Confidentiality and HIV status in Kwazulu-Natal, South Africa: implications, resistances and challenges

This article provides a contextualized comparison and analysis of the former Kwazulu and the new Kwazulu-Natal policy documents on HIV confidentiality, the differing practices within the region, and their implications for support and gender. It is based on interviews with key players in the regional NACOSA (National AIDS Convention of South Africa), and participation in meetings between August and November 1995. The main division is between those influenced by other rural African models, especially the Zambian concept of "shared confidentiality' as a way of ensuring support, and who have gone on to develop more community-based practices to destigmatize the disease, in contrast with the stronger emphasis in the new document on individual rights, assuming a more urban constituency, and where "shared confidentiality' is much more circumscribed. One of the difficulties of the new policy in which "confidentiality' is interpreted as "secrecy', is that it would seem to foreclose and neutralize lay and community support, as distinct from the earlier and unacknowledged policy of former Kwazulu. It also seeks to provide an enhanced role for professional counsellors. This psychologizing of the infection and the distancing from "community', and from women's groups, is surprising in a country in whose townships "community' remains a powerful motivating symbol, and where NGOs and peer groups have been identified everywhere as central to effective HIV/AIDS related prevention, care and support for behavior change.     

Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa

Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions and low motivation. In particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières' experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition and international 'brain drain'. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.     

Young males' gendered sexuality in the era of HIV and AIDS in Limpopo Province, South Africa

This article is focused on young males' sexual identity and behaviors in rural South Africa. The study comprised 19 focus group discussions with adolescents aged 12 to 14 years. The informants depict male sexuality as biologically predetermined, where physical needs and practices such as circumcision legitimize early sexual debut. Furthermore, the construction of male sexual identity and power imbalances in relationships are already evident at an early age, and age and economics are pertinent factors affecting social relations. Violent behavior and sexual abuse are supported by constructed gender inequalities forming an often negative and nonsupportive environment for young people. We stress the importance of planned HIV and sexuality education for young adolescents with support structures that can help endorse individual actions and informed choices. This is especially important in resource-poor settings where young people are likely to be less empowered than is the case in more affluent settings.     

Tuberculosis among Children and Adolescents at HIV Treatment Centers in Sub-Saharan Africa

HIV-infected children and adolescents are at increased risk for tuberculosis (TB). Antiretroviral therapy (ART) reduces TB risk in HIV-infected adults, but its effectiveness in HIV-infected children and adolescents is unknown. We analyzed data from 7 integrated pediatric HIV/TB centers in 6 countries in sub-Saharan Africa. We used a Bayesian mixed-effect model to assess association between ART and TB prevalence and used adaptive lasso regression to analyze risk factors for adverse TB outcomes. The study period encompassed 57,525 patient-years and 1,160 TB cases (2,017 cases/100,000 patient-years). Every 10% increase in ART uptake resulted in a 2.33% reduction in TB prevalence. Favorable TB outcomes were associated with increased time in care and early ART initiation, whereas severe immunosuppression was associated with death. These findings support integrated HIV/TB services for HIV-infected children and adults and demonstrate the association of ART uptake with decreased TB incidence in high HIV/TB settings.     

Scaling up health promotion interventions in the era of HIV/AIDS: challenges for a rights based approach

A sustained scaled up response to global public health challenges such as HIV/AIDS will require a functioning and efficient health system, based on the foundation of strong primary health care. Whilst this is necessary, it is not sufficient. Health promotion strategies need to be put into place to better engage and support families and communities in preventing disease, optimize caring, creating the demand for services and holding service providers to account. There will have to be a move away from the traditional model whereby the problem of HIV/TB/malaria is to be solved by merely increasing resources to a centralized bureaucracy that tries to increase the supply of services including health promotion messages. Development projects and programs that succeed are based on understanding of local practice and preferences, rather than on internationally 'generalized models' of how people or villages should behave and what they should want. This paper will first briefly review different approaches to scaling up health promotion interventions, some of the key obstacles in scaling up and then suggest some possible solutions with a focus on a human rights based approach. This approach changes the emphasis from the content of the message to the characteristics of a community's organisations and institutions. Scaling up occurs as a process of association between state actors and civil society that is planned strategically and involves a sharing of experience and a strong learning process among the association partners. A human rights-based approach can facilitate such an approach through developing a common vision, delineating roles and responsibility and facilitating communication channels for the most vulnerable. But this will require health development agencies to pursue a more overt political agenda.     

Current HIV/AIDS end-of-life care in sub-Saharan Africa: a survey of models,services, challenges and priorities

Background

In response to increased global public health funding initiatives to HIV/AIDS care in Africa, this study aimed to describe practice models, strategies and challenges to delivering end-of-life care in sub-Saharan Africa.

Methods

A survey end-of-life care programs was conducted, addressing the domains of service aims and configuration, barriers to pain control, governmental endorsement and strategies, funding, monitoring and evaluation, and research. Both closed and qualitative responses were sought.

Results

Despite great structural challenges, data from 48 programs in 14 countries with a mean annual funding of US $374,884 demonstrated integrated care delivery across diverse settings. Care was commonly integrated with all advanced disease care (67%) and disease stages (65% offering care from diagnosis). The majority (98%) provided home-based care for a mean of 301 patients. Ninety-four percent reported challenges in pain control (including availability, lack of trained providers, stigma and legal restrictions), and 77% addressed the effects of poverty on disease progression and management. Although 85% of programs reported Government endorsement, end-of-life and palliative care National strategies were largely absent.

Conclusions

The interdependent tasks of expanding pain control, balancing quality and coverage of care, providing technical assistance in monitoring and evaluation, collaborating between donor agencies and governments, and educating policy makers and program directors of end-of-life care are all necessary if resources are to reach their goals.

     

TB control programmes: the challenges for Africa

Governmental neglect of tuberculosis (TB), inadequately managed and inaccurately designed TB control programs, population growth, and the HIV epidemic account for the resurgence of TB in sub-Saharan Africa. The World Health Organization and the International Union against TB and Lung Disease have developed a TB control strategy that aims to reduce mortality, morbidity, and transmission of TB. It aims for an 85% cure rate among detected new cases of smear-positive TB and a 70% rate of detecting existing smear-positive TB cases. The strategy involves the provision of short-course chemotherapy (SCC) to all identified smear-positive TB cases through directly observed treatment (DOTS). SCC treatment regimens for smear-positive pulmonary TB recommended for sub-Saharan African countries are: initial phase = daily administration over 2 months of streptomycin, rifampicin, isoniazid, and pyrazinamide; continuation phase = 3 doses over 4 months of isoniazid and rifampicin or daily administration of thiacetazone and isoniazid or of ethambutol and isoniazid. A TB control policy must be implemented to bring about effective TB control. The essential elements of this policy include political commitment, case detection through passive case-finding, SCC, a regular supply of essential drugs, and a monitoring and evaluation system. Political commitment involves establishing a National TB Control Program to be integrated into the existing health structure. Increased awareness of TB in the community and among health workers and a reference laboratory are needed to make case finding successful. A distribution and logistics system is needed to ensure uninterrupted intake of drugs throughout treatment. These regimens have been very successful and cost-effective but pose several disadvantages (e.g., heavy workload of recommended 3 sputum smear tests). A simplified approach involves 1 initial sputum smear for 6 months; 6-months, intermittent rifampicin-based therapy, 100% DOTS throughout entire treatment course, and ascertainment of treatment completion rates and mortality rates in all patients.     

大数据时代的流行病学研究：机遇、挑战与展望

近年来,高通量组学技术迅速发展,人群队列与样本资源逐渐累积,互联网和信息技术飞速进步,大数据开发工具不断涌现,健康医疗大数据为流行病学研究提供了丰富的数据资源和广阔的科研平台。本文将分析大数据时代流行病学研究的机遇和挑战,展望未来学科的发展方向。流行病学应抓住机遇,开辟新方向、发展新方法,推动医学基础研究成果向公共卫生...     

Nursing in the era of globalisation: challenges for the 21st century

The purpose of this paper was to reflect about issues related to the processes of globalization and the global impacts on health, pointing out some challenges for Nursing in the twenty-first century. In this sense, the author outlines the forms and trends of globalization in the contemporary world, and the drastic impacts on human health and environment. To respond to the challenges of the globalized world, some ways are indicated, among which, the strengthening of nursing discipline stands out, together with some guidelines for education, research and Nursing care, in a local and global scope.     

Syphilis in the HIV era

The incidence of syphilis has consistently increased from 2000 to 2002. We report a case of acquired syphilis with symptoms of Tullio phenomenon in a patient concurrently diagnosed with HIV infection. The resurgence of syphilis in HIV-positive groups at high risk has public health implications for prevention of both diseases.     

Community mobilization as an HIV prevention strategy: challenges and obstacles (South Africa)

This paper explores on the challenges and obstacles confronting the Mothusimpilo Project, a program designed to develop ways of responding to HIV/AIDS in a gold mining community in South Africa. The project utilized participatory approaches to promote active involvement of local groups and the community in designing and implementing the program. It employs 3 full-time workers who were recruited locally. The 2 major components of the program include improved prevention of sexually transmitted diseases and community-based condom distribution and peer education, whose particular targets involve migrant mine workers, commercial sex workers and the young people. It seeks to maximize community involvement through stakeholder management of the program and through grassroots involvement in program implementation. Despite the number of accesses in mobilizing the different components of the community, enormous obstacles, and challenges still remains. Some of these obstacles include poverty, women's lack of background of a male-dominated culture, and their sense of fatalism, which reduces their motivation to protect their sexual health.     

Big Data in Israeli healthcare: hopes and challenges report of an international workshop

In September 2015, the Israel National Institute for Health Policy Research (NIHP) organized a workshop to address the hopes and challenges of Big Data in healthcare in the Israeli context. The paper provides an overview of the challenges and hopes raised by data driven science and Big Data, along with a summary of Israel’s strengths and weaknesses regarding Big Data, as discussed by the speakers in the course of the conference. It concludes with some hints on how Israel’s advantages in this field might be leveraged.