Towards an improved investment approach for an effective response to HIV/AIDS

Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. We propose a strategic investment framework that is intended to support better management of national and international HIV/AIDS responses than exists with the present system. Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV/AIDS. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion. Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29·4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.     

Church mobilisation and HIV/AIDS treatment in Ghana and Zambia:a comparative analysis

This article compares Ghanaian and Zambian church mobilisation on HIV and AIDS. It analyses why long-term interest in HIV and AIDS has declined in Ghana but increased in Zambia, and why church involvement in promoting access to HIV/AIDS treatment has been less apparent in Ghana than in Zambia. The article uses three levels of analysis ― society, state, and international ― to explicate these different patterns. The analysis finds that continued HIV/AIDS stigma hampered Ghanaian church activities, while a decline in stigma opened up space for church-related HIV/AIDS responses in Zambia. The elite and professional nature of Ghana's churches promoted early HIV/ AIDS activities, but may have prevented these activities from responding to the needs of people with HIV or AIDS. Overlapping personal networks between civil society and state elites in Ghana urged early HIV/AIDS church-related actions, while state co-optation and civil-society divisions in Zambia limited early HIV/AIDS activities. As Zambian churches built ties to external actors, however, they gained autonomy in their HIV/AIDS responses. In contrast, the fact that Ghana was less incorporated into global HIV/AIDS responses (particularly, the global treatment movement) weakened the long-term interest in HIV and AIDS among the country's churches. The article is based on more than 50 semi-structured interviews with a range of participants affiliated with HIV/AIDS organisations (e.g. church, secular, government, donor) in Zambia and Ghana.     

Case management community care for people living with HIV/AIDS (PLHAs)

A case management approach to support services was developed in a Toronto-based AIDS service organization (ASO) in Canada to support people living with HIV/AIDS (PLHAs) whose needs could not be addressed through usual self-directed access to services. It was therefore important to determine which PLHAs would benefit most from case management. New clients and those who had been receiving support services from an ASO were randomized to receive either self-directed use of support services or self-directed care plus strengths-based case management for a six-month period. Results indicated that those who benefited most from case management were very depressed at baseline. Strengths-based case management compared to usual self-directed care markedly improved the physical, social and mental health function of very depressed PLHAs, and reduced their risk behaviours. In addition, the case management participants' use of community services was associated with an economically important, though not statistically significant, $3,300 per person per annum lower expenditure for the use of all direct health and social services. Although more research is warranted, this research demonstrates that ASOs and funders ought to seriously consider implementing a case management approach to practical assistance for PLHAs with depression.     

Gender mainstreaming practice: considerations for HIV/AIDS community organisations

Gender is well recognised as a critical consideration for HIV/AIDS organisations. Since the 1990s, HIV/AIDS policy-makers, donors, non-governmental organisations and transnational corporations have adopted gender mainstreaming as the process for integrating gender into development programmes and institutions. There is an increasing body of literature on the successes and challenges of practicing gender mainstreaming within organisational environments, however, little has been said about this practice within HIV/AIDS-specific organisational environments. As a contribution to this gap, this reflective paper aims to generate debate about some of the considerations for gender mainstreaming practice in HIV/AIDS organisations. It draws on the author's experience conducting a gender mainstreaming review with a southern African HIV/AIDS capacity-strengthening organisation, as well as a review of the development literature on gender mainstreaming. The paper looks at three key issues facing gender mainstreaming: (1) donor requirements on disaggregating data by sex; (2) connecting gender mainstreaming with the priorities of community HIV/AIDS organisations; and (3) the role of resistance to gender mainstreaming as neo-colonial. Preliminary understandings of these issues suggest that current approaches to gender mainstreaming may not be flexible enough to consider the multiple ways gender and HIV/AIDS interact in different sociocultural contexts. There is an urgent need for further debate and in-depth research into these issues, given the challenge they pose for HIV/AIDS organisations and donors that have chosen to make gender mainstreaming a criterion for HIV/AIDS funding.     

HIV/AIDS: Here to stay for a long time

Conclusions Despite the rapid increase in knowledge regarding the epidemiology, pathogenesis, and molecular virology of HIV-1 and the continued advances in chemotherapy, HIV/AIDS will be with us for a long time to come. In that vein, it is winning the host-pathogen battle. It is likely that the much-anticipated breakthrough will involve a heretofore unknown and innovative strategy or approach in preventative and therapeutic vaccines, immunotherapy, expanded chemotherapy, and/or viral gene silencing. Stay tuned.     

Rural physicians: a survey analysis of HIV/AIDS patient management

Primary care physicians in South Carolina were asked about their knowledge, attitudes, beliefs, and services provided to HIV/AIDS patients. The study focused on conditions under which physicians would provide additional services in an effort to develop more effective state policies regarding HIV/AIDS. There was a 66 percent (597/900) response rate. This analysis focuses on a group of 338 physicians that identified themselves as rural (nonurban) physicians. Of the rural physicians responding, 42 percent had not treated a case of HIV/AIDS during the last year and 52 percent had seen only 1 to 9 patients. They identified lack of specialty back-up support, likelihood of losing patients, legal and ethical issues, and lack of community services as the primary barriers to service. Gaps in rural physician knowledge included when to refer HIV/AIDS cases to specialists and information on legal and ethical issues. They, like their urban colleagues, would provide additional services to HIV/AIDS patients with specialty back-up (57 percent), better community and social services support (54 percent), additional training (48 percent), and limited liability (47 percent). The authors conclude that policy changes addressing these areas in the broader contexts of rural health issues would expand access to care for persons with HIV infection in rural states.     

Case management for substance abusers with HIV/AIDS: a randomized clinical trial

In a random assignment study, substance-abusing patients with HIV/AIDS in a public general hospital received a brief contact condition or received 12 months of case management delivered by paraprofessionals. Patient outcomes included substance use, HIV transmission risk, physical health, psychological status, and quality of living situation. In both conditions, a significant decrease occurred in a range of problems from Intake to the 6-month interview, followed by no significant pattern of change at 12- and 18-month interviews. On major outcome variables, there were no significant differences between the brief contact and case management conditions. Sixteen percent had died by the 18-month interview. Process data indicated wide variation in the amount of case management received by participants, and the amount of case management was not related to improvement in the outcome measures. The study has limitations yet does not support the hypothesis that case management improves outcomes better than brief contact for this population.     

HIV/AIDS prevention in "Indian country": current practice, indigenist etiology models, and postcolonial approaches to change.

Many tribal and urban American Indians and Alaska Native communities have initiated HIV/AIDS prevention and treatment services. The richness, depth, and scope of these efforts, however, are not well known and have not been sufficiently documented in the academic literature. In this article we assess the strengths and weakness of the published literature using the constructs of the socioecological framework. We discuss the need to apply an "indigenist" etiology paradigm to HIV/AIDS risk and protection. Finally, we define and discuss the varied postcolonial approaches to HIV/AIDS prevention, treatment, and healing.     

A long way from there to here: human rights approaches to HIV/AIDS in a local setting

Although global and national strategies to promote a human rights-based approach to HIV/AIDS have been in place for many years, these strategies appear to have had little impact at the local level, where human rights violations are commonplace. In this article, Peris Jones and Farhana Zuberi summarize findings from a recently completed research project, the Tswelopele study, in South Africa. The study documented human rights violations in three areas: privacy and disclosure; informed consent and HIV testing; and access to health-care services. The article describes these violations and explores why discrimination still occurs at the local level. The authors conclude that remedial action is required, targeting the persons and institutions that shape attitudes and beliefs, including churches, workplaces, schools, and the media; and that this action needs to be complemented by wider public education, activism at hospitals and in the courts and, more generally, fulfillment of socio-economic rights.     

Integrating demographic and epidemiological approaches to research on HIV/AIDS: the proximate-determinants framework

This article presents a conceptual framework for the study of the distribution and determinants of human immunodeficiency virus (HIV) infection in populations, by combining demographic and epidemiological approaches. The proximate-determinants framework has been applied extensively in the study of fertility and child survival in developing countries. Key to the framework is the identification of a set of variables, called "proximate determinants," that can be influenced by changes in contextual variables or by interventions and that have a direct effect on biological mechanisms to influence health outcomes. In HIV research, the biological mechanisms are the components that determine the reproductive rate of infection. The proximate-determinants framework can be used in study design, in the analysis and interpretation of risk factors or intervention studies that include both biological and behavioral data, and in ecological studies.     

Culture and African contexts of HIV/AIDS prevention,care and support

Culture plays a vital role in determining the level of health of the individual, the family and the community. This is particularly relevant in the context of Africa, where the values of extended family and community significantly influence the behaviour of the individual. The behaviour of the individual in relation to family and community is one major cultural factor that has implications for sexual behaviour and HIV/AIDS prevention and control efforts. As the impact of HIV/AIDS in Africa remains unabated, a culture-centered approach to prevention, care and support is increasingly recognised as a critical strategy. In this article PEN-3, a model developed to centralise culture in health promotion interventions, is presented as a framework to be used in HIV/AIDS prevention, care and support in Africa. The three domains of the PEN-3 model incorporate specific constructs: relationships and expectations, cultural empowerment, and cultural identity.The cultural empowerment and relationships and expectations domains are ‘assessment/appraisal’ domains used for cultural assessment. Community identity is the ‘application/transformation’ domain that helps the public health practitioner assist the community to identify the point of entry of the intervention. In this paper the authors describe PEN-3 and then present examples of how the assessment/appraisal domains can be utilised to frame HIV/AIDS-related concerns in the context of Africa.     

Access to HIV community services by vulnerable populations: evidence from an enhanced HIV/AIDS surveillance system

HIV disproportionately affects vulnerable populations such as black and minority ethnic groups, men who have sex with men (MSM) and migrants, in many countries including those in the UK. Community organisations in the UK are charitable non-governmental organisations with a proportion of the workforce who volunteer, and provide invaluable additional support for people living with HIV (PLWHIV). Information on their contribution to HIV care in vulnerable groups is relatively sparse. Data generated from an enhanced HIV surveillance system in North West England, UK, was utilised for this study. We aimed to determine the characteristics of individuals who chose to access community services in addition to clinical services (1375 out of 4195 records of PLWHIV in clinical services). Demographic information, risk factors including residency status, uniquely gathered in this region, and deprivation scores were examined. Multivariate logistic regression modelling was conducted to predict the relative effect of patient characteristics on attendance at community services. Attendance at community services was highest in those living in the most, compared with least, deprived areas (p<0.001), and was most evident in MSM and heterosexuals. Compared to white UK nationals attendance was significantly higher in non-UK nationals of uncertain residency status (Adjusted odds ratio [AOR] = 21.91, 95% confidence interval [CI] 10.48-45.83; p<0.001), refugees (AOR = 5.75, 95% CI 3.3-10.03; p<0.001), migrant workers (AOR = 5.48, 95% CI 2.22-13.51; p<0.001) and temporary visitors (AOR = 3.44, 95% CI 1.68-7.05; p<0.001). Community services, initially established predominantly to support MSM, have responded to the changing demography of HIV and reach the most vulnerable members of society. Consequent to their support of migrant populations, community services are vital for the management of HIV in black and minority groups. Paradoxically, this coincides with increasing funding pressures on these services.