Preventing HIV infections in children and adolescents in sub-Saharan Africa through integrated care and support activities: a review of the literature

Sub-Saharan Africa has been hit harder by the HIV/AIDS pandemic than any other region of the world, and children under age eighteen represent one-third of all new HIV infections occurring there annually. While HIV prevention efforts targeting youth are well established, few prevention programmes provide comprehensive care and support services. One reason for this is that prevention messages are often targeted only at older adolescents, and care and support activities typically emphasise the needs of younger children. By expanding prevention activities to younger children, and expanding care and support activities to older adolescents, more holisitic, and truly integrated programmes can be developed which address the common factors which make children of any age particularly vulnerable to HIV infection, namely: inadequate access to health care and unstable familial and social environments. This paper reviews evidence of the potential impact of care and support activities on HIV prevention among youth, and presents a conceptual framework for the development of comprehensive, effective, integrated HIV/AIDS prevention and care programmes tailored to the specific needs of youth.     

HIV prevalence and sexual behaviour at older ages in rural Malawi

Research on HIV infection and sexual behaviour in sub-Saharan Africa typically focuses on individuals aged 15-49 years under the assumption that both become less relevant for older individuals. We test this assumption using data from rural Malawi to compare sexual behaviour and HIV infection for individuals aged 15-49 with individuals aged 50-64 and 65 and over years. Although general declines with age were observed, levels of sexual activity and HIV remained considerable: 26.7% and 73.8% of women and men aged 65+ reported having sex in the last year, respectively; men's average number of sexual partners remained above one; and HIV prevalence is significantly higher for men aged 50-64 (8.9%) than men aged 15-49 (4.1%). We conclude that older populations are relevant to studies of sexual behaviour and HIV risk. Their importance is likely to increase as access to antiretrovirals in Africa increases. We recommend inclusion of adults aged over 49 years in African HIV/AIDS research and prevention efforts.     

Developing and implementing an HIV/AIDS educational curriculum for older adults

PURPOSE: Recent data (2002) from the Centers for Disease Control and Prevention indicate that almost 11% of all cases of AIDS were diagnosed in people 50 and older. Despite the steady rise and future projections of increase, there is still a paucity of education and prevention programs targeting this population. This article reports on the development and piloting of an HIV/AIDS education prevention program. It describes an educational curriculum that provides older adults with accurate information about the relevance of HIV/AIDS to their lives. DESIGN AND METHODS: A purposive sample (n = 249) of ethnically and economically diverse adults 50 years and older was selected from 14 organizations in rural and urban settings in California. They were surveyed to determine their interest in participating in HIV/AIDS education prevention programs. RESULTS: A majority of participants reported interest in an HIV/AIDS prevention program for older people, with female respondents more likely to attend than male respondents. Participants who were moderately or very religious were also more likely to attend. Participants expressed preference for prevention education through presentations at centers serving older adults, and from physicians and other health care providers. On the basis of these findings, a specialized curriculum targeting older adults was developed, presented, and disseminated. IMPLICATIONS: People 50 years and older are sexually active, lack accurate information about HIV/AIDS, and are in need of HIV/AIDS education.     

What you need to know about AIDS in minority groups

President Clinton recently announced that $156 million in additional funding will be allocated to address HIV/AIDS issues in minorities. The funding will go to prevention programs, drug treatment programs, and programs to help health care workers assess the needs of HIV-infected people. Racial and ethnic minorities account for about 25 percent of the total U.S. population, but more than 50 percent of all AIDS cases. As many as 325,000 African-Americans are infected with HIV, and Hispanics now account for 22 percent of new cases. Poverty plays a role in the increasing number of minorities with HIV, as does injection drug use and limited access to health care. The Centers for Disease Control and Prevention (CDC) currently provide $253 million in funding to State and local health departments for prevention programs. Contact information is included.     

Changing trends in human immunodeficiency virus and acquired immunodeficiency syndrome in the population aged 50 and older

OBJECTIVES: To alert persons in the public and private healthcare professions to the increasing trends in higher proportions of persons aged 50 and older who are newly diagnosed with human immunodeficiency virus (HIV) and who are living with HIV and acquired immunodeficiency syndrome (AIDS). DESIGN: Data from the period 1992 through 2004 from the HIV/AIDS Reporting System (HARS) were analyzed. SETTING: New Jersey is the eleventh-most-populous state, with the highest density of persons per square mile. It also has the fifth-highest number of AIDS cases. PARTICIPANTS: All persons residing in New Jersey and reported to HARS with HIV infection or who are considered to have AIDS. MEASUREMENTS: Trends in persons aged 50 and older were compared with those in the population younger than 50 during 1992 through 2004 for the numbers of persons living with HIV/AIDS and the number of persons newly diagnosed with HIV infection. RESULTS: The proportion of all persons aged 50 and older living with HIV/AIDS in 2004 was significantly greater than the comparable proportion of persons in 1992. Proportionally, more persons were newly diagnosed with HIV who were aged 50 and older according to sex and for each of the three major race or ethnicity groups (white non-Hispanic, black non-Hispanic, and Hispanic) than were persons younger than 50. Each of these increases was statistically significant. CONCLUSION: HIV/AIDS social marketing campaigns should include images and issues related to older persons in educational and prevention efforts. New methods that reach older populations should be considered. Physicians and other healthcare providers should be made aware of their role in prevention and education about HIV. Testing of older populations with risk factors should be encouraged.     

Correlates of service utilization among midlife and older adults with HIV/AIDS: the role of age in the equation

OBJECTIVES. To determine the role of age on service utilization among persons with HIV/AIDS. METHODS. The study examined 571 individuals diagnosed with symptomatic HIV or AIDS ranging in age from 30 to 81 years. All individuals had been enrolled in case management services from July 1995 through June 1996. It was hypothesized that older persons would utilize higher rates of health and medical services and lower rates of psychosocial services. RESULTS. The study found that in the older age groups the proportion of women, those living alone, and those having private health insurance increased. Mortality also increased in the older age groups, whereas survival time from AIDS diagnosis to death decreased. Age did not emerge as a significant variable in a multiple regression of service utilization. Functional dependence and mortality were significant predictors of medical services, whereas geographical location and insurance coverage explained the majority of variance in home care services.     

A Call for an Integrated Biopsychosocial Model to Address Fundamental Disconnects in an Emergent Field: An Introduction to the Special Issue on “Sexuality and Aging”

This special issue of Ageing International is designed to highlight the clinicians, researchers, and public policy makers who focus upon the intersection of sexuality and aging. A theoretical, biopsychosocial model is introduced in response to a variety of apparent paradoxes in the field (e.g., although nearly 1 in 5 new AIDS cases are among adults over the age of 65, no federally funded programs exist for HIV prevention among this age group, and although virtually all findings in the literature are based upon men and women from North American and Western European nations, China boasts the largest population of older adults worldwide). Consistent with this integrated approach, contributors to the special issue provide emergent information in relation to HIV and AIDS among older men and women, cross-cultural perspectives on sexuality and aging within Chinese and Ugandan culture, sexuality within the context of long-term care, and clinical approaches to erectile dysfunction. Directions for future research also are offered.     

Adolescents and the right to health: eliminating age-related barriers to HIV/AIDS services in Rwanda

Under international, regional, and domestic law, adolescents are entitled to measures ensuring the highest attainable standard of health. For HIV/AIDS, this is essential as adolescents lack many social and economic protections and are disproportionately vulnerable to the effects of the disease. In many countries, legal protections do not always ensure access to health care for adolescents, including for HIV/AIDS prevention, treatment, and care. Using Rwanda as an example, this article identifies gaps, policy barriers, and inconsistencies in legal protection that can create age-related barriers to HIV/AIDS services and care. One of the most pressing challenges is defining an age of majority for access to prevention measures, such as condoms, testing and treatment, and social support. Occasionally drawing on examples of existing and proposed laws in other African countries, Rwanda and other countries may strengthen their commitment to adolescents' rights and eliminate barriers to prevention, family planning, testing and disclosure, treatment, and support. Among the improvements, Rwanda and other countries must align its age of consent with the actual behavior of adolescents and ensure privacy to adolescents regarding family planning, HIV testing, disclosure, care, and treatment.     

Barriers to access to care reported by women living with HIV across 27 countries

Increased access to successful antiretroviral therapy (ART) is necessary in order to achieve an AIDS-free generation. Importantly, slightly over half of the people living with HIV are women. Small studies have described many barriers to accessing treatment and care among women living with HIV. This cross-sectional, non-interventional, epidemiological study assessed the prevalence of barriers to accessing care for women living with HIV across 27 countries, divided into four global regions. HIV-positive women attending routine clinical visits were offered the opportunity to participate in the study. Data describing the study sites and demographic characteristics of the participating women were collected. Participating women filled out questionnaires including the Barriers to Care Scale (BACS) questionnaire, on which they reported the extent to which they found each of the 12 potential barriers to accessing health care problematic. A total of 1931 women living with HIV were included in the study: 760 from Western Europe and Canada (WEC), 532 from Central and Eastern Europe (CEE), 519 from Latin America (LA), and 120 from China. The mean age of participating women was 40.1 ± 11.4 years. A total of 88.2% were currently taking ART. A total of 81.8% obtained HIV treatment under a government health plan. The most prevalent barrier to care was community HIV/AIDS stigma. Community HIV/AIDS knowledge, lack of supportive/understanding work environments, lack of employment opportunities, and personal financial resources were also highly prevalent barriers to accessing care. These findings indicate that, more than 30 years after the start of the AIDS epidemic, stigma is still a major issue for women living with HIV. Continued efforts are needed to improve community education on HIV/AIDS in order to maximize access to health care among women living with HIV.     

Disease Progression and Characteristics of HIV-infected Women With and Without a History of Criminal Justice Involvement

Early HIV diagnosis followed by prompt linkage to and consistent retention in HIV-related care is important to decrease morbidity and mortality. Progression to AIDS is of particular interest in HIV-positive women with a history of criminal justice-involvement due to their lack of access to care in the community and poor retention in HIV primary care. In this retrospective cohort study, we characterize the risk of developing AIDS among HIV-infected women with and without a history of criminal justice-involvement. Mean time to AIDS diagnosis was longer [123 ± 3.26 months] for women with no criminal justice-involvement when compared to women who were arrested or who went to prison. Women who were arrested (HR: 1.92, 95% CI: 1.43, 2.58) and women who went to prison (HR: 2.27, 95% CI: 1.52, 3.39) had an increased risk of developing AIDS when compared to women without criminal justice-involvement.     

HIV/AIDS in Women and Racial/Ethnic Minorities in the U.S.

The clinical issues affecting women with HIV/AIDS differ little from those affecting men. However, current research shows that treatment and outcome disparities affect many women with HIV, hypothesized to result from a complex interplay of socioeconomic and gender role influences. These disparities are also a reflection of racial/ethnic differences in treatment and outcome, since 80% of women with HIV/AIDS are black or Hispanic. Women have unique needs for HIV prevention — both prevention of sexual transmission to or from sexual partners and prevention of perinatal transmission. Racial/ethnic minorities continue to be disproportionately affected by the HIV/AIDS epidemic in the U.S. Minorities are less likely to be in care and on HAART than others with HIV/AIDS. These disparities result in poorer outcomes for minorities, especially blacks, with HIV/AIDS. New strategies for optimizing engagement and retention in care, and for prevention hold great promise for women and minorities with HIV in the U.S.     

Service needs and networks of rural women with HIV/AIDS

Despite the fact that one of every 16 women with AIDS in the United States lives in a rural area, little is known about their demographic and epidemiologic characteristics, service needs, social support networks, or service utilization patterns. This article reports key findings from case studies of services to rural women with HIV/AIDS in southwest Georgia, northwest Mississippi, southeastern South Carolina, south Texas, and south-central Washington. Despite the growing numbers of HIV-positive women in these areas, many primary care physicians lack training in the diagnosis and treatment of HIV infection in women, and multidisciplinary protocols for the "shared care" of HIV-positive pregnant women are still being developed. Concerns about confidentiality and the lack of health insurance and transportation pose major access barriers. The findings suggest a need for new kinds of rural initiatives that embed HIV prevention and care into broader programs of educational and economic development.     

HIV/AIDS-related services for women and the rural community context

Rural communities present a different context for HIV/AIDS than urban communities, particularly for women. Theory, research and care and prevention practices for women in urban contexts are not necessarily easily applied to women in rural communities. This paper identifies several important characteristics of the rural community context and discusses how they may impact the development of HIV/AIDS-related care and prevention services for women. A social ecological perspective, with its emphasis on the relationship between individual-level behaviour and experience and different levels of the social environment, is presented as a useful approach to the study of the HIV/AIDS care and prevention service needs of rural women. Finally, recommendations for research are provided, consistent with a social ecological perspective, that can address the current lack of information regarding rural women's HIV/AIDS care and prevention service needs.     

The importance of AIDS-related knowledge for mid-life and older women.

Although the AIDS epidemic has had a major impact on the lives of women throughout the world, there is little knowledge regarding risk factors, transmission factors, prevention methods, and results of prevention efforts for older women, even though almost 10% of all AIDS cases in the United States are among those 50 years and older. This article reports results on AIDS knowledge and risks from the Massachusetts Women's Health Study, a longitudinal community-based study of middle-aged women. AIDS-related questions were asked of this sample at their last study interview, which occurred in 1995 when the women were aged 58-67. Results indicate that this sample of older, predominantly Caucasian women are quite knowledgeable about transmission factors but are less knowledgeable about early interventions and their own risk status. Many are also likely to know someone with HIV or AIDS. Even though these women are generally at low risk, they may be at higher risk than they perceive. They may also be significant disseminators of knowledge to friends and relatives who may be at risk, and thus could represent an important target group for AIDS educational programs.     

CDC: avoid preventive therapy for sexual risk. Centers for Disease Control and Prevention

At a recent meeting, AIDS experts questioned why postexposure prophylaxis that protects health care workers against blood exposure to HIV would not protect someone who has been exposed to HIV through sexual contact. There is no scientific evidence that antiretroviral drugs can prevent sexual transmission. The Centers for Disease Control and Prevention (CDC) points out that the dynamics of transmission via blood exposure versus sexual exposure differ in ways not fully known. The CDC acknowledges that the triple combination of drugs recommended for exposed health care workers has the potential to act as a morning-after pill, and have asked for additional funding to study the role of protease inhibitors in this type of prevention and intervention of HIV. Two groups that would directly benefit from the back-up protection are discordant couples and women who have been sexually assaulted and cannot determine the HIV status of their assailant.     

Acceptance of Routine Testing for HIV among Adult Patients at the Medical Emergency Unit at a National Referral Hospital in Kampala,Uganda

HIV testing is an entry point to comprehensive HIV/AIDS prevention and care. In Uganda, Routine Testing and Counseling for HIV (RTC) is not widely offered as part of standard medical care in acute care settings. This study determined the acceptance of RTC in a medical emergency setting at Mulago national referral hospital. We interviewed 233 adult patients who were offered HIV testing. Overall, 83% were unaware of their HIV serostatus and 88% of these had been to a health unit in the previous six months. Of the 208 eligible for HIV testing, 95% accepted to test. Half the patients were HIV infected and 77% of these were diagnosed during the study. HIV testing was highly acceptable and detected a significant number of undiagnosed HIV infections. We recommend adoption of RTC as standard of care in the medical emergency unit in order to scale HIV diagnosis and linkage to HIV/AIDS care.     

Conferences raise new questions about HAART use by women

The 1999 National Conference on Women and HIV/AIDS included a number of sessions on trends and developments in the treatment of HIV specific to women. Infection rates among women are rising faster than those for men, especially among African-American and Latina women. Summaries include sessions on disease progression and survival; access to medical care; side effects of antiretroviral therapy in women; anemia in HIV-positive women; viral load management; monitoring therapeutic efficacy and resistance; microbicide development; issues related to pregnancy and perinatal transmission; and HIV prevention strategies targeted at women.     

Are sexually active older Americans your next high-risk group?

Older Americans are becoming infected with HIV through sexual contact, more often than they have in the past. Doctors do not routinely question older patients about their sexual practices, and these patients often do not suspect that they are infected with HIV. In many cases, both doctors and patients may attribute some symptoms to the aging process. In addition, since older Americans are not as highly effected by HIV infection as are other populations, Federal agencies will often not support research on this population. Despite the lack of Federal support, some agencies such as the American Association of Retired Persons (AARP), are beginning to focus on educating older Americans about HIV/AIDS.     

Clearinghouse: secondary prevention

Seven references and four clearinghouses involved in HIV secondary prevention are provided. Referenced materials include disclosure of HIV seropositivity to significant others, the impact of HIV/AIDS on women in the United States, and treatment access and secondary prevention issues for women living with drug abuse and HIV disease.     

Reducing social vulnerability to HIV/AIDS: models of care and their impact in resource-poor settings

There has been an increasing understanding of the social, economic, cultural and political factors that have shaped the HIV/AIDS epidemic. It has been widely recognized that in order to have effective prevention programmes for HIV/AIDS, the broader determinants of health must be addressed. Concurrently, a deeper understanding of personal and societal vulnerability to HIV/AIDS has emerged. Some prevention efforts have expanded their focus, addressing not only individual risk factors and behaviour, but also social justice and including community mobilization activities to address the wider context of the disease. However, the transition to an expanded approach to mitigating the effects of the HIV/AIDS epidemic has not been complete. There is little evidence that care and support strategies have systematically tried to address these concepts. While the role care plays in prevention is considered vital, viewing models of care in terms of their impact on the social vulnerability of certain groups to HIV/AIDS has been largely neglected. Yet appropriate care programmes that help reduce vulnerability will arguably also make the greatest contribution for prevention. Drawing on examples of the role social vulnerability has played in prevention efforts, this paper evaluates the impact of HIV/AIDS care models on socially vulnerable groups, such as women and children.