Healthcare providers’ understanding of HIV serodiscordance in South Africa and Uganda: implications for HIV prevention in sub-Saharan Africa

HIV transmission within stable heterosexual HIV serodiscordant couples accounts for almost half the new incident infections in South Africa and Uganda. Advances in HIV prevention provide opportunities to reduce transmission risk within serodiscordant partnerships (e.g., antiretroviral treatment (ART), pre-exposure prophylaxis (PrEP), medical male circumcision, and couples-based HIV counselling and testing). These interventions require a clinical encounter with a provider who recognises prevention opportunities within these partnerships. We explored healthcare provider understanding of HIV serodiscordance in a reproductive counselling study with providers in eThekwini district, South Africa, and Mbarara district, Uganda. In eThekwini, in-depth interviews (29) and focus group discussions (2) were conducted with 42 providers (counsellors, nurses and doctors) from public sector clinics. In Mbarara, in-depth interviews were conducted with 38 providers (medical officers, clinical officers, nurses, peer counsellors and village health workers). Thematic analysis was conducted using NVivo software. In eThekwini, many providers assumed HIV seroconcordance among client partners and had difficulty articulating how serodiscordance occurs. Mbarara providers had a better understanding of HIV serodiscordance. In the two countries, providers who understood HIV serodiscordance were better able to describe useful HIV-prevention strategies. Healthcare providers require training and support to better understand the prevalence and mechanisms of HIV serodiscordance to implement HIV-prevention strategies for HIV serodiscordant couples.     

The epidemiology of gonorrhoea in Norway, 1993–2007: past victories, future challenges

Background  

Gonorrhoea, a bacterial infection caused by Neisseria gonorrhoeae, has been increasing in several European countries, particularly among men who have sex with men (MSM) and teenagers. We describe the epidemiology of gonorrhoea in Norway in the recent 15 years in order to guide recommendations on the diagnosis, treatment and prevention of gonorrhoea. An evaluation of the Norwegian Surveillance System for Communicable Diseases (MSIS) in 1994, involving GPs and microbiological laboratories, suggested that the system has a high coverage, capturing over 90% of patients diagnosed with gonorrhoea.     

The diagnostic value of Rosemont and Japanese diagnostic criteria for ‘indeterminate’, ‘suggestive’, ‘possible’ and ‘early’ chronic pancreatitis

Background

Longitudinal data are lacking to support consensus criteria for diagnosing early chronic pancreatitis.

Grandmothers’ Productivity and the HIV/AIDS Pandemic in sub-Saharan Africa

The human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) pandemic has left large numbers of orphans in sub-Saharan Africa. Botswana has an HIV prevalence rate of approximately 40% in adults. Morbidity and mortality are high, and in a population of a 1.3 million there are nearly 50,000 children who have lost one or both parents to HIV/AIDS. The extended family, particularly grandparents, absorbs much of the childrearing responsibilities. This creates large amounts of additional work for grandmothers especially. The embodied capital model and the grandmother hypothesis are both derived from life history theory within evolutionary ecology, and both predict that one important factor in the evolution of the human extended family structure is that postreproductive individuals such as grandmothers provide substantial support to their grandchildren's survival. Data collected in the pre-pandemic context in a traditional multi-ethnic community in the Okavango Delta of Botswana are analyzed to calculate the amount of work effort provided to a household by women of different ages. Results show that the contributions of older and younger women to the household in term of both productivity and childrearing are qualitatively and quantitatively different. These results indicate that it is unrealistic to expect older women to be able to compensate for the loss of younger women's contributions to the household, and that interventions be specifically designed to support older women based on the type of activities in which they engage that affect child survival, growth, and development.     

Chills in ‘early sepsis’: good for you?

We evaluated the predictive value of chills, bacteraemia and endotoxaemia for in-hospital mortality and survival at 5-10 years long-term follow-up in a prospective cohort of 'early sepsis' patients presenting with fever resulting from community-acquired pneumonia or pyelonephritis. Febrile patients with chills had bacteraemia more often (RR 3.1, 95% CI 1.8-5.4) than those without chills. Neither chills nor bacteraemia were significantly related to in-hospital mortality, but patients with endotoxaemia had a higher in-hospital mortality rate than those without endotoxaemia. Patients with chills had a significantly higher survival rate at long-term follow-up than those without chills on admission: the estimated risk of dying was 0.644 (95% CI 0.43-0.95, P = 0.029) for an individual with chills, compared to a person without chills, adjusting for the other factors [age cohort, underlying disease and the pro-inflammatory response in the blood, i.e. tumour necrosis factor-alpha (TNF-alpha) and blood leucocyte number, as scored on hospital admission] in the Cox proportional hazards model. Chills may characterize a patient subpopulation that upon pulmonary and urinary tract infection is able to raise a more rapid and/or efficient host response.     

Understanding women and men’s acceptability of current and new HIV prevention technologies in KwaZulu-Natal,South Africa

Despite significant advances to the HIV epidemic, prevention remains a challenge globally. Adolescent girls and young women in southern and Eastern Africa are still at high risk of acquiring HIV infection with limited prevention options. The expanding product pipeline of novel drugs and delivery approaches has highlighted the importance of acceptability and uptake of these anti-retroviral based products to realize their full prevention potential. Community engagement is now imperative to inform both product development and uptake; with research directed to understand what potential users are willing to use given the broader cultural-gender context in which HIV prevention product choices are made/negotiated.

We conducted ten gender specific discussion groups with 112 participants in three of the eight highest HIV prevalence districts in urban, peri-urban, and rural KwaZulu-Natal. The participants where purposively selected according to age, location and sex. The data was analysed thematically in terms of the key enablers and barriers of accepting three key HIV dosing strategies; the oral pill, the vaginal ring and the injectable among men and women.

The study found that women are willing to consider HIV prevention options that align with their current sexual and reproductive health routines, offers the longest duration of protection, and requires minimal/no partner involvement, in contrast most men were not supportive of their partners using of any form of PrEP, irrespective of dosing strategies and formulations as it raised questions of infidelity and side effects on men. The findings is indicative of the complexities of women’s product choices, which are often embedded in a system of personal preference on an intrapersonal level, but also of male dominance, gender norms and cultural contexts at an interpersonal level.

Understanding this intrapersonal-interpersonal interplay can enhance PrEP messaging and promotion; further highlighting the need to expand biomedical innovations for women initiated technologies.     

Church representatives’ perspectives on masculinities in the context of HIV: the case of the Ecumenical HIV and AIDS Initiative in Africa

Despite a growing body of literature related to church leaders challenging dominant norms of masculinities that may enable the spread of HIV, research on masculinity issues among African church representatives who are policy makers is scarce. The objectives of this study were to explore the perspectives on masculinities held by church representatives within the Ecumenical HIV and AIDS Initiative in Africa (EHAIA) and to identify strategies they used to transform masculinities in their respective churches. Qualitative interviews were carried out with 14 church representatives belonging to the EHAIA International Reference Group. These interviews were analysed using thematic analysis and four themes were identified: “barriers to challenge masculinities” may contribute to the spread of HIV; “counterproductive conservative church leadership” fails to challenge dominant forms of masculinities; “facilitators to challenge masculinities” perceived as slowly changing men and “an evolving hope for gender equality” would be perceived in certain marital relationships. The latter two were viewed as positive approaches resulting from masculinity workshops and male priests disclosing their HIV-positive status. This research highlights strategies that may help male church-goers challenge masculinities, support gender equality and, improve the lives of men and women in the context of HIV.     

Reticence in disclosure of HIV infection and reasons for bereavement: impact on perinatally infected adolescents’ mental health and understanding of HIV treatment and prevention in Johannesburg,South Africa

Survival rates of perinatally infected HIV-positive adolescents (PIA) are increasing in sub-Saharan Africa. There is a gap in understanding how disclosure and bereavement have an impact on PIA beliefs and understanding of their HIV infection and its management. In-depth interviews were conducted with 25 purposively selected adolescents aged 13–19 years from 5 public health clinics in Johannesburg, South Africa. Data were analysed using NVivo 10 using a thematic approach. PIA experience incomplete disclosure both of their HIV status and reasons for their bereavements, which limits their understanding of how they became infected, vertical transmission and prevention options like prevention of mother-to-child transmission (PMTCT). Most participants were orphaned and were experiencing complicated grieving (i.e., engaged in unresolved tasks of grieving) which had a negative impact on their mental health, and ability to accept their HIV status and adhere to treatment. PIA need improved communication regarding vertical transmission and how they became HIV-positive, as well as reasons for death of their loved ones to properly understand their HIV status and engage effectively in management. Honest communication about how relatives died and truthful engagement in the process of disclosure of HIV status is necessary to reduce stigma and complicated grieving, and improve mental health in this population.     

The HIV infection and immune activation: ‘To fight and burn’

Immune activation, a normal immune reaction to pathogens, is now recognized as a major driving force of the CD4 T-cell depletion and immune disorders caused by HIV. By contrast, the natural hosts of its ancestor virus, simian immunodeficiency virus, have adapted to this virus by blocking immune activation and remaining healthy. This review will focus on evidence demonstrating how immune activation associated with HIV infection exhausts immune defenses to HIV as well as the immune system, thus leading to immunosenescence and immunodeficiency, and how treatment can disrupt this vicious and ultimately fatal circle.     

Acceptability of HIV self-testing among men and women in KwaZulu-Natal,South Africa

Successful implementation of Universal Test and Treat as a strategy to achieve the 90-90-90 target requires higher HIV testing rates. Currently, uptake of HIV testing is not optimal which has directed research initiatives towards identification of additional HIV testing methods. HIV self-testing (HIVST) has received growing attention as a complementary testing approach as it overcomes barriers that are commonly associated with current HIV testing methods. In sub-Saharan Africa, acceptability rates showed a gendered pattern of men benefitting more than women, with limited evidence to explain this difference. This study assessed whether men or women in KwaZulu-Natal displayed a higher acceptance of HIVST and also explored factors that influenced and motivated their acceptability. Participants were recruited through purposive sampling at two clinical research sites to participate and underwent qualitative assessments. The outcomes from focus group discussions coupled with findings from a scoping review informed the design and data collection instruments for in-depth interviews. A randomised cross-over study design exposed participants to HIV counselling and testing and HIVST, accompanied by before (baseline) and after in-depth interviews. HIVST was acceptable among most participants with acceptability higher in women. Men preferred HIVST due to convenience and efficiency, whilst women favoured HIVST due to its potential to provide autonomy and empowerment. Also, lack of HIV counselling and managing a positive HIV result as well as linkage to care were raised as deterrents of HIVST. As HIVST was acceptable by most participants, future research efforts should be directed towards evaluating the feasibility of its introduction into the public health sector.     

Male partners’ involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: A systematic review

Abstract

In sub-Saharan Africa (SSA), male partners are rarely present during prevention of mother-to-child transmission (PMTCT) services. This systematic review aims to synthesize, from a male perspective, male partners’ perceived roles, barriers and enablers of their involvement in PMTCT, and highlights persisting gaps. We carried out a systematic search of papers published between 2002 and 2013 in English on Google Scholar and PubMed using the following terms: men, male partners, husbands, couples, involvement, participation, Antenatal Care (ANC), PMTCT, SSA countries, HIV Voluntary Counseling and Testing and disclosure. A total of 28 qualitative and quantitative original studies from 10 SSA countries were included. Men's perceived role was addressed in 28% (8/28) of the studies. Their role to provide money for ANC/PMTCT fees was stated in 62.5% (5/8) of the studies. For other men, the financial responsibilities seemed to be used as an excuse for not participating. Barriers were cited in 85.7% (24/28) of the studies and included socioeconomic factors, gender role, cultural beliefs, male unfriendly ANC/PMTCT services and providers’ abusive attitudes toward men. About 64% (18/28) of the studies reported enablers such as: older age, higher education, being employed, trustful monogamous marriages and providers’ politeness. In conclusion, comprehensive PMTCT policies that are socially and culturally sensitive to both women and men need to be developed.     

‘A Virus and Nothing Else’: the Effect of ART on HIV-Related Stigma in Rural South Africa

While the World Health Organization acknowledges the potential of antiretroviral therapy to reduce HIV-related stigma, few studies examine the nature of this linkage. This article discusses the connection between ART and HIV-related stigma, using qualitative analysis of interviews with HIV-positive adults at a rural South African clinic. The data has two main implications for ART’s role in stigma reduction: it strengthens the plausibility that ART can reduce stigma through weakening HIV/AIDS’s link with disfigurement and death, and shows that ART enables the establishment of spaces for support, which reduce stigma through normalization of the disease.     

Generational inversions: ‘working’ for social reproduction amid HIV in Swaziland

How do people envision social reproduction when regular modes of generational succession and continuity are disrupted in the context of HIV/AIDS? How and where can scholars identify local ideas for restoring intergenerational practices of obligation and dependency that produce mutuality rather than conflict across age groups? Expanding from studies of HIV/AIDS and religion in Africa, this article pushes for an analytic engagement with ritual as a space and mode of action to both situate local concerns about and practices for restoring dynamics of social reproduction. It describes how the enduring HIV/AIDS epidemic in Swaziland contoured age patterns of mortality where persons identified socially and chronologically as youth have predeceased their elders. Based on discourse analyses of ethnography at church worship services and life cycle rites between 2008 and 2011, the findings show how both elders and youth understood this crisis of ‘generational inversions’ as a non-alignment of age groups and articulated projects to restore succession and continuity in vernacular idioms of ‘work’ as moralised social and ritual action.     

Caregivers’ Intentions to Disclose HIV Diagnosis to Children Living with HIV in South Africa: A Theory-Based Approach

When children know their HIV serostatus, they are more likely to cooperate with steps to manage their health and the risk of transmitting HIV to others. Mounting evidence indicates that caregivers often do not disclose to HIV-positive children that the children are living with HIV, but little is known about the modifiable determinants of pediatric HIV disclosure. The present study examined theory-of-planned-behavior predictors of the intention to disclose to children their HIV diagnosis. The participants were 100 caregivers of HIV-positive children in Eastern Cape Province, South Africa. Proportional-odds logistic regression analysis revealed that normative support for disclosure and caregiver-child communication predicted the intention to disclose, whereas behavioral beliefs regarding the consequences of disclosing and self-efficacy to disclose did not. The results suggest that interventions to increase pediatric HIV disclosure in South Africa should help caregivers enlist support for disclosure among important referents and improve communication with their HIV-infected children.     

‘Clinics aren't meant for men’: Sexual health care access and seeking behaviours among men in Gauteng province,South Africa

Men may be key players in the transmission of sexually transmitted infections (STI), and it is important that STI/HIV health services reach men. The objective of this study was to explore sexual health care access and seeking behaviours in men. This study used focus groups to examine sexual health care access and seeking behaviours in men 5 years after implementation of free antiretroviral therapy (ART) in the South African public sector. Six focus groups (N=58) were conducted with men ?18 years in an urban area of Gauteng province. Men were recruited from various locations throughout the community. Men reported several barriers and facilitators to the use of public and private clinics for sexual health services including HIV testing, and many men reported seeking care from traditional healers. Men often viewed public clinics as a place for women and reported experiences with some female nurses who were rude or judgmental of the men. Additionally, some men reported that they sought sexual health care services at public clinics; however, they were not given physical examinations by health care providers to diagnose their STI syndrome. Most men lacked knowledge about ART and avoided HIV testing because of fear of death or being abandoned by their families or friends. Study findings suggest that men still require better access to high-quality, non-judgmental sexual health care services. Future research is needed to determine the most effective method to increase men's access to sexual health care services.     

How the Term ‘Self-Management’ is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review

AIDS and Behavior - This scoping review assessed how the term ‘self-management’ (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries...