HIV in the Middle East and North Africa: priority, culture, and control

Objectives

This study aimed to assess the priority of HIV/AIDS in the Middle East and North Africa region and compare it with other regions. This review examines the social, cultural and religious features of HIV in the region, and considers their influence on perception of risk and approaches to control, such as condom use and antiretroviral therapy.

Methods

We screened a wide range of sources for comprehensive and reliable data; the search of PubMed, ISI Web of Science, ScienceDirect, and grey literature databases were unrestricted by language and year of publication.

Results

Studies of HIV/AIDS in the region are limited, especially studies of social aspects of HIV/AIDS and their relevance for control. Findings suggest low condom use across the region among high-risk groups, and the general population, and low antiretroviral therapy uptake among people with HIV/AIDS.

Conclusions

The review indicates gaps in the literature and needs for more academic engagement and political commitment. Cultural norms have notable implications for HIV control, which are discussed, considering implications for the priority, prevention, treatment, and control of HIV/AIDS.     

Sources of evidence in HIV/AIDS care: pilot study comparing family physicians and AIDS service organization staff

Background

The improvement of the quality of the evidence used in treatment decision-making is especially important in the case of patients with complicated disease processes such as HIV/AIDS for which multiple treatment strategies exist with conflicting reports of efficacy. Little is known about the perceptions of distinct groups of health care workers regarding various sources of evidence and how these influence the clinical decision-making process. Our objective was to investigate how two groups of treatment information providers for people living with HIV/AIDS perceive the importance of various sources of treatment information.

Methods

Surveys were distributed to staff at two local AIDS service organizations and to family physicians at three community health centres treating people living with HIV/AIDS. Participants were asked to rate the importance of 10 different sources of evidence for HIV/AIDS treatment information on a 5-point Likert-type scale. Mean rating scores and relative rankings were compared.

Results

Findings suggest that a discordance exists between the two health information provider groups in terms of their perceptions of the various sources of evidence. Furthermore, AIDS service organization staff ranked health care professionals as the most important source of information whereas physicians deemed AIDS service organizations to be relatively unimportant. The two groups appear to share a common mistrust for information from pharmaceutical industries.

Conclusions

Discordance exists between medical "experts" from different backgrounds relating to their perceptions of evidence. Further investigation is warranted in order to reveal any effects on the quality of treatment information and implications in the decision-making process. Possible effects on collaboration and working relationships also warrant further exploration.     

Availability of indicators of migration in the surveillance of HIV, tuberculosis and hepatitis B in the European Union – a short note

Background and aim

Data regarding infectious diseases in migrant populations in Europe are scarce. We aimed to assess whether information on migration status is collected in countries of the European Union (EU) as part of their national surveillance systems for major infectious diseases (HIV/AIDS, tuberculosis (TB) and hepatitis B infection).

Methods

Using different electronic sources we collected information about whether indicators of migration status were collected in national infectious diseases surveillance systems in European countries.

Results

Of 27 EU countries, migration status was recorded in all 27 countries for TB surveillance (100%), in 22 countries for HIV (~82%) and in 23 countries for AIDS (~85%). Eight of 20 countries (40%) recorded migration status in hepatitis B surveillance systems. The most commonly recorded indicator of migration status was country of birth. Among countries which conducted migrant specific surveillance, country of birth was collected in ~82% of TB, ~86% of HIV, and ~83% of AIDS surveillance systems. Other indicators of the migration status were ethnicity (used in HIV and AIDS surveillance) and citizenship (TB surveillance).

Conclusion

We showed differences in how migration status is recorded in surveillance systems from European countries. This was especially true for tuberculoses and hepatitis B, whereas data collection as part of HIV/AIDS surveillance was nearly uniform. These results suggest the need for a more uniform reporting of migration status as part of infectious disease surveillance in EU countries.     

Maternal mortality in South Africa in 2001: From demographic census to epidemiological investigation

Background

Maternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS.

Methods

The 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes.

Results

After correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15–49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV/AIDS and external causes of deaths. Our regional estimates of MMR were found to be consistent with other findings in the Cape Town area, and with the Agincourt DSS. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. The effect of urbanization was small, and reversed in a multivariate analysis. Higher risks in provinces were not necessarily associated with lower income, lower education or higher proportions of home delivery, but correlated primarily with the prevalence of HIV/AIDS.

Conclusion

Demographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. In the case of South Africa, the level of MMR increased dramatically over the past 10 years, most likely because of HIV/AIDS. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.     

Multilateral, regional, and national determinants of policy adoption: the case of HIV/AIDS legislative action

Objectives

This article examines the global legislative response to the HIV/AIDS epidemic with a particular focus on how policies were diffused internationally or regionally, or facilitated internally.

Methods

This article uses event history analysis combined with multinomial logit regression to model the legislative response of 133 countries.

Results

First, the results demonstrate that the WHO positively influenced the likelihood of a legislative response. Second, the article demonstrates that development bank aid helped to spur earlier legislative action. Third, the results demonstrate that developed countries acted earlier than developing countries. And finally, the onset and severity of the HIV/AIDS epidemic was a significant influence on the legislative response.

Conclusion

Multilateral organizations have a positive influence in global policy diffusion through informational advocacy, technical assistance, and financial aid. It is also clear that internal stressors play key roles in legislative action seen clearly through earlier action being taken in countries where the shock of the onset of HIV/AIDS occurred earlier and earlier responses taken where the epidemic was more severe.     

Breast cancer knowledge, attitudes, and screening behaviors among African American women: the Black cosmetologists promoting health program

Background

Recent surveillance data from Bangladesh indicate rising HIV infection among intravenous drug users (IDU) in the country. We suggest a likely association between HIV risk factors in this group and other groups, such as males who have sex with males (MSM).

Methods

Data on MSM in Bangladesh was collected and analyzed from numerous primary and secondary sources, including government ministries, non-profit health organizations, and personal communications.

Results

The overall prevalence of HIV in Bangladesh is relatively low, but surveillance data indicate that infection has reached significant proportions in certain high-risk groups and may soon spread to other groups, specifically MSM.

Conclusion

The epidemiology of HIV infection in other countries suggests that increasing rates of HIV in higher-risk populations can precede an epidemic in the general population. We review the data concerning MSM, IDU and HIV in Bangladesh from a variety of sources and propose ways to prevent HIV transmission.     

Out-of-pocket expenditures on traditional and Western medicine in Taiwan

Objectives

Coexistence of traditional and modern medicine is common in Asian countries. This paper investigates out-of-pocket expenditures on traditional medicine, traditional medical service, and Western medicine by households in Taiwan.

Methods

Using a national sample of 13,765 households, the three expenditure equations are estimated with a censored system procedure. Effects of socio-demographic variables are explored by calculating marginal effects on probabilities and levels of medical expenses.

Results

Different types of medical expenditures are correlated. Households with higher income and more aging members use more traditional medicine than others, as do households in agricultural sector and in urban areas. In addition, households living in rural areas relative to those in the cities are more likely to use and also spend more on traditional service. Regional disparity of health care utilization is found.

Conclusions

Higher income households spend more on traditional medicine, likely due to the fact that patients usually pay out-of-pocket for herbal materials needed in preparation of traditional medicine. To ensure equity in health care utilization, establishment of hospitals and clinics in rural areas should be considered.     

The relationship between (stigmatizing) views and lay public preferences regarding tuberculosis treatment in the Eastern Cape, South Africa

Background

Tuberculosis (TB) and human immune virus/acquired immune deficiency syndrome (HIV/AIDS) stigmas affect public attitudes toward TB treatment and policy. This study examined 'stigmatizing' ideas and the view that 'TB patients should line-up in the chronic illness queue' in relation to preferences and attitudes toward TB treatment.

Methods

Data were gathered through a survey administered to respondents from 1,020 households in Grahamstown. The survey measured stigmatization surrounding TB and HIV/AIDS, and determined perceptions of respondents whether TB patients should queue with other chronically ill patients. Respondents selected support and treatment options they felt would benefit TB patients. Statistical analysis identified the prevalence of TB and HIV/AIDS stigmas. Logistic regression analyses explored associations between stigmatizing ideas, views regarding TB patients in the chronic illness queue, and attitudes toward support and treatment.

Results

Respondents with TB stigmatizing ideas held positive attitudes toward volunteer support, special TB queues, and treatment at clinics; they held negative attitudes toward temporary disability grants, provision of information at work or school, and treatment at the TB hospital. Respondents who felt it beneficial for TB patients to queue with other chronically ill patients conversely held positive attitudes toward provision of porridge and disability grants, and treatment at the TB hospital; they held negative attitudes toward volunteer support, special TB queues, information provision at work or school, and treatment at clinics.

Conclusion

These results showed that two varying views related to visibility factors that expose patients to stigmatization (one characterized by TB stigma, the other by the view that TB patients should queue with other chronically ill patients) are associated with opposing attitudes and preferences towards TB treatment. These opposing attitudes complicate treatment outcomes, and suggest that complex behaviors must be taken into account when designing health policy.     

HIV/AIDS und Aussieder aus der ehemaligen Sowjetunion

Background

Ethnic German resettlers from the former Soviet Union are one of the biggest immigrant groups to Germany. Some come from countries with a comparably high prevalence of human immunodeficiency virus (HIV), such as Ukraine and the Russian Federation. However, no data are available concerning this group’s knowledge or attitudes regarding HIV and acquired immunodeficiency syndrome (AIDS).

Methods

In this study, 927 ethnic German resettlers in the federal state of Bavaria, Germany, were questioned in a multicentre survey through an anonymous mail-in questionnaire.

Results

Of the 927, 37.3% participated in the survey. HIV/AIDS was rated as an important or very important topic by 81.7% of the respondents, and 62.3% felt well informed or very well informed about it. Intravenous drug users (89.2%), commercial sex workers (78%), and men who have sex with men (76%) were mentioned as risk groups for HIV/AIDS. Syringes/needles (97%), vaginal (82.5%), anal (65.1%), and oral (50%) sexual intercourse were cited as HIV transmission routes. Condom use (91.6%) and use of disposable syringes/needles (79.9%) were chosen as HIV prevention measures.

Conclusions

Respondents showed an acceptable HIV/AIDS knowledge level, but knowledge regarding sexual transmission routes was not always sufficient; information about conventional HIV prevention measures reaches few ethnic German resettlers.     

Migration and depressive symptoms in migrant-sending areas: findings from the survey of internal migration and health in China

Objectives

China has experienced large-scale internal migration and growing mental health disorders. Limited research has examined the relationship between the two processes. We examined the association between labor out-migration and depressive symptoms of family members left behind in migrant-sending areas.

Methods

We conducted a multistage probability sample survey of Chinese adults in 2008 (“Internal Migration and Health in China”), including 787 people in rural migrant-sending areas. To study whether adults in out-migrant households were more likely to experience depressive symptoms (CES-D) than were adults in non-migrant households, we used multivariate regressions and adjusted for a wide range of confounding factors and for the complex sampling design.

Results

Adults in households with labor out-migrants were more likely to report depressive symptoms than those in households without out-migrants, presumably a result of the absence of family members. However, monetary remittances from labor migrants buffered the mental health costs of out-migration.

Conclusions

Labor out-migration has important consequences for the mental health in migrant-sending communities. There is an urgent need to address the psychological costs of migration and to promote regular remittances.     

The impact of denial on health-related quality of life in patients with HIV

Background/purpose

The purpose of this study was to examine the influence of denial coping on quality of life (QOL) over time among individuals living with HIV, as denial has been understudied as a coping strategy within the literature on HIV/AIDS.

Methods

In a sample of 65 adult men and women, we used multilevel linear modeling to test trajectories of change in physical and mental health-related QOL across baseline, 3, 6, and 12?months, including denial as a predictor and gender as a moderator.

Results

The use of denial coping was associated with lower physical and mental health-related QOL at baseline. Denial coping predicted an increase in QOL over time, though QOL remained low in those who practiced denial coping. Men??s baseline mental health-related QOL was more negatively affected by denial coping than women??s. Women tended to increase in QOL more slowly over time compared to men.

Conclusion

Reliance on denial as a coping strategy is associated with poorer physical and mental health-related QOL in an HIV-positive population, though participants who engaged in denial also displayed more rapid improvement in their QOL over time. Men and women displayed different rates of improvement in QOL, indicating a need for gender-based treatment approaches. Future research should examine the complex role of denial on change in QOL.     

More than just talk: the framing of transactional sex and its implications for vulnerability to HIV in Lesotho, Madagascar and South Africa

Background

Despite massive scale up of funds from global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other donors, the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV/AIDS treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union (FSU) countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV/AIDS services in FSU countries, resulting in limited understanding and implementation of accessible HIV/AIDS interventions. This paper explores the multiple access barriers to HIV/AIDS services experienced by a key risk group-injecting drug users (IDUs).

Methods

Semi-structured interviews were conducted in two FSU countries-Ukraine and Kyrgyzstan-with clients receiving Global Fund-supported services (Ukraine n = 118, Kyrgyzstan n = 84), service providers (Ukraine n = 138, Kyrgyzstan n = 58) and a purposive sample of national and subnational stakeholders (Ukraine n = 135, Kyrgyzstan n = 86). Systematic thematic analysis of these qualitative data was conducted by country teams, and a comparative synthesis of findings undertaken by the authors.

Results

Stigmatisation of HIV/AIDS and drug use was an important barrier to IDUs accessing HIV/AIDS services in both countries. Other connected barriers included: criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV/AIDS, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers.

Conclusions

Approaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. Our study demonstrates that while there is greater availability of HIV/AIDS services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV/AIDS service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the FSU where low or concentrated HIV/AIDS epidemics are prevalent. Funders of HIV/AIDS programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector.     

Rapid assessment response (RAR) study: drug use and health risk - Pretoria, South Africa

Background

Within a ten year period South Africa has developed a substantial illicit drug market. Data on HIV risk among drug using populations clearly indicate high levels of HIV risk behaviour due to the sharing of injecting equipment and/or drug-related unprotected sex. While there is international evidence on and experience with adequate responses, limited responses addressing drug use and drug-use-related HIV and other health risks are witnessed in South Africa. This study aimed to explore the emerging problem of drug-related HIV transmission and to stimulate the development of adequate health services for the drug users, by linking international expertise and local research.

Methods

A Rapid Assessment and Response (RAR) methodology was adopted for the study. For individual and focus group interviews a semi-structured questionnaire was utilised that addressed key issues. Interviews were conducted with a total of 84 key informant (KI) participants, 63 drug user KI participants (49 males, 14 females) and 21 KI service providers (8 male, 13 female).

Results and Discussion

Adverse living conditions and poor education levels were cited as making access to treatment harder, especially for those living in disadvantaged areas. Heroin was found to be the substance most available and used in a problematic way within the Pretoria area. Participants were not fully aware of the concrete health risks involved in drug use, and the vague ideas held appear not to allow for concrete measures to protect themselves. Knowledge with regards to substance related HIV/AIDS transmission is not yet widespread, with some information sources disseminating incorrect or unspecific information.

Conclusions

The implementation of pragmatic harm-reduction and other evidence-based public health care policies that are designed to reduce the harmful consequences associated with substance use and HIV/AIDS should be considered. HIV testing and treatment services also need to be made available in places accessed by drug users.     

A comprehensive analysis of trends and determinants of HIV/AIDS knowledge among the Bangladeshi women based on Bangladesh Demographic and Health Surveys, 2007–2014

Background

South-Asian countries are considered to be a potential breeding ground for HIV epidemic. Although the prevalence of this incurable disease is low in Bangladesh, women still have been identified as more vulnerable group. The aim of this study is to assess the knowledge about HIV/AIDS: its trends and associated factors among the women in Bangladesh.

Methods

We analysed the nationally representative repeatedly cross-sectional Bangladesh Demographic and Health Surveys (BDHSs) data: 2007, 2011, and 2014. These data were clustered in nature due to the sampling design and the generalized mixed effects model is appropriate to examine the association between the outcome and the explanatory variables by adjusting for the cluster effect.

Results

Overall, women’s knowledge about HIV/AIDS has been decreasing over the years. Education plays the leading role and secondary-higher educated women are 6.6 times more likely to have HIV/AIDS knowledge. The likelihood of knowledge is higher among the women who had media exposure (OR: 1.6) and knowledge on family planning (OR: 2.3). A rural-urban gap is noticed in women’s knowledge about HIV/AIDS and significant improvement has been observed among the rural and media exposed women. Results reveal that age, region, religion, socio-economic status, education, contraceptive use have significant (p<0.01) effects on women’s knowledge about HIV/AIDS.

Conclusion

This study recommends to emphasis more on women’s education, media exposure, and family planning knowledge in strengthening women’s knowledge about HIV/AIDS. In addition, residence specific programs regarding HIV/AIDS awareness also need to be prioritized.

     

AIDS-Prävention mit sozial benachteiligten Kindern in der Republik Südafrika

Background

Approximately two-thirds of the worldwide population infected with the human immunodeficiency virus (HIV) are currently living in the sub-Saharan region. The need for increased prevention is not controversial, but preventive efforts are undertaken mainly in relation to adolescents and adults.

Target group and methods

This study deals with a life-skills programme on HIV/AIDS for socially disadvantaged children of primary school age in an informal settlement of the Stellenbosch municipal area in the Western Cape province of the Republic of South Africa. The programme was outlined and evaluated using a questionnaire within a quasi-experimental design with an intervention and a control group and four measuring time points each.

Results

For the children in the intervention group, the results indicate a significant increase in knowledge about HIV and AIDS between the pretest and the posttest. In the subsequent measurements, however, the knowledge values decreased back to the initial level.

Conclusion

The reasons for this lack of sustainability are discussed with regard to the children’s unique socioeconomic and sociocultural life situation. Perspectives for further prevention efforts can be derived.     

S4HARA: System for HIV/AIDS resource allocation

Background

HIV/AIDS resource allocation decisions are influenced by political, social, ethical and other factors that are difficult to quantify. Consequently, quantitative models of HIV/AIDS resource allocation have had limited impact on actual spending decisions. We propose a decision-support System for HIV/AIDS Resource Allocation (S4HARA) that takes into consideration both principles of efficient resource allocation and the role of non-quantifiable influences on the decision-making process for resource allocation.

Methods

S4HARA is a four-step spreadsheet-based model. The first step serves to identify the factors currently influencing HIV/AIDS allocation decisions. The second step consists of prioritizing HIV/AIDS interventions. The third step involves allocating the budget to the HIV/AIDS interventions using a rational approach. Decision-makers can select from several rational models of resource allocation depending on availability of data and level of complexity. The last step combines the results of the first and third steps to highlight the influencing factors that act as barriers or facilitators to the results suggested by the rational resource allocation approach. Actionable recommendations are then made to improve the allocation. We illustrate S4HARA in the context of a primary healthcare clinic in South Africa.

Results

The clinic offers six types of HIV/AIDS interventions and spends US$750,000 annually on these programs. Current allocation decisions are influenced by donors, NGOs and the government as well as by ethical and religious factors. Without additional funding, an optimal allocation of the total budget suggests that the portion allotted to condom distribution be increased from 1% to 15% and the portion allotted to prevention and treatment of opportunistic infections be increased from 43% to 71%, while allocation to other interventions should decrease.

Conclusion

Condom uptake at the clinic should be increased by changing the condom distribution policy from a pull system to a push system. NGOs and donors promoting antiretroviral programs at the clinic should be sensitized to the results of the model and urged to invest in wellness programs aimed at the prevention and treatment of opportunistic infections. S4HARA differentiates itself from other decision support tools by providing rational HIV/AIDS resource allocation capabilities as well as consideration of the realities facing authorities in their decision-making process.     

Herausforderungen der HIV-Pr?vention f��r Migranten

Background

Approximately 30% of new HIV infections in Germany occur among immigrants. HIV prevention thus needs to be better tailored to immigrant communities.

Methods

A survey of the 118 members of the national association of AIDS service organizations (Deutsche AIDS-Hilfe e.V.) was conducted to assess their experiences in providing HIV prevention services to immigrants. The survey is part of a participatory research project (PaKoMi). The analysis focuses on the challenges described by the AIDS service organization (ASO).

Results

A total of 90 ASO participated in the survey (return rate 76%). The great majority (89%) provide HIV prevention services to immigrants. More than half (53%) state a need for further action to improve prevention services to immigrants in their locality. Only a small minority (10%) are satisfied with the level of communal cooperation among local actors on this issue. Major challenges in providing HIV prevention services to immigrants include: intercultural challenges in dealing with cultural differences and taboos, lack of resources, limited access of ASOs to immigrant communities, language barriers, stigmatization processes, and practical and conceptual challenges resulting from the complex needs and multilayered problems of those immigrant groups who are most at risk for HIV/AIDS.

Conclusions

To better manage the challenges described by the ASOs, the participation of immigrant communities in HIV prevention and the cooperation of health and social service providers with community-based immigrant organizations should be improved. Given the social structural factors and legal issues which contribute to the specific vulnerability and increased HIV risks of immigrants, the concept of ??structural prevention?? seems appropriate which conceptualizes HIV prevention as health promotion in the broader social context.