Evolution of China's response to HIV/AIDS

Four factors have driven China's response to the HIV/AIDS pandemic: (1) existing government structures and networks of relationships; (2) increasing scientific information; (3) external influences that underscored the potential consequences of an HIV/AIDS pandemic and thus accelerated strategic planning; and (4) increasing political commitment at the highest levels. China's response culminated in legislation to control HIV/AIDS-the AIDS Prevention and Control Regulations. Three major initiatives are being scaled up concurrently. First, the government has prioritised interventions to control the epidemic in injection drug users, sex workers, men who have sex with men, and plasma donors. Second, routine HIV testing is being implemented in populations at high risk of infection. Third, the government is providing treatment for infected individuals. These bold programmes have emerged from a process of gradual and prolonged dialogue and collaboration between officials at every level of government, researchers, service providers, policymakers, and politicians, and have led to decisive action.     

Towards a "fourth generation" of approaches to HIV/AIDS management: creating contexts for effective community mobilisation

Many biomedical and behavioural HIV/AIDS programmes aimed at prevention, care and treatment have disappointing outcomes because of a lack of effective community mobilisation. But community mobilisation is notoriously difficult to bring about. We present a conceptual framework that maps out those dimensions of social context that are likely to support or undermine community mobilisation efforts, proposing that attention should be given to three dimensions of social context: the material, symbolic and relational. This paper has four parts. We begin by outlining why community mobilisation is regarded as a core dimension of effective HIV/AIDS management: it increases the "reach" and sustainability of programmes; it is a vital component of the wider "task shifting" agenda given the scarcity of health professionals in many HIV/AIDS-vulnerable contexts. Most importantly it facilitates those social psychological processes that we argue are vital preconditions for effective prevention, care and treatment. Secondly we map out three generations of approaches to behaviour change within the HIV/AIDS field: HIV-awareness, peer education and community mobilisation. We critically evaluate each approach's underlying assumptions about the drivers of behaviour change, to frame our understandings of the pathways between mobilisation and health, drawing on the concepts of social capital, dialogue and empowerment. Thirdly we refer to two well-documented case studies of community mobilisation in India and South Africa to illustrate our claim that community mobilisation is unlikely to succeed in the absence of supportive material, symbolic and relational contexts. Fourthly we provide a brief overview of how the papers in this special issue help us flesh out our conceptualisation of the "health enabling social environment". We conclude by arguing for the urgent need for a 'fourth generation' of approaches in the theory and practice of HIV/AIDS management, one which pays far greater attention to the wider contextual influences on programme success.     

The Case for an Integrated Approach to HIV/AIDS Prevention

Abstract

Worldwide, there is growing policy support for providing integrated HIV/AIDS services. Accordingly, this paper examines the challenges as well as the meritsfor implementing an integrated approach to HIV/AIDS services in Canada. Through a discussion of the interconnections between HIV/AIDS prevention, support, and treatment, the author outlines how these issues are fundamentally intertwined in the lives of people livingwith HIV/AIDS (PHAs) and those at risk of HIV infection. This suggests that provision of comprehensive HIV/AIDS services requires approaching these issues from an integrated perspective. The author outlines two existing models of integrated HIV/AIDS services to show the potential viability of such an approach, and concludes with policy recommendations to support service integration.     

An algorithmic approach to intracranial mass lesions in HIV/AIDS

We developed a diagnostic and therapeutic algorithm for intracranial mass lesions in patients with HIV/AIDS that obviates the need for neurosurgical intervention. The approach is based upon CD4(+) lymphocyte count, serum toxoplasma immunoglobulin G (IgG) serology, chest X-ray, routine lumbar puncture studies, cerebrospinal fluid (CSF) cytology, CSF adenosine deaminase or Mycobacterium tuberculosis polymerase chain reaction testing, single positron emission-computed tomography (SPECT) scanning for intracranial enhancing lesions, and limited therapeutic trials. Over a 12-month period involving 26 patients, we found that the algorithm correctly identified the aetiology of focal intracranial lesions in all 23 evaluable patients. Costs for SPECT scanning for the entire study cohort were more than offset by the savings achieved by reduced hospital stays for the four patients with lymphoma alone. An algorithmic approach can accurately identify the cause(s) of central nervous system (CNS) mass lesions in HIV-infected patients, and SPECT scanning can replace stereotactic brain biopsy in most cases where opportunistic malignancy is suspected.     

Sources of data for improved surveillance of HIV/AIDS in China

The objective of this paper is to describe the evolution of human immunodeficiency virus/acquired immunodeficiency syndrome surveillance in mainland China, with a focus on reviewing the sources of data being used for improved surveillance of HIV/AIDS. We review the development of HIV/AIDS surveillance and its multiple data sources to monitor the dynamics of HIV/AIDS in China. The surveillance system for HIV/AIDS in China was initiated in 1986. It has evolved in three stages: (1) passive surveillance, (2) HIV sentinel surveillance with coexisting active surveillance and passive surveillance, and (3) comprehensive surveillance. In parallel with the evolution of the surveillance system itself, the HIV epidemic in China has gone through increasing stages of complexity, through an Introduction Phase, a Spreading Phase, and a Rapidy Spreading Phase. More reliable data from improved surveillance suggest that the HIV/AIDS epidemic is expanding in China. HIV infections among 2005 estimates remain concentrated among injection drug users (IDUs), those buying and selling sex, and men who have sex with men. Better HIV/AIDS surveillance synthesizes multiple data sources to provide a more accurate picture of the dynamics of specific HIV/AIDS circumstances in different areas of China. Improved surveillance is meaningful insofar as data are used to implement more effective HIV prevention programs in China. Support for surveillance and strategic analyses can enable policy decision makers to make more effective program choices and mobilize adequate resources to contain HIV.     

多部门合作人员AIDS防治相关情况调查

目的 了解多部门与艾滋病(AIDS)防治相关工作人员对《中国预防与控制艾滋病中长期规划(1998—2010年)》(简称《中长期规划》)及AIDS知识知晓情况,掌握我国AIDS防治工作存在的问题及需求,为制定AIDS防治策略及多部门人员培训计划提供建议与依据。方法 采用分层整群抽样方法。选择8个AIDS流行率及高危因素各具不同特点的省份的各1个地区(市)和1个县,随机抽样政府多部门与AIDS防治工作政策的制定或实施人员共800人,调查了解他们对《中长期规划》及AIDS知识知晓情况。结果 (1)72．35％的调查对象了解国家制定了《中长期规划》,但只有13．38％的调查对象阅读过《中长期规划》;(2)90％以上的调查对象对握手、游泳、共用办公用品不会传播艾滋病病毒(HIV)及通过性接触途径、接受输血及血制品、共用注射器和母婴途径可传播HIV的回答正确率较高;但对蚊虫叮咬、共用餐具、轻吻不传播HIV等回答的正确率不高。(3)对公开推广安全套态度不同。84．94％的调查对象认为安全套不仅可以避孕,同时也具有预防性病、AIDS的作用;有65．78％的调查对象赞成在宾馆、旅馆等公共场所放置安全套;48．23％的调查对象赞成在大学校园中公开销售安全套。(4)对防治工作的总体评价不同。84．17％的调查对象认为我国有AIDS流行;52．28％的调查对象认为当地有AIDS流行;分别有41．01％及29．53％的调查对象认为近2年来全国及当地的AIDS防治工作比较好;90％以上的调查对象认为AIDS的流行会影响当地经济和社会的发展;近70％的调查对象认为近年来当地打击卖淫嫖娼及禁毒工作取得了一定的成效,在预防与控制AIDS的工作中发挥了积极作用。(5)97．23％的调查对象认为中国需要制定有关AIDS防治的法律或法规;96．47％的调查对象认为AIDS防治有必要采取“多部门合作”的策略;67．83％的调查对象赞成“政府领导、多部门合作、全社会参与”AIDS综合防治对策;75．97％的调查对象认为健康教育是目前预防AIDS最重要和有效的措施。结论 在多部门合作领域,有针对性地开展《中长期规划》宣传和AIDS防治政策与策略的需求调研与评估工作,宣传普及AIDS防治相关知识,可以提高政府多部门间AIDS防治合作应对与决策能力,有效地达到预防和控制AIDS传播目的。     

Understanding the response of large South African companies to HIV/AIDS

This paper provides a framework analysing the response of South African companies to HIV/AIDS. Drawing on three case studies of companies, each with over 20 000 South African-based employees, we identify six ‘drivers’ that influence corporate behaviour regarding HIV/AIDS: legal requirements, voluntary regulation, business costs, social pressures, visibility of the disease, and individuals within companies. We suggest that costs calculations, while possibly underestimating indirect and macro-implications, are not key in driving company responses to HIV/AIDS. The law and voluntary regulation have influenced, but not determined, the response of companies to HIV/AIDS. Social pressures on companies are of importance, but the scale and complexity of need in South Africa has seen the deflecting of this driver. Of greater reference in determining responses has been the social pressure of other companies' responses. The general visibility of the AIDS epidemic is also a significant factor in explaining companies' responses to HIV/AIDS. Moreover, the visibility of HIV/AIDS within companies has influenced the responses of often relatively weak, internal agents who have been attempting to drive companies' HIV/AIDS programmes.

We conclude that external drivers — legal requirements, economic performance, and social pressures — have framed corporate responses to HIV/AIDS to a degree, but have generally been weak. Moreover, there has been relatively little synergy between these external drivers and the internal drivers — voluntary regulation, visibility, and company HIV/AIDS ‘champions’ — that could propel companies into pro-active, bold responses to HIV/AIDS.     

An assessment of government policy response to HIV/AIDS in Ghana

The HIV/AIDS epidemic in Africa has assumed a dimension raising heartbreaking anxiety among national governments and civil society groups. In Ghana for example, the pandemic is well-documented and has gone beyond a health problem, and now encompasses all socio-economic aspects of life. The estimated rate of infection from the mid-1980s to 2000 has more than doubled, and in spite of the control efforts by various groups and organisations, prevalence of the disease has not declined notably. This paper assesses government policy, programmes and strategies to combat the disease, using analysis of time trend sentinel data and weighting these against control efforts. The assessment revealed that 380 000 adults and 36 000 children are currently infected. There are wide spatial variations in prevalence across the country and the overall national prevalence has fluctuated over time, standing at 2.6% in 2000, 3.6% in 2002 and 3.1% in 2004. This appears relatively lower than in adjacent countries, where prevalence is around 5% and over 25% in East and Southern African countries.

Although the review found a robust multipronged government intervention approach to containing the disease, we are hesitant to claim that the fairly stable or low national prevalence in Ghana compared with its immediate neighbours may have been the consequence of the effectiveness of national AIDS control programmes and impact of government interventions.     

Evaluation of the community response to HIV and AIDS: Learning from a portfolio approach

While communities have played a large role in the HIV/AIDS response, their contributions and innovative approaches to HIV prevention, treatment, care and support have not always been the focus of systematic and rigorous evaluations. To address this gap, the World Bank led an evaluation of the impact of the community response to HIV, including country studies in Burkina Faso, India, Kenya, Lesotho, Nigeria, Senegal, South Africa and Zimbabwe over a three-year period. Due to the complexity and varied nature of community responses, the evaluation attempted to determine the results that investments have produced at the community level by applying a mixed method approach: Randomized Controlled Trials, quasi-experimental studies, qualitative studies and analytical studies including financial data. Specifically, the studies examined a typology of community response and the flow of funds to community-based organizations, while investigating the impact of the community responses on (1) knowledge and behavior, (2) use of services, (3) social transformation, and (4) HIV incidence. This editorial summarizes the results of this evaluation portfolio, finding that investments in communities have produced significant results, including, improved knowledge and behavior, and increased use of health services, and even decreased HIV incidence. Evidence on social transformation was more mixed, with community groups found to be effective only in some settings. Each study in the evaluation provides a partial view of how communities shape the local response; however, taken together they corroborate the common wisdom that communities can be a vital part of the global HIV/AIDS response.