Shifting the burden: the private sector's response to the AIDS epidemic in Africa

As the economic burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) increases in sub-Saharan Africa, allocation of the burden among levels and sectors of society is changing. The private sector has more scope to avoid the economic burden of AIDS than governments, households, or nongovernmental organizations, and the burden is being systematically shifted away from the private sector. Common practices that transfer the burden to households and government include pre-employment screening, reductions in employee benefits, restructured employment contracts, outsourcing of low skilled jobs, selective retrenchments, and changes in production technologies. Between 1997 and 1999 more than two-thirds of large South African employers reduced the level of health care benefits or increased employee contributions. Most firms also have replaced defined-benefit retirement funds, which expose the firm to large annual costs but provide long-term support for families, with defined-contribution funds, which eliminate risks to the firm but provide little for families of younger workers who die of AIDS. Contracting out previously permanent jobs is also shielding firms from benefit and turnover costs, effectively shifting the responsibility to care for affected workers and their families to households, nongovernmental organizations, and the government. Many of these changes are responses to globalization that would have occurred in the absence of AIDS, but they are devastating for the households of employees with HIV/AIDS. We argue that the shift in the economic burden of AIDS is a predictable response by business to which a deliberate public policy response is needed. Countries should make explicit decisions about each sector's responsibilities if a socially desirable allocation is to be achieved.     

Causes of death among persons reported with AIDS.

OBJECTIVES. This study describes causes of death in persons with acquired immunodeficiency syndrome (AIDS) and assesses the completeness of reporting of human immunodeficiency virus (HIV) infection or AIDS on death certificates of persons with AIDS. METHODS. AIDS case reports were linked with death certificates in 11 local/state health departments; underlying and associated causes of death were available for 32,513 persons with AIDS who died. RESULTS. HIV/AIDS was designated as the underlying cause of death for 46% of persons with AIDS who died between 1983 and 1986 and 81% of persons with AIDS who died since 1987 (the year specific coding procedures were implemented for HIV/AIDS). Most other underlying causes of death were conditions within the AIDS case definition (notably Pneumocystis carinii pneumonia), pneumonia, infections outside the AIDS case definition, and drug abuse. Unintentional injuries, suicide, and homicide were less common. HIV/AIDS was listed as underlying or associated on 88% of death certificates from 1987 to 1989; reporting varied primarily by HIV exposure category and time between diagnosis and death. CONCLUSIONS. Physicians and other health care professionals should realize their critical role in accurately documenting HIV-related mortality on death certificates. Such data can ultimately influence the allocation of health care resources for HIV-infected individuals.     

Occupationally acquired HIV: the vulnerability of health care workers under workers' compensation laws.

Approximately 800,000 needlesticks and other sharp injuries from contaminated medical devices occur in health care settings each year, of which an estimated 16,000 are contaminated by human immunodeficiency virus (HIV). Health care workers who are occupationally infected by HIV are at risk of being left without workers' compensation coverage. In some states, the definition of an occupational disease is so restrictive that infected health care workers are unlikely to qualify for benefits. For those who are able to meet the definition, compensation is often inadequate. Recourse is also limited by statutory provisions that preclude health care workers from bringing civil suits against their employers. We recommend the amendment of legislation to provide more equitable remedies, including: (1) broadening the definition of occupational disease; (2) eliminating provisions that require a claimant to prove that (a) a specific occupational incident resulted in infection and (b) HIV is not an ordinary disease of life; (3) expanding the time for filing a claim; (4) assuring that lifetime benefits will be provided to the disabled health care worker; and (5) assuring that claims will remain confidential.     

Facing the HIV / AIDS challenge: a study on household and community responses

In countries where the health care system cannot cope with the growing number of AIDS cases, the family and the community are significant sources of care and treatment. A qualitative study conducted in Mumbai, India, in 1994 sought to identify household- and community-based strategies for effective AIDS care. Enrolled were 26 individuals with HIV or AIDS, 4 couples (both partners infected), and 25 members of households with an HIV-infected person; in addition, 18 focus group discussions were held with low-income youth. None of the households contacted had abandoned a member with HIV. Household dynamics played a crucial role in the nature and quality of care received, however. The most supportive care was received by men, even when their female partner was also sick. In-laws often showed little compassion toward widowed, infected daughters-in-law. Individuals without open sores or lesions were better accepted by family members and perceived as less likely to transit the virus. Concerns about social stigmatization and isolation prevented many family members from turning to their community for support. Recommended, on the basis of these findings, are measures such as support programs to reduce the burden on female caregivers, subsidized and appropriate medical care, support groups for people with AIDS, HIV/AIDS community awareness programs, and increased involvement on the part of nongovernmental organizations in integrated programming.     

Long-term continuum of care for people living with HIV/AIDS

The introduction of highly active antiretroviral therapy (HAART), has created new options for those infected and affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Most HIV-infected persons no longer die within months of diagnosis. There is now a long-term continuum of care that can end in misery or relative comfort. The introduction of palliative care in concert with curative therapies throughout the disease trajectory should be the standard of care for all persons. At the very least, the introduction of palliative care and hospice at the end of life is important to the holistic care of persons living with HIV/AIDS.     

Oral lesions in infection with human immunodeficiency virus

This paper discusses the importance of oral lesions as indicators of infection with human immunodeficiency virus (HIV) and as predictors of progression of HIV disease to acquired immunodeficiency syndrome (AIDS). Oral manifestations are among the earliest and most important indicators of infection with HIV. Seven cardinal lesions, oral candidiasis, hairy leukoplakia, Kaposi sarcoma, linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis and non-Hodgkin lymphoma, which are strongly associated with HIV infection, have been identified and internationally calibrated, and are seen in both developed and developing countries. They may provide a strong indication of HIV infection and be present in the majority of HIV-infected people. Antiretroviral therapy may affect the prevalence of HIV-related lesions. The presence of oral lesions can have a significant impact on health-related quality of life. Oral health is strongly associated with physical and mental health and there are significant increases in oral health needs in people with HIV infection, especially in children, and in adults particularly in relation to periodontal diseases. International collaboration is needed to ensure that oral aspects of HIV disease are taken into account in medical programmes and to integrate oral health care with the general care of the patient. It is important that all health care workers receive education and training on the relevance of oral health needs and the use of oral lesions as surrogate markers in HIV infection.     

Connecticut will test newborns if mother isn't tested first

A new law in Connecticut mandates HIV testing for all newborns whose mothers were not screened for HIV during their prenatal care. Connecticut has the fourth highest rate of perinatal transmission in the country, according to Institute of Medicine figures for 1996. Under the new law, health care workers will inform each woman receiving prenatal care that HIV testing is routine. The woman must be counseled about benefits of the testing and must give informed consent before the testing is performed. If a prenatal HIV test is not documented in the mother's medical record, the baby must be tested within 24 hours of delivery unless a specific objection is made. The law also establishes a registry of all infants who have been exposed to HIV or AIDS medication to enable the study of potential long-term effects of the drugs. A second bill, 1705, expands eligibility requirements for the State's AIDS drug assistance program and makes it easier for clients of needle exchange programs to obtain clean syringes.     

Help-seeking in a context of AIDS stigma: understanding the healthcare needs of people with HIV/AIDS in China

Despite the rapid increase of HIV infection cases in China, the majority of this population have not yet accessed AIDS-related healthcare services. Most current research in China focuses on HIV prevention and disease control, and pays inadequate attention to the barriers facing HIV-infected individuals in accessing and adhering with healthcare services. This article, as part of a research project on the illness experiences of people with HIV/AIDS in China, aimed to explore these individuals' healthcare experiences, shedding light on the gaps between their needs and existing healthcare services. Data for this qualitative study were collected through individual in-depth interviews with 21 HIV-infected adults in China. The results of data analysis suggest that these individuals' healthcare experiences were greatly affected by social discrimination and the limitations of healthcare resources. While AIDS stigma has reduced the social resources available for this population, HIV-related health institutions were perceived by them as an indispensable source of social support. It is concluded that healthcare institutions, as one of the few places in which HIV-infected people are willing to disclose their HIV positive status, should incorporate social care into healthcare service development and delivery so as to facilitate this population's accessing healthcare services and to address their unmet needs that go beyond the conventional scope of health care. Improving the visibility of people with HIV/AIDS in health care will also have a long-term impact on their own well-being and on HIV prevention in China.     

Are HIV/AIDS services in Leeds, UK, able to meet the needs of asylum seekers?

BACKGROUND: The Yorkshire and Humberside region of England ranks second only to London for reception of those seeking asylum in the UK. Human immunodeficiency virus (HIV) prevalence amongst asylum seekers is likely to mirror that in the country of origin. In 2001, the city of Leeds received 1100 asylum seekers, including dependents. Many of these were from areas with high seroprevalence of HIV, and HIV-infected asylum seekers require medical and social support. Are the current services for HIV-infected persons in Leeds appropriate and adequate for this new patient group? Provision of sexual health services for this client group needs to be evaluated. OBJECTIVES: To determine whether existing HIV/acquired immunodeficiency syndrome (AIDS) services in Leeds meet the needs of HIV-positive asylum seekers. METHODS: This was a qualitative study using semi-structured interviews. Seven service providers and 14 HIV-positive patients at Leeds Centre for Sexual Health, six of whom were asylum seekers, took part in the study. RESULTS: Asylum seekers and UK residents were equally satisfied with HIV/AIDS services at Leeds Centre for Sexual Health. Other agencies such as the Health Access Team and Terrence Higgins Trust had different strengths that provided valuable support for this client group. Unmet needs of asylum seekers were identified, such as specialist services for torture victims and educational opportunities. In areas of asylum seeker dispersal with increased case loads, this methodology may inform development of client-centred care networks.     

Knowledge,attitudes and practices of Greek health professionals,in relation to AIDS

In order to improve educational programmes directed at health care workers we investigated their knowledge, attitudes and practices in relation to HIV/AIDS.An anonymous self-administered questionnaires was distributed to 609 health care workers. Of these, 59.6% agreed to participate (42.4% of the medical doctors, 74.3% of the nurses and 79.6% of the laboratory technicians, health visitors and other health care workers).All studied groups believed that their knowledge of HIV modes of transmission (84.3%) was sufficient. In contrast, a relatively small percentage reported knowledge of the clinical spectrum of HIV infection (48.8%) and the diagnostic assays (57.6%). Nearly all the study participants believe (92.8%) that there is a risk of acquiring HIV infection during the hospitalization of HIV/AIDS patients. Obligatory screening of all patients was reported by nearly all participants (90.6%) as a chance to minimize their occupational risk.Although health care workers reported satisfactory knowledge of safety measures (87.0%), only 56.7% used gloves and 38.8% accept the hospitalization of HIV/AIDS patients.In spite of the educational programmes for AIDS in Greece, this study demonstrates that health professionals' knowledge and precautionary measures are not sufficient. As a result, a small percentage of them treat AIDS patients without discrimination. There is an urgent need to implement specific educational programmes for health professionals so that they will safely provide high quality care to people affected by HIV/AIDS.Corresponding author.     

HIV/AIDS workshop for primary health care staff

The purpose of this study was to develop and pilot a workshop to train general practitioners and other primary care workers to become competent in the primary, secondary and tertiary prevention of acquired immunodeficiency syndrome (AIDS). The development of the workshop took place at four venues in the South West Thames Region and involved 41 general practitioners and 33 primary care nurses. Questionnaire evaluation before and immediately after each workshop showed a significant improvement in participants' attitudes towards the prevention and management of human immunodeficiency virus (HIV) infection in general practice. We conclude that a suitably designed workshop can be effective in improving the attitudes of primary health care workers towards AIDS prevention and care.     

Stronger health systems for more effective HIV/AIDS prevention and care

Of the 42 million living with HIV/AIDS world-wide some 90% live in developing countries. The international community acknowledges the devastating impact of HIV/AIDS on development and over the past few years resources to control HIV/AIDS have increased considerably. We argue that strengthening of health systems is a necessary prerequisite for improving the prevention of HIV infection and the care of HIV-infected persons. Sexual behaviour change requires a multidisciplinary approach, but health services play a crucial role in detection and treatment of other sexually transmitted infections; HIV counselling and testing; prevention of mother-to-child transmission of HIV; and care of HIV-infected patients. Increasing access to antiretroviral treatment especially poses formidable challenges to health authorities in developing countries. Additional resources for the prevention of HIV-infection and the care of HIV-infected persons may not have the desired impact if health systems in developing countries are not strengthened. Further, any activity in the area of HIV/AIDS prevention and care, carried out within health services, can have a positive ripple effect on other health care activities and vice versa. This interactive effect needs to be acknowledged and built on.     

AIDS phobia, public health warnings, and lawsuits: deterring harm or rewarding ignorance?

Courts in more than a dozen states have decided cases in which a person has claimed money damages for his or her fear of getting acquired immunodeficiency syndrome (AIDS). Although most courts have rejected such claims in the absence of actual exposure to the human immunodeficiency virus (HIV), their reasoning has varied slightly from state to state. This article argues that negligence law should not permit people who are HIV negative to recover damages for an unfounded fear of AIDS. Public health statements intended to educate the public about preventing HIV transmission may have encouraged some fear-of-AIDS lawsuits against health care practitioners. Although well intentioned, such statements have been used to justify inappropriate restrictions on medical practice and disclosure of a practitioner's HIV status. To avoid such misuse, such statements should be revised to make clear that the way in which procedures are performed, not who performs them, determines HIV transmission.     

云南边境少数民族艾滋病低流行地区预防保健工作者相关知识、态度及需求

目的了解云南边境少数民族艾滋病低流行地区预防保健工作者艾滋病知识、态度、开展宣传教育的困难及对艾滋病知识和信息的需求.方法选择怒江傈僳族自治州福贡县全体预防保健工作者作为调查对象,进行问卷调查及个人访谈,并对问卷进行统计分析.结果预防保健工作者对艾滋病传播知识掌握较好,但对艾滋病深入一点的专业知识知晓率却很低,问卷平均得分为56.71,知识知晓状况与是否参加过培训相关.结论应加强边境少数民族艾滋病低流行区预防保健工作者艾滋病的教育,传授宣传教育的技能.     

Food counseling for persons infected with HIV: strategy for defensive living

More than a million people in the United States are now infected with human immunodeficiency virus (HIV), and by 1991, the United States will record 270,000 cases of acquired immunodeficiency syndrome (AIDS). At present, there is no way to estimate the number of AIDS patients who will be living in 1991. Intestinal diseases exert considerable morbidity and mortality on AIDS patients and persons with AIDS-related complex. The elevated frequency of certain intestinal infectious diseases in homosexual male AIDS patients has been attributed to sexual practices, but food seems a probable vector for some proportion of the infections in all AIDS-affected groups. Intestinal infectious diseases and resulting systemic infections can be life-threatening to AIDS patients. The infections may serve as cofactors that hasten HIV disease progression to AIDS, but absolute proof of this hypothesis is lacking. The longer the HIV-infected person maintains good general health and avoids potentially lethal infectious diseases, the better are the chances that effective treatments will be developed and made available. Foodborne diseases are generally avoidable, and increased education of AIDS patients and their physicians as to their nature is the key to their prevention.     

Routine checks for HIV in children attending primary health care facilities in South Africa: Attitudes of nurses and child caregivers

Management of HIV-infected and exposed children is challenging for health workers in primary care settings. Integrated management of childhood illness (IMCI) is a WHO/UNICEF strategy for improving morbidity and mortality in under 5 children attending first level facilities in developing countries. In high HIV-prevalence settings, IMCI includes an HIV component for identification and management of HIV-infected and exposed children, which requires health workers to ask all mothers about their HIV status and check all children for signs of HIV. Effective implementation of the HIV component depends on the ability and willingness of health workers to take every opportunity to identify HIV-infected children during routine care, and implementation in South Africa is poor.     

HIV-related discrimination: a survey of New South Wales general practitioners

Abstract: This study aimed to investigate the correlates of human immunodeficiency virus (HlV)-related discrimination among general practitioners. The survey, conducted in 1993–1994, covered a random sample of 878 general practitioners from six of the 12 New South Wales health areas, augmented by 44 general practitioners from the same areas who were antiretroviral drug prescribers. The response rate was 51 per cent, and the final usable sample was 451. Variables examined were: demographic characteristics, the number of HIV-infected patients, personal contact with people living with HIV or AIDS, personal contact with homosexuals, the degree of anxiety about HIV or AIDS, and the degree of HIV-related discrimination. Discriminatory attitudes among general practitioners decreased as contact with HIV-infected patients (P < 0.001), other people living with HIV or AIDS (P< 0.001), and homosexuals (P < 0.001) increased. Anxiety about HIV or AIDS also decreased as contact increased (P < 0.001). Higher levels of anxiety were strongly associated with higher levels of HIV-related discrimination (P< 0.001). The demographic correlates of discrimination among general practitioners were the same as those found in the wider population. The professional care of people living with HIV and AIDS was concentrated among a small number of general practitioners, many of whom were homosexual. Ten general practitioners were carrying extraordinarily high caseloads of over 200 HIV-infected patients each. Older, heterosexual and male general practitioners are an important target for education campaigns, and the professional care of people living with HIV or AIDS should be encouraged among a wider group of general practitioners.     

Orthopedic surgeons' attitudes and practices concerning treatment of patients with HIV infection

Concern regarding an occupational risk of acquiring human immunodeficiency virus (HIV) infection may influence surgeons' willingness to operate. A questionnaire survey of all orthopedists in the five cities with the most cases of acquired immunodeficiency syndrome (AIDS) was conducted to assess attitudes and practices. Questionnaires were completed anonymously by 325 of 510 orthopedists. In the previous year, 43 percent had examined or operated on an HIV-infected patient, and at least 90 percent who had had an opportunity to operate on an HIV-infected patient had chosen to do so. Decisions to operate did not appear to be based on hospital requirements, perceived ethical obligations, or knowledge of HIV transmissibility. Most orthopedists (85 percent) claimed the right to order preoperative HIV testing of high-risk patients, but such testing was ordered infrequently. Although most orthopedists believed they could not be compelled to operate and that ethically they could refuse when their health was threatened, they almost always were willing to treat HIV-infected patients.     

Assessing business responses to HIV / AIDS in Kenya

A consulting firm conducted interviews with managers of 16 businesses in 3 Kenyan cities, representatives of 2 trade unions, focus groups with workers at 13 companies, and an analysis of financial/labor data from 4 companies. It then did a needs assessment. The business types were light industry, manufacturing companies, tourism organizations, transport firms, agro-industrial and plantation businesses, and the service industry. Only one company followed all the workplace policy principles recommended by the World Health Organization and the International Labor Organization. Six businesses required all applicants and/or employees to undergo HIV testing. All their managers claimed that they would not discriminate against HIV-infected workers. Many workers thought that they would be fired if they were--or were suspected to be--HIV positive. Lack of a non-discrimination policy brings about worker mistrust of management. 11 companies had some type of HIV/AIDS education program. All the programs generated positive feedback. The main reasons for not providing HIV/AIDS education for the remaining 5 companies were: no employee requests, fears that it would be taboo, and assumptions that workers could receive adequate information elsewhere. More than 90% of all companies distributed condoms. 60% offered sexually transmitted disease diagnosis and treatment. About 33% offered counseling. Four companies provided volunteer HIV testing. Almost 50% of companies received financial or other external support for their programs. Most managers thought AIDS to be a problem mainly with manual staff and not with professional staff. Almost all businesses offered some medical benefits. The future impact of HIV/AIDS would be $90/employee/year (by 2005, $260) due to health care costs, absenteeism, retraining, and burial benefits. The annual costs of a comprehensive workplace HIV/AIDS prevention program varied from $18 to $54/worker at one company.