Going underground and going after women: trends in sexual risk behaviour among gold miners in South Africa

Exploring the syndemic interaction between social, environmental and structural contexts of HIV infection in peri-mining areas in South Africa: a qualitative study

OBJECTIVE

To explore the syndemic interaction between social, environmental, and structural contexts and HIV infection in peri-mining areas in South Africa.

DESIGN

Mixed qualitative methods consisting of in-depth interviews (IDIs) and focus group discussions (FGDs) exploring the interaction between HIV infection and the social, environmental and structural factors affecting people living in the peri-mining areas of South Africa. Themes were analysed following the syndemic theoretical framework.

SETTING

Participants were recruited from three mining companies and locations in the peri-mining communities surrounding the mining companies in Limpopo, Mpumalanga, and Northern Cape provinces.

PARTICIPANTS

Inclusion criteria included mineworkers, healthcare workers, female sex workers (FSWs), injection drug users (IDUs), and other community members, ≥18 years, living in the peri-mining area at the time of participation. Three FGDs were conducted (n=30): 13 men and 17 women aged 18-55 years. IDIs were conducted with 45 participants: mineworkers (n=10), healthcare workers (n=11), FSWs (n=15), truck drivers (n=4) and IDUs (n=5).

RESULTS

The findings from this study indicate that a syndemic of four socio-behavioural factors is associated with HIV acquisition in peri-mining areas. These are migrancy, accessibility to alcohol and substance use, commercial and transactional sex, and uptake of HIV prevention services.

CONCLUSIONS

Our findings have implications for HIV prevention programmes in mining companies, which rely on male condom usage promotion. More emphasis on better education about HIV prevalence, transmission and up-to-date prevention alternatives, such as pre-exposure prophylaxis for mineworkers is recommended. Furthermore, collaboration with community-based organisations is recommended to wholly address the syndemic factors influencing HIV transmission in peri-mining communities.

Systematic Review of Peer-Reviewed Literature on Global Condom Promotion Programs

Background: Globally, 1.7 million people were newly infected with HIV in 2018. Condoms are inexpensive, cost-effective, reduce HIV/STI incidence, morbidity, mortality, and unintended pregnancies, and result in health care cost savings. Given the rapid increase in at-risk adolescent and young adult (AYA) populations in countries with high HIV/STI prevalence as well as the reductions in donor support, promoting consistent condom use remains crucial. We synthesized all peer-reviewed literature on condom promotion programs with a focus on promotion in low and lower middle income (LMIC) countries and with AYA users. Methods: We systematically reviewed the published literature. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods, we identified 99 articles published between 2000-2019. Results: Condom promotion programs were generally effective in changing attitudes, social norms, and beliefs in favor of condom use, and 85% demonstrated positive effects on multiple condom use measures. Programs targeting AYA were at least equally as effective as those targeting others and often showed greater use of best practices, such as mass media (66%) and audience segmentation (31%). We also saw differences between programs in the intervention strategies they used and found greater effects of marketing strategies on AYA compared to the overall sample. Conclusion: Condoms remain essential to prevention, and donor support must be maintained to combat the HIV/STI epidemic.

Condom Social Marketing Effects in Low- and Middle-Income Countries: A Systematic Review Update, 1990 to 2019

OBJECTIVE

To update the prior systematic review from studies published in the past 9 years that examine the effects of condom social marketing (CSM) programs on condom use in low- and middle-income countries.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Sociological Abstracts, and EMBASE. Hand searching of AIDS, AIDS and Behavior, AIDS Care, and AIDS Education and Prevention.

STUDY INCLUSION AND EXCLUSION CRITERIA

(a) Published from 1990 to January 16, 2019, (b) low- or middle-income country, (c) evaluated CSM, (d) analyses across preintervention to postintervention exposure or across multiple study arms, (e) measured condom use behavior, and (f) sought to prevent HIV transmission.

DATA EXTRACTION

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 reviewers extracted citation, inclusion criteria, methods, study population, setting, sampling, study design, unit of analysis, loss to follow-up, comparison group characteristics, intervention characteristics, and eligible outcome results.

DATA SYNTHESIS

The 2012 review found 6 studies (combined N = 23 048). In a meta-analysis, the pooled odds ratio for condom use was 2.01 (95% confidence interval [CI]: 1.42-2.84) for the most recent sexual encounter and 2.10 (95% CI: 1.51-2.91) for a composite of all condom use outcomes. Studies had significant methodological limitations. Of 518 possible new citations identified in the update, no new articles met our inclusion criteria.

CONCLUSIONS

More studies are needed with stronger methodological rigor to help provide evidence for the continued use of this approach globally. There is a dearth of studies over the past decade on the effectiveness of CSM in increasing condom use in low- and middle-income countries (LMIC).

A review of transactional sex for natural resources: Under-researched, overstated, or unique to fishing economies?

Environmental change is projected to decrease the availability of key natural resources. Decreasing availability of resources that support food security and livelihoods for vulnerable populations is hypothesised to increase engagement in transactional sex. Therefore, we systematically examined the peer-reviewed literature to characterise what is known about transactional sex for natural resources, document the natural resources that are exchanged for sex, and identify qualitative trends. Of the 1063 articles, 33 were retained for full abstraction. A majority of articles were published after 2005 (93%) and focused on Africa (90%). Two-thirds of articles focused on sex-for-fish exchanges. Reports of transactional sex were also found for other resources, including agricultural land (12%) as well as food, water, and fuel in emergency contexts (12%). Migration and altered resource availability were described as underlying causes of transactional sex. Some studies described an increased risk of sexually transmitted infection, including HIV, as a health consequence of transactional sex. We offer three possible explanations for why the preponderance of previous studies have focused on sex-for-fish rather than other natural resources, and suggest directions for future research.

Effects of Migration on Risky Sexual Behavior and HIV Acquisition in South Africa: A Systematic Review and Meta-analysis, 2000-2017

While human mobility has been implicated in fueling the HIV epidemic in South Africa, the link between migration and HIV has not been systematically reviewed and quantified. We conducted a systematic review of the role of migration in HIV risk acquisition and sexual behaviour based on 29 studies published between 2000 and 2017. Furthermore, we performed a meta-analysis of the association between migration and HIV risk acquisition in four of the studies that used HIV incidence as an outcome measure. The systematic review results show that HIV acquisition and risky sexual behavior were more prevalent among both male and female migrants compared to their non-migrant counterparts. The meta-analysis results demonstrate that migration was significantly associated with increased HIV acquisition risk (aOR = 1.69, 95% CI 1.33-2.14; I² = 35.0%). There is an urgent need for effective combination HIV prevention strategies (comprising biomedical, behavioral and structural interventions) that target migrant populations.

Roads and the spread of HIV in Africa

I here use GIS and HIV data from five African countries to estimate the effect of road proximity on HIV infection. I find a negative effect of the distance to the nearest paved road on the probability of being infected with HIV: a one standard-deviation fall in this distance (approximately 2.4 km) increases the probability of infection by 0.6-2.0 percentage points. Using slope as an instrument for road distance continues to produce a negative and significant estimated coefficient. However this relationship may also reflect selection and reverse causality in individual choice of location, and I extensively discuss the role of migration. While the number of lifetime sexual partners is significantly influenced by the presence of roads in some recent years, the effect of road distance on access to protection has disappeared.

INTIMATE PARTNER VIOLENCE AND CONTRACEPTIVE USE IN INDIA: THE MODERATING INFLUENCE OF CONFLICTING FERTILITY PREFERENCES AND CONTRACEPTIVE INTENTIONS

Several studies report that women exposed to intimate partner violence (IPV) are less likely to use contraception, but the evidence that violence consistently constrains contraceptive use is inconclusive. One plausible explanation for this ambiguity is that the effects of violence on contraceptive use depend on whether couples are likely to have conflicting attitudes to it. In particular, although some men may engage in violence to prevent their partners from using contraception, they are only likely to do so if they have reason to oppose its use. Using a longitudinal follow-up to the Indian National Family Health Survey (NFHS-2), conducted among a sample of rural, married women of childbearing age, this study investigated whether the relationship between IPV and contraceptive use is contingent on whether women’s contraceptive intentions contradict men’s fertility preferences. Results indicate that women experiencing IPV are less likely to undergo sterilization, but only if they intended to use contraception and their partners wanted more children (Average Marginal Effect (AME)=−0.06; CI=−0.10, −0.01). Violence had no effect on sterilization among women who did not plan to use contraception (AME=−0.02; CI=−0.06, 0.03) or whose spouses did not want more children (AME=−0.01; CI=−0.9, 0.06). These results imply that violence enables some men to resolve disagreements over the use of contraception by imposing their fertility preferences on their partners. They also indicate that unmet need for contraception could be an intended consequence of violence.

Recent trends in working with the private sector to improve basic healthcare: a review of evidence and interventions

The private sector provides the majority of health care in Africa and Asia. A number of interventions have, for many years, applied different models of subsidy, support and engagement to address social and efficiency failures in private health care markets. We have conducted a review of these models, and the evidence in support of them, to better understand what interventions are currently common, and to what extent practice is based on evidence. Using established typologies, we examined five models of intervention with private markets for care: commodity social marketing, social franchising, contracting, accreditation and vouchers. We conducted a systematic review of both published and grey literature, identifying programmes large enough to be cited in publications, and studies of the listed intervention types. 343 studies were included in the review, including both published and grey literature. Three hundred and eighty programmes were identified, the earliest having begun operation in 1955. Commodity social marketing programmes were the most common intervention type, with 110 documented programmes operating for condoms alone at the highest period. Existing evidence shows that these models can improve access and utilization, and possibly quality, but for all programme types, the overall evidence base remains weak, with practice in private sector engagement consistently moving in advance of evidence. Future research should address key questions concerning the impact of interventions on the market as a whole, the distribution of benefits by socio-economic status, the potential for scale up and sustainability, cost-effectiveness compared to relevant alternatives and the risk of unintended consequences. Alongside better data, a stronger conceptual basis linking programme design and outcomes to context is also required.

Organizational diversity: making the case for contextual interpretivism

Purpose

– The purpose of this paper is to make a case for contextual interpretivism in managing diversity in organizational settings, specifically in its bearing on internal communication, going against the dominating functionalistic stance of venerated and ubiquitous approaches.

Design/methodology/approach

– Qualitative and quantitative methodologies were employed to explore the potential of contextual interpretivism within the mining and construction industries of South Africa, due to the fecund diversity context of its employee population.

Findings

– This paper points to the enriched understanding that could result from following a contextual interpretivistic approach to internal communication for diversity management, and in so doing discusses the ways in which this could take hold in organizations through the application of germane theoretical assertions of revered internal organizational communication literature, specifically the excellence theory and communication satisfaction.

Research limitations/implications

– The main limitation to this research is the restricted generalizability of its empirical research. Further research is required for the exploration of the central premise in other organizational contexts.

Practical implications

– The paper provides insights into the ways in which organizations could approach its diversity management so as to speak to more than just the functional aspects thereof, and rather to the importance of nurturing an understanding of employees’ interpretation of the organization’s diversity endeavors.

Originality/value

– The implications of applying a new approach to diversity management in organizational settings is discussed and argued, offering an empirical application thereof, which gives way to practical, data-driven recommendations for use in organizational settings.

HIV prevalence and risk behaviors among Mozambicans working in South African mines

Mineworkers are considered a population at risk for HIV due to risk behaviors associated with migratory work patterns. This was the first study in Mozambique to determine the prevalence of HIV and associated demographic and risk behaviors, and assess use and access to prevention and healthcare services among Mozambicans working in South African mines. Men who had worked in a South African mine in the past 12 months were recruited between February and May 2012 using time location sampling (TLS) at the Ressano Garcia border between Mozambique and South Africa. Demographic and behavioral data were collected through a standardized questionnaire, and HIV prevalence was estimated by testing dried blood spots (DBS) with two enzyme immunoassays. In total, 432 eligible mine workers were recruited. Mean age was 43 years. Most were married or cohabitating; among them, 12.6 % had two or more wives/marital partners in Mozambique. In the 12 months preceding the survey, 24.7 % had an occasional sexual partner, and 6.6 % had at least one partner who was a female sex worker. Only one in five (18.5 %) used a condom during last sex. HIV prevalence among mineworkers was 22.3 %, and 74.6 % of those who tested positive as part of the survey did not know their status. HIV prevalence was significantly higher (p = 0.018) among those that were uncircumcised (31.2 %) than those who were circumcised (18.5 %). Multiple partners (multiple spouses, cross-border relations, and multiple occasional partnerships), inconsistent condom use, and a high proportion of infected mineworkers who do not know their HIV status increases the risk of HIV transmission in this population. Combination strategies involving the promotion of condom use, HIV testing, and male circumcision should be strengthened among mineworkers.

Home-based versus mobile clinic HIV testing and counseling in rural Lesotho: a cluster-randomized trial

BACKGROUND

The success of HIV programs relies on widely accessible HIV testing and counseling (HTC) services at health facilities as well as in the community. Home-based HTC (HB-HTC) is a popular community-based approach to reach persons who do not test at health facilities. Data comparing HB-HTC to other community-based HTC approaches are very limited. This trial compares HB-HTC to mobile clinic HTC (MC-HTC).

METHODS AND FINDINGS

The trial was powered to test the hypothesis of higher HTC uptake in HB-HTC campaigns than in MC-HTC campaigns. Twelve clusters were randomly allocated to HB-HTC or MC-HTC. The six clusters in the HB-HTC group received 30 1-d multi-disease campaigns (five villages per cluster) that delivered services by going door-to-door, whereas the six clusters in MC-HTC group received campaigns involving community gatherings in the 30 villages with subsequent service provision in mobile clinics. Time allocation and human resources were standardized and equal in both groups. All individuals accessing the campaigns with unknown HIV status or whose last HIV test was >12 wk ago and was negative were eligible. All outcomes were assessed at the individual level. Statistical analysis used multivariable logistic regression. Odds ratios and p-values were adjusted for gender, age, and cluster effect. Out of 3,197 participants from the 12 clusters, 2,563 (80.2%) were eligible (HB-HTC: 1,171; MC-HTC: 1,392). The results for the primary outcomes were as follows. Overall HTC uptake was higher in the HB-HTC group than in the MC-HTC group (92.5% versus 86.7%; adjusted odds ratio [aOR]: 2.06; 95% CI: 1.18-3.60; p = 0. 011). Among adolescents and adults ≥ 12 y, HTC uptake did not differ significantly between the two groups; however, in children <12 y, HTC uptake was higher in the HB-HTC arm (87.5% versus 58.7%; aOR: 4.91; 95% CI: 2.41-10.0; p<0.001). Out of those who took up HTC, 114 (4.9%) tested HIV-positive, 39 (3.6%) in the HB-HTC arm and 75 (6.2%) in the MC-HTC arm (aOR: 0.64; 95% CI: 0.48-0.86; p = 0.002). Ten (25.6%) and 19 (25.3%) individuals in the HB-HTC and in the MC-HTC arms, respectively, linked to HIV care within 1 mo after testing positive. Findings for secondary outcomes were as follows: HB-HTC reached more first-time testers, particularly among adolescents and young adults, and had a higher proportion of men among participants. However, after adjusting for clustering, the difference in male participation was not significant anymore. Age distribution among participants and immunological and clinical stages among persons newly diagnosed HIV-positive did not differ significantly between the two groups. Major study limitations included the campaigns' restriction to weekdays and a relatively low HIV prevalence among participants, the latter indicating that both arms may have reached an underexposed population.

CONCLUSIONS

This study demonstrates that both HB-HTC and MC-HTC can achieve high uptake of HTC. The choice between these two community-based strategies will depend on the objective of the activity: HB-HTC was better in reaching children, individuals who had never tested before, and men, while MC-HTC detected more new HIV infections. The low rate of linkage to care after a positive HIV test warrants future consideration of combining community-based HTC approaches with strategies to improve linkage to care for persons who test HIV-positive.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01459120. Please see later in the article for the Editors' Summary.

Effectiveness of mass media interventions for HIV prevention, 1986-2013: a meta-analysis

OBJECTIVES

This meta-analysis was conducted to synthesize evaluations of mass media-delivered HIV prevention interventions, assess the effectiveness of interventions in improving condom use and HIV-related knowledge, and identify moderators of effectiveness.

STUDY SELECTION

We systematically searched electronic databases, relevant Web sites, related journals, and reference lists of previous reviews and included studies. Studies that quantitatively evaluated the effectiveness of mass media-delivered HIV prevention using pre-/post-campaign assessments, targeted the general population, reported outcomes of interest, and were available as of September 30, 2013 were eligible for inclusion.

DATA EXTRACTION AND SYNTHESIS

Raters coded report, intervention, and sample characteristics. The standardized mean difference, d, comparing pretest and posttest assessments was calculated for each study sample. Effect sizes were analyzed incorporating random-effects assumptions.

RESULTS

Of the 433 obtained and screened reports, 54 reports containing evaluations of 72 interventions using 93 samples (N = 142,196) met the selection criteria and were included. Campaigns were associated with increases in condom use [d+ = 0.25, 95% confidence interval (CI) = 0.18 to 0.21], transmission knowledge (d+ = 0.30, 95% CI = 0.18 to 0.41), and prevention knowledge (d+ = 0.39, 95% CI = 0.25 to 0.52). Increases in condom use were larger for longer campaigns and in nations that scored lower on the human development index. Increases in transmission knowledge were larger to the extent that respondents reported greater campaign exposure, for more recent campaigns, and for nations that scored lower on the human development index.

CONCLUSIONS

Mass media interventions may be useful in reducing global HIV/AIDS disparities because of their reach and effectiveness.

Development, calibration and performance of an HIV transmission model incorporating natural history and behavioral patterns: application in South Africa

Understanding HIV transmission dynamics is critical to estimating the potential population-wide impact of HIV prevention and treatment interventions. We developed an individual-based simulation model of the heterosexual HIV epidemic in South Africa and linked it to the previously published Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International Model, which simulates the natural history and treatment of HIV. In this new model, the CEPAC Dynamic Model (CDM), the probability of HIV transmission per sexual encounter between short-term, long-term and commercial sex worker partners depends upon the HIV RNA and disease stage of the infected partner, condom use, and the circumcision status of the uninfected male partner. We included behavioral, demographic and biological values in the CDM and calibrated to HIV prevalence in South Africa pre-antiretroviral therapy. Using a multi-step fitting procedure based on Bayesian melding methodology, we performed 264,225 simulations of the HIV epidemic in South Africa and identified 3,750 parameter sets that created an epidemic and had behavioral characteristics representative of a South African population pre-ART. Of these parameter sets, 564 contributed 90% of the likelihood weight to the fit, and closely reproduced the UNAIDS HIV prevalence curve in South Africa from 1990–2002. The calibration was sensitive to changes in the rate of formation of short-duration partnerships and to the partnership acquisition rate among high-risk individuals, both of which impacted concurrency. Runs that closely fit to historical HIV prevalence reflect diverse ranges for individual parameter values and predict a wide range of possible steady-state prevalence in the absence of interventions, illustrating the value of the calibration procedure and utility of the model for evaluating interventions. This model, which includes detailed behavioral patterns and HIV natural history, closely fits HIV prevalence estimates.

Effects of condom social marketing on condom use in developing countries: a systematic review and meta-analysis, 1990-2010

OBJECTIVE

To examine the relationship between condom social marketing programmes and condom use.

METHODS

Standard systematic review and meta-analysis methods were followed. The review included studies of interventions in which condoms were sold, in which a local brand name(s) was developed for condoms, and in which condoms were marketed through a promotional campaign to increase sales. A definition of intervention was developed and standard inclusion criteria were followed in selecting studies. Data were extracted from each eligible study, and a meta-analysis of the results was carried out.

FINDINGS

Six studies with a combined sample size of 23,048 met the inclusion criteria. One was conducted in India and five in sub-Saharan Africa. All studies were cross-sectional or serial cross-sectional. Three studies had a comparison group, although all lacked equivalence in sociodemographic characteristics across study arms. All studies randomly selected participants for assessments, although none randomly assigned participants to intervention arms. The random-effects pooled odds ratio for condom use was 2.01 (95% confidence interval, CI: 1.42-2.84) for the most recent sexual encounter and 2.10 (95% CI: 1.51-2.91) for a composite of all condom use outcomes. Tests for heterogeneity yielded significant results for both meta-analyses.

CONCLUSION

The evidence base for the effect of condom social marketing on condom use is small because few rigorous studies have been conducted. Meta-analyses showed a positive and statistically significant effect on increasing condom use, and all individual studies showed positive trends. The cumulative effect of condom social marketing over multiple years could be substantial. We strongly encourage more evaluations of these programmes with study designs of high rigour.

Socio-demographic characteristics and behavioral risk factors of female sex workers in sub-saharan Africa: a systematic review

Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioral underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers (FSW) in this region, their occupational contexts and key behavioral risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. FSW commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalization, high mobility and hazardous alcohol use. These, in turn, predict behaviors such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviors such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of FSW, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Targeted services at sufficiently high coverage, taking into account the behavioral and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by FSW on the continent.

[The HIV epidemic among industrial male miners in Guinea: prevalence, associated factors and trends from 2001 to 2007]

BACKGROUND

To estimate HIV prevalence, associated factors and trends from 2001 to 2007 among male miners in Guinea.

METHODS

Two hundred and eighty-six male miners in 2001 and 579 in 2007 were tested for HIV and interviewed about their lifestyles and sexual practices. Investigations were conducted in the five mining companies operating in the country. A standard questionnaire was used for collecting data and SAS Windows 9.2 version (SAS Institute, Cary, North Carolina, USA) for statistical analysis.

RESULTS

Median age was 45 years in 2001 and 39 years in 2007 (P=0.001). HIV prevalence was 4.5% (95% Confidence Interval [95% CI]: 2.1-7.0) in 2001 and 6.4% (95% CI: 4.4-8.4) in 2007. In multivariate analysis, HIV prevalence was associated with history of sexually transmitted infections (STIs) (Prevalence Ratio [PR]=2.21; P=0.03), and with paying for sex (PR=6.01; P=0.04), whereas it was significantly higher in divorced, separated or widowed men. HIV prevalence increased but not significantly between 2001 and 2007, whereas casual sex (P=0.03) and counseling activities against HIV (P<0.0007) decreased.

CONCLUSION

HIV prevalence is high in this population and, although not statistically significant, the increase observed between 2001 and 2007 is worrying in a context where the population of miners became younger over time. Prevention of HIV/AIDS has to be reinforced among miners in Guinea.

"Over here, it's just drugs, women and all the madness": The HIV risk environment of clients of female sex workers in Tijuana, Mexico

HIV vulnerability depends upon social context. Based on broader debates in social epidemiology, political economy, and sociology of health, Rhodes' (2002) "risk environment" framework provides one heuristic for understanding how contextual features influence HIV risk, through different types of environmental factors (social, economic, policy, and physical) which interact at different levels of influence (micro, macro). Few data are available on the "risk environment" of male clients of female sex workers (FSWs); such men represent a potential "bridge" for transmission of HIV and other sexually transmitted infections from high- to low-prevalence populations. Using in-depth interviews (n = 30), we describe the HIV risk environment of male clients in Tijuana, Mexico, where disproportionately high HIV prevalence has been reported among FSWs and their clients. A number of environmental themes influence risky sex with FSWs and the interplay between individual agency and structural forces: social isolation and the search for intimacy; meanings and identities ascribed to Tijuana's Zona Roja (red light district) as a risky place; social relationships in the Zona Roja; and economic roles. Our findings suggest that clients' behaviors are deeply embedded in the local context. Using the HIV "risk environment" as our analytic lens, we illustrate how clients' HIV risks are shaped by physical, social, economic, and political factors. The linkages between these and the interplay between structural- and individual-level experiences support theories that view structure as both enabling as well as constraining. We discuss how the "embeddedness" of clients' experiences warrants the use of environmental interventions that address the circumstances contributing to HIV risk at multiple levels.

Trends in loss to follow-up among migrant workers on antiretroviral therapy in a community cohort in Lesotho

Background

The provision of antiretroviral therapy (ART) to migrant populations raises particular challenges with respect to ensuring adequate treatment support, adherence, and retention in care. We assessed rates of loss to follow-up for migrant workers compared with non-migrant workers in a routine treatment programme in Morjia, Lesotho.

Design

All adult patients (≥18 years) initiating ART between January 1, 2008, and December 31, 2008, and followed up until the end of 2009, were included in the study. We described rates of loss to follow-up according to migrant status by Kaplan-Meier estimates, and used Poisson regression to model associations between migrant status and loss to follow-up controlling for potential confounders identified a priori.

Results

Our cohort comprised 1185 people, among whom 12% (148) were migrant workers. Among the migrant workers, median age was 36.1 (29.6–45.9) and the majority (55%) were male. We found no statistically significant differences between baseline characteristics and migrant status. Rates of lost to follow up were similar between migrants and non-migrants in the first 3 months but differences increased thereafter. Between 3 and 6 months after initiating antiretroviral therapy, migrants had a 2.78-fold increased rate of defaulting (95%CI 1.15–6.73); between 6 and 12 months the rate was 2.36 times greater (95%CI 1.18–4.73), whereas after 1 year the rate was 6.69 times greater (95%CI 3.18–14.09).

Conclusions

Our study highlights the need for programme implementers to take into account the specific challenges that may influence continuity of antiretroviral treatment and care for migrant populations.

Antiretroviral treatment outcomes from a nurse-driven, community-supported HIV/AIDS treatment programme in rural Lesotho: observational cohort assessment at two years

INTRODUCTION

Lesotho has the third highest HIV prevalence in the world (an adult prevalence of 23.2%). Despite a lack of resources for health, the country has implemented state-of-the-art antiretroviral treatment guidelines, including early initiation of treatment (<350 cells/mm3), tenofovir in first line, and nurse-initiated and managed HIV care, including antiretroviral therapy (ART), at primary health care level. PROGRAMME APPROACH: We describe two-year outcomes of a decentralized HIV/AIDS care programme run by Doctors Without Borders/Médecins Sans Frontières, the Ministry of Health and Social Welfare, and the Christian Health Association of Lesotho in Scott catchment area, a rural health zone covering 14 clinics and one district hospital. Outcome data are described through a retrospective cohort analysis of adults and children initiated on ART between 2006 and 2008.

DISCUSSION AND EVALUATION

Overall, 13,243 people have been enrolled in HIV care (5% children), and 5376 initiated on ART (6.5% children), 80% at primary care level. Between 2006 and 2008, annual enrolment more than doubled for adults and children, with no major external increase in human resources. The proportion of adults arriving sick (CD4 <50 cells/mm3) decreased from 22.2% in 2006 to 11.9% in 2008. Twelve-month outcomes are satisfactory in terms of mortality (11% for adults; 9% for children) and loss to follow up (8.8%). At 12 months, 80% of adults and 89% of children were alive and in care, meaning they were still taking their treatment; at 24 months, 77% of adults remained in care.

CONCLUSION

Despite major resource constraints, Lesotho is comparing favourably with its better resourced neighbour, using the latest international ART recommendations. The successful two-year outcomes are further evidence that HIV/AIDS care and treatment can be provided effectively at the primary care level. The programme highlights how improving HIV care strengthened the primary health care system, and validates several critical areas for task shifting that are being considered by other countries in the region, including nurse-driven ART for adults and children, and lay counsellor-supported testing and counselling, adherence and case management.

Sexually transmitted infection (STI) testing among young oil and gas workers: the need for innovative, place-based approaches to STI control

BACKGROUND

Northeastern British Columbia is undergoing rapid in-migration of young, primarily male workers in response to the "boom" in the oil/gas industries. Accompanying the boom is a rise in Chlamydia rates among youth, which exceed the provincial average by 22%. STI testing reduces the disease burden, contributing to STI prevention.

OBJECTIVES

1) To document youths' perceptions regarding the socio-cultural and structural forces that affect young oil/gas workers' access to STI testing; 2) to gather service providers' perspectives on sexual health service delivery for workers; and 3) to develop recommendations to improve the accessibility of STI testing.

METHODS

We conducted ethnographic fieldwork (8 weeks) in a remote oil/gas community, including in-depth interviews with 25 young people (ages 15-25) and 14 health and social service providers.

RESULTS

Participants identified limited opportunities to access testing, geographic isolation, and 'rigger' culture as three key categories inhibiting STI testing among oil/gas Workers.

DISCUSSION

These results suggest the need for place-based approaches to STI control. Innovative outreach strategies are suggested to address oil/gas workers' needs, including a locally tailored STI awareness campaign, condom distribution, expanded clinic hours, and onsite STI testing.

A systematic review of published evidence on intervention impact on condom use in sub-Saharan Africa and Asia

OBJECTIVE

There has been much debate about the value of condoms in HIV/STI programming. This should be informed by evidence about intervention impact on condom use, but there is limited compiled literature. This review aims to quantify intervention impact on condom use in sub-Saharan Africa and Asia, in different types of partnership.

METHODS

A systematic review was conducted of papers published between 1998 and 2006 presenting evaluations of interventions involving condom promotion in sub-Saharan Africa and Asia. Data on reported postintervention levels of condom use, and various measures of changes in condom use, by partnership type, were compiled.

RESULTS

A total of 1374 abstracts were identified. Sixty-two met the inclusion criteria (42 reporting significant increases in condom use): 44 from sub-Saharan Africa and 18 from Asia. Many (19) reported on condom use in commercial sex (15 significant), six on use with casual partners (three significant), 11 on use in marital/steady partnerships (nine significant), 14 on use by youths (eight significant) and 20 combined partnership types (11 significant). There is substantial evidence of interventions targeted at sex workers and clients achieving large increases in condom use. Far less evidence exists of intervention impact on condom use in casual relationships. In primary partnerships, postintervention condom use was low unless one partner was knowingly HIV-infected or at high-risk, or avoiding pregnancy. Evaluations of interventions targeting youths recorded limited increases in condom use.

CONCLUSIONS

The findings illustrate the range of evidence about postintervention condom use in different partnerships, and how patterns of use are influenced by partnership type and perceptions of risk. Where possible, intervention studies should also assess biological endpoints, since prevention of infection is the measure of most interest in the evaluation of condom promotion interventions.

Concern and practice among men about HIV/AIDS in low socioeconomic income areas of Lilongwe, Malawi

The HIV prevalence rate in Malawi, currently estimated to be 15%, is among the highest in the world. There is a growing realization that in order to understand the underlying causes and devise more effective prevention strategies focus should be placed on economic, political, social, and cultural forces as well as perceptions of individual risk to HIV/AIDS. During 2003 we conducted field work in Lilongwe, the capital city of Malawi, to examine perceptions of individuals as to their risk to HIV infection using the structured interviews and the focus group discussions with men from five areas of Lilongwe. The discussion in this paper focuses on the perception of risk to HIV infection among men in low socioeconomic income areas that we interviewed. Our findings indicate that while knowledge about HIV/AIDS and the best ways in which one can protect oneself from getting HIV is very high, people continue to engage in at-risk behaviors without using the necessary protection. Many of the men in our sample indicated that they were indeed at risk of getting infected with HIV. In spite of this, some of the respondents in both the structured interviews and the focus group discussions pointed out that some people had began taking measures to protect themselves, such as using condoms with nonregular partners, women leaving their husbands where cheating was obvious, and, for men, reducing the number of extra-marital sexual relations.

Effect of exposure to clinic-based health education interventions on behavioural intention to prevent mother-to-child transmission of HIV infection

HIV and AIDS incidence among infants in South Africa is on the increase. The uptake of prevention of mother-to-child transmission (PMTCT) interventions is often said to be dependent on the beliefs and educational needs of those requiring PMTCT services. This study therefore sought to examine the effect of clinic-based health education interventions (HEI) on behavioural intention of PMTCT among 300 pregnant women from 4 primary health care clinics in Tshilidzini Hospital catchments area, South Africa. An interview schedule was used to obtain information regarding participants' demographic characteristics, level of exposure to clinic-based HEI, salient beliefs and behavioural intention on PMTCT. The major findings included that approximately 85% of the participants had heard of PMTCT. There was very little association between frequency of antenatal clinic (ANC) visits and level of exposure to PMTCT information. Condom use had the lowest set of salient belief scores. Control belief was the most common belief contributing to behavioural intention. Generally, the association between PMTCT salient beliefs and behavioural intention was weak. Clinic-based HEI had an impact on behavioural intention of HIV testing, normative belief of regular ANC visit and nevirapine use. The vital contribution of alternative PMTCT information sources such as the radio and television was observed. Enhancing initiatives that empower women, and a better coordination of the existing HEI through better implementation of health education strategy may strengthen the prevailing moderate PMTCT intention in the area investigated.

Condom use for preventing HIV infection/AIDS in sub-Saharan Africa: a comparative multilevel analysis of Uganda and Tanzania

This study explored the relationships between individual-, household-, and community-level variables and condom use to prevent HIV infection in women and men in Uganda and Tanzania using multilevel modeling. Using data from the Demographic and Health Surveys for Uganda (1995) and Tanzania (1996) as well as data collected by the MEASURE Evaluation Project at the Carolina Population Center for Tanzania (1996 and 1999), the study found higher condom use among men than women. There was also heterogeneity in condom use among different clusters for both women and men. More specifically, women and men living in clusters with higher indicators of development were more likely to use condoms to prevent HIV infection. In addition, condom use was much more prevalent in areas where health care services were nearby (0-5 km). In addition, condom use was more common among women (but not men) who lived in clusters where HIV/AIDS testing, counseling, and treatment were provided. The results further revealed that education improved condom use; however, the effect of education was considerably reduced in the models that included HIV/AIDS knowledge and cluster-level variables. The positive effect of household wealth on condom use also diminished after controlling for the effects of the knowledge and cluster-level factors. Knowledge about HIV and perceiving oneself to be at risk for contracting HIV infection improved condom use.

Variations of HIV and STI prevalences within communities neighbouring new goldmines in Tanzania: importance for intervention design

OBJECTIVES

To measure the prevalence of HIV and other STIs in communities neighbouring new large scale gold mines in northern Tanzania in order to inform the design of a targeted HIV/STI intervention programme.

METHODS

Cross sectional surveys were conducted in adults aged 16-54 years from different sectors of communities neighbouring two newly opened, large scale gold mines near Lake Victoria. Mine workers, men, women, and female food and recreational facility workers (FRFW) from the community were randomly selected for interview and HIV and STI testing.

RESULTS

207 male Tanzanian mine workers, 206 FRFW, 202 other male and 205 female community members were enrolled. Overall, 42% of FRFW were HIV positive, compared to 6% of male mine workers, and 16% and 18% of other community men and women respectively. HIV prevalence in FRFW was significantly associated with alcohol consumption (adjusted odds ratio (aOR) = 2.5, 95% confidence interval (CI) 1.1 to 5.5), past or present syphilis (TPPA+) (aOR = 2.7, 95% CI 1.4 to 5.1) and single status (aOR = 3.8, 95% CI 1.2 to 11.9). Among FRFW, 24% had active syphilis (RPR+, TPPA+), 9% Chlamydia trachomatis, and 4% Neisseria gonorrhoeae. Overall, 50% of FRFW and 50% of community men never used condoms during sex, and 55% mineworkers, 61% male, and 20% female community members reported receiving/giving payment for sex during the previous year.

CONCLUSIONS

There is a high prevalence of HIV and other STIs in communities around new goldmines in Tanzania, especially in FRFW. HIV and STI prevalence in the mining workforce is still relatively low, but high risk sexual behaviour is reported by all adult subgroups surveyed in this study. Programmes focusing on HIV/STI prevention, with targeted interventions for high risk women such as FRFW, will be extremely important in such high transmission communities where there is substantial recent in-migration of men and women seeking work. Such programmes have recently been initiated by a private/public/NGO partnership.

Public policies and the orphans of AIDS in Africa

International help to care for Africa's orphans is essential not only for their immediate welfare but also to protect the long term prosperity of these countries. A researcher in child health and former Ugandan government peace minister assess how to make the best use of resources

Can behavior change explain increases in the proportion of genital ulcers attributable to herpes in sub-Saharan Africa? A simulation modeling study

BACKGROUND

The proportion of cases of genital ulcer disease attributable to herpes simplex virus type 2 (HSV-2) appears to be increasing in sub-Saharan Africa.

GOAL

To assess the contributions of HIV disease and behavioral response to the HIV epidemic to the increasing proportion of genital ulcer disease (GUD) attributable to HSV-2 in sub-Saharan Africa.

STUDY DESIGN

Simulations of the transmission dynamics of ulcerative sexually transmitted diseases (STDs) and HIV with use of the model STDSIM.

RESULTS

In simulations, 28% of GUD was caused by HSV-2 before a severe HIV epidemic. If HIV disease was assumed to double the duration and frequency of HSV-2 recurrences, this proportion rose to 35% by year 2000. If stronger effects of HIV were assumed, this proportion rose further, but because of increased HSV-2 transmission this would shift the peak in HSV-2 seroprevalence to an unrealistically young age. A simulated 25% reduction in partner-change rates increased the proportion of GUD caused by HSV-2 to 56%, following relatively large decreases in chancroid and syphilis.

CONCLUSION

Behavioral change may make an important contribution to relative increases in genital herpes.