsewhere due to cost. Participant satisfaction was not measured. Conclusion High retention rates were achieved despite under-compensation but at a cost three times higher compared to cost of directly reimbursing the mothers. Given the challenges of conducting trials in areas with limited infrastructure, there's need for continuing dialogue between investigators and Ethical Committees regarding amounts given to participants which may be based on a gradient of reimbursement according to distances travelled. There's room for educating mothers/participants on research ethics and non monetary research participation benefits., Background Ensuring informed consent is a complicated component of research, particularly with HIV prevention research conducted in poor settings. An inherent challenge characteristic of the informed consent process for HIV prevention studies is making sure that subjects understand that participation does not increase exposure to HIV and does not necessarily protect them from HIV. It is important to continuously monitor the informed consent process. Methods In June- September, 2011, gender-specific in-depth interviews (n=20) were held with interviewees who had been purposively selected from participants who had exited a vaginal HIV prevention study in Harare, Zimbabwe. An interview guide was used to elicit views around the informed consent process. Discussions were conducted in mother tongue and audio-recorded. Audio-recorded data were transcribed, translated verbatim into English, coded using NVivo 8 and analysed using grounded theory principles. Results Key information about study was given, as subjects articulated study aims well. However, it appeared that the informed consent process had been rushed and some participants had not had enough time to decide. Moreover, some participants reported that due to both excitement and anxiety, they had felt pressured to sign consent forms before comprehending some aspects of the study. Some mentioned that they had found it difficult to ask questions about the study. Both the study procedure and duration had not been fully explained. There were mixed feelings on importance of male partner involvement in decision-making around study participation, with some feeling that spouses should have been involved and others stating that partner consultation did not matter. Conclusion This study elicited some of the issues that characterise the informed consent process for clinical trials conducted in poor settings. It also highlighted the need for researchers' ingenuity in order to come up with strategies that tailor the informed process to suit the specific needs and circumstances of individual participants., Background Conducting community-based research with people living with HIV requires maintaining both individual and collective ethical standards. Research teams need to be cognisant of individual and community conceptions of informed consent, risks and benefits, and confidentiality. Although much has been written about challenges to obtaining ethics approval for HIV CBR, there have been fewer opportunities to describe ethical issues which emerge over the 'life' of these projects. This presentation addresses this gap by describing the ethical tensions which emerged during an HIV CBR study conducted in a hospital setting. Methods Using a case study analysis, this presentation draws on field notes, minutes from team meetings, and reflexive memos to offer a critical chronology of decisions made to improve ethical practice in one HIV CBR study. Various disciplinary (nursing, social work, public health) and stakeholder (clinician, coordinator, researcher, participant) perspectives are highlighted and contrasted to show how 'ethics' was understood and negotiated. Results We discuss the range of issues that emerged at the intersections of HIV, drug use, negotiating clinical space, and piloting innovative arts-based methods. Issues of cognition and HIV required the use of a multi-step informed consent process. Research team members balanced the need to support participants with reminders while being conscious of not creating undue pressure to participate. Maintaining confidentiality proved challenging because of the way space and time are managed in a clinical setting. The sensitive nature of the study and proposed group data collection necessitated changing the study design from group to individual data collection techniques to protect confidentiality. Interestingly, this happened despite having undertaken preliminary community consultations to determine the best approach. Conclusion Our findings highlight the importance of understanding and integrating both individualistic and communitarian ethical concerns, remaining flexible about design issues, and maintaining clear and open lines of communication between all project stakeholders., Background The implementation of this model comes from the minimum interventions of the Peruvian health system towards HIV/AIDS positive children and adolescents. The objective is to establish a program that provides children and adolescents with a caring, quality and confidential service. The model would contribute to reduce stigma and discrimination towards this specific HIV/AIDS positive population in South Lima. Methods The implementation of the model required training sessions to HIV positive children and adolescents of poor families, family members of low educational level, some quechua speakers and teachers from local schools. The topics of the trainings were the following: 1) human rights, stigma and discrimination, 2) self-care for children and adolescents, 3) diagnosis management, 4) psychotherapeutic issues with family members. Teachers and community leaders participate on a specific training on sensitization and advocacy. Results 31 HIV positive children and adolescents were trained on self-care and human rights. 28 families of HIV positive children received psychosocial support and their capacities and knowledge have been strengthened. 45 community leaders are more knowledgeable and sensitive on topics related to HIV/AIDS stigma and discrimination and can reproduce the training. 73 teachers are trained on topics related to HIV and children, stigma and discrimination and reproduced training to students, family members, in order to reduce rejection of HIV positive children and adolescents within their communities. Conclusion HIV/AIDS positive children and adolescents are more assertive and self-confident towards stigma and discrimination. Families and fathers of HIV positive children and adolescents are prepared to assume responsibilities, self-care and care of their children. An informed community and school would strengthen the process of reduce stigma and discrimination and reinforce adherence to treatment., Background In the 2000s, France's policy on illegal drug users has become increasingly stringent. The National AIDS Council wanted to assess the impact of this punitive policy on risk reduction policy targeting drug users, notably injection drug users. Methods Around thirty hearings were held with representatives of the relevant authorities (Ministries of Home Affairs, Justice, and Health), HIV/AIDS control associations, associations specialized in addiction and related issues, and drug user self-help groups. A review of the literature was also undertaken. Results Policies on illegal drugs have focused on strengthening sanctions against drug users. From 2001 to 2007 the number of arrests for drug offences increased by 106%. Accusations relating to drug use represented 85% of all offences during the period in question. Consequently, the cost of this punitive policy, estimated at 590 million Euros in 1995, is now much higher. In comparison risk reduction policy seems to be underfunded. Risk reduction centers have a budget of 30 million Euros and are only present in three-quarters of French counties (départements). Furthermore, this punitive framework means risk reduction tools, notably those targeting women, young people, people in detention, vulnerable users, and injection drug users have not been sufficiently diversified. Conclusion The punitive policy on drug users has been made a top policy and budget priority, with risk reduction policy relegated to second place. This policy has hindered the development of pragmatic risk reduction measures, such as medically supervised injection centres, or prison-based needle exchange programs, adapted across the country to support the most vulnerable populations., Background In 2003, France adopted a law against procuring and soliciting in order to discourage the practice of prostitution. The National AIDS Council wanted to assess its impact on sex workers in terms of prevention. Methods Around thirty hearings were held with representatives of the relevant authorities (Ministries of Home Affairs, Social Affairs, and Health), specialist police units and associations involved in the subject: associations campaigning and working on health and community health, social reintegration, abolition of prostitution, and sex workers' unions. A field investigation was also carried out within a community health association. Finally, all gray literature was analyzed. Results The 2003 law has undermined sex workers, the majority of whom are foreigners, without directly protecting the victims of procuring. Accusations against sex workers multiplied twenty-fold in the first half of the 2000s, before dropping slightly. There has been no increase in accusations for procuring. The activity has shifted to more isolated locations, under clandestine conditions with greater exposure to violence. The prevention work carried out by community health associations has become increasingly difficult, partly due to uncertainties regarding the availability of subsidies. The police and health authorities have not managed to cooperate effectively. Conclusion The introduction of a punitive law has complicated prevention work targeting sex workers. In a hostile legislative context, it seems important to support and reinforce community health actions by means of a comprehensive approach combining prevention, access to health care, social and human rights., Background HIV infection is higher among sex workers than in the general population, yet sex workers often lack access to HIV prevention services. A police practice that interferes with HIV prevention is using condoms as evidence of prostitution. Methods A multi-method investigation of the practice of using condoms as evidence of prostitution was conducted in New York City, Washington, D.C., Los Angeles and San Francisco between October 2011 and April 2012. In-depth interviews with hundreds of sex workers, their advocates, outreach workers, police, prosecutors, judges, and public health officials were conducted, combined with legal and policy analysis. Results Police engage in the routine and widespread practice of using the presence of condoms on individuals to profile them as prostitutes, to threaten arrest and as a basis for arrest on charges related to prostitution. In San Francisco, police and city regulators use condoms as a basis for arrest in clubs frequented by transgendered persons, in massage parlors and other businesses. In New York City, prosecutors introduce condoms into evidence to support prostitution charges. In Washington D.C. police confiscate condoms found on persons they identify as sex workers. In Los Angeles, sex workers follow what they believe to be the “three-condom rule”, fearing arrest for exceeding a routinely enforced limit. In each city these practices take place in a wider context of police harassment and abuse of sex workers and those perceived to be engaging in sex work, including verbal and physical degradation and other misconduct. Transgendered women and LGBT youth are particularly targeted. Conclusion Human rights abuses make some sex workers less likely to carry condoms, particularly those most vulnerable to arrest, such as undocumented immigrants. The criminalization of condoms interferes with the right to health and undermines public health objectives of universal access to disease prevention., Background Many jurisdictions continue to inappropriately prosecute people living with HIV (PLHIV) for non-disclosure of HIV-positive status, alleged exposure and non-intentional transmission. Although most HIV-related criminal cases are framed by prosecutors and the media as being cases of ′deliberate′ HIV transmission, the vast majority have involved neither malicious intent nor has transmission actually occurred or the route of transmission been adequately proven. Methods This global overview of HIV-related criminal laws and prosecutions is based on latest data from GNP+ Global Criminalisation Scan and media reports collated on criminalhivtransmission.blogspot.com. Final ranking will be based on the total number of prosecutions by July 1 2012 per 1000 PLHIV. Results At least 63 countries have HIV-specific criminal laws and at least 48 countries have used HIV-specific (n=19) or general laws (n=31) to prosecute HIV non-disclosure, exposure or transmission. Despite growing national and international advocacy, prosecutions have not diminished, particularly in high-income countries, with the greatest numbers in North America. Since 2010, prosecutions have taken place in Belgium and Republic of Congo for the first time. In 2011, although HIV-specific laws were suspended in Denmark and rejected in Guyana, Romania passed a new HIV-specific criminal statute. In Africa, the continent with the most HIV-specific criminal laws but with few known prosecutions, Guinea, Togo and Senegal have revised their existing HIV-related legislation or adopted new legislation in line with UNAIDS guidance. Conclusion Given the lack or inadequacy of systems to track HIV-related prosecutions in most places, it is not possible to determine the actual number of prosecutions for every country in the world. These data should be considered illustrative of a more widespread, but generally undocumented, use of criminal law against people with HIV. Improved monitoring of laws, law enforcement, and access to justice is still required to fully understand impact on HIV response and PLHIV., Background In Canada, the exposure and/or transmission of HIV is punishable by criminal law. The objective of this study was to investigate the impact of HIV/AIDS criminalization on awareness, prevention, and stigma as outlined in the literature and from the perspectives and experiences of stakeholders in the HIV sector in Ontario, Canada. Methods For the scoping review, we searched 11 databases, and reviewed (in duplicate) the results for any articles addressing topics related to HIV criminalization. We then identified stakeholders (policy/content experts, executive directors and frontline workers from community-based HIV/AIDS organizations) and invited a purposive sample to participate in one-on-one, semi-structured interviews. Results The search yielded 1301 results; 147 articles were included, most of which were case reports, editorials, commentaries and essays (n=136), with only 11 primary studies. Interviews explored perspectives on criminalization and its impact on prevention efforts, community awareness of prosecutions, and stigmatization of people living with HIV/AIDS. Findings highlight confusion regarding behaviours constituting “significant risk,” resulting in difficulties in the application of legal precedent, as well as uncertainty regarding HIV knowledge in the general public. Findings also highlighted uncertainty regarding the behavioural changes attributable to criminalization, but suggest that it contributes to disincentives for testing and disclosure, fears of secondary disclosure and false accusation, strained therapeutic relationships, HIV related stigma, and barriers for promoting shared responsibility for safer sex. Participants recommended guideline development to ensure optimal use of criminal law in case related to HIV/AIDS non-disclosure. Conclusion This study provides further insight into the impact of HIV/AIDS criminalization in the community. Further research is necessary to characterize the impact from the perspective of people living with HIV/AIDS and to inform ongoing policy discussions., Background Sociologists have recently become interested in the rise in prosecutions across the country under criminal HIV disclosure statutes. These law vary in their specifics, but generally make it a crime for HIV-positive individuals to have sex without first disclosing their HIV-positive status. Yet, despite a number of sociological explorations of how HIV-positive individuals relate to these laws, we know very little about how these laws are actually applied on the ground. This paper addresses this gap by exploring how legal actors in Michigan trial courts struggle to frame disclosure cases in terms of medicine and/or the law. Methods Using a database of prosecutions provided by the Michigan State Police, this study analyzes court transcripts from forty prosecutions for HIV non-disclosure. The police dataset included the sentencing dates, counties, and the court′s disposition for cases prosecuted between 1992 (the year the law first was prosecuted) and 2010. In order to request their corresponding court transcripts, these data were cross-referenced with local news reports in order to identify the defendants. This research design was reviewed (and deemed exempt from further review) by the University of Michigan′s Institutional Review Board. Results I argue that these cases can ultimately be understood as a contest to frame the disease as disease or crime. Prosecutors frame defendants as what Thomas Shevory has called “HIV monsters” using legal discourses of negligence, harm, and morality. Their accusers, on the other hand, are framed as undeserving and helpless victims. Defense attorneys attempt to diffuse these arguments by relying on medical discourses that frame disease as victimless and deserving of treatment, not punishment. Conclusion This analysis is the first empirical study to show how HIV disclosure cases are legally argued on the ground. Moreover, this study demonstrates empirically how medical problems become transformed into crime, a poorly understood social process., Background Laws criminalizing certain behaviors, and HIV non-disclosure, exposure and transmission are resurgent in developed and developing countries around the world. This study set out to understand how laws impact health seeking behavior and what coping mechanisms result amongst different key populations and to recommend policy changes. Methods A qualitative four-part questionnaire was developed and used in 27 focus groups carried out by community members during August and September 2011 in all regions of the world. More than 240 participants (51% PLHIV) from 32 countries, selected by their affiliation with a key population, took part in the study. Participants were asked non-identifying information such as HIV status, associated population group, gender, and housing situation. The hundreds of pages of feedback were analyzed for common themes across geographic region and population grouping. Common trends were then verified to develop key findings. Results Results show that individuals are being deterred from seeking health services when their behavior is criminalized. Evidence revealed that laws criminalizing HIV and certain behaviors promote the persecution of people living with HIV. HIV-specific criminal laws are reinforcing or increasing the stigma and discrimination that inhibit access to health services and undermine treatment. Evidence also demonstrated that legal protections for people living with HIV and key affected populations are insufficient or unenforced. Conclusion The current goals of accessing HIV prevention, treatment and care services are being undermined where the legal environment is unable to enforce laws protective of individuals at high risk of or living with HIV. Measures to be taken include: supporting anti-stigma and HIV education campaigns, specifically within the judicial system and amongst law enforcement; opposing and repealing HIV criminal laws; and promoting access to legal aid. Quantitative prevention research on HIV criminal laws and rates of HIV testing would be useful in statistically proving what was discussed in this study., Background In 2010, Action for Health Initiatives (ACHIEVE), Inc. conducted a research wherein evidence was found that the broad language of national anti-prostitution and anti-trafficking laws hinder effective HIV prevention initiatives among sex workers in the city. Considered as “victims”, sex workers are “rescued” while establishments are raided by police authorities using condoms as evidence of prostitution or trafficking. These hamper condom distribution and outreach activities of HIV prevention workers. Methods To address this issue, ACHIEVE, in partnership with the Quezon City Health Department (QCHD), held a series of consultative workshops, individual meetings and interfacing meetings with the Philippine National Police (PNP) officers, Quezon City Police Department (QCPD) officials and the local entertainment establishment organization in January 2011. The consultations sought to build partnership by forming memorandum of agreement (MOA) between QCPD and QCHD to end the conflicting law enforcement practice of using condom as evidence of prostitution. Results Bureaucracy, strict hierarchy within the Police Department and the very fast turnover of officials were identified as constraints in partnership-building with the police. However, the support given by the Quezon City Health Department and the sex work establishment owners association and the community help in convincing police officers and sensitizing them during the process despite their strong moral positions against sex work. After seven months, a MOA was drafted subject for adoption by PNP Chief of Police. Conclusion While the MOA was refused to be signed by the PNP Chief of Police, the process opened many doors for partnerships and for alternative next steps. These include increased support from the Quezon City STI/AIDS Council and garnered support from police officials of various QCPD and PNP offices who were not previously partnered with. The Quezon City Committee on Health also committed to provide support in implementing rights-based and issue-based HIV education among frontline police officers., Background The moralisation and criminalisation of sex work in Zimbabwe creates serious barriers to sex workers realising their rights. This research sought to examine the specific role played by the police in violating the rights of sex workers. The lack of rule of law means police have extensive powers and often act with impunity. This research sought to highlight the impact of the behaviour of law enforcement on the health and human rights of sex workers, particularly around the issue of condoms used as evidence of sex work. Methods Twenty-one sex workers and six outreach workers were interviewed in Bulawayo, Zimbabwe. The research considered the relationship between police and sex workers, specifically the confiscation of condoms. Results All 21 sex workers interviewed characterised their relationship with the police as bad, as 17 of the 21 sex workers cited harassment and intimidation from the police.17 of 21 sex workers said they had been arrested on charges related to sex work.Sex workers said that the police practice of confiscating and destroying condoms or harassing and arresting sex workers with condoms had affected their ability to negotiate condom use in a variety of ways.5 of 21 sex workers said police had confiscated their condoms.Those who had condoms taken from them, reported between 2 and 9 such encounters with police during the previous 12 months. Conclusion The Ministry of Justice should encourage interaction and dialogue between sex workers and organisations working with sex workers and law enforcement agents.The results also reflect the importance of ensuring that sex workers and organisations working with sex workers participate in the development of Zimbabwe's national HIV/AIDS Strategy.A government working group should be created to explore the decriminalisation of sex work., Background A significant body of work has examined the impacts of laws criminalizing commercial sex on sex workers’ health and safety. However, the impacts of laws criminalizing clients and third parties (i.e. managers, receptionists, cleaning staff …) on sex workers have hardly been documented. In Canada, sex work is criminalized through provisions against being found in a bawdy-house, running a bawdy-house, living on the avails of prostitution and communication for the purposes of prostitution. These are used to arrest sex workers, clients and third parties. Methods Stella is an organization by and for sex workers. The analysis of the impact of the different legal provisions criminalizing commercial sex on the health and safety of female and transgender sex workers specifically based on the street and in drug venues (i.e. crack houses, shooting galleries...) arises from available documentary data, reports on violent incidents through our aggressors’ list and also from our observations and personal experience. Results The criminalization of clients under the ‘communicating’ law places sex workers based on the street and in drug venues at greater health and safety risks by limiting their choice of clients and ability to negotiate safer sex, and causing displacement to dangerous and isolated areas far from HIV prevention and outreach services. The provisions against bawdy- houses create a greater risk of homelessness as it is grounds for eviction, including from social housing. Conclusion Often justified as “protecting” sex workers, the laws against clients and third parties actually place sex workers at greater risk, especially as they preclude the opening of safe indoor spaces. Take note that drug use legislations also increase these risks when discriminating sex workers., Background Food insecurity and HIV are part of a vicious and self-perpetuating cycle. In 2009, the World Health Assembly mandated the World Health Organization to report on global nutrition and HIV activities. However, the literature lacks definitional consensus for food insecurity in the context of HIV. Methods Using a standard literature review methodology, the aim was to describe and evaluate current definitions of food insecurity and measurement tools in the context of HIV. This study critically reviewed: operational definitions of food insecurity and its subtypes;clinical and survey measurement tools to assess food insecurity;program monitoring and evaluation tools to assess performance of food security interventions at the population-level. Results Epidemiologically validated tools have been used to measure food insecurity, hunger, and dietary diversity at the individual, household, and community levels. Some of these have been developed and validated in HIV-endemic countries. Examples of tools used with HIV-positive populations include household food insecurity scales and nutritional assessment measures such as dietary intake. Food safety, however, is seldom addressed in the HIV literature. Increasingly, there is a global movement towards integrating food security and HIV indicators across multiple organizations to strengthen program performance. With HAART expansion, profiles of food insecure people living with HIV/AIDS are shifting and measurements must reflect individual, social, and cultural factors such as over/under nutrition, resource constraints, food supplementation, literacy, and addiction. Conclusion Further research is needed to harmonize definitions of food security and its indicators in order to facilitate comparisons. Measurement tools need to be validated in both low and high resource settings, with different ethnic populations and genders and with HIV-positive populations to build a more comprehensive knowledge base., Background Ugandan guidelines recommend 6 months of exclusive breastfeeding (EBF) for HIV-infected women with continued breastfeeding (BF) for at least 1 year. Food insecurity has been posited to be a barrier to adherence to infant feeding recommendations. We therefore explored if greater food insecurity was associated with sub-optimal breastfeeding (BF) practices. Methods Data on food insecurity and BF practices and beliefs were collected among HIV-infected pregnant and BF women on antiretroviral therapy (ART) participating in the PROMOTE trial (NCT00993031) in Tororo, Uganda. Food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS). BF practices were determined using monthly maternal reports from a prospective cohort of 143 PROMOTE infants born between March 6, 2010 and October 9, 2011. Beliefs about food insecurity and BF were assessed using a purposive sample of 32 BF PROMOTE subjects who participated in in-depth interviews (IDIs) in July and August 2011. Results Food insecurity was very high; 82.5% were from severely, 14.7% moderately, and 2.1% mildly food insecure households. Median (inter-quartile range) HFIAS score was 17 (12–22). The prevalence of EBF was 89.5% and 66.9% at 3 and 6 months respectively; the prevalence of BF at 12 months was 84.1%. In multivariate logistic regression adjusting for socio-demographics and HIV-stage, the odds (95% confidence interval) of EBF at 6 months was 0.16 (0.03–0.86) for women in severely food insecure households compared to those in non-severely food insecure households. Consistent with this, IDIs revealed that BF participants associated insufficient nutritional intake with difficulties adhering to infant feeding recommendations: 75.0% were concerned about adequate breast milk production and 46.9% reported experiencing problems while EBF, e.g. unsatisfied baby. Conclusion Severe food insecurity is associated with suboptimal EBF. The mitigation of food insecurity may increase the duration of EBF among HIV+ women in rural Uganda., Background In resource limited settings (RSL) such as Haiti, people living with HIV/AIDS face great challenges in maintaining adequate nutrition.The evaluation of the benefits of nutritional supplementation(NS) programs on HIV clinic attendance among HIV infected subjects in developing countries is limited.This abstract focuses on the assessment of the rate of timely antiretroviral therapy (ART) visit attendance for a cohort of patients before food assistance, while receiving food assistance, and after receiving food assistance by using electronic pharmacy visit data. Methods Our study population included 2654 patients that received at least 6 months of ART prior to receiving NS between October 2007 and January 2011 at the GHESKIO Centers. Using pharmacy visit data, we calculated the number of late visits (at least 6 days after the scheduled visit date) during the 6 months before receiving NS from the World Food Program (WFP), during the approximate 6 months of WFP supplementation , and the 6 months after the receipt of WFP supplementation. Results Among 2654 patients, from a total of 4098 scheduled visits for the period : November 2007- December 2011: there were 1625 late visits during the 6 months period prior to NS which indicates that 39% of the scheduled visits were late visits , there were 1291 late visits during the 6 months of NS ie 31% of the scheduled visits were late visits, and 1135 late visits during the 6 months after NS ie 27% of the scheduled visits were late visits. Conclusion Our findings demonstrate that food assistance plays a key role in the regularity of the visits to the pharmacy, which is associated with ART adherence. NS should be part of the package of care and support offered to all patients on ART, particularly those with advanced immunodepression who are so desperately in need., Background UNHCR and its partners aim to ensure that refugees have similar access to HIV prevention, care and treatment services to that of local surrounding populations, and that HIV status is not used to discriminate against refugee rights to asylum, protection and assistance. HIV-related information is monitored systematically to ensure adequate protection and assistance to refugees. Methods HIV indicators collected routinely at the health facility level through UNHCR's Health Information System implemented in 21 countries where refugees live in camps, as well as review of indicators collected annually through HIV focal points at field level were analysed from 2008–2011. Results By 2011, 81% of pregnant women had access to PMTCT programmes compared with 53% in 2008. 89% of countries had camps with satisfactory universal precautions. 78% of countries were implementing interventions addressing at least one high risk group. The six UNHCR programmes directly managing a blood bank reported 100% of blood screened before transfusion. Fifteen countries reported implementing clinical management of rape survivors; 77% of survivors received PEP within 72 hours. The proportion of countries in Africa, Asia and South America where refugees have similar access to ART as host populations reached 91% by end of 2010. Advocacy against mandatory testing for HIV and for inclusion of refugees in country HIV National Strategic Plans remained stable. Conclusion Access to protection, prevention, care and treatment has increased in most of the 21 countries hosting refugees in camps. HIV programming in emergency and protracted situations is possible and effective., Background Given the importance of adherence to HAART for treatment success, our objective was to evaluate if refugees and the local host community attending a rural refugee camp clinic had acceptable adherence and virologic outcomes. Methods We conducted a cross-sectional survey among refugee and host community ART clients (≥18 years) in a rural camp-based clinic in Kakuma, north-western Kenya. Data sources included a structured questionnaire, a pharmacy-based measure of HAART prescription (Rx) refills over 24 months prior to study start, and HIV viral loads measured on dried-blood spots. Key outcomes were unsuppressed viral load (≥1000 copies/mL) and optimal adherence (≥95% Rx refill rate). Results In refugees and host clients, 85% (n=73) and 86% (n=86), respectively, of all clients not lost to follow-up (≥6 months without HAART Rx refill) participated. Median age (years, IQR) was 36 (31–41) vs. 32 (27–38) (p=0.02),% females was 67 vs. 66 (p=0.91), median time on HAART (weeks, IQR) was 156 (43–264) vs. 139 (34–225) (p=0.43), first available CD4 (IQR) was 196 (136–320), n=61 vs. 198 (119–289), n=76 (p=0.28). Most clients (63%) were taking zidovudine, lamivudine, and nevirapine (twice-daily). Similar proportions of refugee and host clients on treatment for≥25 weeks had unsuppressed viral load (88% vs. 89%, p=0.92; 89% overall). The proportion optimally adhering to pharmacy claim schedule was 79% overall (85% vs. 75%, p=0.14). In multivariable analyses, refugee status was not independently associated with unsuppressed viral load. A longer time since HIV diagnosis (ORadj=6.81, 95% CI 1.20–38.58, p=0.02) and≥8 household members (ORadj=0.10, 95% CI 0.02–0.55, p=0.01) were independent risk factors. Conclusion When available, virologic measures are valuable for monitoring program effectiveness. No differences in treatment outcomes were detected between refugee and host clients; however, levels of viral suppression were unacceptable. Possible reasons include past adherence lapses. Detailed investigations exploring reasons for the poor virologic outcomes are underway., Background There are few data evaluating adherence to HAART and virologic outcomes in clinics attended by urban refugees. Our primary objective was to evaluate if urban refugee and host community clients were maintaining acceptable treatment outcomes. Methods We conducted a cross-sectional survey among adult clients (≥18 years) receiving HAART from a public clinic in Kuala Lumpur, Malaysia. Data sources included a structured questionnaire with self-reported adherence measures, a pharmacy-based measure of HAART prescription (Rx) refills over 24 months prior to study start, and HIV viral loads. Key outcomes were unsuppressed viral load (cut-off, Background For HIV-positive persons, optimal adherence (≥95% of tablets taken as prescribed) to highly active antiretroviral therapy (HAART) is required to prevent development of drug resistance and treatment failure. Forcibly displaced populations such as refugees and internally-displaced persons may face unique challenges with respect to adherence and succeeding on HAART. To this end, we performed a systematic review of the literature on adherence to HAART and treatment outcomes in conflict-affected and forcibly displaced populations, assessed the quality of the evidence, and make suggestions for future research. Methods MEDLINE, EMBASE, and Global Health databases for 1995–2011 were searched using the OVID platform. A backwards citation review of subsequent work that had cited the OVID results was performed using the Web of Science database. ReliefWeb and MSF websites were searched for additional grey literature. Results We screened 297 records and identified 17 reports covering 15 quantitative and two qualitative studies. Three-quarters (11/15) of the quantitative studies were retrospective studies based on chart review; five included, Background HIV has multidimensional effects that pose unique challenges to development in Cambodia. One effect is a large number of orphans and vulnerable children (OVC). Many OVC are less likely to access regular schooling and have low levels of social, financial and psychological support as well as wider community support. KHANA provides a program of community based care and support including social welfare, nutrition and schooling support for these children. Methods KHANA collected data among OVC reached by community based care and support to assess changes in nutrition and schooling as well as care and community support between 2009 and 2011. The sample size was 194 in 2009 and 316 in 2011. Both surveys used cluster sampling with a take-all approach, using health center catchment areas as clusters and the same data collection tools. Chi-square test was used to detect changes in schooling, nutrition and community support. Results There was a significant increase in OVC regular access to schooling (83.1% vs 96.2%, p-value, Background The question of the potential role of income support in an ARV treatment programme is of particular relevance in South Africa, where individuals too ill to work qualify for a specific form of income transfer, or, as it is called in South Africa, a social welfare grant, namely the disability grant (DG). ARV patients face the dilemma of trading off a stable source of income against their current and/or future health and adhering sub-optimally to ARV treatment so as to not lose the grant. Methods This paper employs a pooled longitudinal, panel dataset from two Free State cohort studies of public sector ARV clients to determine how disability grant terminations may impact on virologic and immunologic treatment outcomes. Linear and logistic multivariate random-effects (RE) regression models are employed to assess the impact of grant terminations on CD4 counts, viral load (RNA) and viral suppression. Results The findings suggest that the termination of access to a disability grant does in fact translate into poorer treatment outcomes, particularly in the first year of ARV treatment. Disability grants impact negatively on viral suppression regardless of treatment duration [OR 0.253, 95% CI 0.087–0.733]. Disability grant terminations at the outset of ARV treatment initiation impacts negatively on CD4 counts [−103.8, 95% CI −164.6−43.0], log of viral load [ 4.07, 95% CI 2.58–5.56] and viral suppression [OR 0.019, 95% CI 0.002–0.181] at 3–12 months on ARV treatment. Conclusion Social welfare officers and health care teams, in particular physicians considering applications for the renewal of a disability grant, should take particular care when deciding to refuse applications for the renewal of a short-term grant in the early phases of the ARV treatment career. In the longer term, healthy ARV clients should be referred to welfare-to-work programmes to eliminate dependency on social welfare grants. Abstract Coding Guide Example: MOAA01=(Weekday) MO – (Session type) AA – (Session order) 01 Weekdays: SU (Sunday), MO (Monday), TU (Tuesday), WE (Wednesday), TH (Thursday), FR (Friday) Session types: oral abstract sessions – AA (Track A), AB (Track B), AC (Track C), AD (Track D), AE (Track E), AX (Cross-Track), LBA (Late Breaker Track A), LBB (Late Breaker Track B), LBC (Late Breaker Track C), LBD (Late Breaker Track D), LBE (Late Breaker Track E), LBX (Late Breaker Cross-Track); oral poster discussions sessions – PDA (Track A), PDB (Track B), PDC (Track C), PDD (Track D), PDE (Track E) PDX (Cross-Track) Session order: 01, 02, 03, 04, etc.

Background Due to Lesotho's high adult HIV prevalence (23%), considerable resources have been allocated to the HIV/AIDS response, while resources for non-communicable diseases have lagged. Since November 2011, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has supported Lesotho Ministry of Health to roll out Family Health Days (FHDs), an innovative strategy to increase community access to integrated health services, with a focus on hard-to-reach areas where immunization coverage, HIV service uptake, and screening and treatment for chronic diseases are low. Methods Services were provided at mobile service delivery points from 17th October to 25th November 2011. Delivery points located in rural setting were staffed by multi-disciplinary teams of doctors, nurses, community workers, nutritionists, AIDS officers, and pharmacists (30-40 health professionals present). Results During this campaign, 8,396 adults were tested for HIV (67.3% female; 32.6% male). In all, 588 (7%) tested HIV-positive (6.7% female; 7.1% male). Among those testing HIV-positive, 68.5% (403) received CD4 testing and 36.6% were enrolled into HIV care at their nearest clinics. A total of 324 ART defaulters were identified and linked back to care. Follow-up with referral facilities showed 100% of patients (defaulters and newly enrolled) linked to care were enrolled at a facility. Standard immunizations were administered to 990 children. 4,454 adults (24.7% male; 75.3% female) were screened for hypertension, and of those screened, 24.2% had elevated blood pressure and were linked to care centers. Addtitionally, 3,045 adults had blood sugar tests (27.0% males; 73.0% females); 3.1% had elevated blood sugar and were linked to care facilities. Conclusion Offering integrated services within hard-to-reach communities can increase access to a variety of critical health services, including those for non-communicable diseases, and can link ART clients lost to follow-up back to facilities. This approach will be scaled up throughout Lesotho as a strategy to reach all populations in the country., Background The high burden of undiagnosed HIV in sub-Saharan Africa limits treatment and prevention efforts. Community-based HIV testing campaigns can address this challenge and provide an untapped opportunity to identify non-communicable diseases (NCDs). We tested the feasibility and diagnostic yield of integrating NCD and communicable diseases into a rapid HIV testing and referral campaign for all residents of a rural Ugandan parish. Methods A five-day, multi-disease campaign, offering diagnostic, preventive, treatment and referral services, was performed in May 2011. Services included point-of-care screening for HIV, malaria, TB, hypertension and diabetes. Finger-prick diagnostics eliminated the need for phlebotomy. HIV-infected adults met clinic staff and peer counselors on-site; those with CD4≤100/µL underwent intensive counseling and rapid referral for antiretroviral therapy (ART). Community participation, case-finding yield, and linkage to care three months post-campaign were analyzed. Results Of 6,300 residents, 2,323/3,150 (74%) adults and 2,020/3,150 (69%) children participated. An estimated 95% and 52% of adult female and male residents participated respectively. Adult HIV prevalence was 7.8%, with 46% of HIV-infected adults newly diagnosed. Thirty-nine percent of new HIV diagnoses linked to care. In a pilot subgroup with CD4≤100, 83% linked and started ART within 10 days. Malaria was identified in 10% of children, and hypertension and diabetes in 28% and 3.5% of adults screened, respectively. Sixty-five percent of hypertensives and 23% of diabetics were new diagnoses, of which 43% and 61% linked to care, respectively. Screening identified suspected TB in 87% of HIV-infected and 19% of HIV-uninfected adults; 52% percent of HIV-uninfected TB suspects linked to care. Conclusion In an integrated campaign engaging 74% of adult residents, we identified a high burden of undiagnosed HIV, hypertension and diabetes. Improving male attendance and optimizing linkage to care require new approaches. The campaign demonstrates the feasibility of integrating hypertension, diabetes and communicable diseases into HIV initiatives., Background Planned Parenthood Federation of Nigeria (PPFN) is implementing the Global Fund Round 9 project as Principal Recipient. In 2011, PPFN was challenged with lack of HCT RTK, FP and STI commodities resulting in poor performance. In creating change to optimise PPFN performance, the Rapid Emergency Scale Up Plan was developed to meet the backlog of unmet targets in three weeks; the Kotter's 8 step change mode as theoretical model. The plan addresses HCT and provision of integrated SRH/HIV services through FP/STI services to capture HCT missed opportunities. This abstract therefore seeks to document lesson learnt through the plan surpassing PPFN HCT services. Methods PPFN designed a plan showing targets linked to each clinic. A cumulative target for all clinics within a cluster was assigned to PPFN staff in each of the 35 states. This was replicated by region. To determine if each staff would meet its targets, Kotter's 8 step models was applied. PPFN had the following targets for 2011: provide service in 486 health facilities and ensure that and 225,800 HCT clients were provided with FP and STI services. Results By using FP/STIs services as entry point, PPFN met its target by 110% for HCT services, 213% for FP/STIs services with 88% of facilities providing services Conclusion The paper indicates integration of services as a way to meet client's needs in a challenging environment and therefore increases performance while optimizing resources., Background While policy and implementation support for SRHR/HIV integration is increasing, significant questions and uncertainties remain about what such programming means in practice. This is particularly the case in concentrated HIV epidemics, where little is still known about what integration should look like for key populations, including sex workers, men who have sex with men (MSM), transgenders, injection drug users (IDUs) and people living with HIV (PLHIV). While integration is a desirable goal in the long-run particularly for clinical services, joining programs and systems that are not ready could compromise quality and access for these groups that already face difficulty in obtaining appropriate services for both HIV and SRH needs. Methods India HIV/AIDS Alliance undertook a global review of over 160 resources available on the websites of selected national and international organisations, including NGOs, technical support agencies and UN agencies. The resources included case studies, mappings, toolkits, policy briefings and program reports. Results The review identified the most common challenges in designing and implementing SRH/HIV integrated programs for key populations. These included stigma and discrimination, low levels of demand, lack of rights-based approaches, low attention to gender inequality, low understanding of key populations' specific SRH needs, lack of capacity and sensitivity among service providers, lack of strong referral systems and inadequate resources for additional interventions. The review highlighted key steps that organisations can take to successfully integrate SRHR and HIV in their responses for key populations. Conclusion While SRH/HIV integrated programs present an important opportunity to respond to the unmet needs of key populations, integration that is premature, overly rapid or too large-scale risks compromising rather than enhancing key populations' access to high quality HIV and SRH services. Good practice principles, including gender equality, human rights-based approaches, meaningful involvement of communities, for work with key populations are particularly critical in effective HIV/SRHR integration., Background The Systematic Monitoring of the Male Circumcision Scale-up (SYMMACS) is designed to track voluntary male circumcision (VMMC) service delivery in Kenya, South Africa, Tanzania, and Zimbabwe. The study measured adoption of six elements to increase efficiency in the delivery of clinical VMMC services, including: Methods Data collection took place at 14-30 VMMC sites per country (73 sites total) from April-December 2011. It included observation of the clinical facilities, observation of VMMC procedures, interviews with VMMC providers and the in-charge officer, and compilation of service statistics.Surgical methodTask shifting (allowing non-physicians to perform VMMC)Task-sharing (allowing non-physicians to conduct aspects of VMMC)Rotation among multiple bays in the operating theaterBundling of supplies and toolsUse of electrocautery instead of ligating sutures Results The results are useful for monitoring service delivery in each country and conducting cross country comparisons. The data shows considerable variation by country on 5 of the 6 elements, the exception being nearly universal use of the forceps-guided method (see Table 1). The study revealed stark differences on task-shifting, both in terms of actual practice and provider attitudes toward it. For example, in Zimbabwe, while no providers report using task-shifting, 86.5% say they would implement the practice given the choice. Countries also differed in the use of multiple beds per provider (rotation) during VMMC, with100% of providers in Zimbabwe reported using multiple beds, compared to 38% percent in Kenya, reflecting a different service delivery model. Provider reported use of electrocautery ranged from 5.4% in Tanzania to 88.6% in South Africa. Kenya (n = 85)South Africa (n = 95)Tanzania (n = 93)Zimbabwe (n = 74)If given the choice, providers reported that they would apply the following efficiency measures at their MC clinic:Already do (%)Yes (%)Already do (%)Yes (%)Already do (%)Yes (%)Already do (%)Yes (%)1. Multiple beds per provider36.727.182.914.373.125.8100.00.02. Bundled surgical supplies (purchased as a kit)0.040.088.69.524.732.3100.00.0Bundling of surgical instruments and supplies by clinic staff97.60.07.619.073.120.40.09.53. Task shifting: allowing adequately trained nurses and or clinical officers to perform the entire MC procedure98.81.213.357.173.124.70.086.54. Task sharing: allowing secondary providers to administer local anesthesia38.821.285.713.373.123.768.927.0Task sharing: allowing secondary providers to complete interrupted sutures41.217.681.916.273.123.759.532.45. Use of forceps guided surgical method100.00.091.48.674.224.798.61.46. Electrocautery/diathermy14.141.288.611.45.415.178.416.2Implementation of efficiency measures in VMMC: act. Conclusion The decision to adopt these elements is generally based on national policies. However, the review of these practices across four countries demonstrates alternative methods of service delivery, and is intended to incite potential changes to these policies in the name of increasing efficiency., Background The Systematic Monitoring of the Male Circumcision Scale-up (SYMMACS) is designed to track voluntary male circumcision (VMMC) service delivery in Kenya, South Africa, Tanzania, and Zimbabwe. The study measured adoption of six elements to increase efficiency in the delivery of clinical VMMC services, including:Surgical method (e.g., forceps-guided)Task shifting (allowing non-physicians to perform VMMC)Task-sharing (allowing non-physicians to conduct aspects of VMMC)Rotation among multiple bays in the operating theaterBundling of supplies and toolsUse of electrocautery instead of ligating sutures Methods Data collection took place at 14–30 VMMC sites per country (73 sites total) from April-December 2011. It included observation of the clinical facilities, observation of VMMC procedures, interviews with VMMC providers and the in-charge officer, and compilation of service statistics. A total of 357 providers reported on their attitudes towards their jobs and on the pervasiveness of burnout in the field of VMMC. Results The results are useful for monitoring service delivery in each country and conducting cross country comparisons. The data shows varied levels of burnout and job satisfaction among providers across countries (see Table 1 and Table 2).Table 1Occurrence of VMMC provider reported burnAmong all providersKenya (n = 85)South Africa (n = 105)Tanzania (n = 93)Zimbabwe (n = 74)% reporting to have noticed any provider fatigue/burnout among colleagues when they perform MC full-time as a primary work activityYes, frequently8.214.30.09.5Yes, occasionally80.026.78.624.3Yes, but very rarely7.115.216.132.4No, not at all4.741.074.229.7Don′t know0.02.91.14.1 Table 2VMMC provider personal job satisfaction a% of providers who report to strongly agree or agree with the following statements on job satisfaction:Kenya (n = 85)South Africa (n = 105)Tanzania (n = 93)Zimbabwe (n = 74)Performing (or assisting in performing) male circumcision is a personally fulfilling job.87.182.8100.081.1I personally have begun to experience work fatigue or burnout from performing (or assisting in performing) male circumcision repeatedly.70.636.253.827.0 The various survey instruments allow for an analysis of which program, site and provider level factors may contribute to increased burnout. This paper presents results on: type of site (mobile/ static/ outreach), site volume, provider cadre, education and additional training, time in field, full/part-time status, and variety of tasks performed. For example, preliminary analyses from Zimbabwe indicated that physicians experience higher levels of burnout than their nurse colleagues. Conclusion The review of these practices across the four countries will shed light on alternative methods of staffing and service delivery that contribute to lower levels of burnout among VMMC providers. The results could inform policies and program planning for VMMC as well as other clinical HIV services., Background In 2010 South Africa initiated rapid scale up of MMC services nationally. In support of the service delivery, CHAPS operates a “specialized fixed” VMMC programme in a large urban setting in Johannesburg, Gauteng. SWHP operates a “roving” VMMC programme in the rural district of Uthukela, KwaZulu-Natal. Both programmes have achieved similar uptake of MMC services using different operational models, with each achieving the highest number of MMCs nationally within their applicable settings. Methods A comparative analysis was conducted of CHAPS’ “fixed site” and SWHP's “roving team” over a one year period to analyse unique attributes of each, namely: social mobilisation; staff and capital resources; extent of partnerships with district Departments of Health (DOH), service quality, and cost comparisons between models. Results Social mobilisation activities were similar but customised to address local customs and preferences. There was variation in staffing and capital expenditure due to CHAPS’ initial capital outlay for a fixed site and its permanent team of 27 versus SWHP's skeleton team of 12 with no investment in facilities. Both programmes have strong partnerships with their district DOHs, although SWHP benefited from more support in terms of interim staffing and provision of surgical consumables. This contributed to variances in expenditure and cost per MMC by programme. Adverse events and service quality were comparable, but roving services required greater time and resources in tracking client follow up than fixed services. Table 1 DescriptionCHAPSSWHPCapital Expenditure550 000153 000Salaries & Wages5 135 2223 256 688Awareness Campaigns163 68026 400Surgical Kits & Supplies2 774 0001 778 000Training6 00093 300Transport & Travel37 084123 646Operating Overheads1 254 416544 631 Cost per 12 000 MMC procedures per annum 9 920 402 5 975 665 Cost per MMC Procedure (SA Rands) R 827 R 498 . Conclusion This comparative analysis shows models need to be customised to address the requirements of each target population group and their geographic settings. In urban settings, fixed sites, drawing on large dense surrounding populations, maintain good daily numbers and follow up rates. In rural settings, the roving model, with significant government support, is economical and effective in reaching targets and covering communities spanning large areas., Background Evidence is mixed on the benefit of medical male circumcision (MMC) for women. Questions remain whether there is direct benefit in reducing HIV acquisition among women; whether men put women at risk due to early resumption of sex; whether mass rollout of MMC leads to risk compensation in ways that compromise women's ability to negotiate condom use; and whether MMC increases patriarchal behaviors such as gender-based violence. We present data from various studies to address these questions and make the case for women's shareholding position in MMC. Methods We reviewed over 30 published and ongoing studies on MMC for evidence on early resumption of sex, risk compensation, benefits of MMC to women, and women's views of and reactions to MMC rollout in different African countries. Results About 10 studies have returned the verdict of no risk compensation among circumcised men. In addition, there are few but scientifically solid evidence emerging showing up to 47% direct benefit of MMC in reducing HIV transmission to women, particularly when sex is not resumed early. However, four studies show consistent evidence of early resumption of sex before wound healing, ranging from 24-42% overall, 63-76% among married/cohabiting men, and 12-48% among HIV-positive men. About 15 studies indicate that women support MMC though misconceptions are still common, with up to 77% unaware of the need for sexual abstinence. Some believe that scale-up of MMC translates into reduced risk hence less need for safe sex. Conclusion With the current scale up of MMC for HIV prevention in 14 African countries, there is no evidence of risk compensation; however, early resumption of sex and women's low risk perception because their partners are circumcised may undermine the benefits of MMC to women. MMC programs should target women with correct and complete information and advocate for their involvement in partners' decisions on circumcision., Background Namibia's antiretroviral treatment (ART) programme has expanded rapidly, enrolling 68,000 adult patients on treatment by December 2009, with 35% taking stavudine-based regimens. In 2010 the Ministry of Health & Social Services (MoHSS) adapted WHO recommendations and began implementing new ART guidelines that changed ART eligibility criteria and preferred first line regimens. Thus, MoHSS enlisted the support of the Supply Chain Management System (SCMS) to analyse the supply chain implications of the changes and provide support for a smooth transition. Methods Using MS Excel(r) spreadsheets, SCMS modelled implications of increasing the CD4 threshold for ART initiation and changing to tenofovir-based first line regimens. Backed by Namibian Government funding commitment, CMS accelerated internal procurement processes to avail tenofovir-based formulations, reviewed stock control parameters to manage reduced demand for stavudine and expanded ARV storage capacity to cope with the increased volumes of ARVs. Monitoring systems were intensified including quarterly tracking of trends in consumption and treatment regimens. Results Within 8 months, CMS had managed to accumulate adequate quantities of tenofovir formulations, clearing the way for the national roll-out of the new ART guidelines starting September 2010. As a result, over 34% of the approximately 90,000 adults on ART were taking tenofovir-based regimens one year later. In addition, a potential wastage of about US$ 950,000 worth of stavudine formulations was prevented and stock outs of tenofovir formulations avoided. Interventions to optimise existing storage space at CMS created an additional 328 pallet locations, a 74% increase in racked storage capacity in five rooms for ARVs and general pharmaceuticals. Conclusion A rapid response was achievable due to the Namibian government's commitment and the agility of the supply chain. Timely availability of information through robust monitoring systems established to capture changing consumption patterns informed procurement planning and minimised the risks associated with change in ART guidelines., Background Crisis followed the October 2010 Presidential elections in Cote d'Ivoire. International sanctions were applied, the banking system collapsed, security deteriorated and internal displacement prevented access to healthcare. SCMS, a PEPFAR program administered by USAID, adapted the national HIV/AIDS supply chain strategies to respond to changing conditions and to avoid treatment interruption Methods From the outset, SCMS established a crisis-committee whose daily calls between the field and Washington focused on information sharing with the Ministry of Health (MOH), Mission, USG team, Implementing Partners (IPs) and international donors. SCMS jointly reviewed supply plans and stock-status reports with international donors and IPs and adjusted planned orders to meet urgent national demands. Under threat of air, land and sea border closings, SCMS re-routed all deliveries though its' Regional Distribution Center (RDC) in Accra, Ghana. The RDCs, in turn, pulsed commodities into the country as demand required and security permitted. Meanwhile, in country, the MOH provided patients with two months treatment instead of the usual one. The distribution mechanisms, however, were disrupted and SCMS together with IPs created an interim distribution plan in which IPs picked up their products and distributed them to sites. Results Deliveries continued throughout the crisis; no health facility experienced a stockout of critical products and treatment interruption was averted. Donor collaboration ensured planned deliveries met patient needs. The RDC in neighboring Ghana provided flexibility to maximize in-country stock levels, arrange last-minute flights and make urgent deliveries. On-the-ground collaboration with the MOH and IPs ensured medicines were not only available at service delivery points, but in the patients' hand. Conclusion By creatively leveraging in-country knowledge, regional resources and procurement volumes of supplies, ARVs and other critical products reached patients throughout the crisis., Background Currently, HIV/AIDS care support from donors is shifting from direct service delivery to systems strengthening of country-owned programs. However, frequent stock-outs of HIV supplies occur, as, in many cases, the systems for supply of HIV- and non-HIV-related commodities remain separate, and health facilities do not order for HIV commodities when required. The Strengthening Uganda's Systems for Treating AIDS Nationally (SUSTAIN) Project worked closely with and supported 17 public hospitals in Uganda to harmonize ordering for commodities from the governments' National Medical Stores to improve availability and service delivery. Methods SUSTAIN utilized four low-cost interventions to strengthen supply chain management systems: identification of focal persons responsible for submission of commodity orders to the national stores; training of the order focal persons in ART logistics management followed by onsite coaching and mentoring; telephone text message reminders to the focal persons one week prior to order deadlines; and development of an order checklist to harmonize submission of HIV- and non-HIV-related commodities. Results From January to October 2011, average ordering rates for all commodities improved from 46% to 71%. Improvements were noted in order submission rates for HIV-related commodities: from 29% to 81% for ARVs, 24% to 69% for PMTCT commodities, and 22% to 63% for HIV test kits. 54% of facilities harmonized submission of orders for all commodities, an improvement from 12% in January 2011. Improved submission of orders resulted in increased availability of HIV-related commodities and quality of care. Conclusion Improving availability of commodities and supplies available through the national system can be achieved by supporting hospitals to utilize low cost, simple innovations to improve ordering rates., Background Fragile health commodity supply chain systems have long been a factor inhibiting universal access to care and treatment in ART programs. Weaknesses in the various components of the logistics cycle contribute to non-dependable and irregular supply of quality products at service delivery points which causes poor health-seeking behaviour, treatment interruption and poor adherence and therefore treatment failure and resistance. Methods In June 2010, STAR-EC, a five year USAID-funded project implemented by JSI, initiated training and mentorship of health workers in pediatric ART, logistics management of opportunistic infection medicines and stores management to build capacity for quantification. District focal persons were facilitated to support the sites to submit orders to the national suppliers. Storage was improved through the provision of medicine cabinets and pallets. Destruction of expired commodities was done in high priority health centres to generate space for increasing quantities of products. STAR-EC later supported the collection of these supplies from the facilities to the district stores for destruction by MoH. Data management was improved through the printing and distribution of logistics management information tools that encouraged the use of more optimal formulations. During periods of stock outs, buffer commodities were provided and collaboration with other partners mitigated non-availability at facilities. Consistent communication with national stores to determine availability of supplies and support to facilities to make and retrieve emergency orders was provided. Results The ordering rate for ARVs increased from 46% to 96% and was maintained as shown in Figure 1. Consequently, the availability of products improved which led to increase in number of clients enrolled onto ART as shown in the Figure 2. Figure 1Ordering Rate for ARVs. Figure 2Annual Enrolment of Clients on ART. Conclusion Improved availability of commodities at health facilities and consequently, sustained expansion of ART programs can be achieved by with a holistic approach towards all the elements of the logistics cycle., Background With USAID and Global Fund support, Deloitte Consulting LLP assessed existence and effectiveness of internal controls for government and non-governmental pharmaceutical supply chains in selected African countries. Within these countries, Deloitte traced inventory movements and volumes of selected ARVs, RTKs, and other commodities from the point of entry along the supply chain to end-user consumption. Methods The Deloitte team assessed a variety of sites, including central, provincial, and district warehouses; rural health posts; government, mission, and private hospitals; points of entry; and transportation companies. Site sampling methodology weighted provinces and districts by expected risk areas for diversion, population size, number of sites, and volume of medicine dispensed. ARVs, RTKs and other commodities (e.g., anti-malarials, essential medicines, ITNs) were traced. Assessments incorporated a structured questionnaire, documentation sampling and review, and end-to-end reconciliation of inventory movements across each level of the supply chain. The evaluation focused on eight areas to determine control strength: Control Environment, Monitoring and Evaluation, Port Arrival and Customs Clearing, Transportation, Receiving, Storage, Distribution, and People. Scores were rolled up to province and country level in these eight areas to yield a final risk score for each country's supply chain. Results Assessed supply chains were generally found to be in the second quartile of maturity (with a score between 25 and 50 of 100 points), indicating overall weakness in internal controls. Amongst assessed countries, trends were inconsistent at the central, provincial or district levels. Common to all countries, sub-district facilities had very weak controls, leading to greater losses compared to upstream facilities. Conclusion Country governments and donors must improve documentation practices, particularly at the lowest level of the supply chain for ARV and RTK consumption. Strengthening sub-district facility controls will decrease stock-outs, diversion, and loss due to expiry, increasing available resources for health programming and improving patient outcomes., Background There is a clear and growing body of evidence for increased prevalence of cardiovascular disease (CVD) in HIV patients as a result of viral effects or of antiretroviral medications (ART). This pilot was implemented to assess the feasibility of integrating routine screening of cardiovascular risk factors in an HIV clinic setting in order to inform programmatic approaches. Methods HIV-positive clients enrolled in the facility between May 2010 and August 2011 (12,177 clients) were targeted for clinical CVD screening. Those found with specified CVD risk factors were referred for laboratory evaluation of their fasting blood sugar and lipid profile. In addition, behavioral and biomedical interventions were provided, including referrals to an on-site cardiac clinic for clients with a ten-year CVD risk of developing a fatal or non-fatal cardiovascular event of ≥20% (WHO/ISH AFR-D CVD risk assessment charts). Follow-up annual and biannual CVD risk assessments were also scheduled for clients with, Background Zambia has the world's second highest annual cervical cancer incidence and mortality rates[1] coupled with one of the world's highest HIV prevalence rates at 14.3%.[2] Research has shown an association between HIV infection and a high incidence of invasive cervical cancer with rapid progression. In the Zambia military population where the seroprevalence rate is estimated to be two times higher than the national rate, women are at greater risk of cervical cancer and HIV co-infection. Methods PCI and the Zambia Defence Force (ZDF) adopted the “screen-and-treat” model of the Cervical Cancer Prevention Program in Zambia (CCPPZ) and integrated it into an existing ZDF mobile HIV counseling and testing (CT) unit. The pilot was implemented in 14 ZDF units using existing health facilities and equipment. ZDF nurses were trained on the CCPPZ protocols and used an opt-out approach to enroll women accessing mobile CT services. Nurses screened consenting women using visual inspection with acetic acid (VIA) and provided same-visit treatment using cryotherapy (“screen-and-treat”). Results A total of 839 women accessed mobile CT services; 560 women (67%), median age 35, consented to being screened. Of the 560 screened, 16% (88/560) were found with abnormal cervical lesions of which 11% (62/560) were eligible for on-site cryotherapy and were treated immediately while 5% (26/560) were referred to the Gynecologic Cancer Prevention Unit at University Teaching Hospital and of these 92% (24/26) completed the referral. The prevalence of HIV among women screened was 20% (113/560). Conclusion The high proportion of women (67%) that accepted screening for cervical cancer and the high proportion of women completing the referral, show that existing HIV prevention interventions provide a springboard for rapidly reaching women with timely, life-saving and easily adaptable cervical cancer prevention and treatment programs such as “screen and treat”. [1] GLOBOCAN 2008 [2] Zambia Demographic and Health Survey (2007), Background Zimbabwe is one of the countries with the highest HIV prevalence (13.75%) in the world. It has a strong policy and strategic framework and a National AIDS Trust Fund (NATF) created through an Act of Parliament. All employed individuals and companies in Zimbabwe pay 3% of their taxable income on monthly and quarterly for former and later respectively. The money support the national response to HIV and AIDS and the fund has emerged as an innovative and potentially sustainable internal response resourcing approach. Methods The study was conducted in Zimbabwe and used a combination of secondary literature, key informant interviews (Ministry of Health, NAC, Private Sector and Public Service authorities), focus group discussions (beneficiaries) and observations (Health facilities). Results The NATF is an innovative approach for a self financed/sustained HIV and AIDS response in Zimbabwe. Currently 25% of all people on ART are supported by the fund apart from financing some interventions under prevention, advocacy and monitoring and evaluation. Assisted the country achieve Global Fund grant targets though funding the acceleration of implementation. Strengthened and improved effectiveness of NAC's coordinating capacity. Fund's full potential yet to be realised as the informal sector (with estimated 80% of the employable population) is not contributing and the economy operating 40% of its capacity. NATF is a regional best practice and four countries Tanzania, Botswana, Kenya and Zambia have visited Zimbabwe to learn about the levy. Conclusion The NATF demonstrates potential countries have to generate internal resources to sustain their responses. In the context of diminishing the external global financial support, countries need innovative approaches to avoid reversing response gains. Countries with large informal sectors need to ensure contribution by these as they also benefit from services and commodities. The success of this approach rests on genuine political commitment and private sector collaboration., Background For a small NGO supporting a community health worker program in rural villages, ensuring accurate timely data collection is difficult. Paper based systems are time-consuming to collect and often provide incomplete data. A simple, cost-effective monitoring system using mobile phones can speed up data collection and provide better data. This project aimed to use electronic reporting to better capture the quality of support (social, family, personal) provided by community health workers. Methods The project adapted paper-based monthly reporting tools already in use for implementation on the mobile phone platform using open access Frontline software. 38 CHWs (21% of the total number) were selected from a diverse set of locations. Staff built buy in from participating CHWs for the new technology and trained them on the system. Data was collected through SMS to a central database. CHWs received an initial sum of phone credit and were reimbursed based on the number of messages received, regardless of accuracy. To assess the comparative benefit of the system, SIC measured the collection and accuracy of CHWs using paper surveys. Results One month after initiation, participating CHWs had sent monthly patient information by text for 37.2% of their clients with 9.8% of messages having data errors. For paper, at one month, the percentage of monthly patient reports collected was 6%. At three months, a higher percentage of paper reports (78.7%) had been collected than electronic (45.0%). Paper surveys were two and a half times as likely to have missing information. Conclusion The mobile phone system has a clear advantage in timeliness of data. Over time, however, consistency with mobile phone reporting declined because of difficulties with reimbursements and challenges with system maintenance Next steps are adjusting the reimbursement system and evaluating whether the system is better suited for use in ongoing reporting, annual evaluation or not at all., Background Shortages of health professionals in low-income countries make task shifting to community health workers (CHWs) crucial to AIDS care and treatment. Multiple studies of CHW utilization reveal poor linkages to the formal health sector, lack of clinical decision making support in the field and weak integration of information gathered at the community level with the national health information system. Methods A pilot study was performed at a public HIV clinic in Nairobi that provided CHWs with a mobile telephone system (ClinipakMobile) loaded with surveys that support appropriate clinical decision making and link to an electronic patient information database. Each CHW underwent a one-day training on use of ClinipakMobile and used ClinipakMobile at home visits with clients living with HIV. Variables assessed were: ability of the CHW to use ClinipakMobile based on standardized role-play assessments, CHW satisfaction surveys, ability of the server to store clinical data, and patient-based outcomes assessed by an end-of-study chart review of CHW referrals. Results Seventeen CHWs participated. The CHWs quickly learned and retained skills in using ClinipakMobile across three time points (week 0, 3 and 6) and expressed great satisfaction. The database maintained function and integrity with only one down-time period of 24 hours. CHW patient interviews using ClinipakMobile recorded multiple “red flag” answers for antiretroviral non-adherence (21%), side effects (30%) and opportunistic infection symptoms (33%) resulting in 30% of patients receiving ClinipakMobile-recommended referrals to the health facility. The chart review revealed these problems were infrequently noted by clinicians at follow-up visits. Conclusion ClinipakMobile is an easy-to-use mhealth tool to improve CHW functioning to care for PLWHA. Busy clinicians may not note important clinical “red flag” that CHWs record at home visits. In the future, patient information gathered on ClinipakMobile should be downloaded from the server daily and given directly to clinicians to improve care during clinic visits., Background CD4 determination and is a key step in the prevention of mother-to-child transmission cascade. However, timely access to centrally-processed CD4 results remains a challenge for antenatal clinics in resource-limited settings. Methods As part of an interventional study to improve antenatal access to HAART, we developed an automated platform to wirelessly communicate CD4 results to portable SMS-enabled thermal printers (iBacsTel) in referral antenatal clinics. The system, authored in Python over a MySQL database using Django, directly collects results from flow cytometer (FACSCalibur) output files and integrates demographics and validation status from electronic records. The system then sends validated results via a SMS gateway (Kannel) to printers in referring antenatal clinics. Clinic receipt is confirmed centrally via SMS. A monitoring platform (see Figure 1) permits quick central assessment of clinic printer status, laboratory delays, deviations from expected testing patterns (e.g. due to supply outages, staffing shortages), and identification of women with low CD4 counts. We deployed the system in 16 clinics around Gaborone, Botswana (2 clinics added per month) between August 2011 and February 2012.Figure 1Display from two of the monitoring platform screens, displaying specimen details, validation/transmission status, and clinic status. Results Antenatal CD4 results for 367 women have been transmitted and confirmed, including 92 women qualifying for HAART (CD4, Background Point-of-care CD4 testing (POC CD4) is being implemented in many countries to improve access to CD4 and HIV services, especially in decentralized rural and remote areas. However, the implementation of POC CD4 faces challenges due to the difficulties of monitoring testing quality, operator performance, instrument breakdowns and supply stock-outs in remote sites. Methods At 10 health centers in Sofala Province, Mozambique we implemented twelve POC CD4 devices enabled with GPRS modems capable of transmitting test data to a central database via local mobile phone network. A web-based software interface was customized to allow provincial and national-level supervisors to access the following data from each device: (i) device functionality; (ii) daily test volume; (iii) error type and frequency; and (iv) frequency and performance of daily quality control runs (Figures 1 and 2).Figure 1 Figure 2 Results Data from the twelve POC CD4 devices representing a total of 336 testing days and 3,109 CD4 tests (with 620 quality control runs) were aggregated and reported by the interface. The system identified 376 error events, including 19 quality control failures (Levey-Jennings>2 standard deviations), 4 failures to run daily controls before testing, 45 operator test errors, 6 possible device malfunction events, and 21 instances of attempted use of expired reagents. These events prompted follow-up corrective action by supervisors more quickly than with previous paper-based reporting methods. Conclusion This is the first description of a remote wireless monitoring system to track performance of POC diagnostic tests for HIV in resource-limited settings. This GPRS-based system can improve the management of POC diagnostics by capturing real-time events that might otherwise go unnoticed. This enables detailed management of the quality and performance of POC CD4 testing in remote areas and rapid response to resolve problems and provide additional training or support. This system also has applications in monitoring patient- and population-level epidemiological trends., Background In Nigeria, the progressive loss of patients at every stage in antiretroviral therapy (ART) programs especially at the point of uptake of CD4 monitoring poses a threat to the achievement of treatment targets. Long waiting time coupled with the burden of traveling long distances for blood draw and receipt of CD4 results has led to attrition in the number of clients who test positive to HIV versus the number who eventually commence ART. Methods In order to increase uptake of CD4 monitoring and reduce loss to follow up (LTFU) at three USAID/MSH supported HIV care and treatment clinics, the following interventions were instituted. 1. Task shifting to data clerks to fill laboratory request forms for CD4 monitoring instead of clinicians who complain of heavy workload. 2. Strengthened escort services from the point of enrollment to the laboratory to ensure that clients access laboratory investigations on the same day. 3. Task shifting to laboratory technicians on the use of automated CD4 equipments after consistent onsite training and supervision. 4. Established point of care sample collection for CD4 estimation. 5. We commenced daily CD4 investigations (Monday to Friday) ensuring that clients attending clinics from long distances access CD4 monitoring on any day of the week. 6. Commenced 24 hours turnaround time for release of CD4 result to ensure rapid initiation of eligible clients on ART. Results After 12 months, number of clients accessing CD4 investigations increased from 53.8% to 93.3% while number of clients LTFU reduced from 58.7% to 10.7%. Turnaround time for CD4 results decreased from 7 days to 24 hours. Average client waiting time reduced from 4 hours to 1hour 30mins. Conclusion Strengthening laboratory systems helps increase uptake of CD4 investigations, shorten client waiting time and ultimately reduces LTFU especially among clients attending clinics from hard to reach communities with difficult terrains., Background The Caris Foundation in partnership with the Voila Foundation provides cell phones to mothers of HIV-positive infants identified via the Haiti National EID program. Mothers without access to cell phones are difficult to communicate with; Caris EID teams contact families to increase clinic attendance, improve treatment adherence and monitor children's health. Methods New phones were distributed to mothers of HIV-positive infants identified by the EID program. The program started in May 2010 and is ongoing. The cell phones were donated by Voila, a national cell service provider in Haiti. It was explained that the purpose of the phone was for monitoring the child and the mother would be contacted regularly by members of the Caris team/site providers. Each mother gave signed consent. Caris coordinators call mothers who have phones (donated or pre-existing) approximately weekly to discuss appointments, drugs and their children's health status. Results Over 70% of the phones used to monitor families were still active in Feb 2012. Of the 76 families with functional cell phones, all 76 children were adherent to treatment as defined as attending 6 out of the last 6 hospital appointments given (monthly). All the women felt positive about being called by the Caris teams and 99% felt it was helpful. # of Sites # of Women Given Phones # of Women followed up with their own phones # of Phones Active # of Phones Inactive # of Phones Stolen # of Children of families with phones in active follow up, regular adherence and on treatment 20703876/108 (70.4%)21/108 (19.4%)11/108 (10.2%)76/76 (100%)Cell phone distribution figures. Questions Responses Why were you given a phone? (50 of the 70 women who were given a phone were contactable by the donated phone)To check my child is healthy/ok 45/50 (90%) To remind me of my appointments 37/50 (74%) To contact someone if I my child is sick/ needs help 30/50 (60%)What do you feel when you are called by the team? (108 respondents)Positive Feelings 108(100%) Neutral Feelings 0 (0%) Negative Feelings 0 (0%)Does being contacted by the team help you? (108 respondents)Yes 107 (99.1%) No 1 (0.9%)If being called is helpful-why? (108 respondants)Appointment Reminder 86 (80%) Medication Reminder 68 (63%) To help me when my child is ill 55 (51%)What are the problems you have with your phone? (108 respondants)Lack of money to buy minutes 81 (75%) Difficulty in finding a place to charge the phone 43 (40%) Poor phone reception 27 (25%) Fear of phone being stolen 23 (21%)Cell phone questionnaire, Haiti. Conclusion The distribution of cell phones to families of HIV-positive children identified with the EID program in Haiti has helped our teams monitor the progress of children. Approximately 20% of PCR positive children identified are lost to follow up within the first year and contact by phone can help. Phones are available for approximately 20USD in Haiti; the program is not prohibitively expensive. 30% of the phones were non-functional/stolen within 21 months of the project. The use of mobile phones, combined with an active community tracing program has benefitted the Haiti EID program., Background Despite expanded access to HIV testing, most newly-diagnosed South Africans present with severe immunosuppression. We sought to determine the risk factors for presentation with late-stage HIV disease and the perceived barriers to presenting earlier for care. Methods We enrolled and surveyed adults prior to HIV testing at four outpatient clinics in urban and peri-urban areas of Durban from August 2010 to November 2011. Late-stage HIV disease was defined as a CD4 count, Background Improving access to HIV testing is recognized as a key priority in scaling up HIV treatment and prevention services. Home-based testing (HBT) as an approach to delivering wide-scale HIV testing is explored in this study. Methods A systematic review and random effects meta-analysis of published studies reporting on uptake of HBT in sub-Saharan Africa since 2000 were conducted to assess the proportion of individuals accepting HBT and receiving their test result. Three electronic databases were searched. Results Our initial search yielded 1199 articles, 114 were reviewed as full-text articles and 19 publications involving 21 studies (N=524,787 offered HBT) were included for final review. The studies came from 5 countries: Uganda, Malawi, Kenya, South Africa, Zambia. The proportion of people who accepted HBT (N=474,516) ranged from 58.1% to 100%, with a pooled proportion of 83.8% (95% CI: 80.9–86.6%) (Figure 1). Heterogeneity was high (t20.13). Sixteen studies reported on the number of people who received the result of HBT (N=432,835). The proportion of individuals receiving their results out of all those offered testing ranged from 24.9% to 99.7% with a pooled proportion of 77.4% (95% CI: 74.0–80.7%), (t2 0.12) (Figure 2). HIV prevalence ranged from 2.9%–36.5%. New diagnosis of HIV following HBT ranged from 40–79% of those testing positive. Forty-eight percent of those offered testing were men and they were just as likely to accept HBT as women (pooled odds ratio 0.84 (95% CI: 0.56–1.26)(t20.33). The proportion of individuals previously tested for HIV among those offered a test ranged from 5–66%. No evidence was reported of negative consequences of HBT.Figure 1Proportion accepting HBT. Figure 2Prop receiving HBT of all those offered. Figure 3Sub-group analyses of proportions accept. Conclusion Home based voluntary counselling and testing has the potential to dramatically increase awareness of HIV status in previously undiagnosed men and women in sub-Saharan Africa. HBT is a gateway to accessing care early and the benefits for individual and public health, both for treatment and prevention, make it an invaluable tool in the fight against HIV., Background Washington DC has an estimated HIV prevalence rate of 3.2% and only 50% may be aware of their infection. Using large volume public service venues may promote HIV testing and directly increase access to HIV testing, thereby increasing the number of residents who know their HIV status. Family and Medical Counseling Service, Inc. (FMCS) implemented a novel program to provide HIV testing at the Department of Motor Vehicles (DMV) which provides driver's license and automobile tag services to over 150,000 residents annually. Methods Dedicated project staff discuss the importance of routine HIV testing and offer the test to everyone awaiting DMV services. Rapid HIV testing is conducted in a private office inside the DMV, and all who test positive are immediately referred to care and support services. We present data describing the HIV testing outcomes from the program. We also asked a sample of 406 persons who didn't test about their reason for refusal. Results From October 2010 to February 2012, 108,188 individuals were offered an HIV test, 8,152 (8%) accepted, 6,788 (83%) were tested, and 34 (0.5%) were positive. The most common reasons for refusal were “already had a test in the past six months” (138/406, 30%) and “do not feel I'm at risk” (76/406, 17%). Twenty-three percent (n=1,566) of those tested had never been tested before; the majority of whom were aged 13–24. Conclusion Conducting HIV testing in high volume non-clinical settings, such as the DMV, is a feasible strategy to engage individuals in HIV counseling and testing services, including those who have never tested before. Expansion of this program model to similar public service sites may be necessary to increase access to HIV testing services, encourage routine screening and increase the percentage of individuals in the general population who know their HIV status. Total African American Female 13–24 Year Olds 25–44 Year Olds 45+ Year Olds Tested6,7886,652 (98%)3,869 (67%)1,493 (22%)3,190 (47%)2,105 (31%)First Ever Tested1,5661,542 (98%)829 (53%)564 (135%)547 (35%)456 (28%}Demographic Data Table., Background South Africa has an estimated 5.6 million people living with HIV, representing a quarter of the disease burden in sub-Sahara Africa and one fifth of the global disease burden. The National HCT Campaign was launched in April 2010 and ended in June 2011, coordinated by the National Nerve Centre. Methods The Campaign was launched at national, provincial and district levels and targeted everyone between the ages of 12–60 years, not exclusive of younger or older persons. Confidentiality and informed consent was required to test and every site was linked to a referral facility providing ART, care and support. HCT was done at health facilities, work places and community outreach sites. Results South Africa committed a significant budget of US$3.5 billion to support the HCT Campaign and Treatment Expansion. By June 2011 a record 13,269,746 HIV tests were conducted and 2,155,312 (16%) people tested positive of whom 48% had CD4 counts above 350. Over 400,000 patients were initiated on ART, of whom 57,000 were pregnant women. National Laboratory DNA PCR results indicated that mother to child transmission rates at 8 weeks reduced to 5% compared to 11% in 2009. Over 8 million people were screened for TB and 185 million male condoms and 524,000 female condoms were distributed. 237 males were medically circumcised, exceeding the Campaign target of 100,000. The procurement system achieved a 53% ARV price reduction through competitive tenders and 3,686 (80%) health facilities were capacitated to deliver ART through task shifting and training of 10,542 nurses. Conclusion South Africa has succeeded in implementing a massive HCT campaign linked to a comprehensive HIV prevention model that optimizes treatment for prevention and reduction of new HIV infections. The Campaign created a shift from testing for treatment to testing for prevention and promoted combination prevention to turn the AIDS epidemic tide for South Africa., Background Recent estimates indicate that 40% of the HIV infections in the Netherlands are undiagnosed. Earlier diagnosis of HIV will improve individual health outcomes and reduce further spread. Self tests for HIV have become available, which allow individuals to test at home without involvement of health care professionals. Although self tests may help to increase HIV test uptake, there are concerns about test quality, counseling and medical follow up. The Amsterdam Public Health Service has initiated the HivTest@Home project to develop and evaluate a service that provides reliable HIV self tests using oral fluid in combination with an Internet counseling strategy for individuals at high risk for HIV, especially MSM and migrants from HIV endemic countries. Methods A website and logistic infrastructure will be developed that provides an intake with personal advice about HIV self testing, and enable individuals to purchase the HIV self test we provide online. With the test, they will receive a code to access a pre-test trajectory including step-by-step instructions, counseling, and low-threshold contact options with health care professionals. For those who test positive, a follow-up procedure will be developed to motivate them to access regular health care for confirmation testing and referral to an HIV clinic. Results The service will be launched in 2013, accompanied by a media campaign targeting high risk groups. We aim to distribute 2,000 tests within a 12-month period, assuming an HIV prevalence of newly diagnosed individuals of 2.5-5.0%. Using data collected online from participants, web statistics, interviews with participants, and clinical follow-up data, we will evaluate the feasibility and acceptability of the service and its effectiveness in identifying undiagnosed HIV infections. Conclusion If feasible and effective this new method can create another reliable low-threshold testing option for different risk populations -an option hardly needed to break the cycle of low-testing numbers., Background Jurisdictions use a mix of horizontal and vertical approaches to achieve health system reform. Horizontal approaches like British Columbia's Innovation and Change Agenda aim to strengthen the overall health system, while vertical strategies, supported by specialized provincial structures, address specific health issues. Both approaches have drawbacks, so public health leaders such as Jaime Sepúlveda and Julio Frenk have described a third way, “the diagonal approach”: explicit intervention priorities, with cost effectiveness and improved reach and engagement embedded as foundational principles, can generate positive disease-specific outcomes for individuals and populations, while dealing with generic health system issues such as human resource development and quality assurance. Methods BC is using an explicit HIV Treatment as Prevention (TasP) pilot, Seek and Treat to Optimally Prevent HIV (STOP HIV), as a diagonal approach to drive innovation and strategic change in BC's health system. Emphasis has been placed on several outcomes: improved screening; increased diagnoses due to improved screening; and increased linkage to care/treatment. Several discrete initiatives have been deployed to enhance health system capacity to reach (“Seek”) and sustainably engage (“Treat”) vulnerable groups in an overall program of care. Results STOP HIV is driving health system change. Latest data is confirming that British Columbians’ in the pilot areas are being better engaged leading to increased HIV testing, diagnoses, treatment and reduced AIDS mortality—see Figures (1)–(3).Figure 1Dramatic Increase in HIV testing in Vancouver—one of the two STOP HIV pilot areas—compared non-pilot areas. [Increases in HIV Testing]. Figure 2Reversal in new diagnosis trends in Vancouver—one of the two STOP HIV pilot areas—compared to non-pilot areas [Increases in HIV Diagnoses]. Figure 3Increasing trend in treatment starts in the two STOP HIV pilot areas (Vancouver Coastel Health and Northern Health) compared to the rest of the province [Increases in Treatment]. Conclusion STOP HIV is a real-world implementation of HIV TasP, aimed at reducing HIV/AIDS-related morbidity and mortality, as well as new HIV diagnoses, and as a result containing associated health system costs. The initiative has become a driver of diagonal health care reform—and by engaging the most vulnerable and hard to reach, contributes to reducing health inequalities., Background A large scale HIV prevention programs among long distance trucker drivers was started in 2003 across 36 Transhipment locations (TSLs) alongside the national highways. Program was re-designed in the year 2006 by reducing number intervention locations to 17 high performing TSLs. The current research assesses the effectiveness of program after the re-design process. Methods Program monitoring data over seven years and two rounds of cross-sectional behavioral survey conducted in January 2008 (N=1402) and July 2009 (N=1407) were used. Indicators on program outreach and service utilization were examined. Multivariate logistic regression models were used to assess if the increase from first survey to next was significant. Results Coverage of program increased from 43535 in 2004 to 311667 in 2010, though there was a decline in number of TSLs. Along with this, there was a significant increase in number of truckers utilizing clinical services. Analysis from survey data showed that there was a seven-fold increase in clinic visit in last 12 months from 2008 to 2009 (21% vs. 63%, P< 0.001). Significant level of increase was also observed in percent of truckers who watched street plays, participation in health exhibitions. Furthermore, increase from round-1 to round-4 was significant in the following indicators: received condom (13% to 22%, P< 0.001), one-one counseling (15% to 21%, P< 0.01). Treatment seeking for sexually transmitted infection (STI)-related symptoms from STI clinics also increased six times during this time (16% vs. 50%, P< 0.001). Conclusion The re-designing of the intervention has increased the program coverage and service utilization. Implementing truckers program in limited number of high-impact locations after proper planning can help in saturating the coverage and optimum utilization of the available resources., Background ‘Test-and-treat’ programs combining expanded HIV diagnosis, linkage to care, and ART delivery are under consideration, but real-world experience is lacking. During 2011, in rural southwestern Uganda, implementation of ART eligibility to CD4 < 350/uL began. Concomitantly, we (A) conducted a community-wide HIV testing/linkage-to-care campaign, and (B) offered ART to adults with CD4≥350 via a research study (EARLI: NCT01479634). One year later, we conducted a second health campaign and examined the population distribution of HIV RNA levels. Methods During weeklong campaigns in May 2011 and 2012, all Kakyerere Parish residents were offered HIV testing (Determine, Inverness) in multi-disease diagnosis and linkage “health fairs”. In HIV+ individuals, HIV RNA levels were measured by a validated fingerprick blood collection method and RT-PCR (Abbott). We assessed population HIV RNA levels by computing (1) the proportion of persons with an undetectable VL, (2) the median VL, and (3) the mean log(VL) among HIV+ persons. Results After community mobilization, 4,343 and 4,872 persons attended the 2011 and 2012 campaigns, respectively. We estimated 69% and 71% community participation based on census data from 2011 and 2012, respectively. Adult HIV prevalence (≥18yrs.) was 7.8% in 2011 (179/2,282 adults) and 9.4% in 2012 (210/2271 adults). Prevalence was 18.6% on the final day of the health fair located at the parish trading center, and 8.2% across prior days (p< 0.001). A substantially higher proportion of HIV+ individuals had an undetectable HIV RNA level in 2012 vs. 2011 (55% vs. 37%), and both median VL and mean log(VL) were lower in 2012 (see table). May 2011 Health Campaign (n=165 HIV+ adultsa)May 2012 Health Campaign (n=210 HIV+ adults) Undetectable VL, n (%) 62 (37%)115 (55%)VL 486–10,000 copies/mL, n (%)40 (24%)48 (23%)VL 10,000–100,000 copies/mL, n (%)42 (25%)40 (19%)VL>100,000 copies/ mL, n (%)21 (13%)7 (3%) Median VL (IQR), copies/mL 2185 (, Background Current funding levels from PEPFAR/Global Fund may be too low to ensure Universal Access to antiretrovirals (ARVs) in the long-term. Additional, sustainable sources of funding are required. Methods For the 20 countries with the largest HIV epidemics, the additional costs required to achieve Universal Access were calculated, using WHO 2011 estimates of patient numbers requiring ARV treatment, combined with Clinton Foundation prices of ARVs, and PEPFAR estimates of cost of care/diagnostics. WHO estimates of adult population size, annual alcohol and tobacco consumption (commercially supplied) were used to estimate annual revenues from a “Global Health Charge” of 1 US cent per 10mL unit of alcohol, and 10c per 20 cigarettes. Results In the 20 countries with largest HIV epidemics, 5.2/11.3 million eligible patients were receiving antiretrovirals (coverage 46%). The minimum cost of care was $861 per patient-year (antiretrovirals, $406, medical $300, diagnostics $155). Ten of the 20 countries (Botswana, Brazil, China, India, Nigeria, Thailand, Russia, Uganda, Ukraine and Vietnam), could fund 100% of Universal Access costs from National revenue using the “Global Health Charge”: $2.57 of the total $17.97 billion of revenue collected per year would cover treatment of 3.0 million eligible patients in these countries. In the other 10 countries (Cameroun, Cote d'Ivoire, DR Congo, Kenya, Malawi, Mozambique, Tanzania, South Africa, Zambia, Zimbabwe) $937 million could be collected annually with the Global Health Charge: sufficient to treat 1.1 million eligible patients (35% of the additional $2.67 billion budget required for Universal Access). Conclusion A “Global Health Charge” of 1 US cent per unit of alcohol, and 10 cents per 20 cigarettes, collected and spent at a National level, would be sufficient to fund an additional 4.1 million patients per year with antiretroviral treatment and care; Universal Access could be acheived in 10 of the 20 countries with this system., Background HIV and TB treatment is provided free of charge in the public sector in South Africa. However, patients may lose time and incur expenses due to utilizing these services. We measure time and financial costs of utilizing HIV and TB services, and examine in how far they lead to financial distress (patients’ self-report of either borrowing money or selling assets to finance healthcare). Methods We randomly selected patients in a two-stage-sampling scheme and collected data in patient exit interviews: 300 patients on antiretroviral treatment (ART), 200 enrolled in a pre-ART programme, and 300 receiving TB treatment in rural KwaZulu-Natal, South Africa. We assess factors associated with financial distress in multiple regressions, controlling for sex, age and employment. Results Most patients utilizing healthcare were women: 79% (in pre-ART), 62% (ART), 53% (TB). The average times patients spent utilizing care at the last clinic visit was: 3.5 (pre-ART), 2.8 (ART), and 1.1 hours (TB). The average total costs of utilizing healthcare during the last visit were: 15 (pre-ART), 25 (ART), and 20 South African Rand (ZAR) (TB). Transport was the single largest cost component in all three patient categories. 39% (ART), 31% (pre-ART), and 41% (TB) of patients reported financial distress due to healthcare utilization. For each additional hour spent utilizing healthcare, the odds of financial distress increased by 3% (pre-ART), 21% (ART) and 64% (TB). For every additional 10 ZAR spent on utilizing healthcare, the odds of financial distress increased by 25% (pre-ART), 9% (ART), and 6% (TB). Conclusion In this poor, rural community, very high proportions of patients utilizing HIV or TB services report financial distress due to healthcare utilization. Frequent, free transport to HIV and TB clinics would likely substantially reduce the time and financial burdens of healthcare, as well as the prevalence of financial distress., Background ART rollout may have important indirect effects on households and communities. We assess household spillover effects of ART on economic outcomes, in a region of rural South Africa with high HIV prevalence. Methods Longitudinal socioeconomic data from a large population surveillance system (n>100,000) were linked with clinical records from the government ART program serving the area (n=6964). We first describe the extent of household-level exposure to ART among residents in the community. We then employ panel data techniques to evaluate the impact of ART on household assets, food insecurity, and perceived financial status; household composition; and the labor market participation and school enrollment of other household members. We assess trends in these economic outcomes, relative to the dates when household members accessed the ART program and/or initiated ART. As a point of contrast, we examine similar trends relative to dates of death due to HIV in the era before the public sector ART rollout. Results By 2010, two-fifths of area residents lived with someone who had sought care in the government ART program. Prior to widespread availability of ART, households in the region experiencing an HIV-related death faced large economic costs. In contrast, we find little evidence that households of ART initiators experience significant economic hardship due to HIV illness. Conclusion South Africa′s public sector ART rollout has provided substantial social protection for households against the economic costs formerly associated with HIV illness and death. Through indirect exposure to ART via household living arrangements, large populations now enjoy the economic benefits of ART., Background Improved diagnosis of tuberculosis (TB) is a high priority in people living with HIV/AIDS. A lateral flow assay is now available for point-of-care detection of lipoarabinomannan (LAM, a cell wall component of Mycobacterium tuberculosis) in urine. This assay improves sensitivity of TB diagnosis in highly immunocompromised individuals, but its cost-effectiveness is uncertain. Methods We incorporated data from a clinical evaluation of lateral-flow urine LAM into a decision-analytic cost-effectiveness model. Our study cohort consisted of hospitalized, HIV-infected South African adults with CD4+ T-cell counts, Background We sought to forecast the clinical impact and cost-effectiveness of routine HIV screening in Portugal, where the burden of disease remains high. Methods We used a computer model of HIV detection and treatment, coupled with Portuguese national clinical and economic data, to estimate life expectancy (LE), cost, and the incremental cost-effectiveness ratios (ICERs) of alternative HIV screening strategies. We compared current HIV detection practices in Portugal to routine HIV screening in adults aged 18–69. We considered a variety of target populations with differing levels of HIV risk and several testing strategies including the current strategy, one-time screening, screening every five years, screening every three years, and annual screening (Table 1). Baseline input values included: undiagnosed HIV prevalence (0.16%), annual incidence (0.020%), mean age (42 years), mean CD4 at care initiation (292 cells/µL), test acceptance (63%), linkage to care (78%), HIV test cost (_5.40), and an annual discount rate (5%). We conducted extensive sensitivity analyses on these values. Table 1National base case resultsHIV-INFECTED POPULATIONGENERAL POPULATION UndiscountedDiscountedUndiscountedDiscounted Screening strategyLYsLYsQALYsCosts (Euros)LYsLYsQALYsCosts (Euros)ICER (Euros/QALY)Current screening practice36.11715.42614.54976,93038.21616.09716.089720—One-time screening36.59715.65214.75283,50038.22116.09916.09178036,500Screening every 5 yrs37.12815.77814.87188,53038.22616.10116.092840dom*Screening every 3 yrs37.38115.85014.94091,32038.22716.10116.09387057,200Annual screening37.89616.01115.09097,98038.23316.10316.09498091,700*dom=“weakly dominated.” Costs more and confers fewer QALYs than an alternative strategy.**DOM=“strongly dominated.” Costs more and is less effective than an alternative strategy. Results One-time testing increased discounted HIV-infected LE from 15.426 to 15.652 LYs and undiscounted HIV-infected LE from 36.117 to 36.597 LYs, as compared to current detection practice (Table 1). One-time testing yielded greater increases in HIV-infected LE and was more cost-effective in regions with greater HIV risk (Table 2, Lisbon, Undiagnosed HIV Prevalence=0.29%, Annual Incidence=0.037%), compared to regions with lower HIV risk (Table 3, Guarda, Undiagnosed HIV Prevalence=0.03%, Annual Incidence=0.004%). In Lisbon, the cost-effectiveness ratio of screening every three years was 48,200 _/QALY and the cost-effectiveness ratio of annual screening was 76,300 _/QALY.Table 2Lisbon region base case resultsHIV-INFECTED POPULATIONGENERAL POPULATION UndiscountedDiscountedUndiscountedDiscounted Screening strategyLYsLYsQALYsCosts (Euros)LYsLYsQALYsCosts (Euros)ICER (Euros/QALY)Current screening practice36.07715.41614.53877,02038.15216.08316.0681,300—One-time screening36.56015.64614.74483,71038.16116.08616.0711,41034,900Screening every 5 yrs37.09215.77214.86388,74038.17016.08916.0731,51047,900Screening every 3 yrs37.35015.84314.93191,55038.17416.09016.0741,56048,200Annual screening37.87116.00215.07998,19038.18416.09216.0761,72076,300 Table 3Guarda region base case resultsHIV-INFECTED POPULATIONGENERAL POPULATION UndiscountedDiscountedUndiscountedDiscounted Screening strategyLYsLYsQALYsCosts (Euros)LYsLYsQALYsCosts (Euros)ICER (Euros/QALY)Current screening practice36.17615.43514.55976,75038.28016.11216.111140—One-time screening36.62215.66214.76483,32038.28016.11316.11115062,800Screening every 5 yrs37.15815.78614.88188,38038.28216.11316.111170dom*Screening every 3 yrs37.41615.86014.95391,09038.28216.11316.11118097,800Annual screening37.93416.01015.09197,86038.28216.11316.111240DOM** Conclusion One-time, routine, voluntary HIV screening in the Portuguese general population meets accepted international standards of cost-effectiveness. One-time screening is more attractive in regions with higher undiagnosed HIV prevalence and even more frequent screening may be justified in these regions given their higher incidence rates., Background Since the introduction of antiretroviral therapy (ART) in low-resource settings the use of laboratory monitoring for HIV infection has been the subject of great debate. This study aimed to assess the cost and cost-effectiveness of clinical plus laboratory monitoring (LAB) compared with clinical monitoring alone (CLIN). Methods A randomized non-inferiority trial was performed in nine rural district hospitals in Cameroon. HIV-infected, ART-naive adults with WHO stage 3-4 disease were enrolled and followed-up for 2 years. Participants were randomly assigned to CLIN (quarterly clinical monitoring) or LAB (six-monthly HIV viral loads and CD4 cell counts plus quarterly clinical monitoring) by a computer-generated list. Clinical outcomes and related-costs were calculated among patients followed-up for at least six months excluding the period unrelated to ART monitoring. Incremental cost-effectiveness ratios (ICER; US$ per life-years saved) were computed based on two HIV-RNA test costs (Abbot molecular technology, $67 and in house ANRS test, $35). One-way and multivariate sensitivity analyses were performed. Results Analyses were conducted among 188 and 197 patients in the LAB and CLIN groups respectively. With the Abbott test, results per 100 individuals showed that LAB compared with CLIN increased costs by $49,800 and saved 10.6 life-years (ICER=$4678 per life-year saved). With the ANRS test, the incremental cost is $34,900 per 100 individuals, i.e. an ICER of $3276 per life-year saved. 50 000 trial Monte Carlo simulation showed ICERs (IQR) from $3536-$5136 and $2553-$3642 per life-year saved with the first and second tests respectively. Considering a cost-effectiveness threshold of $3800 (i.e. three times the Cameroonian capita gross domestic product), LAB is cost-effective when the cost of HIV-RNA plus CD4 cell count are lower than $75. Conclusion Monitoring of HIV viral load and CD4 cell count to guide switching to second-line ART is cost-effective in resource-limited settings when using less costly generic tests., Background Expanding HIV testing in healthcare settings needs more economic evidence in China with concentrated HIV epidemic. This study was aimed to examine the costs and benefits of strategies to improve HIV testing and promote case finding. Methods Cost-effectiveness analysis based on a Markov model was applied to compare three HIV testing strategies for patients in outpatient departments: Strategy A=targeted testing based on risk behavior and symptoms, Strategy B=non-targeted testing all male adult patients with blood withdrawn for any clinical reasons, Strategy C=non-targeted testing all adult patients with blood withdrawn. Unidentified HIV prevalence, number of testing, number of newly identified cases, and related costs were derived from a controlled trial, which compared the effectiveness of strategies above in areas with concentrated epidemic in China. Long-term costs and health outcomes were derived from the literature. Incremental cost utility was evaluated from a societal perspective using a lifetime horizon. The benefit from reduced HIV transmission was not considered. Results With 0.3% of the undiagnosed outpatient HIV prevalence in study areas, the cost per new HIV infection identified was $146.1, $258.4 and $350.9 under strategy A, B, C, respectively. Strategy A resulted in per-patient lifetime discounted costs of $11,349 and benefits of 6.21 quality-adjusted life-year (QALY) gained. Strategy B increased mean QALY by 0.018, with an incremental cost-effectiveness of ?5,710/QALY, and Strategy C increased mean QALY by 0.017 than strategy B, with an incremental cost-effectiveness of $6,592/QALY. Sensitivity analysis showed that even if the undiagnosed HIV prevalence was as low as 0.113%, annual implementation of strategy C would still be cost-effective, with a cost of $14,059 to save a QALY, which was just 3 times of GDP per capital in China. Conclusion In concentrated epidemic area, non-targeted HIV testing in healthcare setting is cost-effectiveness and justified for sustainable investment., Background Progress in reducing HIV incidence in the US epidemic has stalled in recent years. Modeling studies suggest that test-and-treat interventions could powerfully control some HIV epidemics. Using mathematical modeling, we assess cost-effectiveness of test-and-treat strategies in the HIV epidemic in Newark, NJ, one of the most severe in the U.S. Methods A compartmental model was developed representing populations at HIV-risk in Newark with transmission through sex and intravenous drug use. The model was calibrated to NJ data on annual prevalent cases by acquisition mode, 2002–2009. Three interventions (In) were considered: In1 increased HIV testing coverage; In2 provided In1 and case management; In3 provided In2 and universal antiretroviral therapy. In current practice, at-risk subjects were assumed tested once every four years. Expanded testing resulted in the testing frequency doubling. Health resource use and unit costs were estimated, testing and HIV-related outpatient costs calculated, and inpatient and emergency department costs abstracted from the literature. A health care system perspective, 3% discount rate, and ten-year program time horizon were used. Costs are in U.S. dollars (USD) 2011. Results At the start, 220,500 individuals were HIV-uninfected but at-risk and 16,550 were HIV-infected. Annually, In1, In2, and In3 averted a median of 142, 581, 658 incident cases and 162, 826, and 901 HIV-related deaths respectively. Ten-year costs, cases/ deaths averted are presented (Table 1). ICERs per death averted for In1, In2, and In3 were $146,800, $28,000 and $143,100 respectively. In1 is less efficient than a blend of current practice and In2. If such a blend were implementable, then In1 would be eliminated and ICERs for In2 and In3 would be $62,800 and $143,100 respectively. Table 1Costs and cases/deaths averted, Newark NJInterventionOutpatient costs (USD)*Inpatient + emergency costs (USD)*Total costs (USD)*Net costs (USD)*HIV cases averted*HIV deaths averted*Current practice$758,618,000$276,685,000$1,035,302,000–––In1$934,916,000$368,002,000$1,302,918,000$267,616,0001,0971,823In2$1,058,479,000$367,446,000$1,425,926,000$123,008,0003,0364,395In3$1,128,486,000$394,732,000$1,523,218,000$97,292,000485680*=10-year aggregated totals, discounted, increments relative to next strategy. Conclusion Test-and-treat strategies, particularly testing combined with case management +/− universal ART, may substantially decrease HIV transmission in this high prevalence area, prevent HIV-related deaths, and do so in a cost-effective fashion., Background The UNAIDS Investment Framework highlights ‘'critical enablers’‘ that influence the success of HIV programmes; and synergies with other development sectors. Although the need to address the structural drivers of HIV vulnerability is well recognised, there is a danger that these interventions are not prioritised in HIV budgets, given the limited body of evidence on their cost-effectiveness. A key challenge to economists evaluating such interventions is how to assess the wide range of costs and consequences of these comprehensive structural interventions. We use two methods to estimate the cost-effectiveness of a conditional cash transfer in Malawi to keep girls in school. Methods We model national costs based on full coverage of girls of secondary school age (15–19 years) living on less than US$1.25 a day. Based on trial evidence, we model a 64% reduction in HIV incidence among the target group to estimate economic benefits. We use two economic evaluation approaches, one that apportions the total costs of the intervention according to the HIV-related proportion of total economic benefit and another based on the WHO cost-effectiveness threshold. Results We find that about 30% of estimated economic benefits in Malawi are related to HIV. The trial estimated a cost per infection averted (IA) of US$12,500, which we translate into a cost per DALY of US$711. Allocating total costs according to the proportion of HIV-related economic benefit reduces the cost per IA to US$3,750 and the cost per DALY to US$213. Alternatively, if the HIV programme wishes to achieve cost-effectiveness at the WHO threshold of GDP per capita (US$310) then it would achieve value for money by funding 44% of total costs. Conclusion HIV programmes are recommended to allocate funds to structural interventions based on proven effectiveness and according to the threshold at which the intervention becomes cost-effective from an HIV perspective, rather than estimating conventional cost-effectiveness ratios., Background PLHA have decreased economic productivity both due to direct and indirect causes. Data from developed countries have shown that at the societal level, high costs ART are offset by increased productivity. However, these data have to be substantiated in developing countries where the expenditure for ART largely borne by individuals. We hypothesized that post-ART the SES would improve regardless of the baseline SES and will be sustained over time. Methods We performed a comprehensive SES evaluation pre/post ART initiation using an ambispective cohort study design. Indian household-specific SES validated tool” (Aggarwal OP 2005), with score of 76 being affluent was used prospectively, along with clinical, ART adherence data at 6 &18 months post ART, compared using paired t-tests. Results Among 140 started on ART, 118 had pre ART SES data, median f/u was 22 months, of these: 57% were women; median age 38 years; 67% married; 89 (78%) heterosexual sex as HIV risk; 40 (34%) had major OI and/or TB at presentation. Reported self-occupation was: skilled laborers 35%; 10% unskilled laborers; 23% housewives; 22% were professionals/ blue collar job;1 CSW, 1 student, 10 unemployed. The median pre-post ART CD4 cell counts were: 187& 454 (p, Background This study assessed the cost-effectiveness of maternal triple-drug ART or infant nevirapine to reduce HIV transmission during breastfeeding from HIV-infected Malawian mothers, not meeting treatment guidelines for their own health. Strategies were evaluated at two entry points into the health system: (1) time of delivery, for mothers who have not accessed ART antenatally, and (2) antenatally. Methods Cost-effectiveness was estimated from the healthcare perspective, using nationally representative unit costs, and was evaluated in terms of HIV transmissions averted, life-years gained, quality adjusted life-years (QALYs), and disability adjusted life-years (DALYs). The risk of HIV transmission associated with the antenatal and postnatal strategies were taken from the Kesho Bora and BAN studies, respectively. Antenatal regimens were (1) AZT and (2) AZT, 3TC, lopinavir/ritonavir. The postnatal interventions were (1) maternal ART (AZT, 3TC, lopinavir/ritonavir); (2) infant NVP; and (3) no extended post-natal prophylaxis. Scenario analyses evaluated alternative drug combinations and prices, 2nd trimester initiation, and varying paediatric ART coverage. Results For entry into the health system at delivery, infant nevirapine throughout breastfeeding was cost effective. With antenatal entry to the health system, antenatal AZT plus infant nevirapine during breastfeeding was cost effective. The incremental cost-effectiveness ratios for these strategies were $616.28 and $1,031 per HIV transmission averted, $31.84 and $53.33 per life-year saved, $34.25 and $57.20 per QALY and $32.47and $54.42 per DALY averted, respectively. The recommended strategies did not change in the alternative scenario analyses. Conclusion For pregnant, HIV-1 infected women presenting to the health system at delivery and not requiring ART for their own health, infant nevirapine throughout breastfeeding is a highly cost-effective method for postpartum PMTCT. For those presenting antenatally, antenatal AZT followed by infant nevirapine throughout breastfeeding (World Health Organization Option A) is the most cost-effective PMTCT strategy., Background US guidelines recommend once-daily, one-pill efavirenz/emtricitabine/tenofovir as a preferred first-line ART regimen. With the anticipated availability of generic efavirenz in the US, the cost of a once-daily, three-pill alternative (generic efavirenz, generic lamivudine, tenofovir) will decrease, but adherence and virologic suppression may be lower. We project the clinical impact, cost, and cost-effectiveness of the generic-based vs. brand-name options. Methods Using an HIV simulation model (CEPAC-US), we examine 3 strategies: 1) No ART (for comparison); 2) three-pill generic-based ART; and 3) one-pill brand-name ART. Inputs are from peer-reviewed data: ART efficacies (24-week suppression: 78% generic-based vs. 85% brand-name); drug costs are 25% of average wholesale price (AWP) for generics and 77% of AWP for others ($8,600/year vs. $15,370/year for the regimen); the cohort is 84% male, mean CD4 317/µl. From the US health system perspective (2010 USD), we report incremental cost-effectiveness ratios (ICERs, $/QALY) compared against a $100,000/QALY threshold. We also project the potential annual savings for those initiating ART (incident diagnoses, ~2,500) and those eligible to switch to the generic-based regimen (prevalent cases, ~147,000) Results Compared to No ART, generic-based ART has an ICER of $21,600/QALY. Compared to generic-based ART, brand-name ART increases lifetime costs by $43,900, and per-person survival gains by 0.36 quality-adjusted life years (due to increased efficacy and reduced resistance from emtricitabine compared to lamivudine), for an ICER of $121,300/QALY (Table). ICERs are sensitive to decreases in generic-based ART efficacy and to generic drug costs; most plausible combinations lead to ICERs >$100,000/QALY (Figure). Estimated annual savings if all eligible US incident/prevalent patients switched to the generic-based regimen are $1.01B.FigureIncremental cost-effectiveness or brand-name compared to generic based first-line ART regimen. Per person life expectancy (QALYs)* Per person lifetime cost* (USD 2010) ICER ($/QALY) No ART4.05131,300–Three-pill generic-based ART12.09305,20021,600One-pill brand-name ART12.45349,100121,300QALY: Quality-adjusted life year; ICER: Incremental cost-effectiveness ratio.*QALYs and costs discounted at 3% annually; undiscounted life expectancy for one-pill brand-name = 19.33 QALYs. Conclusion Compared to a slightly-less effective generic-based regimen, the cost-effectiveness of the guideline-recommended brand-name regimen exceeds the $100,000/QALY threshold. Switching to generic-based regimens would yield substantial savings for programs that fund HIV treatment., Background In many developing countries, reliance on private providers for healthcare, even among the poor, is high. However, less is known about health seeking behavior specific to HIV/AIDS care. As countries increasingly view the private health sector as an integral part of the overall health system, it is critical to understand the current and potential role of private providers in addressing HIV/ AIDS needs. Methods We analyze 20 Demographic and Health Surveys from 18 countries conducted between 2005 and 2011 in which information on source of HIV test is available. Results Use of private providers for HIV testing varies greatly across countries (see Figure 1). Overall use of the private sector for HIV testing is strongly correlated with use of the private sector for other health services but not strongly correlated with per capita GDP, uptake of HIV testing, or overall HIV prevalence.Figure 1Among Those Who Received an HIV Test, Share Who Received Test from Private Provider [Use of Private Sector for HIV Testing]. At the household level, use of the private sector is highly correlated with household wealth in nearly all countries (see Figure 2) but not strongly associated with level of education, marital status or location (urban vs. rural) in most countries.Figure 2Among Women Reporting Having Received an HIV Test from the Private Sector, Share from Each Wealth Quintile [Breakup of Users of Private Sector for HIV Testing]. In addition to information on source of most recent HIV test, DHS data also contains information on whether women who received ANC were offered an HIV test allowing us to compare public and private providers on this simple measure of performance. In all countries but two (Malawi and Uganda) private providers were more likely to offer an HIV test during ANC than their public and non-profit counterparts. Conclusion The private sector plays a significant role in HIV testing in many countries. More research is needed to understand how private providers could be further leveraged to increase levels and quality of HIV testing and counseling and strengthen national HIV responses., Background Supply chains are essential to securing availability of life-saving commodities for patients. Unfortunately, logistics training is often absent from the professional education of staff operating the supply chain. In-service training, while traditionally used to teach supply chain skills, takes personnel away from their work, is expensive to implement and often relies heavily on external technical assistance. USAID is investing in pre-service training (PST) as a cost-effective and sustainable alternative to build a competent health workforce in supply chain management (SCM). Methods The Supply Chain Management System (SCMS), a project under PEPFAR administered by USAID, works with local universities to incorporate SCM courses into pharmacy and nursing programs and build the capacity of university staff to plan, teach and manage those courses. Course content is based on local context and existing supply chain systems and prepares health workers for day-to-day supply chain tasks they will encounter post-graduation. Results As a result of SCMS PST initiatives, the Namibian School of Pharmacy now includes pharmaceutical management and procurement courses in its curriculum. In Zimbabwe, with support from the USAID ∣ DELIVER PROJECT, three pharmacy programs offer SCM courses, with nursing programs to follow suit. Two national universities in Rwanda and Zambia require laboratory logistics courses for laboratory science degree programs. Since the Zambia course's introduction, SCMS in-service training costs have been reduced by 62%; 80% of the 272 students trained currently work in MOH facilities. Conclusion SCMS PST activities build local capacity in health supply chain and develop a sense of ownership for local training institutions in creating a skilled SCM workforce. Future health workers graduate with a fundamental understanding of SCM, enabling them to make an immediate contribution to the health system. Savings from reduced reliance on in-service training can be reinvested into national HIV programs, allowing for expanded services and potentially improved health outcomes., Background Sex Workers (SWs) in Mumbai, India are highly vulnerable and face numerous incidents of harassment from police, stakeholders, clients, family members. Since 2004, FHI 360 has implemented a BMGF supported HIV/STI prevention project with over 80,000 male, female and transgender SWs in Mumbai. A community led, crisis response system (CRS) was devised to address the crises incidents. Methods In January 2007, SWs were collectivized by peer educators (PEs) into site-level Task Force Committees (TFCs), members of which are community leaders. The focus of the TFCs was to provide instant support in times of harassment from key stakeholders including police, criminal elements and regular partners. Core TFC members were capacitated through training programs on legal literacy, skill building on addressing incidents of stigma, discrimination and harassment and improving negotiation and communication skills. Results From January 2007–December 2011, over 84,000 crisis incidents were supported. Analysis of program data, showed that the percent of crises support increased from 47% (January 2007) to 100% (December 2011) [Graph 1]. The average response time to the crises incidents reduced from 75 minutes (September 2007) to 21 minutes (December 2011) [Graph 2]. Also the percent of police arrests, out of the total crises occurred, reduced from 62% (January 2007) to 10% (December 2011) [Graph 3].Figure 1Crisis incidents supported. Data from Behavioural Tracking Survey, a cross-sectional behavioural study with 2,106 FSWs conducted in 2010 also showed that 90.7% FSWs who were aware of CRS had accessed crisis services at least once in the last six months, as compared to those who were not aware of the CRS (66.8%) (p, Background High HIV and TB rates, poor health services, overcrowding and lack of human and financial resources are common in prisons of sub-Saharan African countries, including Zambia. Severe staff shortages and the need for inmate buy-in led to recruitment and training of inmates to assist in the implementation of prison-based HIV testing and TB screening. We describe the inmate peer educator program implemented during a TB REACH-funded collaboration between the Zambia Prisons Service (ZPS) and the Centre for Infectious Disease Research in Zambia. Methods Eligible peers were chosen by prison officers, and received 5 days of training to complete symptom assessments, refer inmates for TB/HIV screening, collect sputum, assist with enrollment into National HIV and TB treatment programs, and provide educational outreach and counseling. Inmate drama members were also mentored to convey health messages through acting, music, and dance. Results We trained 74 peer educators and 57 drama members and found that they were enthusiastic and committed to the screening program. Between November 2010 and September 2011, peers led 6,436 inmates (average of 32 inmates screened per day), through HIV testing and TB screening. Challenges included: requests for incentives, concerns over TB exposure, and difficulty maintaining adequate numbers of peers because of inmate release and transfer. Solutions included: promotions within inmate hierarchies, provision of N95 respirators, and additional training to maintain peer numbers and establish peer-to-peer mentorship. Conclusion Scale-up of prison health services in sub-Saharan Africa is an urgent priority. This inmate peer educator program was a low-cost, effective intervention that was critical to the successful implementation of this prison-based HIV and TB program. Ongoing support and ownership by ZPS and prisoners is needed to ensure long-term program sustainability., Background In order to improve access to antiretroviral therapy (ART), Lesotho was one of the first countries in southern Africa to adopt task-shifting from hospitals to nurse-led health centers (HC). We compared outcomes in patients who initiated ART at HC with those who started at hospitals in two catchment areas in rural Lesotho. Methods Patients aged ≥16 years who started ART in one of two hospitals or one of their 12 affiliated HCs between 2008 and 2011 were included. Baseline characteristics were compared using Mann-Whitney and Pearson's chi-square tests. No follow-up was defined as no recorded follow-up after starting ART, lost to follow-up (LTFU) as not returning to the facility for≥180 days after the last visit. Crude retention in care was estimated using Kaplan-Meier methods. Mortality, no follow-up and LTFU in patients who started ART in hospitals and HCs were compared using logistic and cause-specific Cox regression models. Odds ratios and hazard ratios, adjusted for gender, age, CD4 count, WHO stage at start of ART and type of first-line ART regimen are reported. Results A total of 3,733 patients, including 2,036 (54.5%) who started ART at HC and 1′697 (45.5%) at hospital level, were analyzed. Patients who started ART at hospitals had more advanced disease than those in the HC-group (Table 1). Overall, 46 patients (2.3%) in the HC and 58 (3.4%) in the hospital group had no follow-up visit. Over 5,504 person-years, 414 patients died (11.1%) and 577 (15.5%) were lost to follow-up. Crude, three-year retention was higher at HC (67.8% (95% CI: 64.6–70.7) versus 61.9% (58.8–64.9)). However, in adjusted analyses, mortality and LTFU were similar in both groups (Table 2).Table 1Baseline characteristics of patients ART start at Hospital ART start at Health Center p-value Total Number of patients 1′6972′0363′733 Number of women (%) 1′081 (63.7)1′307 (64.2)0.752′388 (63.9) Median age in years (IQR) 37 (31–47)39 (32–49), Background Pre-antiretroviral therapy for HIV (pre-ART) is increasingly recognized as an entry point to the continuum of care for HIV to facilitate timely initiation of antiretroviral therapy (ART). In this study we assess a public pre-ART program at primary health care level in rural Uganda. Methods This retrospective analysis used a file and register audit at all four governmental health centres (HC) providing ART and pre-ART care in Iganga district, Uganda. All HIV patients registered from February 2005 to August 2009 were included. We report rates of retention and attrition for patients in pre-ART care and facility performance indicators. Results Out of 2357 registered HIV-patients, 2024 (85.9%) were still not initiated on ART by the time of our study. The overall retention in care of these patients was 19.3% after 4.6 years since introduction of the program with 1634 patients lost to follow up (LTFU) and 390 retained in care. At one HC, the retention rate was 3.6% (22 patients retained out of 603). The probability of retention in care was 0.75 [CI 0.72-0.78] at the first month, 0.46 [CI 0.42-0.49] at 6 months, 0.36 [CI 0.32-0.39] at 12 months and 0.26 [CI 0.23-0.30] at 24 months after enrollment and significantly lower than among patients who initiated ART. Of the patients alive and attending the pre-ART program, 20.8% were eligible to ART according to national guidelines but not yet initiated. Stock-outs of Cotrimoxazole occurred at all HCs. At two HCs, more than one third of the individual patient files of pre-ART patients were not available. Conclusion The pre-ART program at HC-level in the district under investigation faces challenges in high rates of LTFU early after enrollment of the patients. To assure timely initiation of ART, better quality and new strategies to retain patients in pre-ART care programs are needed., Background As essential services for PMTCT are increasingly decentralized to antenatal care (ANC) sites, the consequences of shifting services from dedicated HIV care and treatment (C&T) clinics remain incompletely explored. We compared service delivery at ANC and C&T clinics in Kinshasa, DRC, a low HIV prevalence, resource-deprived setting. Methods In 10/2010, an enhanced standard of care was introduced at 44 ANC sites: personnel were retrained to implement the 2010 WHO PMTCT guidelines including Option A and co-located post-delivery care, and were provided with new individual-level tracking tools and supportive supervision. Women were encouraged to enroll at either of two affiliated C&T sites for continued PMTCT and HIV care but could opt to receive AZT-based prophylaxis at ANC sites when it became available alongside CD4 testing in 2011. Antiretroviral therapy was available only at C&T sites. Results Of 1,233 HIV-infected women tracked between 10/2010 and 12/2011, 926 (75.1%) were newly diagnosed; 306/926 (33.0%) enrolled in C&T. Newly diagnosed women were more likely to receive CD4 testing (RR=2.2; 95% CI 1.9-2.6) and a WHO-recommended regimen (RR=1.6; 95% CI 1.4-1.8) if they enrolled in C&T than if they remained at an ANC site. Infants were more likely to receive a package of extended NVP, cotrimoxazole and DNA PCR testing at C&T than at an ANC site (RR=1.9; 95% CI 1.6–2.3). At ANC sites, 116 women received AZT-based prophylaxis and 91 received CD4 testing; 95 infants received the postnatal package. Conclusion Individual-level tracking of mothers and infants was feasible in Kinshasa and revealed that PMTCT services were delivered less effectively at sites historically focused on ANC rather than HIV C&T. While decentralization increased care access, its potential to further reduce vertical transmission cannot be fully realized without sustained training and supervisory support to ensure optimal quality of service delivery throughout the entire PMTCT cascade., Background Since 1988, Nepal has evolved from a “low HIV prevalence” to a “concentrated epidemic”. In 2005, the Government initiated PMTCT services in hospitals, but they were found to be least accessible by most disadvantaged pregnant women living in remote areas. In 2009, UNICEF and Government in collaboration with CBOs introduced a community based PMTCT service integrated with MNCH, in one of the highest HIV burden districts of Nepal Methods The CB-PMTCT model uses the government's existing MNCH structures. Trained Volunteers provide HIV information to pregnant women and refer them for ANC services. During ANC visits pregnant women are encouraged to take HTC services. If positive, the pregnant woman is referred for further treatment and support. During the pregnancy she is provided with counselling on delivery preparedness and treatment adherence. HIV-positive women are encouraged for institutional delivery Results The CB-PMTCT intervention increased the ANC coverage from 78.7% in 2009 to 82.2% in 2011. HTC uptake increased from nationally 9% in 2008 to 40% in 2011 in the intervention areas. In 2011, 82% positive pregnant women received ARV prophylaxis compared to 50% in 2008, and infant ARV coverage reached 85% from 57% in 2009. Institutional delivery increased from 7.5% to 16.1%. Conclusion Utilization of PMTCT by pregnant women dramatically increased by taking services at the community level. The volunteers and WLHIV created demand for PMTCT services and care practices. The integration of PMTCT in MNCH services is an efficient, cost effective and sustainable approach. Because of the proven efficacy of the intervention Government is keen to scale up the model in 7 districts with Global Fund funding. In order to improve the service utilization, HTC services should be decentralized up to the community level. It is also imperative to address stigma and discrimination and change social norms to ensure equitable access to services by KAP., Background Travel time and distance are barriers to care for HIV-infected children in resource-poor settings. Decentralization is one of the strategies to scaling-up access to antiretroviral treatment (ART), but few such programs have been evaluated. We compared outcomes for children receiving care in mobile and hospital-based HIV clinics in rural Zambia. Methods Outcomes were measured within an ongoing cohort study of HIV-infected children seeking care at Macha Hospital, Zambia since September 2007. Children in the outreach group received ART from the Macha HIV clinic and transferred to one of three mobile outreach clinics administered by Macha Hospital. Children in the hospital group received ART at the Macha HIV clinic, and reported Macha Hospital as their nearest healthcare facility. Results 46 children in the outreach group and 41 children in the hospital group were included. The median time between enrolment and transfer to the outreach clinic was 10.2 months (IQR:5.7,14.9). After transfer to the outreach clinic, travel time was significantly shorter and fewer caretakers used public transportation (before:47.8%; after:2.8%; p95%) was significantly lower in the outreach compared to the hospital group (65% vs. 84%; p=0.02). Conclusion Despite similar clinical and immunologic outcomes, children in the outreach group were less likely to achieve virologic suppression, potentially due to lower adherence. Continued adherence counseling is critical for the success of decentralized care., Background As Anti Retroviral Treatment (ART) programmes improve survival in early life the number of adolescents in need of ART will continue to increase. Programmes will need to scale up services which address the particular needs of adolescents. Here we assess the experience of such scale up in a large urban adolescent cohort. Methods Between 2004 and 2010 9,360 adults and 1,776 adolescents commenced antiretroviral therapy (ART) at Mpilo OI ART clinic, Bulawayo. A package of specific activities for adolescents was implemented, to provide comprehensive care including active defaulter tracing, a comprehensive, dedicated counselling programme and psycho-social activities operating both inside and outside the clinic, such as a youth club. Adolescents were engaged in decisions regarding their care. In this retrospective cohort analysis adolescents were defined as those ≥ 10 and, Background Community based organizations (CBOs) and non-governmental organizations (NGOs) have generally proven to be effective instruments for sustainable implementation of HIV prevention programs among female sex Workers (FSW). Affinity and integrity with FSWs have enabled them to expand coverage and medical service delivery by transferring responsibility to FSWs and fostering demand driven approach. To identify and understand factors that enhance performance of programs with FSWs, Technical Support Unit (TSU) of the Karnataka State AIDS Prevention Society (KSAPS) Government of Karnataka, conducted case studies of two programs implemented by FSWs collective (CBO) and an NGO. Both programs have achieved high standards of service delivery. Methods Focused group discussions (FGD) were conducted with the following: board members of CBO and NGO 2 FGDs (11 participants), outreach team 2 FGDs (18 participants), FSW peer educators 2 FGDs (27 participants), Female Sex Workers 2 FGDs: (17 participants). FGDs were conducted with the KSAPS and TSU whose mandate is to provide technical assistance to the prevention programs. Results Factors that contributed significantly to improved performance were that these projects are components of broader, holistic agenda that puts women at its centre, addressing women's needs, including, but not limited to, HIV prevention. Programs generate evidence-based plans from program data. Site-based peer plans are used, which plan for individual FSW and tailor services according to individual profiles, have improved TI performance. This has helped Peer Educators to spend quality time in the field, while also improving their productivity. Supportive hand holding by Technical Support Unit has helped in diagnosing problems and its resolution. Conclusion Embedding HIV prevention within broader programs that respond to women's needs, and in which FSWs play a deciding role, increases likelihood of success of the programs. As NACP-III nears its end and the nation prepares for NACP-IV, these findings indicate promising direction for future., Background The prevalence of HIV infection in Ukraine is 1.33% (adult). In Europe it is one of the highest rates. The highest concentration of-among IDUs. Pharmacy interventions started in Ukraine in 2007. The clients of pharmacy interventions are mainly belong to IDUs, including female IDUs, and commercial sex workers (CSWs). Currently 143 pharmacies are implementing pharmacy-based prevention projects in cooperation with 25 NGOs in 13 out of 27 regions of Ukraine. Methods Organization of the project activities: an NGO and a pharmacy sign a cooperation agreement. NGO: transfers consumables to the pharmacy, trains pharmacy workers, informs the target group about the project, pays for the pharmacy services within the project and reports to the donor agency funding the project (ICF “International HIV/AIDS Alliance in Ukraine”, funded by the Global Fund). Pharmacy: provides free of charge services to the program clients, provides the program client cards to the new clients (IDUs and FSWs), and keeps record of the clients and distributed products. The basic package at the pharmacies includes: syringe distribution/exchange (3–5), alcohol swabs, condoms, information products, delivery of the harm reduction program client cards to the new clients. Counseling on safe behavior, referral of the clients to NGOs to receive other services (testing for HIV, STIs, counseling by specialists) are also provided. Results Achievements for 2011: General year coverage: 27 435 clients, who made more than 387 000 visits to the pharmacies.11 714 new clients (IDUs, CSWs) became the participants and were issued à Participant card of the pharmacy programme. Syringes exchange organized in 32 pharmacies (out of 143)- permission for such exchange obtained from the local controlling institutions. Conclusion Approximately 20.5 % of the over-all number of new clients (57 143) was involved into the HIV prevention programs of Alliance in Ukraine through the pharmacies in 2011., Background Sub-Saharan African antiretroviral treatment (ART) programmes have a severe professional staff shortage resulting in inadequate support for patients which contributes to increasing virologic failure. However, community-based adherence-support (CBAS) workers now form a significant work-force. This study evaluated the effect of CBAS on virological outcomes at 57 non-governmental organization-supported public ART facilities in four South African provinces. Methods CBAS workers provide education and psychosocial support for ART patients through home visits to assess and address adherence challenges. A multicentre cohort study was performed, including adults starting ART between January 2004–September 2010 at clinics where patients were eligible to receive CBAS. Prospectively collected routine electronic data were analysed. Outcome measures were virological suppression (VS) (viral load < 400 copies/ml) at six-monthly intervals until 5 years of ART. Multivariable generalised estimating equations were used to compare VS between patients who received and not receiving CBAS, using an intention-to-treat approach. Extreme-case sensitivity analyses were performed to estimate bias due to missing viral load results. Results 66,953 patients were included: 19,668 (29.4%) received CBAS and 47,285 (70.6%) did not. At baseline, median age was 34.8 years; 45,844 (68.5%) were female; median CD4 cell count was 125 cells/µl (IQR: 65–175). After six months of ART, VS was 76.6% (95% CI: 75.8%-77.5%) and 72.0% (CI: 71.3%-72.5%) in CBAS patients and non-CBAS patients, respectively (P< 0.0001). In multivariable analyses after one and five years of ART, CBAS was associated with improved VS, adjusted odds ratio (aOR) 1.33 (CI: 1.24–1.43) and aOR 2.66 (CI: 1.61–4.40), respectively. Improved virological suppression in CBAS patients remained evident in sensitivity analyses considering missing test results as either suppressed (aOR 1.44 [CI: 1.37–1.52]) or unsuppressed (aOR 1.15 [CI: 1.11–1.19]).Figure 1Proportions of patients achieving virological suppression in (a) intention-to-treat (ITT) analyses censoring missing values, (b) ITT analyses regarding missing values as suppressed, (c) ITT analyses regarding missing values as unsuppressed and (d) on-treatment analyses. Conclusion CBAS was associated with improved virological suppression, the magnitude of which increased for longer therapy duration. Expanded implementation of this intervention should be considered in resource-poor settings., Background In the DRC, traditionally stigmatized groups such as MSM are also those most at risk of HIV infection. In the first activity of its kind in Kinshasa, Projet Integré de VIH/SIDA au Congo (ProVIC), a USAID/PEPFAR-funded HIV/AIDS project, partnered with local nongovernmental organization Progrès Santé Sans Prix (PSSP) to assess the receptiveness to and feasibility of providing voluntary nighttime mobile HIV counseling and testing (HCT), or “moonlight” testing, to MSM using rapid finger-prick technology. Providing quality services to MSM and addressing their specific needs, including combating stigma, are important to reversing the HIV/AIDS epidemic in the DRC. Methods MSM were identified through risk mapping conducted at 15 sites in Kinshasa in 2010. Teams worked with groups of MSM peer educators from both the community and PSSP to provide HCT services using the rapid finger-prick method. Four mobile HCT teams, each including two laboratory technicians and a supervisor, conducted two moonlight HCT clinics per week. Attendance at the mobile HCT was carefully monitored, and observations on the strategy's successes were solicited from program staff. Results MSM attendance was initially low, with only 20 MSM accessing HCT services per night; over the course of the pilot, however, this number grew to an average of 80 clients per night. A seroprevalence of 30 percent was found among MSM ages 20 to 30. Involving MSM peer counselors in this intervention played an important role in the feasibility and effectiveness of this pilot. Conclusion Rapid moonlight HIV testing for MSM led to increased service utilization because services were more easily accessible; clients were pleased to receive prompt, quality services without the perception of negative judgment. Staff reported that involving MSM peer counselors in this intervention plays an important role in these outcomes. Nighttime testing for MSM under ProVIC has since been expanded to two additional provinces in 2012., Background Post-electoral unrest in Ivory Coast led to major population displacement. Looting, lack of personnel, shortage of drugs, difficult physical accessibility and insecurity challenged access to HIV services. Given the individual and public health impact of antiretroviral therapy (ART) interruption, addressing continuity of treatment was defined as a priority since up to 14,500 Ivorians under treatment could be affected. Methods As such, UNHCR ensured that all partners integrate HIV and AIDS related Identification, Communication and Case Management in the overall relief response. Out reach and registration of refugees and internally displaced persons were used as opportunities to link up those in need of ART. Messages delivered during gatherings encouraged PLWH to contact focal points for care and treatment. HIV Joint assessment missions highlighted lack of ART-related inputs conflict affected areas. Results In Ghana and Liberia, among 258 refugees living with HIV registered, 142 were receiving ART. 60% of PLWH receiving ART in western Ivory Coast and 83% in Abidjan had interrupted their treatment for more than 3 weeks at time of identification. Language barriers (refugees), fear for stigmatisation and lack of ART services in refugees and IDP hosting areas were main reasons for treatment interruption. People in need of ART were referred to closest treatment centres. Cross-border arrangements were made between Liberia and Ivory Coast to overcome a difference in second line therapy. UNHCR procured portable CD4 machines in conflict-affected areas to improve treatment quality. Conclusion Early identification of cases and communication through different strategies was essential to limit treatment disruption. Cross-border coordination and contingency planning for drug procurement and distribution enables continuity of treatment. The importance of continuity of HIV-related business continuity including treatment need to be further emphasised to patients, as well as planners and relief assistance managers. Media should be cautious when talking about HIV status of a displaced population., Background Post-election crisis in 2010 in Ivory Coast caused militaries conflicts in several cities, disturbing health centres activities. NGO Aconda tried to support provision of care to PLWHA. To describe strategies implemented by Aconda to ensure continuum of care and support to PLWHA in health centers located in conflict zones. Methods It is a prospective study which describes activities of Aconda in health centres located at conflict area during war in Ivory Coast. Data has been collected from monthly reports. Strategies were based on reduction of HIV activities package to an absolute minimum: supplying ARV to health centres; providing ART to patients in follow; continuing PMTCT and providing ARV prophylaxis to pregnant women. Communities based Organizations made active research of patients lost to follow and referred them to health facilities for care. Pharmacists gave systematically at least 3 monthly ARV provision to patients coming to visits. Counselling and testing Activities, biology and ART initiation were stopped. Results From January to June 2011, 05 health regions: Abidjan, Duékoué, Guiglo, Bloléquin and Toulépleu were located conflict zones. We noted 45/68 centres were functional: 40 in Abidjan, 3 in Guiglo and 2 in Duékoué. We note that 11 centres have been looted; 7 completely and 4 partially. Because of non accessibility for drug's vehicle, 32 sites had failures in delivering ART. In 28 sites, less than 50% of medical staff was present. In 12 centres where caregivers were absent, the provision of ART to patients has been ensured by counsellors and data managers. In the 3 months, 17,471 PLWHA (8.7% of children) received ART and 475 pregnant women, the ART prophylaxis. Conclusion Militaries conflicts cause a dislocation of health systems. Aconda managed to maintain care and support to PLWHA in health centres in war area, by reducing to absolute minimum services., Background HIV/AIDS has a devastating impact on the livelihood of peoples living with HIV/AIDS (PLHA) in a developing country like Bangladesh. Stigma and discrimination in the local conservative society makes their socio-economic condition more miserable. Methods Notun Jibon Shomaj Kollan Shongstha, a PLHA self help organization has started a peer-led programme, known as Income Generating Initiatives for the PLHA in Bangladesh (IGIPB) since March, 2010 to address the socioeconomic vulnerability of PLHA in Bangladesh. Results To date, the programme has covered total 46 PLHA families having average 4 members per family living at rural areas. A total of 143 PLHA has been supported, out of which, 43% were male (n=61), 33% (n=47) were female and the rest were children. After affected by HIV, the house hold income dropped, on average, by 33%, whereas household expenditure increased by 110%, which was mainly for medical purposes. Through the programme, the following services were provided: vocational training to all covered adult male and female (76%, n=108); job assistance (n=17), 42% (n=7) of them were female; microcredit loans to start small scale business (n=7, all were widowed female; health loans (n=22), 68% (n=12) of them were female and 13% were children (n=3). Lump sum educational assistance grant (45 US Dollar per year per children) was provided to 35 HIV affected children (24% of the total covered PLHA). Moreover, job place advocacy and sensitization on HIV/AIDS were also done in different organizations (n=12), Compared to the baseline, the average monthly income in each house hold increased 5.7 times higher after 1 year of coverage (mean±SD in US Dollar, 35±11 vs 201±21, p, Background The India AIDS Initiative (Avahan) is involved in scale up of HIV prevention interventions among high-risk groups (HRGs). The few existing studies limit their cost analysis to the implementing non-governmental organisations (NGOs). This is the first study to analyse the costs of HIV prevention at scale, over four years, including systems costs. These systems costs are particularly important for those replicating scale-up of HIV prevention in different settings. We present here the final results of a four year costing effort. Methods Financial and economic costs were collected from 64 districts, 137 NGOs and supporting costs at the state and costs of programme management by the Bill and Melinda Gates Foundation over four years, presented in US$ 2008 (3% discount rate). The intervention package included outreach, STI services, condoms, capacity building, community mobilisation, advocacy and enabling environment. Results Unit costs per person reached, per contact, per estimated population ranged US$ 232 (44–840), US$ 68 (13–242) and US$ 175 (95–443) respectively. Key factors driving cost variation include scale. Although costs fell with scale, they also increased over time with inclusion of new districts and activities as the programme developed (including high risk men who have sex with men, advocacy, and community mobilisation). The total economic costs (2004–2008) were US$ 97,966,216 of which approximately 35% was spent at NGO level, 30% at the State level and 35% at the national level which were mainly incurred for capacity building and programme management. Conclusion The rapid scaling up HIV prevention requires significant investment in expertise enhancement and programme administration. These are not captured in routine cost analysis, which may misinform resource planning. At scale the unit cost of services provision falls, however actual cost reduction may take longer as programmes evolve, and activities are added. Policy makers should take into account these additional costs while planning public health interventions., Background Syringe exchange for injecting drug users (IDU) is controversial and has limited funding in the US. To inform policy, we examine whether increasing investment in syringe exchange programs (SEPs) would be cost-effective for HIV prevention. Methods We model HIV incidence in hypothetical cases with higher SEP syringe coverage (i.e., percent injections with a new syringe from SEP) than current level–base case, and estimate additional funding required, number of injections averted, and HIV treatment costs saved. The ratio of HIV incidence (hypothetical to base case) is established based on the transmission equation and simplified to the ratio of proportions of HIV-contaminated syringes (hypothetical to base case), which is a function of number of injections with a receptively shared (“borrowed”) syringe and numbers of syringes from SEPs and other sources. A maximal bound for hypothetical case incidence is calculated. SEP syringe coverage and costs data are from the Beth Israel/NASEN survey. HIV incidence and lifetime treatment costs are from the CDC. We assume 1/2 of IDU-category and 1/4 of MSM/IDU-category infections are due to injection risk. We conduct sensitivity analyses on “borrowing” probability, number of non-SEP syringes, extent to which SEP syringes replace non-SEP syringes, and proportions of IDU-category and MSM/IDU-category infections that are due to injection risk. Results Increasing SEP syringe coverage (now 2.9%) to 5% would avert 169 infections, requiring 19 million USD additional investment but saving 66 million USD in treatment costs. A larger increase to 10% would avert 497 infections, requiring 64 million USD investment but saving 193 million USD in treatment costs. Results should be updated when new data on parameter values become available. Conclusion SEPs are effective and cost-saving, and thus should be priority in the US. The ban on federal funding for SEPs should be lifted, and federal funding allocated to expanding SEPs. Figure 1 Figure 2Additional investment required & savings in HIV treatment costs (million 2011 USD) for each SEP syringe coverage level. Table 1Parameters in Modeling n number of injecting drug users Ntotal number of drug injections per yearSSEP total number of syringes supplied by SEPs-base caseΔShypothetical increase in number of SEP syringsSSEP-H total number of syrings supplied by SEPs-hypothetical case =SSEP-HΔSSCSEP SEP syringe coverage-base case=SSEP/N SSEP-H SEP syringe coverage-hypothetical case=SSEP-H/NSnon-SEP number of syringes a user gets from non-SEP sources per yearSnon-SEP Total nuber of syrings from other sources-base caserreplacemant rate (rate at which increased SEP syrings supply lower use of non-SEP syrings)=Snon-SEP*nSnon-SEP-H Total number of syrings from other sources hypothetical case=Snon-SEP*rΔSBNumber of injection with from other sources hypothetical caseCH Proportion of syrings contaminated with HIV-hypothetical case≤c(B + SSEP + SnonSEP)/(B + SSEP-H + SnonSEP-H)INumber of new HIV infections due to IDU per year-base caseIH Number of new HIV infection due to IDU per year-hypothetical case=I(CH/C)Iavert Number of infections averted as a result of increased SEPI − IH ∣uCost of syringe exchange programming, per syringeFAdditional founding requried=ΔS*U t Life time treatment cost per infected personTsaved Savings in life time treatment cost=Iaverted*t, Background Estimating costs associated with OVC services is crucial in resource allocation, budgeting and sustainability planning. The estimated OVC population is 5.4 million in Ethiopia but only 130,000 in Botswana. In Ethiopia, it is estimated that only about 5% of orphans are receiving support from the government and NGOs, whereas in Botswana, approximately 49% are receiving support. Methods A costing exercise was conducted for 20 OVC programs in Ethiopia and 19 in Botswana. The data collection process involved conducting interviews with program managers and finance officers. This study followed an economic approach, where the value of all resources deemed necessary to deliver services to OVC were taken into account. Results Most of the organizations in both countries offered between 4 and 8 services to OVC. The most common services offered to OVC were education, psychosocial support and food/nutrition. The cost of reaching an OVC differed significantly across countries, with a unit cost of $80 in Ethiopia and $946 in Botswana. Even for specific services, the cost differed significantly both within and across countries. Conclusion This analysis provides important comparative information about the range of costs by service area and the overall cost per child reached. The analysis shows that unit costs decline significantly as programs are scaled-up (diminishing marginal returns), but then increase as OVC programs grow bigger (diseconomies of scale). Differences in unit costs appear to be largely attributable to the type and intensity of services provided, as well as the overall difference in the cost of living between the two countries. The analysis could not, however, make any conclusions about the effectiveness of the interventions provided. It is recommended that future OVC research focus on measuring both costs and effectiveness., Background Based on 2009 WHO clinical guidelines for the prevention of mother to child transmission of HIV (PMTCT), the Government of Ghana updated its National PMTCT Guidelines in 2010, indicating new antiretroviral (ARV) drug regimens for treatment and prophylaxis, and introducing new services. Few international studies have examined costs of PMTCT services under new WHO guidelines and until now, no studies in Ghana had examined the cost of delivering these services. Methods We analyzed the cost of PMTCT services in the National PMTCT Guidelines: HIV testing and counseling (HTC), antiretroviral prophylaxis and/or therapy for seropositive pregnant women and postpartum care for seropositive mothers and their HIV-exposed infants. We used a normative approach with elements of top-down and bottom-up costing, first developing a representative care schedule according to national guidelines, and refining it based on expert interviews. Data were collected at the central level and from a purposive sample of 14 facilities reflecting characteristics thought to influence unit cost, including facility level and facility ownership. Results We found an average cost of US$56 for providing HTC services, US$739 for seropositive pregnant women on ARV prophylaxis, and US$1,054 for sero-positive pregnant women on ARV treatment. The cost for providing PMTCT services to an HIV-exposed infant ranged from US$29 to US$69 (Figure 1).Figure 1PMTCT Unit cost for Mother/child pairs, in US$. Direct costs accounted for the majority of total cost, comprised primarily of costs for antiretroviral drugs, laboratory testing, and staff time; suggesting that the unit cost of delivering PMTCT services will not vary significantly in terms of changes in client load (Figure 2).Figure 2Distribution of direct and indirect costs, by mother/child pairs. Conclusion We found higher staff costs for delivering the same services at higher-level facilities, where more specialized staff deliver services, suggesting task shifting could achieve cost efficiencies. These data can be used to better inform resource allocation decisions as PMTCT programs are scaled up in Ghana and other countries., Background In 2009, the WHO recommended the transition from stavudine (d4t) containing regimens due to side effects in favor of regimens containing zidovudine (ZDV) and tenofovir (TDF). We describe the transitions from stavudine to preferred regimens and the current purchasing trends. Methods We analyzed 17,819 adult antiretroviral purchases between 2009 and 2011, as reported to the World Health Organization Global Price Reporting Mechanism, the Global Fund Price Quality Report and by UNITAID. Results Stavudine's total market value declined from 99.85 million USD in 2009 to 29.7 million USD in 2011. Purchases of 3-in-1 fixed dose combinations (FDC) containing d4t represented 1.2 million people who could be treated in a year (person-years) in 2009, increasing to 1.3 million person-years, before dropping to 472,000 person-years in 2011. Purchases of TDF 3-in-1 FDCs increased from 41,000 to 145,000 person-years from 2009 to 2011. Zidovudine 3-in-1 FDC purchases increased from 1.18 to 1.74 million person-years between 2009 and 2010, but then dropped in 2011. Of the 74 countries purchasing stavudine in 2009, 24% did not purchase stavudine in 2010 or 2011, while an additional 24% did not purchase stavudine in 2011. In all, 52% of countries continue to purchase stavudine products. The median annual price of the 3-in-1 FDC containing d4t dropped from 77 to 62 USD per year from 2009 to 2011. ZDV median prices were 137 and 113 USD in 2009 and 2011, respectively. TDF 3-in-1 with emtricitabine exhibited the smallest change, from 250 USD/year in 2009 to 242 USD in 2011. The 3-in-1 with TDF and lamivudine held the lowest median price, at 174 USD in 2011. Conclusion Transition from stavudine has been slow, though some countries have exhibited rapid transition. Price remains a critical concern in transition from stavudine to ZDV or TDF regimens., Background Approximately 25% of Zimbabwe's children are estimated to be orphaned, with the majority orphaned due to AIDS-related illnesses. HIV-affected households often face severe financial constraints making them unable to meet their basic needs. Financial stress can negatively impact overall mental health, life satisfaction, and wellbeing in numerous ways. Perceived control over one's economic situation and sense of self can mediate financial distress. Methods Over a one year period, 2000 adolescents participated in community-based savings and lending groups (SLG), and 50% also received life skills education (LSE). A quantitative survey was administered to a randomly selected sub-sample of the project population matched with a sample of adolescents from a non-intervention control ward. Surveys were administered in Shona and back translated into English. Data were entered into SPSS and analyzed using univariate and bivariate measures. Results 160 adolescents participated in the survey. Average age was 15-years-old with an average household size of seven members. Adolescent SLG group members (n=139) reported statistically significant higher scores on self-efficacy (p, Background Despite growing evidence that socio-economic outcomes among HIV-infected adults show improvement after antiretroviral therapy (ART) initiation, little is known about the variation in these outcomes among a population that also includes individuals with high CD4 counts and those not enrolled in care. We examined associations between CD4 count and socio-economic outcomes among adults participating in a community-wide health campaign in a rural Ugandan parish. Methods A one-week community health campaign offering diagnostic and treatment services for HIV and other infectious and non-communicable diseases was conducted in May 2011. Data on campaign participants′ employment were collected, and a detailed household socio-economic survey was conducted among a random subset of participants. Multivariable regression was used to assess relationships between CD4 count and employment and educational outcomes. Results 2,323 adults (74% of the community) participated in the campaign. 179 adults (7.8%) tested HIV-positive and 46% were newly diagnosed. HIV-positive adult participants with CD4 >550 and 350–550 worked 4.8 and 5.3 more days during the past month than those with CD4350 had 20% higher school enrollment rates than children in households of adults with CD4, Background Large increases in adult life expectancy are anticipated in HIV endemic regions, due to antiretroviral treatment (ART). Such changes may have important implications for economic decision-making on the part of individuals and governments. Methods We estimate adult life expectancy (15+e15) annually for 2000–2011 using data from a large population cohort in rural South Africa (n=149,640), a population where 28% of adults were infected with HIV in 2011. We assess the distribution of life spans in 2003, prior to the public sector roll out of ART in South Africa, and in 2011. We use observed changes in adult life expectancy to compute a cost-benefit ratio for government provision of ART in this setting. Results After declining in the early 2000s, adult life expectancy in the population cohort increased from 52 years in 2003 to 61 years in 2011 (Figure 1); gains were larger for women (9.5 years) than for men (6.6 years). Changes in the distribution of lifespans reveal a substantial shift towards older ages (Figure 2). Applying standard estimates of the value of a statistical life-year (1-3 times per capita GDP), ART roll-out in this community has led to lifetime gains of $26,000 to $77,000 per capita. This is 2-6 times larger than the per capita cost of providing lifelong ART to every person who contracts HIV in this community, which we estimate at $13,400, based on 2012 cost figures from the President′s Emergency Plan for AIDS Relief.Figure 1Adult life expectancy, 2000–2011. Figure 2Distribution of Lifespans, 2003 and 2011. Conclusion ART roll-out has resulted in large increases in adult life expectancy in rural South Africa. The economic value of these health gains far outweighs the costs of treatment. Future research is needed to understand how people perceive these changes in longevity, and how these changes affect attitudes, such as fatalism, and behaviors, such as healthcare-seeking, risk-taking, and educational choices., Background Antiretroviral therapy (ART) for treatment of HIV/AIDS patients in less developed countries (LDCs) produces an impact on individual health and indirectly impacts socio-economic status. We investigated the impact of an ART program on work productivity and household income as these are key parameters for cost-benefit analyses of HIV public programs and policies.Mean Value (status class)Mean increase in status class and % change95% confidence interval of difference VariablesBaseline (t0)Follow-up (t1)MinMaxP Malnutrition (BMI) 21.38 (0.82)21.79 (0.92)0.10 (12%)0.030.180.009 Hemoglobin 11.61 (1.76)12.99 (1.96)0.20 (11%)0.100.29, Background Unsafe sex is the major cause of transmission of HIV in developing countries like India. Condom use is, therefore, seen as the most effective instrument against the transmission of HIV. However, use of condoms in commercial sex is still nowhere universal. Part of the reason could lie in the evidence that sex workers lose income when they enforce the use of condoms among their clients. This paper re-examines how condom use affect the price for commercial sex. Methods A survey of 5498 female sex workers from four high HIV prevalence states of India was analyzed using a simultaneous equations model using three-stage least squares method, to identify the causality between condom use and price for commercial sex. Results The data indicated that 77 percent of the sex workers are consistent condom user. The analysis shows that there both price of sex and condom use influences each other. Also, results indicate that all types of sex workers (Road, Brothel, Hotel and Bar) except brothel-based workers received 35 percent higher earnings when they have protected sex than unprotected sex. Brothel based sex workers earned 24 percent less when they enforced the use of condom. The other exogenous factors that affect the price are negotiating power, level of education, type of sex workers (other sources of income, number of client visit per day, contract under pimp etc.). Hotel and bar based sex worker getting comparatively higher price. Conclusion The market for sex work has changed in favour of sex workers and condom use generally no longer has a negative premium for most of the sex workers. It is, therefore, possible to step up the intensity of behavioral intervention for enhancing condom use among the sex workers without worrying about its impact on their earnings., Background HIV impacts heavily on rates of absenteeism, labour force turnover and, ultimately, cost of operations of companies in sub-Saharan Africa. Employers increasingly supply HIV testing and antiretroviral treatment (ART) programmes at the workplace. The full economic impact of ART provision on a mining workforce has not yet been analysed. Methods We developed a dynamic health-state transition model to analyse the economic impact of HIV and the cost benefit of ART provision in a mining company in South Africa between 2003 and 2022. The model was fitted to the workplace using information on the size, composition, turnover, HIV prevalence and CD4+ counts of the workforce from company records. Bottom-up analyses of economic costs at the company supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacing a sick worker. Costs are analysed from the company perspective and presented undiscounted and discounted at 5%. Results As a result of lower mortality and morbidity in the employees covered by ART, survival in employment of HIV-positive employees grows by 7% as ART coverage increases from 21% to 80% of eligible HIV-positive employees by 2022. The associated reduction in absenteeism and benefit payments more than offsets the additional cost of the ART programme, leading to a 9% decrease in the total and annual cost of HIV to the company and a 15% decrease in the mean cost per HIV-positive employee by 2012 (Table 1). 48% and 37% of cost savings are due to reductions in benefits and absenteeism, respectively (Table 2). Savings to the company average USD 1.1 million per year. Total HIV-related costs equal 1.5 to 3.5% of payroll.Table 1Cost of HIV to company 2003–2022 Cost (2010 USD) No ART With ART Difference to No ART undiscountedTotal cost (millions)363331−9%Mean annual cost (millions)1817−9%Mean annual cost per HIV-positive employee15,13712,881−15%discountedTotal cost (millions)282257−9%Total annual cost (millions)1413−9%Mean annual cost per HIV-positive employee11,79210,003−15% Table 2Mean annual cost per item 2003–2022 Annual cost per item in 2006 USD (% of annual cost) Difference to No ART (% of total savings) Cost item No ART With ART ART programme cost–0.6 (5%)+0.6 (−)Medical care (inpatient and outpatient)1.4 (12%)1.3 (12%)−0.1 (6%)- of which inpatient care0.4 (9%)0.3 (9%)−0.1 (0.2%)- of which outpatient care1.1 (3%)0.9 (3%)−0.2 (6%)Absenteeism5.2 (42%)4.6 (41%)−0.6 (37%)Benefits5.0 (40%)4.2 (37%)−0.8 (48%)Training and recruitment0.7 (6%)0.6 (5%)−0.1 (9%) Conclusion ART provision at the workplace level is cost-saving for the company. Our results point to private-sector ART provision as a viable alternative to overburdened public sector ART programmes., Background Given recent international commitments to the prevention of HIV among young people, we sought to assess the national response to prevent new infections among 10-24 year olds in countries with high HIV prevalence. Methods For 20 countries with generalized HIV epidemics, current national strategic plans and progress reports were reviewed to assess the national response in terms of: planning, measured by the inclusion of youth-specific strategies within national AIDS plans; and implementation, or the extent to which prevention activities reach the intended audience. Results All 20 countries include youth-specific strategies in their current national AIDS plan, and school-based HIV prevention was the youth prevention strategy most often included. Governments of all 20 countries report that school-based HIV education is reaching the majority of people in need, and included in primary, secondary, and teacher training curricula. The proportion of schools providing life-skills based HIV education varies from 2% to 100%. Programmes for out-of-school youth, behaviour change communication, and condom promotion were commonly included in national strategies, however, their content, quality and coverage were generally not reported. In UNGASS country progress reports, few countries disaggregate by age and sex the UNGASS indicators relevant to young people, or report comparable statistics over time. Conclusion In 20 high-prevalence countries, HIV prevention among young people is considered a priority in national plans, and the most widely implemented intervention for youth is school-based prevention. Monitoring youth-focused programmes should be improved to assess coverage, quality and delivery through comparable data over time. At a minimum, reporting UNGASS indicators by age and sex will improve the usefulness of national progress reports in tracking prevention efforts for youth. As a priority, systems are needed to report planning and programmes to promote condoms and HIV testing among young people, given the scarcity of data at the national level., Background The political will to achieve universal access of HIV services by 2015 versus the decline in HIV donor funding requires HIV programs to rethink the current model of scaling up towards universal access, particularly when it relies heavily on donor funding.CountryIncome levelHIV prevalence (2008–9)ART coverage (2009)Funding issuesGuyanaLower middle1.1% among pregnant women83.5%Decrease in HIV funding from World Bank and PEPFARKenyaLow6.3% among 15–49 year olds61%Need to sustain the funding for the high level of coverage despite being low-incomeSierra LeoneLow1.5% among 15–49 year olds50%Need to sustain the funding for the high level of coverage despite being low-incomeSouth SudanLow3% among pregnant women8.3%Global Fund grant (a key source of HIV funding in the country) ending, with no other funding source in placeBackground characteristics Methods The study reviews the results of the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) studies in four countries: Guyana, Kenya, Sierra Leone, and South Sudan. It focuses on sustainability challenges in the areas of financing, programming and human resources, and selected proposed solutions to these challenges.Prioritization1) Tailored IEC/BCC for MARPs and mass media for general populations (Sierra Leone, South Sudan); 2) Prioritization of use of various mass media based on unit cost per message exposure (South Sudan); 3) Target setting based on past performance to factor proxy for capacity (Sierra Leone, South Sudan)Efficiency1) Limiting the number of financing agents (South Sudan); 2) Identification of existing datasets that can be assembled into a central strategic database to facilitate coordination of donors (Guyana); 3) Integration of HIV-related social services into other general social services (Guyana)Resource mobilization1) Providing a plan to close a US$1.67 billion gap, through a combination of air freight levy, increasing the insurance premium, increasing government budget allocation, and decentralizing ART service delivery (Kenya); 2) Illustrating to donors the added value of their funding by unit cost analysis (South Sudan)Examples of Sustainability Recommendations Results The sustainability issues encountered in the four countries were largely associated with these countries’ heavy dependence on donor funding. In the initial years of the respective HIV/AIDS programs, this led to the expansion of HIV services beyond the levels that can be sustained without donor support. This expansion, for example, included stand-alone HIV clinics catering to a small number of patients. Solutions to the sustainability challenges can be categorized into one of the following: 1) Prioritization, both between different interventions, and between target populations to be reached by a given intervention. Prioritization is more challenging where no cost-effective information exists, e.g., when dealing with non-clinical interventions. In such cases, the relevance of the intervention to the specific country context and the capacity to scale-up and sustain were assessed; 2) Efficiency, which includes, among others, partial or full integration of HIV services with the wider health and social services; and 3) Resource mobilization, from traditional sources such as governments, as well as innovative resources such as a levy tax on airlines. Conclusion With the decline in donor HIV funding, national HIV Programs will have to reassess the components of their respective programs in the context of sustainability. Countries will benefit from integrating sustainability plans into their strategies, operational plans and funding proposals., Background Although prices for first-line drugs fell during the last years, affordability remains a critical issue in developing countries. Failure to first-line drug treatment increases the number of people living with HIV/AIDS (PLWHA) that require second-line treatment. The aim of this study is to analyze the global antiretroviral prices between 2003 and 2011 and associated factors, particularly differences between innovator/generic drugs, and the innovator prices evolution as the patents get closer to expiration. Methods Retrospective transactional data for antiretroviral procurements between 2003 and 2011 from the Global Price Reporting Mechanism (GPRM/WHO) was used. For every transaction, price, quantity, supplier and drug characteristics were recorded. Descriptive analyses were based on daily dose prices and quantities (PDD, QDD). Logarithm of PDD was regressed on transaction year, log(QDD), therapeutic class, years before patent expiration, formulation, and innovator/generic indicator. Results Mean PDD decreased from US$1.1 in 2003 to US$0.48 in 2011. In this period, mean PDD of generic drugs fell about 40.8%, while mean PDD of innovator drugs increased about 22%. Innovator firms sold 7% of purchased quantity (20% of total expenditure in antiretrovirals). Econometric analysis demonstrates price sensitivity to therapeutic classes, formulation, and quantities. Innovator prices are 35% (p< 0.001) higher than generics. In addition, the estimation suggests that innovator prices increase when initial patents arrive to expiration: 6.3% (p< 0.001) per year. Although first-line prices are in average 131% (p< 0.001) lower than second-line, innovator prices for first-line drugs are 33% (p< 0.001) higher than generic drugs. Conclusion Procurement policies should pay attention not only to higher prices practiced by innovator firms for drugs recommended in first-line regimens, but also to drugs with patents arriving to expiration whose prices are higher than drugs with patents expiring later. Where patent protection is concerned, high prices may impair the delivery of higher quality treatment in developing countries., Background Providing HIV treatment consumes substantial program resources. Forecasting future resource requirements can help ensure uninterrupted service delivery as treatment programs grow. We undertook cost analyses and projections for PEPFAR resources required to continue supporting the national ART program in Ethiopia under various scenarios from FY2011 through FY2015.Figure 1Base Case projections FY 2011–2015. Methods We collected data on actual expenditures devoted to supporting treatment programs in FY 2010, and used these data to calculate unit costs for various services. Data about patient and program characteristics were collected from performance reports, indicator targets, results of cohort analyses, and known program mark-ups and prices. We used the PEPFAR ART Costing Model 2010 to calculate resource requirments under scenarios describing different rates of new patient enrollment. The base case scenario assumed continued program growth at its current pace, adding 4,000 new ART patient slots every month from an initial patient volume of 207,458 ART patients. We assumed that Pre-ART patient volume continues to grow proportional to ART patient volume. This base case scenario was compared to 1) a slower (50% reduction) in patient uptake from base case scenario, 2) linear scale-up to universal access targets, 3) rapid scale-up to universal access targets.Figure 2Trends in projected costs (in millions USD). Results Faster rate of scale-up requires markedly increased resources for expanding capacity to accommodate a large number of patients at the initial phase, but in subsequent years, annual costs drop sharply and drop below the slower rate of scale-up for universal access. However, the total 5 year cost was higher than in all other scenarios. ARV costs represent a small fraction of total PEPFAR costs, as these costs are largely covered by the national government through Global Fund and other donors. Conclusion Programs need to weigh the higher costs of rapid scale-up, and the improved health outcomes and economic gains of universal access in making planning decisions., Background In 2003, the South African government committed to providing ART free to HIV-positive patients attending public health care facilities. National Treasury increased the budget allocations to cope with the rapid rate of ART roll-out, and has committed to increasing its allocations by 22% on average over the Medium Term Expenditure Framework (MTEF) period (2010/11 to 2012/13). Initially, provinces struggled with lack of capacity, stock-outs and even underspending. In recent years, some of these challenges have been reduced as procurement and supply systems have been improved and human resource capacity has been expanded. However, examining the different provincial ART expenditure in relation to respective numbers of ART patients and HIV prevalence shows interesting variations, highlighting possible areas for improved efficiency in some provinces. Methods The total public spending that was labelled as“ART” by the South African provinces was identified for the years 2007/08, 2008/09 and 2009/10, and broken down into cost components. This was limited by the level of disaggregation available in the public expenditure records. Simple unit costs were calculated using the total provincial ART spending per annum, divided by the number of public ART patients in that province in each year. Results The rough estimates of unit costs over the three years show increasing efficiencies in delivery, with variations in the key cost drivers per province. Comparing the provincial spending with estimated numbers of patients in need of treatment indicates that allocations and spending appear to be along lines of capacity to deliver, rather than of need. As spending on ART in SA dramatically increased, spending on prevention interventions decreased nominally and proportionally, raising concerns of sustainability. The attached figures present some key findings.Figure 1South African Provincial DOH Spending on ART and Numbers of ART Patients (ZAR Mill, ‘000s patients, 2009/10). Figure 2South African Proportional ART Spending per Production Factor, By Province (2009/10). Figure 3South African Provincial DOH Public ART cost per patient per annum (ZAR) and HIV Prevalence (%, 2009/10). Conclusion The study concludes with recommendations for improved efficiency of ART spending and delivery, and suggestions for more equitable allocations across provinces in South Africa., Background Mobile phone reminders for adherence support in HIV have gained popularity in recent years. While many studies have proven the effectiveness of such reminders, few have assessed the costs on a large scale. This study aims to assess their costs of such reminders to support adherence in patients on antiretroviral therapy (ART) within the context of the National AIDS control Program of India. The mobile phone reminder in this study consists of a combination of an interactive voice response (IVR) and picture message (SMS); both forms of adherence reminders are received by patients once a week. This intervention was developed for the HIVIND trial in India. Methods The study was done from a program perspective at St. John's Medical College Hospital, Bangalore, India. Total costs of establishing and maintaining the mobile phone reminders were studied. Sequential procedure for costing was used. This involved identifying, measuring and pricing resource use in natural units (eg: minutes). Sensitivity analysis for scale up involved: (1) varying the number of patients and (2) varying the constituents of intervention ie; (i) IVR and SMS (ii) SMS alone (iii) IVR alone. Results Total cost for mobile phone adherence reminders is 2.89USD/patient/year for 1600 patients on ART at the study site (Table 1 ). Estimated cost to the national program is 0.68USD /patient/year for scale up from 0.42million currently on ART to 0.8million patients expected to receive ART by 2017 (Figure 1 ). Cost estimates for individual components ie; IVR alone and SMS alone for 0.8million patients are 0.64USD/patient/year and 0.16USD/patient/year respectively (Table 2 ). Figure 1Total and variable costs for scale up of mobile phone adherence reminders (IVR+SMS) for Antiretroviral Therepy in the Indian context [Total and Variable costs for scale up]. Table 1Healthcare program costs for mobile phone adherence support for patients attending an HIV clinic in South IndiaAt healthcare provider level One-time costs* Costs (USD) Annualised cost (USD) Development of the intervention402.66/5yrs80.53Development of the web interface201.33/5yrs40.27Equipment costs (llaptop and 1 mobile phone)664.38/5yrs132.88 Fixed costs* Cost (USD) Annualised cost (USD) Service maintenance603.99/year603.99Equipment maintenance28.19/3years9.40Program manager(10% of annual time, 503.32USD/mth salary)603.99Overheads201.33/year114.40Data manager (15min/week, 140.93USD/mth salary)10.63Tota cost1596.07 Variable Costs* Costs (USD) Annual Cost/patient (USD) IVR cost0.03Q/IVR1.57SMS cost0.004/SMS0.21Counselor(20min/patientyyear, 24.16USD/mth salary)0.11Total variable cost1.89 Total costs Annual Cost (USD) Total cost =One-time cost + Fixed costs + n(vanable costs)4627.60Total cost/patient (number of patients 1600)@ 2.89*One time costs: one time investments made either by healthcare providers. #Fixed costs: Costs that do not change with the units of consumption. $Variable costs: Costs that change with the units of consumption.@Number of patients receiving ART at St. Johns Medical College Hospital. Bangalore. India. 1USD = 49.67INR as of 15th February 2012Cost of mobile phone reminders Table 2Sensitivity analysis of costs for mobile phone adherence support for antiretroviral therapy based on the number of patients and type of mobile supportPatient Numbers100000426000$ 800000# Mobile support IVR SMS IVR SMS IVR SMS Onetime+fixed costs (USD) 1596.071596.071596.071596.071596.071596.07 Annual variable cost/patient* (USD) IVR cost/30 sec call0.52NA0.52NA0.52NACost/SMSNA0.04NA0.04NA0.04Counselor cost0.110.110.110.110.110.11Total variable cost* 0.640.160.640.160.640.16 Total costs (USD) One time cost* Fixed costs* n (variable costs)65437.4217279.58273560.2368407.83512326.89127064.16Total Cost/patient* 0.650.170.640.160.640.16*IVR cost/30 sec call=0.01USD, and cost/SMS=0.0008USD if number of patients ≥100000 patients.$Number of patients on ART under the National AIDS Control Program in 2011 (NACP).#Number of patients expected to receive ART under the NACP Phase IV (2012–2017) (Reference: Working group on AIDS control for the 12th five year plan, Planning commission, GOI). @Total costs approach variable costs as number of patients increase. 1USD=49.67INR as of 15th February 2012.Sensitivity analysis of costs. Conclusion From our study, the Indian program would incur an overall cost of 0.086% of its current 5year budget to provide such adherence support. The costing results of this study are relevant for policy makers when considering interventions to enhance adherence support within the national program., Background Increasing numbers of women are presenting in labour without prior antental care (ANC) with unknown HIV status in the town of Chitungwiza, Zimbabwe (from 918 in 2009 to 4768 2010) depite efforts to raise community awareness and national maternal and child health campaigns. A study was conducted to identify factors associated with utilisation and non-utilisation of ANC services among women delivering in four Chitungwiza clinics. Methods A one to one unmatched case control study was conducted at four PMTCT sites from February--April 2011. A case was any woman who presented in labour without prior ANC or had attended only one ANC visit. A control was any woman who presented in labour having attended two or more ANC visits. Systematic sampling was done using delivery registers as sampling frames. First case was randomly selected then every second woman until the required sample size was reached. An administered questionnaire was used to collect data. EpiInfo v3.5.3 was used for analysis. Results There were 232 cases and 232 controls with a median age of 25 in both groups. Unaffordable of ANC fees (OR=3.8; 95% CI: 1.39–10.46), seeking Tradtional Birth Attendant (TBA) servises (OR=3.2; 95% CI: 1.16–8.85), and religious beliefs (OR=1.7; 95% CI: 1.09–2.68) increased the likelihood of not booking for ANC. Independent determinats of non-utilisation of ANC included belonging to the apostolic faith (AOR=3.1[1.05–9.18],seeking TBA services with previous pregnancy (AOR=3.2 [1.16–8.86], unaffordable user fees (AOR=3.0 [1.15–7.69]). Having received information on ANC with previous pregnancy (AOR=0.16 [0.10–0.26], death of a child (AOR=0.41 [0.19–0.93] and being HIV-positive (AOR=0.39 [0.23–0.64)] were independent determinants of ANC utilisation. Conclusion Revision and enforcement of national polices on ANC user fees is necesary to improve ANC utilisation, access to HIV testing and counselling, treatment care and support during pregnancy and ensure that ANCservices are accessible to pregnant women at an affordable fee., Background Loss to follow-up (LTFU) negatively affects antiretroviral therapy (ART) programmes by leading to viral resistance as well as immunological and clinical failure among patients and by biasing mortality estimates. Among children, risk factors for LTFU and true outcomes of these patients are not well known. The objectives of the study were to analyze LTFU risk factors of children on ART and to determine their true outcomes through active tracing. Methods Descriptive retrospective cohort study of 1182 children that were on ART at an urban HIV clinic in Malawi between April 2006 and December 2010. Since 2006, the clinic implements an innovative programme, Back-to-Care (B2C), to increase ART patient retention through phone and field tracking. Baseline characteristics routinely collected at ART initiation were gathered together with the information obtained from the B2C field tracing team to determine ART initiation factors that influenced subsequent LTFU. Results Of 985 children (1999 children-years) on ART included in the analysis, 251 (25%) were LTFU, a LTFU rate of 12.6/100 children-years. No available CD4 count at initiation [Adjusted Hazard Ratio (AHR): 2.01, 95% CI: 1.31–3.07]; nutritional wasting (AHR: 1.6, 95% CI: 1.17–2.18) and age under 2 years (AHR: 1.55, 95% CI: 1.02–2.37) all independently increased the risk of LTFU. Of 201 LTFU children traced, 158 (79%) were found: 11% died, 26% transferred out (TO) to another treatment centre and 63% were alive. LTFU rate was reduced by 62% after tracing. Mortality estimates were corrected, increasing from 2.6% to 4.8%. Conclusion Increased patient retention efforts, coupled with more active tracing of LTFU children on ART, could reduce LTFU, increase patient adherence, and improve mortality rate estimates., Background In Kenya, about 47,000 (9%) of the 520,000 people on antiretroviral therapy (ART) are children. Use of virologic measurement to monitor response to ART is not routinely provided due to cost and accessibility; however, viral load (VL) testing is being offered in limited settings to confirm treatment failure. Methods We analysed demographic and clinical data from pediatric patients (50% of peak, to baseline, or below threshold value for age. Clinical criteria included new/recurrent WHO stage 3/4 conditions, poor growth, or recurrent infections. We evaluated the positive predictive value (PPV) of using immunologic and clinical criteria to diagnose virologic failure (VL>1,000 copies/ml, after>6 months of ART). Results Between Sept 2008-June 2011 336 pediatric samples were tested; patient median age 10 years (range 1–14) and 143 (43%) were female. 94% were on a first-line nevirapine/efavirenez-based regimen, median duration on ART was 2.6 years, 213 (63%) patients met >1 immunologic criteria, 51 (15%) >1 clinical criteria, and 71 (22%) met both. Despite 99% of clinicians reporting satisfactory patient ART adherence, 287 (85%) samples indicated virologic failure. The PPV of immunologic criteria was 87% (95% Confidence Intervals [CI] 84%–90%) compared to 62% PPV (95% CI 50%–73%) for clinical criteria. The PPV of both criteria present was 96% (95% CI 88%–98%). Conclusion Virologic failure was confirmed in 85% of pediatric ART patients with suspected treatment failure. Immunologic criteria in combination with clinical criteria were more useful in correctly identifying patients requiring regimen changes and reduced the number of false positives compared to using clinical criteria or immunologic alone., Background Highly active antiretroviral therapy (HAART) among HIV-infected women during pregnancy and breastfeeding reduces the risk of HIV transmission. Maternal HIV viral load (VL) is an important predictor of transmission risk, and VL monitoring during pregnancy could be useful to optimize clinical management. However, routine VL monitoring is not widely available in Kenya. We assessed routine VL monitoring for pregnant HIV-infected women on HAART to determine the proportion of women who were not reaching treatment and prophylaxis goals Methods We initiated a pilot in September 2008 in Nyanza at 66 clinical sites offering VL testing for patients identified as meeting clinical and immunologic criteria for treatment failure or who were pregnant. Frequencies, proportions, and interquartile ranges (IQR) for demographic and clinical data were calculated. Bivariate analysis examined potential correlates of detectable VL (>400 copies) Results Between 2008 and June 2011, pregnant women, without evidence of clinical or immunological failure, constituted 683 (8%) of 8073 patient samples submitted for VL testing. Median age was 29 years (IQR 26–33) and median baseline CD4 count was 190cells/ mm3 (IQR 102–279). The median duration of HAART was 2 years (IQR 1–3) and 99% were on a first-line regimen (zidovudine/stavudine+lamivudine+nevirapine/efavirenz). 161 (24%) of samples yielded a detectable VL. Women with a baseline CD4200. Age and duration of HAART were not associated with a detectable VL Conclusion One in four pregnant women on HAART, without current indications of treatment failure, had a detectable VL. Pregnant women, especially those with low baseline CD4 counts, should receive enhanced ART adherence counseling and close clinical monitoring. Routine use of VL testing during pregnancy can identify women requiring additional intervention to maximize care and prevention outcomes. Disclaimer The content and views in this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the affiliated organizations, United States Government, or Government of Kenya., Background Transition to CD4 monitoring for pre-ART assessment and viral load (VL) monitoring for ART response assessment is planned in Malawi. We assessed how often clinicians ordered these tests as compared to current guidelines, and whether the samples were successfully and promptly processed. Methods We conducted a retrospective review from electronic medical records of all patients seen from August 2010 through July 2011, in two urban HIV-care clinics that utilize 6-monthly CD4 monitoring regardless of ART status. We calculated the percentage of patients on whom clinicians ordered CD4 or VL analysis for routine care, using blood-draw as a proxy for ordering. For all CD4 and VL samples sent to the adjacent Ministry of Health central laboratory, we determined rates of successful lab-processing, and mean time to returned results. Results Of 22,488 patients seen, 8147 (35%) had at least one blood draw for CD4 count. Of all CD4 samples sent, 8061/8754 (92%) samples were returned as successfully processed. Of those, mean time to processing was 1.6 days (s.d 1.5) but mean time to results being available to clinician was 9.7 days (s.d. 3.5). Regarding VL, 189 patients (1% of the 18,330 on ART) had a blood draw and only 118/213 (55%) samples were returned as successfully processed. Mean processing time was 39.9 days (s.d. 24.6); mean time to results being available to clinician was 43.9 days (s.d. 28.8). During the one-year evaluated, there were multiple lapses in processing VL samples for up to 2 months; no samples were processed after May 2011. Conclusion Clinicians grossly underutilize CD4 and VL as diagnostic and monitoring tools. Laboratory processing failures and turnaround times are unacceptably high, especially for viral load analysis. Alternative processing techniques or results reporting strategies, such as point-of-care devices or SMS result reporting, may offer considerable improvement before successfully adopting these tests as standard-of-care., Background Treatment-eligible HIV-positive pregnant women have the highest risk (>75%) of transmitting HIV to their infants, but only a small proportion of women are being initiated on antiretroviral therapy (ART) during pregnancy in Zimbabwe, partially due to limited access to CD4 testing to determine treatment eligibility. We assessed whether introducing point-of-care (POC) CD4 machines at 43 high-volume, Elizabeth Glaser Pediatric AIDS Foundation supported, PMTCT sites in Zimbabwe increased the proportion of HIV-positive pregnant women assessed for ART eligibility and subsequently initiated on ART. Methods A quasi-experimental before and after study design was conducted, with 43 high-volume PMTCT sites selected based on number of HIV-positive pregnant women seen. POC CD4 machines were deployed to all 43 sites in June 2011 following health worker trainings on usage of machines and tools (registers, summary sheets). Data were collected before (April–June 2011) and after (July–September 2011) deployment of POC CD4 machines (intervention). Data were analyzed using SPSS v15.0. Differences between proportions were tested using Wilcoxon signed rank test. Results Before introduction of the POC machines, 617 (51%) of 1,210 HIV-positive pregnant women received a CD4 test at the 43 sites. After the machines were introduced, 890 (81%) of 1,100 women received a CD4 test. There was a significance difference between the proportion of women tested for CD4 count before and after the intervention (P=0.023) and between the proportion initiated on ART before and after the introduction of the CD4 machines (9% [104] before versus 25% [276] after; (P=0.001). Conclusion Deployment of POC CD4 machines was associated with increased CD4 testing and ART initiation for HIV-positive pregnant women at the 43 intervention sites. Based on these early results, expansion of POC CD4 machines to all high volume PMTCT sites in Zimbabwe is recommended to increase access to ART eligibility towards elimination of new HIV infections in children by 2015., Background Evidence has emerged linking the lack of readily available accurate information of the patent status of key ARVs with high prices in some countries. Despite their similar socio-economic circumstances, it shows that countries often pay significantly different prices for the same ARVs. Greater cost savings can be achieved if organizations and officials involved in the national procurement have more transparent information regarding the patent status of key ARVs. Methods UNDP has co-sponsored the development of a methodology written by Barbara Milani and Cecilia Oh that can be used by officials involved in procuring ARVs and other essential medicines in low and middle income countries to determine their patent status and ascertain whether and when generics can be freely imported into their country. Results The methodology was preliminarily tested in Canada, China, India, and South Africa in 2006 and proved to be effective in determining the patent status of ARVs. An updated and expanded version of the methodology is being finalized and will be launched before the AIDS Conference in July 2012. Conclusion In light of the decrease in AIDS funding and growing need for countries to lower treatment cost, the methodology can be used by officials and organizations involved in procurement to ensure that generic ARVs are imported legally, and by low and middle income countries to facilitate the use of other flexibilities, where necessary, if valid patents for key ARVs are hampering the procurement of more affordable equivalents of comparable quality., Background Voluntary licensing has gained increased attention as a potential policy measure to improve access to generic versions of widely-patented antiretroviral (ARV) medicines in developing countries, particularly in relation to the Medicines Patent Pool, an international voluntary licensing mechanism. This study offers a description of “baseline” voluntary licensing practices before UNITAID's decision to establish the Pool in 2009, analyzes the evolution of licensing practices since then, and highlights the types of license provisions with the most important implications for public health. Methods We compiled data on all publicly-announced voluntary licenses between major ARV patent-holders and generic firms, and analyzed various provisions covering: geographic scope for production and sales; degree of competition enabled for end products and active pharmaceutical ingredients; royalty rates; freedom to co-formulate into fixed-dose-combinations and pediatric formulations; technology transfer; regulatory data; and various other provisions with public health relevance. Results There is wide variation in voluntary licensing practices, with geographic scope ranging from one to 112 countries; number of licensees ranging from one to unlimited; royalty rates ranging from 0% to 5% of the generic price; freedom to co-formulate ranging from none to unlimited; and access to technology transfer and regulatory data ranging from minimal to extensive. Other terms and conditions may have important public health impact, but the lack of transparency on the text of licenses limits the scope of the analysis. Conclusion Voluntary licenses offer one potential route to improving access to low-cost, generic ARVs in a predictable, sustainable manner. However, attention must be paid to license provisions that can limit access to generic medicines, restrict competition, create onerous burdens, or otherwise reduce the public health benefits of licensing. Increased transparency in licensing practices, critical analyses of license provisions, and improved license terms are necessary to maximize the potential public health benefit of this policy tool., Background In Brazil the number of patents and patent applications has increased, making it difficult to place generic drugs in the market. At the same time, it is fundamental that the pharmaceutical companies-either innovators or generic-register their drugs, formulations or combinations in the National Agency Sanitary Surveillance-ANVISA (acronym in Portuguese) so that the general population to access is their sanitary registration. Methods This study was conducted between April 2010 and April 2011 and it was funded by the Brazilian Ministry of Health. The research resulted in two methodological outcomes: 1) an ARV patent and sanitary registration database; 2) research methodology aimed at overcoming one key difficulty faced in Brazil in this area of investigation, which is that patents are not automatically linked to their corresponding final products. The methodology was designed for Brazil, but it may be adapted to other countries. Regarding to sanitary registration of ARVs, ANVISA provides an online database of granted and not granted sanitary registrations. Results Patents and registration for 23 single-drug medicines and 8 combinations were reviewed. The study identified 96 patents or patent applications related to these drugs and combinations, which account for more than 3 patents/drug. One study result is that the granting of a secondary patent delays the entry of generic medication in the market. In the case of darunavir, the first patent will expire in 2016, but if the last patent application is granted (for Tibotec), the patent applicant, will benefit from a monopoly until 2025. Conclusion The results of the research led to the following policy recommendations: 1: Wide application of the Bolar Exception and rigid standards for patent examinations; 2: Incentives for pre and post-grant oppositions; 3: A possible solution for the non-transparent nature of the patent system in Brazil is the compulsory publication of granted patents., Background Access to HIV programmes for refugees and internally displaced persons (IDPs) is a human rights issue and a public health priority for affected and host populations. Primary source of funding for HIV programmes for many countries is the Global Fund. This article analyses the current HIV National Strategic Plans (NSPs) and Global Fund approved proposals from rounds 1–8 for countries in Africa hosting populations with refugees and/or IDPs to document their inclusion. Methods The review was limited to countries in Africa as they constitute the highest caseload of refugees and IDPs affected by HIV. Only countries with refugee and/or IDP populations of =10,000 persons were included. NSPs were retrieved from primary and secondary sources while approved Global Fund proposals were obtained from the organisation's website. Results Majority of countries did not mention IDPs (57%) compared with 48% for refugees in their HIV NSPs. A minority (21–29%) of HIV NSPs referenced and included activities for refugees and IDPs. The majority of countries with =10,000 refugees and IDPs did not include these groups in their approved HIV proposals (61%–83%). Conclusion Besides legal obligations, Governments have a public health imperative to include these groups in NSPs and funding proposals. Governments may wish to add a component for refugees that is additional to the needs for their own citizens. The inclusion of forcibly displaced persons in funding proposals may have positive direct effects for host populations as international and UN agencies often have strong logistical capabilities that could benefit both populations. Given recent developments in the Global Fund and HIV funding in general, the HIV funding situation for forcibly displaced persons may worsen. It is essential for their inclusion to occur if we are to reach the stated goal of universal access and the Millennium Development Goals., Background The President's Emergency fund for AIDS Relief (PEPFAR) is the largest donor in Southern Africa, spending over US $6 billion since 2004 and supporting ARV treatment for 1.5 million people. However, since the introduction of PEPFAR conflicting narratives have appeared regularly. These conflicting narratives often tend to differently describe and interpret the content, intent, impact and outcome of PEPFAR policies, particularly with regards to prostitution. Methods This analysis utilized a competing narrative approach to identify recurrent and conflicting narratives relating to PEPFAR and its implementation among organizations and populations in southern Africa. A competing narrative methodology allows the identification and comparison of differing interpretations of phenomena. Here narratives found in published, ethnographic and interview sources from sex work and public policy communities in Southern Africa and elsewhere were analyzed and similarities and differences in these communities' interpretations of the PEPFAR policy compared. Results The presentation and discussion of PEPFAR's anti-prostitution clause vary widely, and have varied over time. Sex worker communities and organizations have spoken of PEPFAR's "dark ripple effect"-the incremental phase-out of sex worker-accessed services, the increasing isolation of sex workers, and fears about disseminating and sharing information about sex work programs and funding. In contrast, public policy communities have been slow to acknowledge, publicly, the policy's suggested failures, or to provide clarifying guidance or response to proposed shortcomings. Conclusion Among the two often-opposing communities, conflicting narratives about PEPFAR and its implementation were found. Evident were narratives of PEPFAR's suggested harms and the lack of response to it. This analysis builds on earlier work to suggest that fostering improved dialogue between sex work and US funding communities would help to better broad understandings of PEPFAR's impacts, while potentially translating to improved HIV service access for sex workers., Background Ukraine is a lower-middle income country with the most severe and growing HIV-epidemic in Europe (1.1% estimated adult prevalence), concentrated among people who inject drugs (PWID), sex workers (SWs) and men who have sex with men (MSM). Ukraine's financial needs for the adequate HIV response are dramatically increasing while it continues to highly depend upon external funding. The major challenge is to sustain financing of the HIV response while the global financial crisis prompts uncertainty of the level and scope of future donor support, especially for middle-income countries. We aimed to examine the financial sustainability of Ukraine's HIV response, and make recommendations for its mid- and long-term financing strategies.Table 1Annual expenditures on HIV (in USD) by programme areas and sources of financing – 2009–201020092010 HIV expendituresDomestic governmentalExternal and NGODemestic governmentalExternal and NGOPrevention tor PWID169 3733 292 357146 7723 625 771Prevention, for other MARPs191 7931 278 82656 7431 540 867PMTC4 951 137420 1945 410 734437 383Other prevention4 857 1703 875 4734 015 7434 717 556Treatment23 196 7733 911 84322 537 0447 884 386Care and support564 399 2 179 320 962 8902 701 316Organizational and administrative support4 121 96012 386 8754 924 27213 877341Total38 052 60427 344 88838 054 198 34 784619GRAND TOTAL65 397 49272 838 817 Methods We analyzed trends in the annual expenditures using the National AIDS Spending Assessments; financing needs for 2011–2015 using the 2011–2013 National Operational Plan and the gap analysis for 2014–2015; future domestic and external funding allocations; policy environment, and implications of all those on future financial sustainability. Results The HIV expenditures dramatically increased since 2004 (USD3.3M) with external and non-governmental resources comprising 42–48% of the USD 65.4–72.8M in 2009–2010. Despite the increasing future funding allocations from all sources, the financial gap remains substantial estimated at USD 138M in 2015. All HIV care and prevention services remain free through public and community-level settings regardless of the funding source.Table 2Annual estimated financing needs by HIV programme areas, future financing allocations for HIV by sources and financing gap (in USD) – 2012–2015HIV financing needs2012201320142015Prevention51 319 63256 318 716 Treatment100 366 043117 037 132Care and support17 789 48722 175 823Organizational and administrative support13 460 97816 703 643TOTAL182 936 140212 235 315250 437 671295 516 452 Sources of future financial allocation 2012 2013 2014 2015 Governmental47 330 85963 627 78363 627 78363 627 783Other domestic2 000 0002 000 0002 000 0002 000 000External (Global Fund)71 420 14044 052 91964 668 34669 911 446External (other)23 686 80823 750 00021 750 00021 750 000TOTAL144 437 807133 430 702152 036 129157 289 229 Financial gap 2012 2013 2014 2015 TOTAL38 498 33378 804 61398 401 542138 227 223 Conclusion While domestic investments for treatment increase, HIV prevention especially for key populations is almost fully funded externally. Allocation of a larger proportion of governmental resources is critical, along with policy initiatives aimed at reduction of costs per client through efficient service delivery modalities, including HIV service integration into primary and other care. While donor-funding commitments will be still required for the next few years, establishment of alternative modalities like financing HIV from a national health insurance, introducing cost-sharing arrangements, and facilitating private-public partnerships will be needed.Table 3Unit costs of HIV prevention and treatment interventions per client per year (in USD)IntervantionPrevention for PWIDPrevention for SWsPrevention for MSMPrevention for prisonersART with 1st line ARVsART with 2st line ARVsUnit cost55625123928 (incl. USD 843 for ARVs)1716 (incl. USD 1631 for ARVs), Background The President′s Emergency Plan for AIDS Relief (PEPFAR) in its second phase (2009–14) has an increased emphasis on promoting the sustainability of the HIV/AIDS response. Such sustainability is related to greater country ownership, local capacity, and strengthened health systems. Investments promoting sustainability can compete for resources with the rapid delivery of services. There is need to measure the costs associated with an increased emphasis on sustainability. Methods The USAID HPI Costing Task Order evaluated the cost of PEPFAR support to service delivery and sustainability for the PMTCT program in Kenya. Data were analyzed from two implementing partners: FHI360 and the Elizabeth Glaser Pediatric AIDS Foundation. Data sources included implementation and financial records as well as interviews with partner staff. From this data, unit costs of PEPFAR support per mother receiving ARV-based prophylaxis and per infection averted were calculated for the study period, 2005–2010. Results The average unit cost across EGPAF and FHI360 of PEPFAR support (excluding commodity costs) per HIV-positive mother provided antiretroviral-based prophylaxis declined by 52% from $567 to $271. PEPFAR support for commodities and supply chain added $48 to the latter cost in 2010. The unit cost of PEPFAR support per averted mother-to-child infection declined by 66% from $7,117 to $2,440, excluding commodity costs. The sustainability-related proportion of the unit cost of support to PMTCT increased from 12 to 33% over the study period. Investment into sustainability has grown in proportion and complexity while overall unit costs of support have declined. Conclusion Investing in sustainability did not inhibit the expansion of PMTCT services. Such investments build long-term viability and enhance the prospect of a transition from reliance on donor support. We do not see a trade-off between scaling-up services and investing in sustainability. Rather, investment in sustainability is critical to service delivery scale-up and an effective, affordable use of PEPFAR resources., Background Of late, donors adjusting their funding policies and companies and agencies working on treatment access initiatives have included World Bank set economic criteria in their decision making. What has been the impact of these new parameters in HIV funding and treatment access in so-called "middle income" countries? Methods The analysis looks at 1) Changes in Global Fund funding criteria; 2) Changes in price discounts by MNCs on ARVs and 3) The coverage of the Medicines Patent Pool licence announced in 2011. The situations of India, China, Argentina, Botswana and Namibia are examined in particular. Results The study finds that in all three cases, economic criteria are now playing a key role in determining the level and extent of assistance in relation to funding and treatment access. While the Global Fund funding criteria attempts to balance the economic status of a developing country with its disease burden, in the other two situations, the use of economic criteria appears motivated only by private interests in profits. Conclusion The use of GDP to determine access to HIV funding and treatment has gained acceptance in part because of the impression that the "middle income" status of a country indicates the ability of the country or its people to fund HIV programmes or HIV treatment. The GDP does not however reflect actual situations in country or the fact that several HIV programmes with marginalized communities are only in existence because of neutral, evidence based funding from the Global Fund. Such an approach undermines the very basis of Universal Access and is likely to be counterproductive both in the short term (with countries hesitating from adopting evidence of treatment as prevention into policies) and in the long term (as HIV programmes in these countries shrink or are shaped by national priorities and prejudices including in relation to marginalized groups)., Background The worldwide financial crisis has forced The Global Fund to scale-down funding for HIV programming, particularly in Sub-Saharan Africa. There are few documented reports of patient outcomes when decreased Global Fund appropriations lead to disruption of HIV care and treatment. Methods We conducted a cross-sectional survey to assess transfer behavior, care satisfaction, ART treatment and adherence, and disease progression among patients experiencing unexpected disruption of HIV services in Lubumbashi, Democratic Republic of Congo. A systematic random sample (n=1,000) was selected from HIV+ patients enrolled in the Central Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA). Results Of 1,000 patients, 363 were lost-to-follow-up, 36 deceased, 540 found and 61 have unknown status. Of the 540 patients who were found, data are currently available from 299. Of these, 259 (87%) were formally transferred to another facility, predominately government-run (95%). 91% (n=231) of transferred patients presented at least once for continued care. Of those who continued care, 20% received adherence counseling and 45% had CD4 testing. 87% of the 299 patients with available data were on ARVs at the time of clinic closure. Among these, 78% continued taking ARVs after transfer, 1% started second line therapy, 7% started a new ART regimen, and 2% stopped taking ARVs. 24% of patients on ARVs reported non-adherence to one or more drug. Prior to transfer, 25% of the patients were WHO stage I/II and 75% were stage III/ IV, compared to 28% in WHO stage I/ II and 72% in stage III/ IV one year after the disruption. Conclusion When faced with disruption of care, patient retention is jeopardized. Many countries with grave HIV epidemics have experienced reductions in Global Fund appropriations. A better understanding of the consequences of these reductions is needed. Abstract Coding Guide Example: MOAA01=(Weekday) MO – (Session type) AA – (Session order) 01 Weekdays: SU (Sunday), MO (Monday), TU (Tuesday), WE (Wednesday), TH (Thursday), FR (Friday) Session types: oral abstract sessions – AA (Track A), AB (Track B), AC (Track C), AD (Track D), AE (Track E), AX (Cross-Track), LBA (Late Breaker Track A), LBB (Late Breaker Track B), LBC (Late Breaker Track C), LBD (Late Breaker Track D), LBE (Late Breaker Track E), LBX (Late Breaker Cross-Track); oral poster discussions sessions – PDA (Track A), PDB (Track B), PDC (Track C), PDD (Track D), PDE (Track E) PDX (Cross-Track) Session order: 01, 02, 03, 04, etc.

BACKGROUND: For many estimation purposes, individuals who repeatedly refuse to participate in longitudinal HIV surveillance pose a bigger threat to valid inferences than individuals who participate at least occasionally. We investigate the determinants of repeated refusal to consent to HIV testing in a population-based longitudinal surveillance in rural South Africa.METHODS: We used data from two years (2005 & 2006) of the annual HIV surveillance conducted by the Africa Centre for Health and Population Studies, linking the HIV surveillance data to demographic and socioeconomic data. The outcome for the analysis was “repeated refusal”. Demographic variables included sex, age, highest educational attainment, and place of residence. We also included a measure of wealth and the variable “ever had sex”. To compare the association of each variable with the outcome, unadjusted odds ratios and standard errors were estimated. Multivariable logistic regression was used to estimate adjusted odds ratios and their standard errors. Data were analyzed using STATA 10.0.RESULTS: Of 15,557 eligible individuals, 46% refused to test for HIV in both rounds. Males were significantly more likely than females to repeatedly refuse testing. Holding all other variables constant, individuals in the middle age groups were more likely to repeatedly refuse testing compared with younger and older age groups. The odds of repeated refusal increased with increasing level of education and relative wealth. People living in urban areas were significantly more likely to repeatedly refuse an HIV test than people living in peri-urban or rural areas. Compared to those who had ever had sex, both males and females who had not yet had sex were significantly more likely to refuse to participate.CONCLUSIONS: The likelihood of repeated refusal to test for HIV in this longitudinal surveillance increases with education, wealth, urbanization, and primary sexual abstinence. Since the factors determining repeated HIV testing refusal are likely associated with HIV status, it is critical that selection effects are controlled for in the analysis of HIV surveillance data. Interventions to increase consent to HIV testing should consider targeting the relatively well educated and wealthy, people in urban areas, and individuals who have not yet sexually debuted.

BACKGROUND: Concurrent sexual partnerships are widely believed to be one of the main drivers of the HIV epidemic in sub-Saharan Africa. This view is supported by theoretical models predicting that increases in prevalence of concurrent partnerships could substantially increase the rate of spread of the disease. However, the effect of concurrent partnerships on HIV incidence has not been appropriately tested in a sub-Saharan African setting.METHODS: For this population-based cohort study, we used data from the Africa Centre demographic surveillance site in KwaZulu-Natal, South Africa, to try to find support for the concurrency hypothesis. We used a moving-window approach to construct estimates of the geographical variation in reported concurrent and lifetime partners in sexually active men aged 15-55 years (n=2153) across the study area. We then followed up 7284 HIV-negative women (?15 years of age) in the population and quantified the effect of the sexual behaviour profiles of men in the surrounding local community on a woman's hazard of HIV acquisition.FINDINGS: During 5 years' follow-up, 693 new female HIV infections occurred (incidence 3.60 cases per 100 person-years). We identified substantial intercommunity heterogeneity in the estimated point-prevalence of partnership concurrency (range 4.0-76.3%; mean 31.5%) and mean number of lifetime sexual partners (3.4-12.9; mean 6.3) in sexually active men in this population. After adjustment for individual-level sexual behaviour and demographic, socioeconomic, and environmental factors associated with HIV acquisition, mean lifetime number of partners of men in the immediate local community was predictive of hazard of HIV acquisition in women (adjusted hazard ratio [HR] 1.08, 95% CI 1.03-1.14, p=0.004), whereas a high prevalence of partnership concurrency in the same local community was not associated with any increase in risk of HIV acquisition (adjusted HR 1.02, 95% CI 0.95-1.09, p=0.556).INTERPRETATION: We find no evidence to suggest that concurrent partnerships are an important driver of HIV incidence in this typical high-prevalence rural African population. Our findings suggest that in similar hyperendemic sub-Saharan African settings, there is a need for straightforward, unambiguous messages aimed at the reduction of multiple partnerships, irrespective of whether those partnerships overlap in time.

Hlabisa health sub-district, KwaZulu-Natal, South Africa.To describe the establishment of a community-based multidrug-resistant tuberculosis (MDR-TB) treatment programme embedded in the district TB control programme and to evaluate whether early outcomes are comparable to those in the traditional hospital-based model of care.Cases who initiated community-based MDR-TB treatment (CM) between March and December 2008 were compared with patients who initiated MDR-TB treatment under the traditional hospital-based model of care (TM) between January 2001 and February 2008. Time to initiation of treatment and time to sputum smear and culture conversion were compared for the two groups in Kaplan-Meier survival curves using the Mantel-Cox log-rank test.Overall, 50 CM cases and 57 TM cases were included; 39 of the 50 CM cases (78.0%) were human immunodeficiency virus positive. The median time to initiation of treatment was 84 days for CM and 106.5 days for TM (P = 0.002). Median time to sputum smear conversion was shorter for CM than TM (59 vs. 92 days, P = 0.055), as was time to sputum culture conversion (85 vs. 119 days, P = 0.002).Community-based treatment for MDR-TB can be implemented within the existing TB control programme in rural South Africa and should be scaled up where resources allow.

SETTING: Hlabisa health sub-district, KwaZulu-Natal, South Africa. OBJECTIVE: To describe the establishment of a community-based multidrug-resistant tuberculosis (MDR-TB) treatment programme embedded in the district TB control programme and to evaluate whether early outcomes are comparable to those in the traditional hospital-based model of care. DESIGN: Cases who initiated community-based MDR-TB treatment (CM) between March and December 2008 were compared with patients who initiated MDR-TB treatment under the traditional hospital-based model of care (TM) between January 2001 and February 2008. Time to initiation of treatment and time to sputum smear and culture conversion were compared for the two groups in Kaplan-Meier survival curves using the Mantel-Cox log-rank test. RESULTS: Overall, 50 CM cases and 57 TM cases were included; 39 of the 50 CM cases (78.0%) were human immunodeficiency virus positive. The median time to initiation of treatment was 84 days for CM and 106.5 days for TM (P = 0.002). Median time to sputum smear conversion was shorter for CM than TM (59 vs. 92 days, P = 0.055), as was time to sputum culture conversion (85 vs. 119 days, P = 0.002). CONCLUSION: Community-based treatment for MDR-TB can be implemented within the existing TB control programme in rural South Africa and should be scaled up where resources allow.