Social science research on HIV in Vietnam: A critical review and future directions

Social science research can enhance the response to Vietnam's growing HIV epidemic by capturing the country's rapidly changing social and political context. The present paper reviews the published, peer-reviewed and English-language social science literature on HIV in Vietnam in order to identify critical theoretical and substantive gaps, while laying the groundwork for future research. We found four broad foci for work on the social context of HIV and AIDS in Vietnam: the cultural meanings and social relationships that shape Vietnam's HIV epidemic; stigma and discrimination; social inequality and structural violence as contributors to HIV risk; and, finally, how broader global and social systems shape Vietnam's HIV epidemic. We signal the particular need for additional research on the effects of the media on attitudes towards HIV and AIDS, on social movements, and on health systems, as well as on a number of other key areas. Work along these lines, in addition to more effective communication of policy-relevant findings to those responsible for the development and implementation of policies and programmes, will strengthen Vietnam's response to HIV and AIDS.     

HIV in the United States at the turn of the century: an epidemic in transition.

OBJECTIVES: The current status of and changes in the HIV epidemic in the United States are described. METHODS: Surveillance data were used to evaluate time trends in AIDS diagnoses and deaths. Estimates of HIV incidence were derived from studies done during the 1990s; time trends in recent HIV incidence were inferred from HIV diagnoses and seroprevalence rates among young persons. RESULTS: Numbers of deaths and AIDS diagnoses decreased dramatically during 1996 and 1997 but stabilized or declined only slightly during 1998 and 1999. Proportional decreases were smallest among African American women, women in the South, and persons infected through heterosexual contact, HIV incidence has been roughly constant since 1992 in most populations with time trend data, remains highest among men who have sex with men and injection drug users, and typically is higher among African Americans than other racial/ethnic groups. CONCLUSIONS: The epidemic increasingly affects women minorities, persons infected through heterosexual contact, and the poor. Renewed interest and investment in HIV and AIDS surveillance and surveillance of behaviors associated with HIV transmission are essential to direct resources for prevention to populations with greatest need and to evaluate intervention programs.     

Regulating compassion: an overview of Canada's federal medical cannabis policy and practice

The epidemic of HIV/AIDS linked to injecting drug usage is one of the most explosive in recent years. After a historical epicentre in Europe, South and North America, at present it is clearly the main cause of dissemination of the epidemic in Eastern Europe and some key Asian countries. Recently, 10 African countries reported the spread of HIV through people who inject drugs (PWID), breaking one of the final geographical barriers to the globalization of the epidemic of HIV among and from PWID. Several countries of the Asia and Pacific Region have HIV epidemics that are driven by injecting drug usage. Harm reduction interventions have been implemented in many countries and potential barriers to implementation are being overcome. Harm reduction is no longer a marginal approach in the Region; instead, it is the core tool for responding to the HIV/AIDS epidemic among PWID. The development of a comprehensive response in the Region has been remarkable, including scaling up of needle and syringe programmes (NSPs), methadone maintenance treatment (MMT), and care, support and treatment for PWID. This development is being followed up by strong ongoing changes in policies and legislations. The main issue now is to enhance interventions to a level that can impact the epidemic. The World Health Organization (WHO) is one of the leading UN agencies promoting harm reduction. Since the establishment of the Global Programme on AIDS, WHO has been working towards an effective response to the HIV epidemic among PWID. WHO's work is organized into a number of components: establishing an evidence base; advocacy; development of normative standards, tools and guidelines; providing technical support to countries; ensuring access to essential medicines, diagnostics and commodities; and mobilizing resources. In this paper, we trace the course of development of the HIV/AIDS epidemic among and from PWID in the Western Pacific and Asia Region (WPRO) as well as WHO's role in supporting the response in some of the key countries: Cambodia, China, Lao PDR, Malaysia, the Philippines and Viet Nam.     

Exposing misclassified HIV/AIDS deaths in South Africa

Objective

To quantify the deaths from human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) that are misattributed to other causes in South Africa’s death registration data and to adjust for this bias.

Methods

Deaths in the World Health Organization’s mortality database were distributed among 48 mutually exclusive causes. For each cause, age- and sex-specific global death rates were compared with the average rate among people aged 65–69, 70–74 and 75–79 years to generate “relative” global death rates. Relative rates were also computed for South Africa alone. Differences between global and South African relative death rates were used to identify the causes to which deaths from HIV/AIDS were misattributed in South Africa and quantify the HIV/AIDS deaths misattributed to each. These deaths were then reattributed to HIV/AIDS.

Findings

In South Africa, deaths from HIV/AIDS are often misclassified as being caused by 14 other conditions. Whereas in 1996–2006 deaths attributed to HIV/AIDS accounted for 2.0–2.5% of all registered deaths in South Africa, our analysis shows that the true cause-specific mortality fraction rose from 19% (uncertainty range: 7–28%) to 48% (uncertainty range: 38–50%) over that period. More than 90% of HIV/AIDS deaths were found to have been misattributed to other causes during 1996–2006.

Conclusion

Adjusting for cause of death misclassification, a simple procedure that can be carried out in any country, can improve death registration data and provide empirical estimates of HIV/AIDS deaths that may be useful in assessing estimates from demographic models.     

Addressing the Unique Needs of African American Women in HIV Prevention

African American women continue to be disproportionately affected by the HIV/AIDS epidemic, yet there are few effective HIV prevention interventions that are exclusively tailored to their lives and that address their risk factors.Using an ecological framework, we offer a comprehensive overview of the risk factors that are driving the HIV/AIDS epidemic among African American women and explicate the consequences of ignoring these factors in HIV prevention strategies.We also recommend ways to improve HIV prevention programs by taking into consideration the unique life experiences of adult African American women.Despite more than 25 years of accumulative research demonstrating that behavioral interventions can curb HIV risks among adult women,^1–7 few US-based studies have focused exclusively on African American women and only a limited number of studies tailored for this population have been identified as Centers for Disease Control and Prevention–sanctioned evidence-based HIV prevention.⁸Recent US incidence data show that the rate of HIV infection is 7 times higher among African Americans than it is among Whites.⁹ In the United States in 2006, African American women had an HIV incidence rate that was 15 times higher than that of White women and nearly 4 times higher than that of Hispanic women.¹⁰ This alarming discrepancy raises several important questions: What is driving the HIV/AIDS epidemic among adult African American women? What unique prevention challenges do these women face? How well do available prevention strategies consider the everyday realities of the lives of African American women?Using Bronfenbrenner''s ecological perspective,¹¹ we present factors related to the HIV/AIDS epidemic among African American women that can be used to effectively target prevention interventions. We also describe how the various factors in each system interact and their additive impact on African American women''s risky behaviors. An understanding of these factors will inform the development of appropriate HIV prevention strategies.The ecological perspective consists of 4 levels of risk factors: (1) the ontogenetic system, which refers to personal factors such as childhood sexual abuse, posttraumatic stress disorder (PTSD), and substance abuse; (2) the microsystem, which refers to interactional and relationship contexts, such as relationship dynamics and experience and fear of intimate partner violence (IPV); (3) the exosystem, which refers to external stressors that impinge upon the immediate setting and increase the likelihood of engaging in risky behavior, such as poverty and lack of access to HIV prevention services; and (4) the macrosystem, which includes the broad cultural values and belief systems (e.g., gender roles, gender inequalities, social norms, attitudes toward sexual activity and safe sexual practices) that interact with all the other system levels. We discuss how lack of attention to these factors in existing prevention strategies poses major challenges that constitute barriers and prevent African American women from participating in HIV prevention programs. We also identify the types of strategies that are needed to reduce their risks of HIV transmission.     

HIV Infection and AIDS in the Deep South

We examine epidemiological and demographic data documenting the HIV/AIDS epidemic in the Deep South region of the United States. These data document substantial increases in AIDS cases in the Deep South from 2000 to 2003. In contrast, other US regions are experiencing stable rates or small increases in new AIDS cases. Furthermore, the AIDS epidemic in the Deep South is more concentrated than in other regions among African Americans, women, and rural residents.The Deep South also has some of the highest levels of poverty and uninsured individuals, factors that complicate the prevention and treatment of HIV infection. Further research is needed to determine the cause of the disproportionate rise in AIDS incidence and to develop effective means of preventing HIV infection and providing care of those infected in this region.     

Male and female genital cutting among Southern Thailand's Muslims: rituals,biomedical practice and local discourses

This paper explores the manifestation of HIV‐related stigma in seven‐ and eight‐year‐old white South African children's responses to HIV and AIDS. Drawing from elements of ethnographic and interview data, it shows how young children's responses to HIV and AIDS are inscribed within popular accounts of contagion and articulate gendered, sexual, raced and classed discourses in South Africa. Rejecting static accounts of stigma, the paper shows how children resist and confirm power inequalities involving intense self‐regulation as well as inscribing within discourses of care and concern for others infected with HIV and AIDS. The findings have implications for scaling up educational efforts to address awareness of HIV and AIDS and stigma, but also to build on positive insights that young children demonstrate with regard to the disease.     

Rites of passage to adulthood: traditional initiation schools in the context of HIV/AIDS in the Limpopo Province,South Africa

The HIV/AIDS epidemic and its disproportionate effect on the lives of young people has been a source of major concern in South Africa. Research has, until now, focussed on the broad cultural determinants of risky sexual behaviour among this group and on the barriers that impede the promotion of health seeking behaviour in the context of HIV/AIDS. Still missing is a dedicated investigation into the role of traditional rites of passage customs in influencing the sexual behaviour of young people. This article presents the findings from a study investigating the perceptions of young people from Venda, a former South African homeland under apartheid, of the cultural and educational importance of traditional initiation schools. The results of the study suggest that traditional initiation schools remain both an important rite of passage and source of sexual information for many young people. However, it is also discovered that initiation schools are not currently providing young people with the relevant information to adopt health-seeking behaviour in the era of HIV/AIDS.     

Australian and South African Undergraduates' HIV-Related Knowledge, Attitudes, and Behaviors

To understand safe sexbehavior in two countries which have been differentially affected by the HIV/AIDS epidemic, the present study compared the AIDS-related knowledge, attitudes, and behaviors of 920 heterosexual undergraduate students in Australia and 228 heterosexual undergraduate students in South Africa. South African students were found to have significantly less knowledge about HIV/AIDS, and significantly less favorable attitudes toward safe sexbehavior than their Australian counterparts. Theywere also more likely to report that they have avoided various groups of people for fear of contracting AIDS. Experience from Australia over the period 1986-1995 suggests that significant improvements in the AIDS-related knowledge, attitudes, and behaviors of South African undergraduates are achievable.     

The impacts of AIDS movements on the policy responses to HIV/AIDS in Brazil and South Africa: A comparative analysis

Abstract

Brazil and South Africa were among the first countries profoundly impacted by the HIV/AIDS epidemic and had similar rates of HIV infection in the early 1990s. Today, Brazil has less than 1% adult HIV prevalence, implemented treatment and prevention programmes early in the epidemic, and now has exemplary HIV/AIDS programmes. South Africa, by contrast, has HIV prevalence of 18% and was, until recently, infamous for its delayed and inappropriate response to the HIV/AIDS epidemic. This article explores how differing relationships between AIDS movements and governments have impacted the evolving policy responses to the AIDS epidemic in both countries, including through AIDS programme finance, leadership and industrial policy related to production of generic medicines.     

Experiencing everyday ethics in context: Frontline data collectors perspectives and practices of bioethics

Data collectors play a vital role in producing scientific knowledge. They are also an important component in understanding the practice of bioethics. Yet, very little attention has been given to their everyday experiences or the context in which they are expected to undertake these tasks. This paper argues that while there has been extensive philosophical attention given to ‘the what’ and ‘the why’ in bioethics – what action is taken place and why – these should be considered along ‘the who’ – who are the individuals tasked with bioethics and what can their insights bring to macro-level and abstract discussions of bioethics. This paper will draw on the philosophical theories of Paul Ricoeur which compliments a sociological examination of data collectors experiences and use of their agency coupled with a concern for contextual and institutional factors in which they worked.In emphasising everyday experiences and contexts, I will argue that data collectors' practice of bioethics was shaped by their position at the frontline of face-to-face interactions with medical research participants and community members, alongside their own personal ethical values and motivations. Institutional interpretations of bioethics also imposed certain parameters on their bioethical practice but these were generally peripheral to their sense of obligation and the expectations conferred in witnessing the needs and suffering of those they encountered during their quotidian research duties.This paper will demonstrate that although the principle of autonomy has dominated discussions of bioethics and gaining informed consent seen as a central facet of ethical research by many research institutions, for data collectors this principle was seldom the most important marker of their ethical practice. Instead, data collectors were concerned with remedying the dilemmas they encountered through enacting their own interpretations of justice and beneficence and imposing their own agency on the circumstances they experienced. Their practice of bioethics demonstrates their contribution to the conduct of research and the shortcomings of an over-emphasis on autonomy.     

Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia

Objective: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection. Approach : These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence‐based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues. Conclusion : Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random‐controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random‐controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a ‘surgical vaccine’ is criticised as polemical and unscientific. Implications : Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.     

Overview on Current HIV/AIDS in Asia: "Some Implications for Food and Nutrition Security"

Although Asian countries in general face relatively low national HIV/ AIDS prevalence rates, there are serious localized epidemics in some countries that have important implications for food and nutrition security. The rapid development of the HIV/AIDS epidemic in African countries should serve as a warning to Asian countries. While some of the important modes of transmission of relevance to Asia are highlighted, the focus of this article is on the impact of the HIV/AIDS epidemic on the food security and nutrition situation at the household and community levels. Acknowledging the fact that HIV/AIDS is not merely a medical problem, the impact of the epidemic on nutritional issues, food production, income and the difficulties of poor households in coping with the situation are discussed. The article concludes with some remarks in relation to possible actions to mitigate the HIV/AIDS epidemic before it escalates beyond control in Asia.     

‘Taking care’ in the age of AIDS: older rural South Africans’ strategies for surviving the HIV epidemic

Older adults have been largely overlooked in community studies of HIV in highly endemic African countries. In our rural study site in Mpumalanga Province, South Africa, HIV prevalence among those aged 50 and older is 16.5%, suggesting that older adults are at risk of both acquiring and transmitting HIV. This paper utilises community-based focus-group interviews with older rural South African men and women to better understand the normative environment in which they come to understand and make decisions about their health as they age in an HIV endemic setting. We analyse the dimensions of an inductively emerging theme: ku ti hlayisa (to take care of yourself). For older adults, ‘taking care’ in an age of AIDS represented: (1) an individualised pathway to achieving old-age respectability through the taking up of responsibilities and behaviours that characterise being an older person, (2) a set of gendered norms and strategies for reducing one’s HIV risk, and (3) a shared responsibility for attenuating the impact of the HIV epidemic in the local community. Findings reflect the individual, interdependent and communal ways in which older rural South Africans understand HIV risk and prevention, ways that also map onto current epidemiological thinking for improving HIV-related outcomes in high-prevalence settings.     

Identifying and addressing the governance accountability problem

Successive global health crises – from HIV and AIDS to SARS and H5N1 to Ebola – highlight one of the most pressing challenges to global health security: the GAP – the governance accountability problem. Introduced in 2014 in the book entitled, HIV/AIDS and the South African state: The responsibility to respond, this article takes up Alan Whiteside’s challenges, in a book review in these pages, to offer a more comprehensive analysis of the GAP. The GAP [?ehovi?, A. B. (2014). HIV/AIDS and the South African state: The responsibility to respond. Ashgate Global Health.] posits that there is a disconnect between ad hoc, state and non-state interventions to respond to an epidemic crisis, and the ultimate guarantee for health (security), which remains legally vested with the state. The existence and expansion of such ad hoc solutions result in a negligence: a failure of re-ordering of health rights and responsibilities for health between such actors and the accountable state. The GAP aims to highlight this disjunction. This article first defines the GAP. Second, it asks two questions: First, what is the contribution of the GAP thesis to understanding the emerging health security landscape? Second, what can the GAP offer in terms of practical insight into viable solutions to the re-ordering of state/non-state-based responsibility and accountability for global health security?     

Improving resource allocation decisions for health and HIV programmes in South Africa: Bioethical,cost-effectiveness and health diplomacy considerations

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012–2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.     

The smokescreen of culture: AIDS and the indigenous in Papua, Indonesia

In health transition studies on AIDS, government activities typically have been accorded less importance than local cultural practices. Certain social and cultural values, theorists argue, prevent potentially at-risk individuals from taking effective precautions to prevent HIV infection during sexual intercourse. This paper shows how a focus on culture is inadequate to understanding the issue of risk when the AIDS epidemic occurs in a colonial context. A study conducted in 2001 in Papua (West Papua), eastern Indonesia, shows that ongoing colonial relationships between indigenous Papuans and in-migrant Indonesians create inequities in AIDS awareness. Rates of HIV infection in Papua are high, but indigenous Papuans have a low level of awareness. Drawing on a survey of condom use and the sex work industry, this paper shows that government values, and economic conditions, need to be scrutinized as closely as culture in order to provide effective AIDS prevention in Papua.     

HIV Prevention in Africa: Programs and Populations Served by Non-Governmental Organizations

The AIDS epidemic in Africa remains an urgent health crisis. Non-governmental organizations (NGOs) in Africa play a critical role in the delivery of HIV prevention services and assistance to persons living with AIDS. African NGOs are conducting numerous HIV prevention programs with several at-risk populations, yet their efforts have only rarely been systematically documented. To address this gap in the literature, the authors surveyed one NGO in each of 29 African countries regarding their HIV prevention activities and populations served. This report provides details concerning HIV prevention activities across the continent and describes in detail innovative programs from Togo and South Africa. NGOs in the present sample operate with modest budgets and small staff sizes, yet conduct programs that reach large segments of their communities. NGOs were most likely to report community-level interventions such as peer-education or community outreach. Faced with an epidemic where the main transmission occurs via heterosexual activity, African NGOs were most likely to direct their attention to the general public and to youth. NGOs in Africa are struggling to implement sustainable, cost-effective programs with few resources. Strengthening the infrastructure and capacity of these key agencies is crucial to fighting the AIDS epidemic in Africa.     

The changing age of HIV: sexual risk among older African American women living in rural communities

BACKGROUND: African American women aged 50 and older are disproportionately affected by the HIV/AIDS epidemic. Despite African Americans making up 11% of all older women in the United States, in 2001, they accounted for more than 50% of AIDS cases among older women and more than 65% of HIV cases among older women. Using the AIDS Risk Reduction Model as a conceptual framework, this study investigated HIV risk behavior among older rural African American women (mean age = 58 years). METHODS: A cross-sectional survey was conducted (n = 181) in three rural counties in South Carolina. RESULTS: Most (67%) of the women had at least one sex partner in the past five years, and of these, more than half (59.5%) reported at least one sexual risk behavior. High-risk behavior was associated with less education, lower condom use self-efficacy, more peers who discussed HIV-related risk behavior, and less comfort communicating with partners about sex. CONCLUSIONS: A significant proportion of older African American women living in rural counties are at increased risk for HIV infection, suggesting an urgent need for HIV prevention efforts to target this population.