Mapping HIV/STI behavioural surveillance in Europe

BACKGROUND

Used in conjunction with biological surveillance, behavioural surveillance provides data allowing for a more precise definition of HIV/STI prevention strategies. In 2008, mapping of behavioural surveillance in EU/EFTA countries was performed on behalf of the European Centre for Disease prevention and Control.

METHOD

Nine questionnaires were sent to all 31 member States and EEE/EFTA countries requesting data on the overall behavioural and second generation surveillance system and on surveillance in the general population, youth, men having sex with men (MSM), injecting drug users (IDU), sex workers (SW), migrants, people living with HIV/AIDS (PLWHA), and sexually transmitted infection (STI) clinics patients. Requested data included information on system organisation (e.g. sustainability, funding, institutionalisation), topics covered in surveys and main indicators.

RESULTS

Twenty-eight of the 31 countries contacted supplied data. Sixteen countries reported an established behavioural surveillance system, and 13 a second generation surveillance system (combination of biological surveillance of HIV/AIDS and STI with behavioural surveillance). There were wide differences as regards the year of survey initiation, number of populations surveyed, data collection methods used, organisation of surveillance and coordination with biological surveillance. The populations most regularly surveyed are the general population, youth, MSM and IDU. SW, patients of STI clinics and PLWHA are surveyed less regularly and in only a small number of countries, and few countries have undertaken behavioural surveys among migrant or ethnic minorities populations. In many cases, the identification of populations with risk behaviour and the selection of populations to be included in a BS system have not been formally conducted, or are incomplete. Topics most frequently covered are similar across countries, although many different indicators are used. In most countries, sustainability of surveillance systems is not assured.

CONCLUSION

Although many European countries have established behavioural surveillance systems, there is little harmonisation as regards the methods and indicators adopted. The main challenge now faced is to build and maintain organised and functional behavioural and second generation surveillance systems across Europe, to increase collaboration, to promote robust, sustainable and cost-effective data collection methods, and to harmonise indicators.

Strengthening families to support children affected by HIV and AIDS

This paper provides an overview of the arguments for the central role of families, defined very broadly, and we emphasise the importance of efforts to strengthen families to support children affected by HIV and AIDS. We draw on work conducted in the Joint Learning Initiative on Children and AIDS's Learning Group 1: Strengthening Families, as well as published data and empirical literature to provide the rationale for family strengthening. We close with the following recommendations for strengthening families to ameliorate the effects of HIV and AIDS on children. Firstly, a developmental approach to poverty is an essential feature of responses to protect children affected by HIV and AIDS, necessary to safeguard their human capital. For this reason, access to essential services, such as health and education, as well as basic income security, must be at the heart of national strategic approaches. Secondly, we need to ensure that support garnered for children is directed to families. Unless we adopt a family oriented approach, we will not be in a position to interrupt the cycle of infection, provide treatment to all who need it and enable affected individuals to be cared for by those who love and feel responsible for them. Thirdly, income transfers, in a variety of forms, are desperately needed and positively indicated by available research. Basic economic security will relieve the worst distress experienced by families and enable them to continue to invest in the health care and education of their children. Lastly, interventions are needed to support distressed families and prevent knock-on negative outcomes through programmes such as home visiting, and protection and enhancement of children's potential through early child development efforts.

Families, children, migration and AIDS

Migration is very often a family affair, and often involves children, directly or indirectly. It may give rise to better quality of life for an entire family, or to bitter disappointment, and may also increase vulnerability to HIV and AIDS. This review, carried out for the Joint Learning Initiative on Children and AIDS, links the literature on "migration", on "HIV and AIDS" and on "families". Three themes are sketched: (1) As both HIV prevalence and circular migration increase, former migrant workers affected by AIDS may return to their families for care and support, especially at the end of life, often under crisis conditions. Families thus lose promising members, as well as sources of support. However, very little is known about the children of such migrants. (2) Following patterns of migration established for far different reasons, children may have to relocate to different places, sometimes over long distances, if their AIDS-affected parents can no longer care for them. They face the same adaptation challenges as other children who move, but complicated by loss of parent(s), AIDS stigma, and often poverty. (3) The issue of migrant families living with HIV has been studied to some extent, but mainly in developed countries with a long history of migration, and with little attention paid to the children in such families. Difficulties include involuntary separation from family members, isolation and lack of support, disclosure and planning for children's care should the parent(s) die and differences in treatment access within the same family. Numerous research and policy gaps are defined regarding the three themes, and a call is made for thinking about migration, families and AIDS to go beyond description to include resilience theory, and to go beyond prevention to include care.

HIV/AIDS institutional discrimination in Switzerland

A UNAIDS protocol designed to identify discrimination against people living with HIV/AIDS was applied in Switzerland, a country where policies against such discrimination had been actively promoted since the beginning of the HIV epidemic. Discrimination, in its strict legal definition, was examined in nine areas of everyday life, and at three levels: legislation, written regulations, and actual practices. Data concerning both expert opinion and subjective experience of discrimination was gathered by members of an interdisciplinary work group by means of: (1) interviews with over 200 key informants and experts, covering each of the areas investigated, and (2) actively seeking testimonies as to experiences of discrimination through local AIDS groups and through informal contacts of work group members. The study revealed little institutional discrimination in the region investigated, attesting to the efficacy of clear and actively promoted anti-discrimination policies. Individual discrimination and stigmatisation persist, however. It is in combating individual discrimination and stigmatisation that efforts must now concentrate. The UNAIDS protocol was found to be a valuable tool for tracking the sorts of discrimination that can most easily be influenced by policy measures.

HIV/AIDS prevention for migrants and ethnic minorities: three phases of evaluation

There are now a number of HIV/AIDS prevention programmes for migrant and ethnic minority communities throughout the world, both 'top down' programmes organised, for example, by governments and large NGOs, and 'bottom up' programmes, organised by migrant groups themselves. Evaluation of such programmes, however, is in most cases sorely lacking. The Swiss 'Migrants Project' is, to the authors' knowledge, the only such programme to have been systematically accompanied by evaluation throughout. This paper describes three phases of evaluation of the Migrants Project (exploratory studies, process, and outcome evaluations). The evaluations have highlighted the need for culturally and linguistically appropriate prevention efforts which use already-existing community structures, as well as the need to identify and train people from within communities to carry out local prevention efforts. Outcome evaluation has shown that: a government sponsored HIV/AIDS prevention programme can meet with acceptance by migrant communities; considerable engagement in prevention activities can be mobilised; and AIDS prevention among such communities can be effective. Such efforts can create levels of sensitivity to HIV issues and of protective behaviour that are equal to those of the host country population. The strategy adopted by the programme is thus supported. Key elements are to avoid potential for stigmatising by: (1) placing HIV/AIDS prevention efforts for migrant populations within an overall national HIV/AIDS prevention strategy; (2) informing and sensitising general populations within migrant communities before initiating more targeted prevention with migrant IDUs, MSM, and CSWs; (3) encouraging, facilitating and guiding health promotion efforts which emerge from within migrant communities themselves.

Health behaviours and psychosocial adjustment of migrant adolescents in Switzerland

BACKGROUND

Except for that of skilled and professional personnel, labour migration has practically ceased in Europe since the mid-1970s, and many of those who migrated as single males now have families in host countries. In Switzerland, among school-attending adolescents both of whose parents were born outside the country, some three quarters are children of labour migrants. Our hypothesis is that these adolescents present particular adjustment difficulties attributable to low socio-economic status and double cultural affinity.

OBJECTIVE

To compare Swiss and labour-migrant adolescents in attitudes towards health risks, psychological adjustment and family relationships.

METHOD

As part of the Swiss Multicentric Adolescent Survey on Health, an anonymous self-administered questionnaire was distributed in school classes among a national representative sample of 9300 fifteen- to twenty-year-olds. The subsample of labour-migrant youth includes 1200 adolescents both of whose parents are from Italy, Spain, Portugal, Turkey or former Yugoslavia.

RESULTS

Bivariate analyses show significant differences between Swiss and labour-migrant adolescents in health concepts and health behaviour (notably, sexual behaviour and substance use), general well-being and family relationships. Only alcohol consumption and drink-driving behaviour place migrant adolescents at a lower risk than their Swiss peers. When sociodemographic variables are controlled in multivariate analysis, less favourable perceptions of the future, more marks risk behaviours, symptoms of depression, and difficult relationships with parents all appear to be strongly associated with migrant status.

CONCLUSION

The findings of this study reflect the negative effects of lack of social stability and of clear opportunities and positive perspectives on the health and psychosocial adjustment of migrant adolescents.

Migrant populations: the development of something to evaluate

The setting up of the "migrants" of the European Community "Assessing AIDS Prevention" Concerted Action in 1989 practically coincided with the start of HIV/AIDS prevention activities for migrants in European countries. This article discusses the migration situation in Europe, why migrants may, or may not, be important for HIV/AIDS prevention, and the particular difficulties inherent in such prevention. Government-sponsored and NGO programmes for foreigners in 12 European countries are described.

CONCLUSIONS

programmes need to be based on the right to know rather than on notions of risk group. The category "migrants" includes people with vastly different backgrounds and needs. Migrants or ethnic minority populations cannot be assumed to be reached by HIV/AIDS education messages directed towards the general population of that country, but specific programmes for them should follow the model developed for other general populations, with culturally adapted messages aimed at the entire population, followed by specific targeted interventions for particular sub-groups. For both aspects it is essential to work with the target community, in synergy between "top down" and "bottom up" programmes. The main needs in the field of HIV/AIDS prevention among migrants are for: adequately funded programmes; serious evaluation, both of baseline information and programme evaluation; international networking and cooperation concerning programmes, materials and methods, and research.

[Evaluation of AIDS-related knowledge and behavior among seasonal workers in Switzerland]

Although an increasing number of AIDS prevention programmes are addressing migrants and ethnic minorities, few are either solidly research-based or adequately evaluated. Reported on here is a baseline evaluation of a marginal foreign population, Spanish and Portuguese seasonal workers in Switzerland. AIDS-related knowledge, attitudes and behaviours were assessed with both qualitative and quantitative methods during the winter of 1989-1990. The seasonal workers studied had been reached by prevention programmes both in the host country and in the country of origin, and knowledge was better than expected. Zones of ambiguity, such as confusion between AIDS and treatable STDs, persist however. Legal restrictions which prohibit family reunification affect sexual behavior: respondents report both more abstinence and more transitory sexual relations than the comparison Swiss population. Only about one in five report always using condoms during transitory relations. Qualitative material is used to suggest a relation between attitudes and protective behaviors. HIV/AIDS prevention programmes for Spanish and Portuguese populations in Switzerland are being established on the basis of the research findings.

International employment and children: geographical mobility and mental health among children of professionals

The literature concerning geographical mobility, psychiatric disturbances and mental health among children of professional and executive level migrants is reviewed. Most studies were found to be conceptually and methodologically flawed, tending to find whatever they set out to look for. Various problems that might be experienced by geographically mobile children, both in the short and the long term are reviewed. The question is raised as to what eventually becomes of third culture children, brought up neither in their home culture nor that of the host culture, but in an expatriate community.