Peer education in HIV prevention: an evaluation in schools

BACKGROUND: In recent years a number of publications have come out about the peer education method used as a tool in HIV prevention for young people. Our survey aimed at testing the effectiveness of the peer education method in HIV prevention in high school settings through a pilot intervention. METHODS: A peer education intervention took place in 10 high schools in Athens over a 1 year period. A cohort of 702 students was surveyed (n = 493 intervention group, n = 209 control group) from 13 high schools through anonymous questionnaires based on the KABPs model, pre- and post-intervention. The statistical package used was SPSS using the chi(2)-test. RESULTS: Compared with control students, the intervention students were slightly empowered: (i) to increase their personal responsibility; and (ii) to adopt a safer behaviour in sexual practice. Knowledge did not show any significant modification between the two groups. However, discrimination about certain groups of people, the attitude about condoms and initiation of sexual relations did not appear to be influenced. CONCLUSIONS: The peer education approach can influence the behaviour of young people regarding their personal protection from HIV infection. In order to test its effectiveness, peer education should be further evaluated as a health education method in HIV prevention in high schools, other youth settings and community interventions, where the aim is behavioural change.     

The potential impact of an HIV vaccine with rapidly waning protection on the epidemic in Southern Africa: examining the RV144 trial results

Background

The prime-boost HIV vaccine regimen used in the recent RV144 trial resulted in modest efficacy of 31% over 3.5 years, but was substantially higher in the first year post-vaccination. We sought to explore the potential impact of a vaccine with rapidly waning efficacy in a South African population.

Methods

We explored two strategies using a dynamic compartmental epidemic model for heterosexual transmission of HIV: [1] vaccination of a single cohort (30%, 60% or 90% of the initial population), with exponentially waning efficacy, but booster vaccinations at 5- or 2-year intervals, and [2] continuous vaccination of the unvaccinated population at the same coverage levels (30%, 60% or 90%) but with a constant efficacy vaccine of short duration. We also examined potential changes in post-vaccination condom use.

Results

The single cohort vaccination strategies did not have a substantial impact on HIV prevalence, although without boosters they still prevented 2-6% of the expected infections at 20 years, depending on the population coverage. The 5-year and 2-year booster strategies prevented 8-24% and 17-45% of the expected infections, respectively. Continuous vaccination to maintain population coverage levels resulted in more substantial reductions in population HIV prevalence and greater numbers of infections prevented: HIV prevalence at 20 years was reduced from 23% to 8-14% and the number of expected infections was decreased by 34-59%, depending on the population coverage level. Moderate changes in post-vaccination condom use did not substantially affect these outcomes.

Conclusions

An HIV vaccine with partial efficacy and declining protection similar to the RV144 vaccine could prevent a substantial proportion of HIV infections if booster vaccinations were effective and available. Our estimates of the population impact of vaccination would be improved by further understanding of the duration of protection, the effectiveness of booster vaccination, and whether the vaccine efficacy varies between subpopulations at higher and lower risk of exposure.     

Considering individual differences in the design of preventive interventions: HIV primary prevention as an example

This study examined how individual differences in personality style influenced children's receptivity to HIV primary prevention. Prior to taking part in a HIV prevention program, 123 fifth graders from an ethnically diverse inner city school district were administered the Weinberger Adjustment Inventory (WAI) and scales measuring HIV-related beliefs, attitudes, and knowledge. The HIV scales were readministered at the conclusion of the program. WAI groups (formed by contrasting dimensions of restraint and distress) were found to differ significantly on measures of knowledge about HIV, HIV-related fears, safe behavior attitudes, and risk behavior at pre-test. The intervention's impact, as reflected in scale change scores, did not show significant differences among WAI groups. Although subtle differences were evident among groups, findings suggest that HIV primary prevention programs may be equally effective among children with differing degrees of self-restraint and distress. HIV; primary prevention; personality; elementary grades; HIV knowledge and attitude.     

Body–drug assemblages: theorizing the experience of side effects in the context of HIV treatment

Each of the antiretroviral drugs that are currently used to stop the progression of HIV infection causes its own specific side effects. Despite the expansion, multiplication, and simplification of treatment options over the past decade, side effects continue to affect people living with HIV. Yet, we see a clear disconnect between the way side effects are normalized, routinized, and framed in clinical practice and the way they are experienced by people living with HIV. This paper builds on the premise that new approaches are needed to understand side effects in a manner that is more reflective of the subjective accounts of people living with HIV. Drawing on the work of Deleuze and Guattari, it offers an original application of the theory of ‘assemblage’. This theory offers a new way of theorizing side effects, and ultimately the relationship between the body and antiretroviral drugs (as technologies). Combining theory with examples derived from empirical data, we examine the multiple ways in which the body connects not only to the drugs but also to people, things, and systems. Our objective is to illustrate how this theory dares us to think differently about side effects and allows us to originally (re)think the experience of taking antiretroviral drugs.     

Peer education for HIV prevention in the Socialist Republic of Vietnam: a national assessment

In 2000, the government of Vietnam conducted the first assessment of its national peer education program for HIV prevention. Twenty (32%) of Vietnam's 61 provinces and urban areas had functioning peer education programs, and program coordinators of all 20 were interviewed regarding their programs. In addition, on-site reviews were done for 10 of the 20 programs, including interviews of peer educators and high-risk persons in each program.The assessment found that a total of 500 peer educators were functioning either independently or as part of one of 79 teams. In the 20 provinces, the peer educators made an estimated 7,000 total contacts per month with high risk persons, but many persons were likely contacted repeatedly. Despite this, coverage was limited: some provinces with high numbers of persons reported with HIV/AIDS had few peer educators. Although most provinces targeted IDU and many targeted CSW, few provinces targeted sex partners of IDU or CSW. The definition of peer education and composition of teams varied substantially by province; only one province included persons living with HIV/AIDS as peer educators. The services provided by peer educators were primarily distributional: delivering information either through word of mouth, pamphlets, or brochures, providing condoms, and sometimes providing clean syringes and needles. Skills building or goal setting interventions aimed at HIV risk reduction were rarely provided. Most provinces had concerns about ongoing funding and sustainability of the programs. Based on the assessment, specific recommendations were provided for strengthening and expanding Vietnam's peer education programs.     

HIV prevention among street‐based sex workers (SSWs) in Chongqing,China: interviews with SSWs,clients and healthcare providers

Street‐based female sex workers (SSWs) are subjected to a relatively high risk of HIV transmission, even higher than establishment‐based female sex workers in China. However, very few HIV intervention programmes have targeted this particular group to date. Based in Southwest China, this study aims to identify perceived barriers, demands and suggestions on HIV prevention from the perspectives of SSWs, clients and healthcare providers in Chongqing. Face‐to‐face, in‐depth interviews were conducted in July 2008 with 23 participants. They were recruited by purposive, convenience sampling and included 12 SSWs, 5 male clients, 4 government healthcare providers and 2 outreach workers from a community‐based non‐governmental organisation. Thematic analysis was used. SSWs were largely rural‐to‐urban migrants with a low socioeconomic status. Most of their clients shared a similar background. Both SSWs and their clients demonstrated a low awareness of HIV infection and a lack of understanding of effective preventive strategies. Financial hardships, lack of family support, fear of police arrest and stigma in relation to sex work were identified as SSWs’ major barriers for accessing healthcare services. Both SSWs and their clients indicated an urgent demand for accessing adequate HIV prevention and care programmes. On the other hand, government organisations trying to provide services to this group have also encountered obstacles, specifically their limited ability to establish mutual trust. Programmes provided by community‐based non‐governmental organisation, however, were perceived to be more attractive. In conclusion, there remains a substantial gap between the need of adequate HIV prevention services for SSWs and their clients and what is currently available. Strengthening inter‐sectoral collaboration, providing specifically tailored health services, actively involving SSW peers and their clients, and reducing stigma in the society are keys to meet this urgent demand by SSWs in China.     

HIV/AIDS prevention in China: A challenge for the new millennium

China’s first HIV infection was officially reported in 1985 and by the end of 1996, there may have been up to 200,000 people affected nationwide. In 2001, this figure probably exceeded 600,000. By 2003, the predicted number of HIV cases had reached 1.5 million. At least 80,000 individuals now have fullblown AIDS. China may soon have the largest HIV-infected population in the world, possibly 6 million cases by 2005. With infection rates rising at about 30% per year, it is feared this figure might exceed 10 million by 2010. Although the Chinese government was initially slow to accept the problem, in the late 1990s definite changes began occurring. In 2003 Premier Wen Jiabao publicly shook the hand of an AIDS patient and his government promised to introduce a range of free HIV-related services. Large preventive education campaigns are now underway. Unfortunately, there will still be many obstacles in controlling the epidemic and preventing further spread of this disease. Without doubt, China faces a serious predicament in the new millennium, and one which will pose numerous challenges for preventive medicine.     

Contributions of an intensive HIV prevention programme in increasing HIV testing among men who have sex with men in Andhra Pradesh,India

The objective of this study was to identify the factors associated with uptake of HIV testing and to assess their relative contributions in increasing HIV testing. Data are drawn from two rounds of cross-sectional Integrated Behavioural and Biological Assessment (IBBA) surveys of self-identified men who have sex with men (MSM) from Andhra Pradesh, India, recruited through probability-based sampling in 2005–2006 and 2009–2010 (IBBA1, n = 1621; IBBA2, n = 1608, respectively). Logistic regression model was used to assess the relationship between socio-demographic characteristics, sexual behaviours, programme exposure and HIV testing. Significant factors were further parsed using decomposition analysis to examine the contribution of different components of that factor towards the change in HIV testing. There was a significant increase in the proportion of MSM reporting HIV testing from IBBA1 to IBBA2. Higher literacy levels, being 25–34 years old, being a kothi (predominantly receptive), engaging in both commercial and non-commercial sexual relationships and intervention programme exposure contributed the most to the increase in HIV testing.     

The necessary contradictions of 'community-led' health promotion: a case study of HIV prevention in an Indian red light district

Health promotion interventions with marginalised groups are increasingly expected to demonstrate genuine community participation in their design and delivery. However, ideals of egalitarian democratic participation are far removed from the starting point of the hierarchical and exploitative social relations that typically characterise marginalised communities. What scope is there for health promotion projects to implement ideals of community leadership within the realities of marginalisation and inequality? We examine how the Sonagachi Project, a successful sex-worker-led HIV prevention project in India, has engaged with the unequal social relations in which it is embedded. Our ethnographic study is based on observation of the Project's participatory activities and 39 interviews with a range of its stakeholders (including sex worker employees of the Project, non-sex-worker development professionals, brothel managers, sex workers’ clients). The analysis shows that the project is deeply shaped by its relationships with non-sex-worker interest groups. In order to be permitted access to the red light district, it has had to accommodate the interests of local men's clubs and brothel managers. The economic and organisational capacity to run such a project has depended upon the direct input of development professionals and funding agencies. Thus, the ‘community’ that leads this project is much wider than a local grouping of marginalised sex workers. We argue that, given existing power relations, the engagement with other interest groups was necessary to the project's success. Moreover, as the project has developed, sex workers’ interests and leadership have gained increasing prominence. We suggest that existing optimistic expectations of participation inhibit acknowledgement of the troubling work of balancing power relations. Rather than denying such power relations, projects should be expected to plan for them.     

Barriers to and facilitators for female participation in an HIV prevention project in Rural Ethiopia: Findings from a qualitative evaluation

Ethiopian women face complex social and cultural factors that influence their probability of HIV infection. HIV prevention efforts among this population are particularly important; however, female participation in a rural, HIV prevention project has been minimal. This programme evaluation investigated barriers and facilitators influencing women's ability to participate in project activities. Evaluation data were collected through nine focus groups and 20 semi‐structured interviews, which were conducted between October and November 2003. The main themes found to negatively influence women's decisions to participate in this HIV prevention activity included: domestic workloads, lack of education and awareness, and cultural norms that have discouraged discussions about HIV and sexuality. Domestic chores, which are labour intensive and limit time and energy, were found to be the primary barrier to participation among women. Respondents also indicated that female illiteracy and limited educational attainment occur within a social context that traditionally supports education for men but discourages formal knowledge among women, including HIV prevention. Lack of education and inability to freely discuss sexuality denies women access to health information, potentially exposing women to adverse consequences such as HIV infection. Identified facilitators of participation included a radio serial drama and the one female peer educator associated with the project.     

Community stakeholders' perspectives on the impact of the minority AIDS initiative in strengthening HIV prevention capacity in four communities

Objective. The Minority AIDS Initiative (MAI) was launched in 1998 to address the disproportionate rates of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) among racial and ethnic minorities in the United States. The Centers for Disease Control and Prevention (CDC) conducted an evaluation to assess the influence of MAI in four communities, and the extent to which these communities increased their capacity to meet the HIV prevention needs of racial and ethnic minorities.

Design. Retrospective data were collected annually through individual interviews over three years. Individual interviews were conducted with community stakeholders across the three waves of data collection. Data were analyzed using standardized qualitative methods including codebook development, coding, inter-coder agreement assessments, and data interpretation. This paper will highlight one area of inquiry—community stakeholders’ perceptions of the impact of MAI in their communities.

Results. Community stakeholders reported that MAI increased capacity to respond to the HIV epidemic and provide services to racial and ethnic minorities. Specifically, MAI was perceived to have increased community empowerment, involvement, and awareness of HIV/AIDS; expanded HIV-related services and organizational self-sufficiency; and improved collaboration and the coordination of services in the community. Although recognizing MAI gave national focus to the impact of the epidemic on minority communities, respondents raised concerns about the implementation process and the lack of sustainability planning.

Conclusion. MAI represented an initial national attempt to address the disproportionate rates of HIV/AIDS among racial and ethnic minorities. However, other strategies are also needed to address these significant health disparities. At CDC, steps are currently underway to develop a comprehensive strategy to prevent and reduce the burden of HIV/AIDS among racial and ethnic minorities. As community stakeholders are critical partners in the effort to prevent the spread of HIV, strengthening their capacity and promoting their involvement can help combat the epidemic.     

HIV pre‐exposure prophylaxis and the ‘problems’ of reduced condom use and sexually transmitted infections in Australia: a critical analysis from an evidence‐making intervention perspective

HIV pre‐exposure prophylaxis (PrEP) has been embraced in Australia, making PrEP available with public funding to people at risk of HIV. Here, we consider the associated ‘problems’ of reduced condom use and sexually transmissible infections (STIs), as seen by HIV professionals. Twenty‐one interviews were conducted during May‐August 2017. All agreed that PrEP was a valuable addition to HIV prevention, but their views about reduced condom use and STIs were variable. Using poststructural policy analysis, three main stances were identified: (1) Concerned/alarmed. PrEP was seen as causing reduced condom use, STIs and antibiotic resistance, posing threats to the general population; (2) Neutral/normalising. Stakeholders emphasised that condom use was declining and STIs increasing independently of PrEP, and that PrEP was simply a new tool to be accommodated; (3) Optimistic/critical. PrEP was seen as diminishing fear of HIV and engaging users in more frequent testing and treatment that could lead to declining STI rates. What linked all three stances was the selective performance of evidence, deploying a mixture of personal experience, clinical observations, behavioural data and epidemiology. Anticipating possible futures through evidence‐making suggested practical, political and moral consequences for what PrEP could become. We encourage others to consider these consequences with care.     

Stochastic variation in network epidemic models: implications for the design of community level HIV prevention trials

Important sources of variation in the spread of HIV in communities arise from overlapping sexual networks and heterogeneity in biological and behavioral risk factors in populations. These sources of variation are not routinely accounted for in the design of HIV prevention trials. In this paper, we use agent‐based models to account for these sources of variation. We illustrate the approach with an agent‐based model for the spread of HIV infection among men who have sex with men in South Africa. We find that traditional sample size approaches that rely on binomial (or Poisson) models are inadequate and can lead to underpowered studies. We develop sample size and power formulas for community randomized trials that incorporate estimates of variation determined from agent‐based models. We conclude that agent‐based models offer a useful tool in the design of HIV prevention trials. Copyright © 2014 John Wiley & Sons, Ltd.     

Embodied,clinical and pharmaceutical uncertainty: people with HIV anticipate the feasibility of HIV treatment as prevention (TasP)

Evidence of the efficacy of HIV treatment as prevention (TasP) precipitated a highly optimistic global response and a radical redesign of HIV policy. Sociologists and others have framed TasP within promissory or enterprising discourses which require HIV prevention planners and people with HIV to engage in anticipatory assessments of risk and uncertainty. In 2013, I conducted focus groups with people with HIV in London, UK, to explore their understandings and anticipations of TasP. An environment of economic constraint obliged participants to triage clinical need and presentation, and they expressed scepticism about the sustainability of pharmaceutical investment in treatment innovation. These perceptions were informed by an embodied knowledge of HIV which implies a construction of health as a form of capital that is finite and must be conserved. This is contrasted with a biomedical construction of health as a form of capital that can be exponentially generated through investment. The imperative of conservation entailed by people with HIV’s anticipations contrasts with the speculative economy of biomedical production entailed in planners’ anticipations of TasP. Rather than researching ‘TasP acceptability’ and considering whether people with HIV’s behaviours constitute an obstacle to TasP’s effectiveness, we should recognise that people with HIV are already involved in shaping what TasP is, what it will be and ultimately how it ‘works’.     

Degrees of disclosure: A study of women's covert use of the diaphragm in an HIV prevention trial in sub-Saharan Africa

In sub-Saharan Africa more women are infected with HIV/AIDS than men and new prevention methods are urgently needed. One major attribute of female-initiated HIV prevention methods is that they can be used covertly, without a male partner's knowledge. Using mixed methods, we explored the predictors and dimensions of covert use of the diaphragm in a randomized controlled trial that tested its effectiveness for HIV prevention. The Methods for Improving Reproductive Health in Africa (MIRA) trial was conducted in Zimbabwe and South Africa, and data collection took place between September 2003 and January 2007. This study is a secondary analysis of quantitative and qualitative data from participants randomized to the intervention group, and their male partners. It includes survey data from 2316 women (mean age = 28.3), 14 focus group discussions (FGD) conducted with 104 women, and 7 FGD and 10 in-depth interviews with 37 male partners. The median follow-up for trial participation was 21 months (range: 12–24). At their final visit, approximately 9% of women had never disclosed to their primary partners that they were using the diaphragm (covert use). In multivariate analysis, predictors of covert use included being older, not co-habiting with the partner, having a partner who did not use condoms, and being from South Africa. Qualitative analysis revealed that covert use was not dichotomous, but ranged along a continuum, which we categorized into five levels (i.e. full disclosure; mostly open use; occasional covert use; mostly covert use; and completely covert use). We discuss the critical role of the option of covert use for many women in the context of an HIV prevention trial, as well as gender power dynamics which may influence women's decisions about disclosure.