What makes a structural intervention? Reducing vulnerability to HIV in community settings,with particular reference to sex work

Abstract

Increasing emphasis is being placed on the need for ‘structural interventions’ (SIs) in HIV prevention internationally. There is great variation in how the concept of SI is defined and operationalised, however, and this has potentially problematic implications for their likely success. In this paper, we clarify and elucidate what constitutes a SI with particular reference to the structured distribution of power and to the role of communities. We summarise the background to the growing emphasis being placed on the concept of SIs in HIV prevention policy, and present ethnographic case-study material from a sex worker's HIV project in Kolkata, India, to illustrate the nature of HIV vulnerability and its implications for the design and targeting of successful SIs. The paper draws attention to the dual importance of (1) attending to local complexities in the micro and macro-level structures that produce vulnerability; and (2) clarifying the meaning and role of communities within SIs.     

Drugs into bodies: global AIDS treatment and activism

Abstract

The number of children orphaned due to HIV/AIDS in sub-Saharan Africa was estimated in 2007 by UNAIDS at upwards of 12 million. In Uganda alone, 800,000 of the estimated 1.6 million orphans are said to be orphaned due to this cause. These children suffer life-long consequences from the loss of their parents. This study explores the situation of children living in child-headed households in Uganda's western Kabarole district. Through qualitative research, including in-depth interviews with 20 child heads of households, the health concerns of these children are documented. The interview data were analysed using qualitative research techniques. The study reveals that the psychological and physical effects of orphanhood are magnified for those living in child-headed households. In particular, it highlights the fears of theft and abuse which are a constant source of anxiety for these children. It reports that illness episodes among younger siblings are also particularly worrisome for child heads of households. The article concludes with recommendations for addressing this urgent problem in sub-Saharan Africa.     

The changing cultural and economic dynamics of polygyny and concurrent sexual partnerships in Iringa,Tanzania

Polygyny has been identified both as a ‘benign’ form of concurrency and as the cultural basis of concurrent partnerships that are considered important drivers of the HIV epidemic in sub-Saharan Africa. This paper investigates the changing cultural and economic dynamics of polygyny in concurrency in Iringa, Tanzania, a region with traditions of polygyny and high prevalence of HIV. Our analysis of focus group discussions, in-depth interviews and key informant interviews indicate that contemporary concurrent partnerships differ from regional traditions of polygyny. Whereas in the past, polygyny reflected men's and their kin group's wealth and garnered additional prestige, polygyny today is increasingly seen as a threat to health, and as leading to poverty. Nevertheless, participants evoked the social prestige of polygyny to explain men's present-day concurrency, even outside the bounds of marriage, and despite continued social prohibitions against extramarital affairs. Difficult economic conditions, combined with this prestige, made it easier for men to engage in concurrency without the considerable obligations to wives and children in polygyny. Local economic conditions also compelled women to seek concurrent partners to meet basic needs and to access consumer goods, but risked greater moral judgement than men, especially if deemed to have excessive ‘desire’ for money.     

Cross-generational relationships in rural Jamaica

In keeping with trends in the most affected regions of the world, Jamaican young women are at greater risk of becoming infected with HIV than their male peers. Cross-generational relationships (CGRs), or sexual relationships between younger females and older men, have been reported as contributing to this increased risk. Utilizing a qualitative research design, this study aimed to (1) delineate the context in which CGRs occurred in some rural communities in Jamaica and (2) investigate the sexual risk behaviors that occurred in these relationships. The results indicated that young women engaged in these relationships for three main reasons: economic gain, status, and emotional support. At the intrapersonal, interpersonal, and community levels based on the social ecological model, findings also highlighted various factors which facilitated the occurrence of these relationships in some rural communities, including the transactional nature of the relationships, as well as family knowledge and encouragement. The results also highlighted the occurrence of sexual risk behaviors, such as multiple concurrent partnerships and lack of consistent condom use, which may increase young girls' risk of exposure to HIV and other sexually transmitted infections (STIs). This study's findings are consistent with previous research and underscore the challenges faced by intervention planners when promoting safe sex.     

National response to orphans and other vulnerable children in sub-Saharan Africa: The OVC Policy and Planning Effort Index, 2004

Abstract

The orphaned and vulnerable children (OVC) Policy and Planning Effort Index measures the amount of effort put into place by governments, non-governmental organizations (NGOs) and other stakeholders in countries in response to the needs of the increasing numbers of orphans and children made vulnerable by HIV/AIDS. The OVC Index was applied to 36 countries in sub-Saharan Africa in 2004. All countries have some organized effort to respond to the needs of OVC. Most countries have established a coordination mechanism and organized a national consultation to discuss the situation of these children. However, the average score for sub-Saharan Africa was just 48% of the maximum effort and only five countries scored 70 or above. There is considerable room for improvement in all sub-regions and countries. The best efforts are in the areas of coordination and consultation of stakeholders, action planning and government commitment. Legislative review and monitoring and evaluation are the weakest areas. The development of a widely adopted policy specific for orphans and other vulnerable children is another challenge for most countries. The challenge is to build and expand on current efforts and the commitment expressed by governments to assure that the needs of the growing number of children orphaned and made vulnerable by the AIDS epidemic are addressed.     

Study of oxidative,enzymatic mitochondrial respiratory chain function and apoptosis in perinatally HIV-infected pediatric patients

Abstract

Mitochondrial toxicity in perinatally human immunodeficiency virus (HIV)-infected pediatric patients has been scarcely investigated. Limited data are available about HIV or antiretroviral (ARV)-mediated mitochondrial damage in this population group, specifically, regarding oxygen consumption and apoptosis approach. We aimed to elucidate whether a given mitochondrial DNA depletion is reflected at downstream levels, to gain insight on the pathology of HIV and highly active antiretroviral therapy (HAART) in perinatally HIV-infected pediatric patients. We studied 10 healthy control participants and 20 perinatally HIV-infected pediatric patients (10 under ARV treatment and 10 off treatment). We determined mitochondrial mass, subunits II and IV of complex IV, global and specific mitochondrial enzymatic and oxidative activities, and apoptosis from peripheral blood mononuclear cells. Global oxygen consumption was significantly compromised in HIV-infected untreated patients, compared to the control group (0.76?±?0.01 versus 1.59?±?0.15; P?=?0.014). Apoptosis showed a trend to increase in untreated patients as well. The overall complex (C) CI-III-IV activity of the mitochondrial respiratory chain (MRC) was significantly decreased in HIV-infected treated patients with respect to the control group (1.52?±?0.38 versus 6.38?±?1.53; P?=?0.02). No statistically significant differences were found between untreated and HAART-treated patients. These findings suggest the pathogenic role of both HIV and HAART in mitochondrial dysfunction in vertical infection. The abnormalities in mitochondrial genome may be downstream reflected through a global alteration of the MRC. Mitochondrial impairment associated with HIV and HAART was generalized, rather than localized, in this series of perinatally HIV-infected patients.     

Equipment for Ambulances A Joint Statement from the National Association of EMS Physicians,the American College of Emergency Physicians,andthe American College of Surgeons Committee on Trauma

Objective. To develop model infectious disease exposure plans for emergency medical services agencies in King County, Washington. Methods. All fire departments in King County, Washington, were surveyed to determine their pathogen exposure policies. After these agencies were surveyed, model response plans were developed for both bloodborne andairborne pathogen exposure. Results. Twenty-four of the 35 fire departments in King County submitted infectious disease exposure policies. There was diversity among the plans, andnot all were deemed able to provide prophylaxis in a timely fashion. Based on this lack of uniformity among response plans, model response plans were developed for bloodborne andairborne infectious disease pathogens. Conclusion. Great variety was present throughout the exposure plans currently in use throughout King County, Washington. Model plans would likely universalize response to pathogen exposure andhelp to ensure prompt andappropriate postexposure prophylaxis.