Programmes, resources, and needs of HIV-prevention nongovernmental organizations (NGOs) in Africa, Central/Eastern Europe and Central Asia, Latin America and the Caribbean

Evaluation of the iCARE Nigeria Pilot Intervention Using Social Media and Peer Navigation to Promote HIV Testing and Linkage to Care Among High-Risk Young Men: A Nonrandomized Controlled Trial

IMPORTANCE

Nigeria has the fourth-largest HIV epidemic globally, yet high levels of social stigma inhibit HIV testing among Nigerian youths and young men who have sex with men (MSM).

OBJECTIVE

To report pilot data from iCARE Nigeria (Intensive Combination Approach to Roll Back the Epidemic in Nigerian Adolescents), a combination intervention using social media and peer navigation to promote HIV testing and linkage to care among high-risk youths and young men (hereinafter referred to as young men), including predominantly young MSM.

DESIGN, SETTING, AND PARTICIPANTS

This nonrandomized controlled study assessed an organizational and community-level 12-month, preintervention-postintervention pilot trial of a combination intervention designed to increase HIV testing uptake, increase the rate of identified seropositive cases, and improve linkage to care among young men, including MSM, using social media outreach and peer navigation. Data were collected from June 1, 2019, to May 30, 2020. Participants were young men aged 15 to 24 years in the city of Ibadan, Nigeria, and surrounding areas. Frequencies and percentages were examined, and a Fisher exact test was used to evaluate outcomes compared with historical surveillance data. Linkage to care was defined as 2 clinic visits, including HIV confirmation, within 2 months of a positive rapid test result.

INTERVENTION

Four peer navigators conducted social media outreach promoting sexual health and guiding individuals to HIV counseling and rapid testing in clinical, community, or home-based settings.

MAIN OUTCOMES AND MEASURES

Primary outcomes included the number of young men tested for HIV at university-based iCARE catchment clinics or by iCARE peer navigators in the community, the postintervention HIV seroprevalence of these groups, and linkage to care of participants diagnosed with HIV infection.

RESULTS

A total of 339 participants underwent testing for HIV (mean [SD] age, 21.7 [1.9] years), with 283 (83.5%) referred through social media. The main referral sources for social media were WhatsApp (124 [43.8%]), Facebook (101 [35.7%]), and Grindr (57 [20.1%]). Regarding testing location, participants chose home (134 [39.5%]), community-based (202 [59.6%]), or clinic (3 [0.9%]) settings. Eighty-six participants reported no prior HIV testing. Thirty-six participants (10.6%) were confirmed as HIV seropositive; among those, 18 (50.0%) reported negative test results within the past year, and 31 (86.1%) were linked to care. In two 6-month follow-up periods, the intervention increased HIV testing by 42% and 31%, respectively, and seroprevalence increased compared with historical trends with odds ratios of 3.37 (95% CI, 1.43-8.02; P = .002) and 2.74 (95% CI, 1.10-7.11; P = .02), respectively.

CONCLUSIONS AND RELEVANCE

These findings suggest that use of iCARE Nigeria was associated with increased HIV testing and linkage to care in a high-risk, difficult-to-reach population, making it a promising combination intervention for young MSM.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN94590823.

Barriers and facilitators to pre-exposure prophylaxis uptake among male sex workers in Mexico: an application of the RE-AIM framework

Background

The ImPrEP México demonstration project is the first to distribute free HIV pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and transgender women living in Mexico. In Mexico City, MSM who are also male sex workers (MSWs) face a disproportionately high risk of HIV infection. PrEP is highly effective for HIV prevention, yet “real-life” implementation among MSWs is a challenge due to the unique adherence barriers faced by this population.

Methods

This study uses the RE-AIM implementation science framework to characterize the unique barriers to and facilitators of PrEP uptake among MSWs in Mexico City. We conducted 9 in-depth key informant interviews and 2 focus group discussions with MSWs across 5 clinic and community sites. Qualitative data were analyzed using inductive, open coding approaches from grounded theory. We supplemented findings from the primary qualitative analysis with quantitative indicators derived from ImPrEP program records to describe the current Reach of the ImPrEP program among MSWs in Mexico City and the potential for wider PrEP Adoption among other high-risk populations in Mexico.

Results

The Reach of the ImPrEP program was 10% of known HIV-negative MSWs in Mexico City. Program Reach was lowest among MSWs who were street-based sex workers, of lower socioeconomic status, migrants from other states and self-identified as heterosexual. Barriers to program Reach included limited PrEP knowledge, HIV-related stigma, and structural barriers; facilitators included in-person program recruitment, patient-centered care, and spread of information through word of mouth among MSWs. Two out of the four eligible institutions had adopted the ImPrEP protocol. Barriers to wider program Adoption included HIV- and sexual identity– related stigma, protocol limitations, and lack of a national policy for PrEP distribution; facilitators of Adoption included existing healthcare infrastructure, sensitized providers, and community support from non-governmental organizations.

Conclusions

Increasing the ImPrEP program’s Reach among MSWs will depend on improving PrEP education and addressing HIV-related stigma and access barriers. Future Adoption of the ImPrEP program should build on existing clinical infrastructure and community support. Creation of a national policy for PrEP distribution may improve the Reach and Adoption of PrEP among highest-risk populations in Mexico.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12167-9.

Engagement of non-governmental organisations in moving towards universal health coverage: a scoping review

BACKGROUND

Developing essential health services through non-governmental organisations (NGOs) is an important strategy for progressing towards Universal Health Coverage (UHC), especially in low- and middle-income countries. It is crucial to understand NGOs' role in reaching UHC and the best way to engage them.

OBJECTIVE

This study reviewed the role of NGOs and their engagement strategies in progress toward UHC.

METHOD

We systematically reviewed studies from five databases (PubMed, Web of Science (ISI), ProQuest, EMBASE and Scopus) that investigated NGOs interventions in public health-related activities. The quality of the selected studies was assessed using the mixed methods appraisal tool. PRISMA reporting guidelines were followed.

FINDINGS

Seventy-eight studies met the eligibility criteria. NGOs main activities related to service and population coverage and used different strategies to progress towards UHC. To ensure services coverage, NGOs provided adequate and competent human resources, necessary health equipment and facilities, and provided public health and health care services strategies. To achieve population coverage, they provided services to vulnerable groups through community participation. Most studies were conducted in middle-income countries. Overall, the quality of the reported evidence was good. The main funding sources of NGOs were self-financing and grants from the government, international organisations, and donors.

CONCLUSION

NGOs can play a significant role in the country's progress towards UHC along with the government and other key health players. The government should use strategies and interventions in supporting NGOs, accelerating their movement toward UHC.

Collaboration between the government and nongovernmental organizations in providing health-care services: A systematic review of challenges

BACKGROUND

Given the expanding range of health influencing factors, increasing expectations from the health systems, and general challenges such as insufficient resources, the health services needed by people cannot be provided completely by the governments alone. Therefore, nongovernmental organizations (NGOs)-government collaboration is considered a common approach in health-care provision for different communities. Since the NGO-government collaboration is complicated and usually influenced by many challenges and issues, the present study was conducted to identify collaboration challenges between the government and NGOs in providing health-care services.

MATERIALS AND METHODS

Using a systematic review method and searching in ISI Web of Science, Scopus, PubMed, and Embase databases, using related keyword/terms, between March 2020 and June 2020, studies on NGO-government collaboration in the health area were collected without time limitation. After completing the article selection process, those articles that consistent with the research purpose were chosen for the final analysis.

RESULTS

From 4236 initially collected studies, 16 studies were chosen for the final analysis. Based on the content analysis of the selected articles, 70 challenges were identified in the NGO-government collaboration to provide health-care services. These challenges were divided into five main themes: structural issues, process issues, issues related to roles and responsibilities, trust and communications issues, and control and power relation issues and 11 subthemes.

CONCLUSION

The present study provides significant challenges by NGO-government collaboration in providing health-care services. Awareness of these challenges plays an important role in promoting such collaborations and enables these organizations to highly exploit the strengths of each other, resulting in a collaboration with win-win situation.

Behavioral Intention to Initiate Antiretroviral Therapy (ART) Among Chinese HIV-Infected Men Who Have Sex With Men Having High CD4 Count in the Era of "Treatment for All"

China has updated its national guideline recommending antiretroviral therapy (ART) to all people living with HIV (PLWH) since 2016. This study was to investigate the prevalence of behavioral intention to initiate ART among HIV-infected men who have sex with men (MSM) with CD4 levels >350 cells/mm³, who had just become eligible to receive free ART in China. A cross-sectional survey was conducted among 262 eligible HIV-infected MSM who had never received ART. The theory of planned behavior (TPB) was used to guide the variable selection. The prevalence of behavioral intention to initiate ART was 69.9%. After adjusting for significant background variables, all five constructs of TPB were significantly associated with behavioral intention to initiate ART. These significant constructs were: positive attitudes (adjusted odds ratios, AOR: 1.14; 95% CI [1.06, 1.24]) and negative attitudes (AOR: 0.89; 95% CI [0.82, 0.97]) toward immediate ART initiation; perceived their significant others would support them to initiate ART immediately (perceived subjective norm; AOR: 1.14; 95% CI [1.03, 1.25]); perceived high proportion of PLWH having similar CD4 cell levels were on ART (perceived descriptive norm; AOR: 2.22, 95% CI [1.16, 4.24]); and being confident in initiating ART immediately (perceived behavioral control; AOR: 1.21; 95% CI [1.04, 1.39]). Prevalence of behavioral intention to initiate ART was high among this group of MSM. Effective health promotion is needed to translate behavioral intention into related action. TPB may be a useful framework for developing future health promotion increasing ART coverage in this group.

The realities of HIV prevention. A closer look at facilitators and challenges faced by HIV prevention programmes in Sudan and Yemen

Background: HIV/AIDS prevention has historically encountered many obstacles. Understanding the factors affecting HIV/AIDS prevention is central to designing and implementing suitable context-specific interventions. Research relating to HIV prevention in the Middle East and North African region is required to address the gradually increasing HIV epidemic.

Objective: This study aimed to explore the perspectives of employees/health care professionals who are working or have worked within HIV prevention in Sudan and Yemen on the challenges and facilitating factors facing HIV prevention.

Methods: A qualitative approach was employed using an open-ended questionnaire. Sixteen stakeholders from governmental and non-governmental agencies participated in the study. The questionnaire focused on the various challenges and facilitating factors facing HIV prevention as well as proposed possible solutions from the perspectives of the participants. The data were analysed using thematic analysis.

Results: The study illustrated the similarities in context and HIV prevention systems between Sudan and Yemen. Thematic analysis resulted in three main themes: I) much is achieved despite difficulties; II) a programme left to be paralysed; this theme addressed the main obstacles facing HIV prevention in Sudan and Yemen generating a total of six sub-themes; III) comprehensive change is needed. The participants drew focus and attention to vital changes required to improve the delivery of HIV prevention services.

Conclusion: Increased financial support for HIV prevention in Sudan and Yemen is urgently needed. De-stigmatisation and increased political support, advocacy and improved legislation for people living with HIV (PLHIV) are required for the sustainability and effectiveness of HIV prevention programmes in Sudan and Yemen. Civil society organisations must be aided and supported in their role in engaging key populations.

Strategies for Improving Mobile Technology-Based HIV Prevention Interventions With Latino Men Who Have Sex With Men and Latina Transgender Women

Mobile technology-based interventions show promise for conveying HIV prevention information to Latino men who have sex with men (LMSM) and Latina transgender women (LTGW); however, implementing such interventions can pose serious challenges. To understand how to adapt existing interventions for these populations, we conducted nine focus groups (N = 91 participants, 52 LMSM, 39 LTGW) in Los Angeles, California. We used a rapid assessment process to create narrative reports that we examined using thematic analysis to explore differences across sites and between LMSM and LTGW. Lessons learned: requiring smartphone use could diminish participation of poor participants; sending personalized messages on the same days and times can help participants anticipate receiving study information; working with community partners is essential for building trust; recognizing different language literacies and diverse countries of origin can improve the cultural competency of intervention materials. Addressing these challenges may enhance efforts to address the HIV prevention needs of these communities.

Low sustainability, poor governance, and other challenges encountered by grassroots non-governmental organizations targeting HIV prevention for men who have sex with men in China - a nation-wide study

Grassroots non-governmental organizations (NGOs) played pivotal roles in HIV prevention among men who have sex with men (MSM) in China. Their governance and sustainability issues were under-studied. This nation-wide study surveyed leaders of 202 of the HIV related NGOs in China.58.4% of the leaders believed that their NGO would last for ≤5 years; which was negatively associated with perceived good relationship with CDC. 65.3% mentioned ≥3 non-sustainability issues; associated factors included perceived inadequacies in prevention skills, management skills, policy support, technical support, operational support, and CDC's support; a reverse association was found for frequent collaboration with organizations in China. 30.6% of the leaders mentioned ≥7 governance issues; a stepwise model found a positive association with having no office and negative associations with number of full-time staff and core volunteers. These problems would severely limit the effectiveness of HIV prevention among MSM. Related improvements and support are warranted.

Funding of community-based interventions for HIV prevention

Since the start of the HIV epidemic, community responses have been at the forefront of the response. Following the extraordinary expansion of global resources, the funding of community responses rose to reach at least US$690 million per year in the period 2005-2009. Since then, many civil society organisations (CSOs) have reported a drop in funding. Yet, the need for strong community responses is even more urgent, as shown by their role in reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track targets. In the case of antiretroviral treatment, interventions need to be adopted by most people at risk of HIV in order to have a substantial effect on the prevention of HIV at the population level. This paper reviews the published literature on community responses, funding and effectiveness. Additional funding is certainly needed to increase the coverage of community-based interventions (CBIs), but current evidence on their effectiveness is extremely mixed, which does not provide clear guidance to policy makers. This is especially an issue for adolescent girls and young women in Eastern and Southern Africa, who face extremely high infection risk, but the biomedical prevention tools that have been proven effective for the general population still remain pilot projects for this group. Research is especially needed to isolate the factors affecting the likelihood that interventions targeting this group are consistently successful. Such work could be focused on the community organisations that are currently involved in delivering gender-sensitive interventions.

Chinese non-governmental organizations involved in HIV/AIDS prevention and control: Intra-organizational social capital as a new analytical perspective

HIV/AIDS is a major public health and social problem worldwide, and non-governmental organizations (NGOs) have played an irreplaceable role in HIV/AIDS prevention and control. At the present time, however, NGOs have not fully participated in HIV/AIDS prevention and control in China. As an emerging focus on international academic inquiry, social capital can provide a new perspective from which to promote the growth of NGOs. The Joint United Nations Program on HIV/AIDS (UNAIDS) recommends creating regional policies tailored to multiple and varying epidemics of HIV/AIDS. In order to provide evidence to policymakers, this paper described the basic information on NGOs and their shortage of social capital. This paper also compared the actual NGOs to "government-organized non-governmental organizations" (GONGOs). Results indicated that i) Chinese NGOs working on HIV/AIDS are short of funding and core members. GONGOs received more funding, had more core members, and built more capacity building than actual NGOs; ii) Almost half of the NGOs had a low level of trust and lacked a shared vision, networks, and support. The staff of GONGOs received more support from their organization than the staff of actual NGOs. Existing intra-organizational social capital among the staff of NGOs should be increased. Capacity building and policymaking should differentiate between actual NGOs and GONGOs. The relationship between social capital and organizational performance is a topic for further study.

Knowledge of Hepatitis B Transmission Risks Among Health Workers in Tanzania

Healthcare workers are at increased risk of contracting hepatitis B virus (HBV), particularly in settings of high HBV seroprevalence, such as sub-Saharan Africa. We evaluated HBV knowledge among health-care workers in rural Tanzania by distributing an HBV paper survey in two northern Tanzanian hospitals. There were 114 participants (mean age 33 years, 67% female). Of the participants, 91% were unaware of their HBV status and 89% indicated they had never received an HBV vaccine, with lack of vaccine awareness being the most common reason (34%), whereas 70% were aware of HBV complications and 60% understood routes of transmission. There was a significant difference in knowledge of HBV serostatus and vaccination between participants with a medical background and others, P = 0.01 and 0.001, respectively. However, only 33% of consultants (senior medical staff) knew their HBV serostatus. There was no significant difference between knowledge of HBV transmission routes and occupation. Our study reveals low knowledge of HBV serostatus and vaccination status among hospital workers in Tanzania.

A "Common Factors" Approach to Developing Culturally Tailored HIV Prevention Interventions

The current dominant model of HIV prevention intervention dissemination involves packaging interventions developed in one context, training providers to implement that specific intervention, and evaluating the extent to which providers implement it with fidelity. Research shows that providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally generated solutions. In this study, we used the concept of "common factors," or broad constructs shared by most evidence-based HIV prevention interventions, to train service providers to develop their own programs. We recruited eight Ukrainian HIV prevention organizations from regions with HIV epidemics concentrated among people who inject drugs. We trained staff to identify HIV risk behaviors and determinants, construct behavior change logic models, and develop and manualize an intervention. We systematically reviewed each manual to assess intervention format and content and determine whether the program met intervention criteria as taught during training. All agencies developed programs that reflected common factors of effective behavior change HIV prevention interventions. Each agency's program targeted a unique population that reflected local HIV epidemiology. All programs incorporated diverse pedagogical strategies that focused on skill-building, goal-setting, communication, and empowerment. Agencies struggled to limit information dissemination and the overall scope and length of their programs. We conclude that training service providers to develop their own programs based on common elements of effective behavior change interventions can potentially transform existing processes of program development, implementation, and capacity building. Expanding this model will require committed training and support resources.

Organizational characteristics of HIV/syphilis testing services for men who have sex with men in South China: a social entrepreneurship analysis and implications for creating sustainable service models

Background

UNAIDS has called for greater HIV/syphilis testing worldwide just as local HIV/syphilis testing programs are cut or altered. New models are needed to make HIV/syphilis testing services sustainable while retaining their essential public health function. Social entrepreneurship, using business principles to promote a social cause, provides a framework to pilot programs that sustainably expand testing. Drawing on fieldwork in two South Chinese cities, we examined organizational and financial characteristics of current HIV/syphilis testing systems for men who have sex with men (MSM) in addition to new pilot programs focused on revenue-generation for sustainability.

Methods

We undertook a qualitative study to explore organizational and financial characteristics of HIV/syphilis testing for MSM. Data were collected from men who have sex with men and policy stakeholders in Guangzhou and Hong Kong. Framework analysis was used to identify themes and then code the data.

Results

Our qualitative research study included MSM and policy stakeholders (n = 84). HIV/syphilis testing services were implemented at a wide range of organizations which we grouped broadly as independent community-based organizations (CBOs), independent clinics, and hybrid CBO-clinic sites. From an organizational perspective, hybrid CBO-clinic sites offered the inclusive environment of an MSM CBO linked to the technical capacity and trained staff of a clinic. From a financial perspective, stakeholders expressed concern about the sustainability and effectiveness of sexual health services reliant on external funding. We identified four hybrid CBO-clinic organizations that launched pilot testing programs in order to generate revenue while expanding HIV testing.

Conclusion

Many MSM CBOs are searching for new organizational models to account for decreased external support. Hybrid CBO-clinic organizations create a strong foundation to increase HIV/syphilis testing using social entrepreneurship models in China.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0601-5) contains supplementary material, which is available to authorized users.

Shaped by asymmetrical interdependence: a qualitative case study of the external influences on international non-governmental organizations' implementation of equity principles in HIV/AIDS work

INTRODUCTION

Addressing inequities is a key role for international non-governmental organizations (INGOs) working in health and development. Yet, putting equity principles into practice can prove challenging. In-depth empirical research examining what influences INGOs' implementation of equity principles is limited. This study examined the influences on one INGO's implementation of equity principles in its HIV/AIDS programs.

METHODS

This research employed a case study with nested components (an INGO operating in Kenya, with offices in North America). We used multiple data collection methods, including document reviews, interviews (with staff, partners and clients of the INGO in Kenya), and participant observation (with Kenyan INGO staff). Participant observation was conducted with 10 people over three months. Forty-one interviews were completed, and 127 documents analyzed. Data analysis followed Auerbach and Silverstein's analytic process (2003), with qualitative coding conducted in multiple stages, using descriptive matrices, visual displays and networks (Miles and Huberman, 1994).

RESULTS

There was a gap between the INGO's intent to implement equity principles and actual practice due to multiple influences from various players, including donors and country governments. The INGO was reliant on donor funding and needed permission from the Kenyan government to work in-country. Major influences included donor agendas and funding, donor country policies, and Southern country government priorities and legislation. The INGO privileged particular vulnerable populations (based on its reputation, its history, and the priorities of the Kenyan government and the donors). To balance its equity commitment with the influences from other players, the INGO aligned with the system as well as pushed back incrementally on the donors and the Kenyan government to influence these organizations' equity agendas. By moving its equity agenda forward incrementally and using its reputational advantage, the INGO avoided potential negative repercussions that might result from pushing too fast or working outside the system.

CONCLUSIONS

The INGO aligned the implementation of equity principles in its HIV/AIDS initiatives by working within a system characterized by asymmetrical interdependence. Influences from the donors and Kenyan government contributed to an implementation gap between what the INGO intended to accomplish in implementing equity principles in HIV/AIDS work and actual practice.

A novel, bottom-up approach to promote evidence-based HIV prevention for people who inject drugs in Ukraine: protocol for the MICT ('Bridge') HIV prevention exchange project

Background

Ukraine has one of the most severe HIV epidemics in Eastern Europe, with an estimated 1.6% of the adult population living with the virus. Injection drug use accounts for 36% of new HIV cases. Nongovernmental organizations in Ukraine have little experience with effective, theory-based behavioral risk reduction interventions necessary to reduce the scope of the HIV epidemic among Ukrainians who inject drugs. This study seeks to promote the use of evidence-based HIV prevention strategies among Ukrainian organizations working with drug users.

Methods/design

This study combines qualitative and quantitative methods to explore a model of HIV prevention intervention development and implementation that disseminates common factors of effective behavioral risk reduction interventions and enables service providers to develop programs that reflect their specific organizational contexts. Eight agencies, located in regions of Ukraine with the highest HIV and drug use rates and selected to represent key organizational context criteria (e.g., agency size, target population, experience with HIV prevention), will be taught common factors as the basis for intervention development. We will use qualitative methods, including interviews and observations, to document the process of intervention development and implementation at each agency. Using risk assessments with intervention participants, we will also assess intervention effectiveness.

The primary outcome analyses will determine the extent to which agencies develop and implement an intervention for drug users that incorporates common factors of effective behavioral interventions. Effectiveness analyses will be conducted, and effect size of each intervention will be compared to that of published HIV prevention interventions for drug users with demonstrated effectiveness. This study will explore the role of organizational context on intervention development and implementation, including resource allocation decisions, problem-solving around intervention development, and barriers and facilitators to inclusion of common factors and delivery of a high quality intervention.

Discussion

This innovative approach to HIV prevention science dissemination and intervention development draws on providers’ ability to quickly develop innovative programs and reach populations in greatest need of services. It has the potential to enhance providers’ ability to use HIV prevention science to develop sustainable interventions in response to a rapidly changing epidemic.

How community trust was gained by an NGO in Malawi, Central Africa, to mitigate the impact of HIV/AIDS

Trust is valuable social capital that is essential for effective partnerships to improve a community's health. Yet, how to establish trust in culturally diverse communities is elusive for many researchers, practitioners, and agencies. The purpose of this qualitative study was to obtain perspectives of individuals working for a nongovernmental organization (NGO) about gaining community trust in Malawi in order to mitigate the impact of HIV/AIDS. Twenty-six interviews were conducted over 12 months. Content analysis revealed the relationship between NGO staff and the community is crucial to gaining community trust. Gender, social context, and religious factors influence the establishment of trust within the relationship, but NGO assumptions about the community can erode community trust. Nurses and other health professionals working with the NGOs can help create conditions to build trust in an ethically and culturally sensitive manner whereby communities can develop processes to address their own health concerns.

Funding and expenditure of a sample of community-based organizations in Kenya, Nigeria, and Zimbabwe

Over the last decade, international donors, technical specialists, and governments have come to recognize the potential of community-based organizations (CBOs) in the fight against HIV/AIDS. Recent empirical studies suggest that community engagement, including the involvement of CBOs, adds value to the national response to HIV/AIDS. With the emerging evidence of the effectiveness of engaging communities in the fight against AIDS, it is crucial to understand the economic dimension of community engagement. This article provides an analysis of funding and expenditure data collected from CBOs in three African countries: Kenya, Nigeria, and Zimbabwe. It presents descriptive information regarding CBO funding and expenditure and examines the factors associated with the total amount of funds received and with the proportions of the funds allocated to programmatic activities and program management and administration. An average CBO in the sample received US$29,800 annually or about US$2480 per month. The highest percentage of CBO funding (37%) came from multilateral organizations. CBOs in the sample spent most of their funds (71%) on programmatic activities including provision of treatment, support, care, impact mitigation, and treatment services.

Social entrepreneurship for sexual health (SESH): a new approach for enabling delivery of sexual health services among most-at-risk populations

Joseph Tucker and colleagues argue for social entrepreneurship, a new approach to help improve delivery of sexual health services.

The relationship between community structural characteristics, the context of crack use, and HIV risk behaviors in San Salvador, El Salvador

This paper explores community structural factors in different low-income communities in the San Salvador, El Salvador, that account for differences in the social context in which crack is used and HIV risk behaviors among crack users. Results suggest that both more distal (type of low-income community, level of violent crime, and poverty) and proximate structural factors (type of site where drugs are used, and whether drugs are used within or outside of community of residence) influence HIV risk behaviors among drug users. Additionally, our results suggest that community structural factors influence the historical and geographic variation in drug use sites.

Loss to follow-up in a community clinic in South Africa--roles of gender, pregnancy and CD4 count

BACKGROUND

Faith-based organisations have expanded antiretroviral therapy (ART) in community clinics across South Africa. Loss to follow-up (LTFU), however, limits the potential individual and population treatment benefits and optimal care.

OBJECTIVE

To identify patient characteristics associated with LTFU 6 months after starting ART in a large community clinic.

METHODS

Patients initiating ART between April 2004 and October 2006 in one South African Catholic Bishops' Conference HIV treatment clinic who had at least one follow-up visit were included and routinely monitored every 6 months after ART initiation. Standardised instruments were used to collect data. Rates of LTFU over time were estimated by the Kaplan-Meier method. The Cox proportional hazard regression examined the impact of age, baseline CD4 count, baseline HIV RNA, gender and pregnancy status on LTFU.

RESULTS

Data from 925 patients (age >14 years, median age 36 years, 70% female, of whom 16% were pregnant) were included: 51 (6%) were lost to follow-up 6 months after ART initiation. Younger age (< or = 30 years) (hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.05 - 4.38) and pregnancy for women (HR 3.75, 95% CI 1.53 - 9.16) were significantly associated with higher LTFU rates. When stratified by baseline CD4 count, gender and pregnancy status, pregnant women with lower baseline CD4 counts (< or = 200 cells/microl) had 6.06 times the hazard (95% CI 2.20 - 16.71) of LTFU at 6 months compared with men.

CONCLUSIONS

HIV-infected pregnant women initiating ART were significantly more likely to be lost to follow-up in a community clinic in South Africa. Urgent interventions to successfully retain pregnant women in care are needed.

Internet use, recreational travel, and HIV risk behaviors in men who have sex with men

Previous studies have documented higher rates of HIV risk behavior in gay and bisexual men traveling for leisure. Most of these studies collected data in high-risk tourist areas known for promoting alcohol and other substance use. The present study sampled a broader range of men by collecting data at a Gay Pride celebration, and asking participants about vacation experiences over the past 12 months. We also collected information about men's use of the Internet to find sexual partners before they traveled. Overall, two-thirds of participants reported recreational travel in the previous year. Of these men, 17% reported having sex with a new partner during their most recent vacation. Forty-three percent of the respondents were sexually active during their vacation. Sexually-active participants reported a mean of 2.01 unprotected anal sex acts during their brief vacation stay (M = 6.2 days). Close to half of the sexually-active men reported having sex with a partner of unknown HIV status. Alcohol and drug use were associated with unprotected sex. Men who used the Internet to set up dates prior to travel reported significantly more sexual partners and were significantly more likely to report having sex with a new partner. Many gay and bisexual men on vacation report behaviors that may place their health at risk, including substance use and unprotected sexual activity. Interventions designed to reduce risk behaviors in this population are needed.

Core indicators evaluation of effectiveness of HIV-AIDS preventive-control programmes carried out by nongovernmental organizations. A mixed method study

Background

The number of nongovernmental organizations working on AIDS has grown. There is great diversity in the type of activities and population groups that have been targeted. The purposes of this study are: to describe and analyze the objectives and HIV-AIDS preventive activities that are carried out by the AIDS-NGOs that work with AIDS in Catalonia and that receive subsidies from the Department of Health; and to develop a comprehensive proposal for measurable and agreed upon core quality evaluation indicators to monitor and assess those objectives and activities that can have an impact on the fight against inequalities and stigmatization, and incorporate the perspectives of the service providers and users.

Methods

A mixed method study has been carried out with professionals from the 36 NGOs that work with HIV/AIDS in Catalonia, as well as their users. This study achieved the completeness model using the following phases:

1. A systematic review of AIDS-NGOs annual reports and preparation of a catalogue of activities grouped by objectives, level of prevention and AIDS-NGOs target population; 2. A transversal study through an ad-hoc questionnaire administered to the AIDS-NGOs representatives; 3. A qualitative study with a phenomenological approach through focus groups, individual interviews and observations; 4. Consensus meetings between AIDS-NGOs professionals and the research team using Haddon matrices in order to establish a proposal of evaluation indicators.

Results

The information was classified according to level of prevention and level of intervention. A total of 248 objectives and 258 prevention activities were identified. 1564 evaluation indicators, addressed to 7 target population groups, were produced. Thirty core activities were selected. The evaluation indicators proposed for these activities were: 76 indicators for 15 primary prevention activities, 43 for 5 secondary prevention activities and 68 for 10 tertiary prevention activities.

Conclusions

The results could help to homogeneously assess the preventive-control activities carried out of AIDS-NGOs. The proposed indicators could help the professionals to improve the evaluation of the preventive-control AIDS-NGOs activities. Furthermore, the Haddon matrix enables us to identify deficiencies of activities at intervention levels and strategies to bear in mind in order to enhance the future AIDS prevention programs.

Experiences about HIV-AIDS preventive-control activities. Discourses from non-governmental organizations professionals and users

OBJECTIVES

The main aim of this study was to identify the experiences of professionals in nongovernmental organizations (NGO) in Catalonia (Spain) working in HIV/AIDS prevention and control activities and potential areas of improvement of these activities and their evaluation. A further aim was to characterize the experiences, knowledge and practices of users of these organizations with regard to HIV infection and its prevention.

METHODS

A phenomenological qualitative study was conducted with the participation of both professionals and users of Catalan nongovernmental organizations (NGO) working in HIV/AIDS. Theoretical sampling (professional) and opportunistic sampling (users) were performed. To collect information, the following techniques were used: four focus groups and one triangular group (professionals), 22 semi-structured interviews, and two observations (users). A thematic interpretive content analysis was conducted by three analysts.

RESULTS

The professionals of nongovernmental organizations working in HIV/AIDS adopted a holistic approach in their activities, maintained confidentiality, had cultural and professional competence and followed the principles of equality and empathy. The users of these organizations had knowledge of HIV/AIDS and understood the risk of infection. However, a gap was found between knowledge, attitudes and behavior.

CONCLUSIONS

NGO offer distinct activities adapted to users' needs. Professionals emphasize the need for support and improvement of planning and implementation of current assessment. The preventive activities of these HIV/AIDS organizations are based on a participatory health education model adjusted to people's needs and focused on empowerment.

Providers' perceptions of and receptivity toward evidence-based HIV prevention interventions

Since 1999, the Centers for Disease Control and Prevention have trained over 10,000 service providers from more than 5,000 agencies to implement evidence-based HIV prevention interventions through its Diffusion of Effective Behavioral Interventions DEBI) program. Based on in-depth, semistructured interviews with a convenience sample of 22 HIV prevention service providers from eight agencies in Wisconsin who participated in DEBI training, this article explores providers' motivations for attending DEBI training, perceptions of the utility and value of the DEBI program, and criticisms of the program. Providers indicated that they attended training as part of general skill-building efforts, as a way to improve services through the adoption of evidence-based interventions, and to better meet client needs. DEBI training participants were critical of the program's "top down" approach, perceived lack of fit between the DEBI and their target populations, and what they perceived as a lack of evidence that the interventions would work with their particular populations. These results suggest that in order for the DEBI program to be more widely accepted, the experiences and expertise of providers need to be more fully integrated into the processes of developing, disseminating, and adapting evidence-based HIV prevention interventions.

Provider perspectives on evidence-based HIV prevention interventions: barriers and facilitators to implementation

Since the beginning of the HIV/AIDS epidemic, community-based organizations (CBOs) have been key players in combating this disease through grassroots prevention programs and close ties to at-risk populations. Increasingly, both funding agencies and public health institutions require that CBOs implement evidence-based HIV prevention interventions, most of which are researcher developed. However, after completing training for these evidence-based interventions (EBIs), agencies may either abandon plans to implement them or significantly modify the intervention. Based on 22 semistructured interviews with HIV prevention service providers, this article explores the barriers and facilitators to dissemination and implementation of EBIs included in the Centers for Disease Control and Prevention's (CDC) Diffusion of Effective Behavioral Interventions (DEBI) program. Results suggest that there is a tension between the need to implement interventions with fidelity and the lack of guidance on how to adapt the interventions for their constituencies and organizational contexts. Findings suggest the need for HIV prevention intervention development and dissemination that integrate community partners in all phases of research and dissemination.

Peer-led interventions to reduce HIV risk of youth: a review

One approach in HIV prevention programming targeting youth is to use peer leaders in what is referred to as peer education programming. This paper critically reviews and synthesizes the results and lessons learned from 24 evaluated peer-led programs with an HIV/AIDS risk reduction component that target youth in the communities where they live and are delivered in low- and middle-income countries. Interventions were identified through a comprehensive search of the peer reviewed AIDS-related literature as well as publication lists of major organizations in the UN family that address HIV and AIDS. Our synthesis of study results finds that these programs have demonstrated success in effecting positive change in knowledge and condom use and have demonstrated some success in changing community attitudes and norms. Effects on other sexual behaviors and STI rates were equivocal. We include an overview of characteristics of successful programs, a review of program limitations, and recommendations for the development and implementation of successful community-based peer-led programs in low-income countries.

Activism, NGOs, and HIV Prevention in Postsocialist Poland: The Role of "Anti-Politics"

With the collapse of socialism, the number of nongovernmental organizations in Eastern Europe increased dramatically, as part of democracy and capitalism building. In the West, NGOs have served as key players in shaping the response of the HIV epidemic, reflecting both the withdrawal of the state from service provision in line with neoliberal reforms and the activist roots from which many of these organizations originated. As a result, AIDS NGOs and the people who work in them are often characterized as engaging in an activist endeavor in order to affect social and political change that will enable better prevention and care. This article explores the extent to which a similar framework applies to AIDS NGOs in Poland and Eastern Europe, more generally, where the notion of "anti-politics" and disengagement from political activism remains strong. As they developed in Poland, AIDS NGOs have focused on caring for clients, cultivating a professional identity, and abstaining from politics, to the eschewal of advocacy activities on behalf of their clients. This orientation has implications for the types of HIV prevention programs these organizations offer, as well as the possibilities for collaborating with researchers and service providers from the West.

Resources and obstacles to developing and implementing a structural intervention to prevent HIV in San Salvador, El Salvador

HIV prevention researchers have increasingly advocated structural interventions that address factors in the social, political and economic context to reduce disparities of HIV/AIDS among disadvantaged populations. This paper draws on data collected in three different types of low-income communities (n=6) in the San Salvador metropolitan area in El Salvador. Nine focus group discussions were conducted between January 2006 and July 2007, 6 with community leaders, and 3 with crack cocaine users, as well as in-depth interviews with 20 crack users and crack dealers. We explore opportunities and barriers to the implementation of a community-level, structural intervention. We first analyze the different forms of leadership, and other community resources including existing HIV prevention activities that could potentially be used to address the related problems of crack use and HIV in the communities, and the structural factors that may act as barriers to capitalizing on communities' strengths in interventions. Each of the communities studied demonstrated different resources that stem from each community's unique history and geographic location. HIV testing and prevention resources varied widely among the communities, with resources concentrated in one Older Central community despite a strong need in all communities. In many communities, fear of gang violence and non-responsiveness by government agencies to communities' needs have discouraged community organizing. In the discussion, we offer concrete suggestions for developing and implementing structural interventions to reduce HIV risks that use communities' different but complementary resources.

The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa

Peer education is a community-based intervention being implemented worldwide as an approach to HIV prevention. However, its results are inconsistent, with little consensus on why some projects succeed while others fail. Considering peer education as an 'intervention-in-context', we systematically compare the context and the implementation of two peer education interventions run by sex workers, one in India and one in South Africa, which produced contrasting outcomes. In so doing, we aim to identify key factors in the projects' successes or failures that may inform future peer education efforts. The Indian project's relative success was facilitated (1) by a more stable and supportive social, material and political context, and (2) by a community development ethos which devoted significant resources to sex workers' involvement, ownership and empowerment, as opposed to a biomedical approach which marginalised sex workers' concerns. We conclude with lessons learned and implications for current trends in peer education.

A review of HIV/AIDS system-level interventions

The escalating HIV/AIDS epidemic worldwide demands that on-going prevention efforts be strengthened, disseminated, and scaled-up. System-level interventions refer to programs aiming to improve the functioning of an agency as well as the delivery of its services to the community. System-level interventions are a promising approach to HIV/AIDS prevention because they focus on (a) improving the agency's ability to adopt evidence-based HIV prevention and care programs; (b) develop and establish policies and procedures that maximize the sustainability of on-going prevention and care efforts; and (c) improve decision-making processes such as incorporating the needs of communities into their tailored services. We reviewed studies focusing on system-level interventions by searching multiple electronic abstracting indices, including PsycInfo, PubMed, and ProQuest. Twenty-three studies out of 624 peer-reviewed studies (published from January 1985 to February 2007) met study criteria. Most of the studies focused on strengthening agency infrastructure, while other studies included collaborative partnerships and technical assistance programs. Our findings suggest that system-level interventions are promising in strengthening HIV/AIDS prevention and treatment efforts. Based on our findings, we propose recommendations for future work in developing and evaluating system-level interventions.

Behavioural strategies to reduce HIV transmission: how to make them work better

This paper makes five key points. First is that the aggregate effect of radical and sustained behavioural changes in a sufficient number of individuals potentially at risk is needed for successful reductions in HIV transmission. Second, combination prevention is essential since HIV prevention is neither simple nor simplistic. Reductions in HIV transmission need widespread and sustained efforts, and a mix of communication channels to disseminate messages to motivate people to engage in a range of options to reduce risk. Third, prevention programmes can do better. The effect of behavioural strategies could be increased by aiming for many goals (eg, delay in onset of first intercourse, reduction in number of sexual partners, increases in condom use, etc) that are achieved by use of multilevel approaches (eg, couples, families, social and sexual networks, institutions, and entire communities) with populations both uninfected and infected with HIV. Fourth, prevention science can do better. Interventions derived from behavioural science have a role in overall HIV-prevention efforts, but they are insufficient when used by themselves to produce substantial and lasting reductions in HIV transmission between individuals or in entire communities. Fifth, we need to get the simple things right. The fundamentals of HIV prevention need to be agreed upon, funded, implemented, measured, and achieved. That, presently, is not the case.

Client perceptions of satisfaction with AIDS services: an instrument development

The purpose of this article is to show how AIDS Service Organizations (ASOs) can develop their own instruments to assess client satisfaction by using support from academic partners. The Client Satisfaction Questionnaire (CSQ) is an example of this process. The initial 12-item CSQ was piloted using a sample of 46 HIV-infected men and women, resulting in a revised 8-item CSQ that was assessed by using a sample of 121 HIV-infected men and women. The initial CSQ (12-item) yielded three factors, volunteer's skill/access, volunteer's attitude, and volunteer's caring, accounting for 74.6% of the explained variance (Cronbach's alpha = 0.84). The revised CSQ (8-item) resulted in one factor accounting for 67% of the explained variance (Cronbach's alpha = 0.92). Findings indicated acceptable reliability and validity of the CSQ to assess client satisfaction as an outcome of ASO client-agency interaction. Guidelines for instrument development by ASOs are proposed. Strategies to collaborate with the academic community to facilitate instrument development are discussed.

The community popular opinion leader HIV prevention programme: conceptual basis and intervention procedures

OBJECTIVE

To describe the community popular opinion leader (C-POL) intervention employed in the NIMH Collaborative HIV/STD Prevention Trial, including its theoretical, conceptual, and empirical basis, intervention procedures and methods, core elements, and how its content was culturally tailored to address the needs of varied populations.

DESIGN

The programme is designed to identify, recruit, train, and intensively engage C-POLs of a target population to convey HIV risk reduction messages to people in their communities, with the intention of reducing high-risk behavior at a population level.

METHODS

Based on the diffusion of innovation theory, the intervention identified, trained, and engaged C-POL within a high-risk community population to advocate, recommend, and endorse the importance of safer behavior to other members of the same population. Nine core elements of the intervention are discussed. Data collected during rapid ethnography were used to adapt the content of the intervention for food market owners and workers in China, male patrons of wine shops and at-risk women congregating nearby in India, young people in social gathering venues in Peruvian barrios, dormitory students in Russia, and people congregating in commercial areas of growth points in Zimbabwe.

RESULTS

The C-POL intervention model taps into community strengths, altruism, and people's desire to do something to help fight against AIDS. With few exceptions, C-POLs participated enthusiastically in the training sessions and reported having conversations in the community.

CONCLUSION

Rapid ethnography can be used to tailor an intervention to diverse settings while maintaining fidelity to the core elements of the intervention.