AIDS and public policy: the lessons and challenges of "success" in Thailand

Intersectional stigma and coping strategies of single mothers living with HIV in Thailand

Stigma and discrimination are barriers to the prevention and treatment of HIV, and have serious biomedical, psycho-social and socio-cultural consequences, especially for marginalised groups such as sex workers, transgender people and sexual minorities. There has been little research to date on single mothers living with HIV to situate the stigma they experience within the context of gender, class, ethnicity and other intersecting social inequalities. Drawing on participant observation and in-depth interviews with 28 single mothers living with HIV in Thailand in 2020-21, this article finds that single mothers living with HIV experience intersectional stigma based on their class, ethnicity, religious status and gender, which manifests at the self, family, community and societal levels. In response to this stigmatisation, single mothers have developed four different coping strategies: self-presentation, identity talk, self-exclusion (through distancing and selective association), and empowerment. Findings from the research indicate that an intersectional approach is needed if academics, health workers, policy makers - and even the individuals concerned - are to understand and respond effectively to the HIV-related stigma experienced by specific socio-demographic groups.

Common factors in HIV/AIDS prevention success: lessons from Thailand

BACKGROUND

Thailand has achieved global acclaim for its response to HIV/AIDS. However, the success of some of the country's most well-known initiatives was by no means a foregone conclusion. Policy entrepreneurs on the periphery of power had to achieve buy-in from stakeholders in state and society to scale and mainstream their ideas. This paper offers a comparative and historical understanding the process by which three of the country's most well-known initiatives came into being: a civil society campaign to promote condom usage; a Ministry of Public Health program that aimed to prevent the spread of Human Immunodeficiency Virus (HIV) by targeting high-risk populations (the 100% condom program); and a universal Prevention of Mother-To-Child Transmission (PMTCT) program.

METHODS

The research relied on existing literature and interviews with high-ranking ministerial officials, representatives from international and non-governmental organizations, professors, and philanthropic organizations, in addition to a review of the existing literature. Taking a comparative and historical approach that is common within political science and sociology, we analysed the in-depth qualitative interviews in relation to the literatures and used an inductive cross-case analysis aimed to draw out critical features that the initiatives shared in common.

RESULTS

Common factors in HIV/AIDS prevention that cut across the three key cases include policy entrepreneurs who championed the programs, successful demonstration projects that produced a credible evidence base for policy adoption, and a diverse set of institutional partners that played critical roles in helping to mainstream their initiatives into national HIV/AIDS policy and scale programs nationally. The findings from this comparative research project have implications not only for the building of understanding related to one single project, but for broader theoretical understanding related to the mainstreaming of health policy from peripheral spaces of power.

CONCLUSIONS

This analysis draws out the role that demonstration projects played in building a credible evidence base for policy adoption and the role that a diverse set of institutional partners played in elevating the profile of policy entrepreneurs' ideas and helping to scale them nationally as state policy. Success was contingent on entrepreneurs first identifying and then taking advantage of different political opportunities that arose during each of the historical periods. Over time, these initiatives have evolved from vertical programs into an integrated program, in parallel with the evolution of the HIV/AIDS landscape at the global level.

Typologies and Correlates of Police Violence Against Female Sex Workers Who Inject Drugs at the México-United States Border: Limits of De Jure Decriminalization in Advancing Health and Human Rights

Decriminalization of sex work is increasingly promoted as a structural measure to improve the health of vulnerable groups. In México, sex work is not illegal, but knowledge of policies' street-level impact is limited. This study describes typologies of police violence against female sex workers who inject drugs (FSWID), identifying risk and protective factors for violence exposure to inform policy responses. Survey data were collected during 2008-2010 among HIV-negative FSWID in a behavioral intervention in Tijuana and Ciudad Juarez (N = 584). Latent class analysis identified typologies of police violence in the past 6 months: asked for money, money taken, syringes taken, asked for sex, and sexually assaulted. Structural equation modeling (SEM) predicted latent class membership using sociodemographic, behavioral and risk environment factors, controlling for age, education, marital status, and city. Recent police violence was reported by 68% of FSWID, with three typologies emerging: Low (36.6%); Material (47.8%): having money/syringes taken or being asked for money; and Material/Sexual (15.7%): material violence and being asked for sex or sexually assaulted. In multivariable SEM, Material Violence was associated with: being jailed [adjusted Odds Ratio (aOR) = 4.34], HIV testing (aOR = 2.18), and trading sex indoors (aOR = 1.66). Factors associated with Material/Sexual Violence included: being jailed (aOR = 41.18), injecting with clients (aOR = 3.12), earning more money for sex without a condom (aOR = 2.88), being raped by a client (aOR = 2.13), drinking with clients (aOR = 2.03), receiving substance use treatment (aOR = 1.95), being <18 when first trading sex (aOR = .43), trading sex outdoors (aOR = .53), and poor working conditions (aOR = .56). Despite de jure decriminalization of sex work, police violence against FSWID at the México-United States border is pervasive with implications for sex- and drug-related harms. Closing gaps in policy implementation and mitigating material/sexual violence from police is imperative to decreasing economic vulnerability, risk of overdose and HIV, and improving engagement in HIV and harm reduction services.

A systematic review of selected human rights programs to improve HIV-related outcomes from 2003 to 2015: what do we know?

Background

Repressive legal environments and widespread human rights violations act as structural impediments to efforts to engage key populations at risk of HIV infection in HIV prevention, care, and treatment efforts. The identification and scale-up of human rights programs and rights-based interventions that enable coverage of and retention in evidence-based HIV prevention and treatment approaches is crucial for halting the epidemic.

Methods

We conducted a systematic review of studies that assessed the effectiveness of human rights interventions on improving HIV-related outcomes between 1/1/2003–28/3/2015 per PRISMA guidelines. Studies of any design that sought to evaluate an intervention falling into one of the following UNAIDS’ key human rights program areas were included: HIV-related legal services; monitoring and reforming laws, policies, and regulations; legal literacy programs; sensitization of lawmakers and law enforcement agents; and training for health care providers on human rights and medical ethics related to HIV.

Results

Of 31,861 peer-reviewed articles and reports identified, 23 were included in our review representing 15 different populations across 11 countries. Most studies (83%) reported a positive influence of human rights interventions on HIV-related outcomes. The majority incorporated two or more principles of the human rights-based approach, typically non-discrimination and accountability, and sought to influence two or more elements of the right to health, namely availability and acceptability. Outcome measures varied considerably, making comparisons between studies difficult.

Conclusion

Our review revealed encouraging evidence of human rights interventions enabling a comprehensive HIV response, yet critical gaps remain. The development of a research framework with standardized indicators is needed to advance the field. Promising interventions should be implemented on a larger scale and rigorously evaluated. Funding for methodologically sound evaluations of human rights interventions should match the demand for human rights-based and structural approaches to protect those most vulnerable from HIV infection.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3692-1) contains supplementary material, which is available to authorized users.

Violence, abuse and discrimination: key factors militating against control of HIV/AIDS among the LGBTI sector

The Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) South Africans continue to face considerable challenges, including societal stigma, homophobic violence (particularly corrective rape), and high rates of sexually transmitted diseases and infections (particularly Human Immunodeficiency Virus (HIV)/AIDS) even when discrimination based on sexual orientation was outlawed by South African’s post-apartheid constitution. This study was conducted to ascertain violence, abuse and discrimination against the LGBTI sector as key factors that hinder the smooth implementation of HIV/AIDS programme among sexually minority (LGBTI) group in Walter Sisulu University, South Africa. The self-structured questionnaire was used to collect data. The study involved 3048 purposively selected participants (1285 male and 1763 female) aged 17–38 years. About 70.5% of the participants witnessed physical attack as a form of violence against people in same-gender relationship; 47.7% disagreed that violent targeted at this sexually minority group is justified. The LGBTI face challenges which include verbal insults (937, 32.4%), bullying (532, 18.4%) and name-calling (1389, 48%). Discrimination against members of the LGBTI sector was witnessed in various forms: non-acceptance (981, 33.9%), disapproval of act of homosexuals (1308, 45.2) and denial of rights (327, 11.3). Violence, abuse and discrimination which constitute stigmatisation among the LGBTI sector are received with mix feeling. Some respondents justified the use of one or more of these key elements of stigmatisation against the LGBTI (6.6%, supports violence), others condemned these acts of stigmatisation (28.8%), against discrimination). Social stigma which resulted from violence, abuse and discrimination exist in this institution and is responsible for the unwillingness of disclosure of sexual orientation among the LGBTI members. An enabling environment should be created where the LGBTI members could come out freely to access programmes targeted at the prevention and control of HIV/AIDS.

Healthcare avoidance by people who inject drugs in Bangkok, Thailand

BACKGROUND

Although people who inject drugs (IDU) often contend with various health-related harms, timely access to health care among this population remains low. We sought to identify specific individual, social and structural factors constraining healthcare access among IDU in Bangkok, Thailand.

METHODS

Data were derived from a community-recruited sample of IDU participating in the Mitsampan Community Research Project between July and October 2011. We assessed the prevalence and correlates of healthcare avoidance due to one's drug use using multivariate logistic regression.

RESULTS

Among 437 participants, 112 (25.6%) reported avoiding health care because they were IDU. In multivariate analyses, factors independently associated with avoiding health care included having ever been drug tested by police [adjusted odds ratio (AOR) = 1.80], experienced verbal abuse (AOR = 3.15), been discouraged from engaging in usual family activities (AOR = 3.27), been refused medical care (AOR = 10.90), experienced any barriers to health care (AOR = 4.87) and received healthcare information and support at a drop-in centre (AOR = 1.92) (all P < 0.05).

CONCLUSIONS

These findings highlight the need to address the broader policy environment, which perpetuates the criminalization and stigmatization of IDU, and to expand peer-based interventions to facilitate access to health care for IDU in this setting.

Correlates of HIV Testing Experience among Migrant Workers from Myanmar Residing in Thailand: A Secondary Data Analysis

BACKGROUND

Thailand continues to attract an increasing number of migrant workers (MW) from neighboring countries including mainly Myanmar, Cambodia, and Laos; however, little is known about the extent to which MWs from these countries have access to HIV prevention, treatment, and care services. We used data from the baseline survey of the Prevention of HIV/AIDS among MWs in Thailand (PHAMIT-2) project to document the prevalence of, and factors associated with, HIV testing among MWs from Myanmar, the largest group of MWs in Thailand.

METHODS AND FINDINGS

The baseline survey of PHAMIT-2 was conducted in 2010 among MWs from Myanmar, Cambodia, and Laos in 10 purposely-selected provinces of Thailand. Of the 1,034 participants who qualified for the analysis to identify correlates of HIV testing, only 5.3% reported ever having been tested for HIV. Factors associated with HIV testing included having a secondary or higher education level (AOR, 2.58; CI, 1.36-4.90; P = 0.004), being female (AOR, 1.96; CI, 1.05-3.66; P = 0.033), knowing someone who died of AIDS (AOR, 1.81; CI, 1.00-3.27; P = 0.048), working in the fishery sector (AOR, 2.51; CI, 1.28-4.92; P = 0.007), and not having a work permit (AOR, 3.71; CI, 1.36-10.13; P = 0.010).

CONCLUSION

Our study, in addition to revealing significantly low HIV testing among MWs from Myanmar, identifies important barriers to HIV testing which could be addressed through interventions that promote migrants' culturally-sensitive and friendly service, for example by facilitating flow of information about places for HIV testing, availability of language assistance, and ensuring confidentiality of HIV testing.

Displacement and HIV: Factors Influencing Antiretroviral Therapy Use by Ethnic Shan Migrants in Northern Thailand

Migrant populations face increased HIV vulnerabilities, including limited access to antiretroviral therapy. Civil conflict in Myanmar has displaced thousands of people from the minority Shan ethnic group into northern Thailand, where they bear a disproportionate HIV burden. To identify barriers and facilitators of antiretroviral therapy use in this population, we conducted a rapid ethnographic assessment and case study with a clinical sample of Shan migrants receiving treatment for HIV in a district hospital in Chiang Mai, Thailand, Thai nurses providing their care, and health care administrators (n = 23). Barriers included fears of arrest and deportation, communication difficulties, perceived social marginalization, limited HIV knowledge, and lack of finances. Facilitating factors included hospital-based migrant registration services and community outreach efforts involving support group mobilization, referral practices, and radio broadcasts. These findings provided a contextualized account to inform policies, community interventions, and nursing practice to increase treatment access for minority migrant groups.

Changes in Sexual Behavior and Attitudes Across Generations and Gender Among a Population-Based Probability Sample From an Urbanizing Province in Thailand

Thailand has undergone rapid modernization with implications for changes in sexual norms. We investigated sexual behavior and attitudes across generations and gender among a probability sample of the general population of Nonthaburi province located near Bangkok in 2012. A tablet-based survey was performed among 2,138 men and women aged 15-59 years identified through a three-stage, stratified, probability proportional to size, clustered sampling. Descriptive statistical analysis was carried out accounting for the effects of multistage sampling. Relationship of age and gender to sexual behavior and attitudes was analyzed by bivariate analysis followed by multivariate logistic regression analysis to adjust for possible confounding. Patterns of sexual behavior and attitudes varied substantially across generations and gender. We found strong evidence for a decline in the age of sexual initiation, a shift in the type of the first sexual partner, and a greater rate of acceptance of adolescent premarital sex among younger generations. The study highlighted profound changes among young women as evidenced by a higher number of lifetime sexual partners as compared to older women. In contrast to the significant gender gap in older generations, sexual profiles of Thai young women have evolved to resemble those of young men with attitudes gradually converging to similar sexual standards. Our data suggest that higher education, being never-married, and an urban lifestyle may have been associated with these changes. Our study found that Thai sexual norms are changing dramatically. It is vital to continue monitoring such changes, considering the potential impact on the HIV/STIs epidemic and unintended pregnancies.

Challenges to successful implementation of HIV and AIDS-related health policies in Cartagena, Colombia

The Caribbean region presents the highest prevalence of HIV/AIDS worldwide after sub-Saharan Africa; leading to serious social, economic and health consequences at the local scale but also at the regional and global levels. In Colombia, a national plan to tackle the epidemic was formulated with little evidence that its implementation in the local context is effective. This study focused on Cartagena - one of Colombia's largest cities and an international touristic hub - that presents one of the highest HIV prevalences in the country, to investigate whether the national plan accounts for local specificities and what are the barriers to local implementation. Based on the Contextual Interaction Theory (CIT), this qualitative research relied upon 27 interviews and 13 life stories of local inhabitants and stakeholders, collected in a first fieldwork in 2006-2007. A follow-up data collection took place in 2013 with 10 participants: key policymakers and implementers, NGO representatives and local inhabitants. Barriers identified by the participants included: local population's understandings and beliefs on condom use; stigma and discrimination; lack of collaboration from the Church, the education sector and local politicians; corruption; high staff turnover; frequent changes in leadership; lack of economic and human resources; and barriers to health care access. The findings suggest that global influences also have an impact on the CIT framework (e.g. international organisations as a major financier in HIV prevention). The participants put forward several feasible solutions to implementation barriers. We discuss how several of the proposed solutions have been applied in other Latin American and Caribbean countries and yielded positive results. However, further research is needed to find possible ways of overcoming certain barriers identified by this study such as corruption, the lack of collaboration of the Church and barriers to health care access.

Combination HIV prevention for female sex workers: what is the evidence?

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

Community health nurses' HIV health promotion and education programmes: a qualitative study

BACKGROUND

Globally, nurses practice in many settings with people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), taking an increasing share of the professional burden of care and helping to reduce morbidity and mortality. International literature is sparse about Thai community nurses providing primary healthcare programmes for people with HIV.

AIM

This study aimed to describe background, experiences and strategies of community nurses regarding their design and delivery of programmes for people living with HIV and AIDS in Chiang Mai Province, Thailand.

DESIGN

This study used a qualitative mixed-methods study employing a qualitative survey and in-depth interviews.

METHODS

Twenty community health nurses from 18 small community hospitals completed a survey comprising demographic data and 13 open-ended questions. Four of them later engaged in in-depth interviews using the same questions. Survey, interview data and field notes were analysed using interpretive content analysis.

FINDINGS

Four themes and six sub-themes portrayed participants' rich experiences and knowledge of HIV health promotion and education; challenges of daily work, discrimination and ethical issues; success through programme diversity comprising promotion of community volunteerism, networking and relationships; and holistic connections with Thai cultural traditions and Buddhism.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Findings help to recognize the diversity, uniqueness and contributions of Thai community nurses regarding culturally appropriate health promotion and education programmes for people living with HIV and AIDS. Findings inform nurses and health officials in and outside of the country to complement innovation in future HIV health promotion and education programmes.

LIMITATIONS

Our sample came from one province of Thailand. Findings might not be reflective of nurses elsewhere.

IMPLICATIONS FOR HEALTH AND NURSING POLICY

Three decades of collective experience in providing holistic and multifaceted HIV and AIDS nursing care, education and health promotion by community health nurses have the potential to effect new and existing policies and protocols on HIV community care in Thailand, but more research is required for this.

To tell or not to tell: disclosure to children and family amongst Thai women living with HIV/AIDS

HIV disclosure is a complex phenomenon. The choice of disclosure or non-disclosure is a reflection of how each HIV-positive person experiences and deals with HIV/AIDS in their everyday life. In this study, we qualitatively explore the experiences of disclosing HIV status to family members and children among HIV-positive women living in Thailand. Due to fear of stigma and discrimination, the women decided to tell only a few people, usually their significant others including parents and children. Although most women received good support from their family members, some were rejected and discriminated against by their family members. This stems from lack of knowledge about HIV/AIDS among family members. Women found disclosure to their children a difficult decision to make. Only some women told their children about their HIV status. They wished to protect their children from emotional burden. This protection also appeared in their attempts to prepare their children for dealing with HIV/AIDS. Support from family members played a major role in the lives of HIV-positive women. Although disclosure has been promoted as a means of ending stigma and discrimination, our data suggested that disclosure may not be positive for some women. This has implications for health promotion in HIV health care. Healthcare providers need to appreciate the ramifications of promoting disclosure to HIV-positive women who are mothers.

Is endemic political corruption hampering provision of ART and PMTCT in developing countries?

INTRODUCTION

Leadership is a key factor in the success of HIV prevention and treatment. Positive HIV-related outcomes are also affected by funding levels for HIV, health sector resources, disease burden and the socio-economic environment. Leadership on HIV as well as these other factors are affected by the quality of political governance of the country, which may be an overarching factor that influences the making of effective responses to the HIV epidemic.

AIM

The aim of the study was to investigate the association between quality of political governance, on one hand, and coverage of antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT), on the other, in low- to middle-income countries.

METHODS

This investigation was carried out through a global review, online data sourcing and statistical analyses. We collected data on health burden and resources, the socio-economic environment, HIV prevalence, ART and PMTCT coverage and indicators of political governance. Outcome variables were coverage of ART (from 2004) and PMTCT (from 2007) to 2009 as a percentage of persons needing it. Potential predictors of treatment coverage were fitted with a baseline multilevel model for univariable and multivariable analyses.

RESULTS

Countries with higher levels of political voice and accountability, more political stability and better control of corruption have higher levels of ART coverage but not PMTCT coverage. Control of corruption (in standard deviation units) had a strong association with ART (AOR=1.82, p=0.002) and PMTCT (AOR=1.97, p=0.01) coverage. Indicators of economic development were not significant when control of corruption was included in the multivariable regression model. Many countries in all income groups had high ART but not PMTCT coverage (e.g. Mexico, Brazil and Romania in the upper-middle-income group; Papua New Guinea and Philippines in the lower-middle-income group; and Cambodia, Laos and Comoros in the low-income group). Very few low-income countries (notably, Haiti and Kenya) had high PMTCT coverage.

CONCLUSIONS

Our research found a significant relationship between quality of political governance and treatment coverage. Measures and policies for improving the quality of political governance should be considered as a part of HIV programme implementation to more effectively improve the welfare of people living with HIV, particularly mothers living with HIV and their babies.

Assessing the effects of HIV/AIDS and TB disease control programmes on health systems in low- and middle-income countries of Southeast Asia: a semi-systematic review of the literature

OBJECTIVE

To systematically review the literature on if and how HIV/AIDS and TB programmes have impacted on general healthcare systems in Association of Southeast Asian Nations (ASEAN) countries.

METHODS

Medline, Embase, Global Health and CINHAL were searched for English language literature published between 1st January 2003 and 31st March 2011. Papers included had to focus on: HIV and/or TB control programmes; the low- and-middle-income ASEAN countries; and factors related to any health systems functions. The effects were examined along six system functions: Stewardship and Governance; Financing; Planning; Service Delivery; Monitoring and Evaluation; and Demand Generation. A comprehensive thematic analytical tool aligned with the above six health systems functions was developed to support data extraction and analysis.

FINDINGS

88 papers met the inclusion criteria. Most programme effects highlighted were related with health service delivery. The other five health system functions were seldom scrutinized, and each covered by less than a quarter of papers. Overall 69% of effects highlighted were positive effects whereas 31% were negative.

CONCLUSION

There was a paucity of robust evidence. Effects on health systems were rarely a focus of research protocols but more often a minor component in the Results/Discussion sections. Particular attention should be paid by Global Health Initiatives to the negative effects that emerged from this study, such as the development of parallel systems, specific incentives not available to the general health systems, and lack of integration of services with private healthcare providers.

HIV epidemic in Asia: optimizing and expanding vaccine development

The recent evidence in Thailand for protection from acquisition of HIV through vaccination in a mostly heterosexual population has generated considerable hope. Building upon these results and the analysis of the correlates of risk remains among the highest priorities. Improved vaccine concepts including heterologous prime-boost regimens, improved proteins with potent adjuvants and new vectors expressing mosaic antigens may soon enter clinical development to assess vaccine efficacy in men who have sex with men. Identifying heterosexual populations with sufficient HIV incidence for the conduct of efficacy trials represents perhaps the main challenge in Asia. Fostering translational research efforts in Asian countries may benefit from the development of master strategic plans and program management processes.

Social and behavioral characteristics of gharwalis who operate brothels in the Ganga-Jamuna area of Nagpur, India

Nagpur is an industrial hub in Maharashtra, a state in Central India that has the second highest HIV prevalence in the country. Approximately 3000 brothel-based female sex workers (FSWs) are estimated to be working in Nagpur's Ganga-Jamuna red light district. The extent to which brothel madams, known as gharwalis, support HIV/STI prevention for FSWs has not been examined. The present study sought to identify personal, social, and behavioral characteristics of gharwalis in Nagpur as well as enhance our understanding of the gharwali's role in shaping the sexual practices of brothel-based FSWs. Thirty gharwalis participated in a survey that covered personal, social, behavioral, and environmental characteristics. Respondents ranged in age from 29 to 50 years (M = 38.9) and had worked as a gharwali for an average of 5.3 years; 80% had no formal education, 43% had never married, and 30% were divorced or separated, and 93% earned money from their own sex work. Gharwalis managed an average of 4.2 FSWs (range 2-10). Overall, gharwalis reported positive attitudes toward condoms, promoted use of condoms by their FSWs with clients, taught FSWs how to use condoms, knew where to obtain condoms for free, and required HIV testing for their FSWs; however, levels of HIV prevention knowledge were low. Gharwalis also reported providing a range of support services to FSWs who lived in their brothels, including shelter, protection from drunk and aggressive clients and police, emotional support, caring and love, and health care. These data suggest the feasibility of involving gharwalis in brothel-based HIV prevention programs.

Living positively: the experiences of Thai women living with HIV/AIDS in central Thailand

Living with an incurable illness such as HIV/AIDS is a stressful experience. However, many HIV-positive individuals are able to maintain their emotional well-being. This begs the question of what strategies these individuals employ to allow them to do so. In this article, we examine how Thai women living with HIV/AIDS learned about their health status, what feelings they had, and how they dealt with the illness. In-depth interviews were conducted with 26 women in central Thailand. The women adopted several strategies to deal with their HIV status, including taking care of themselves, accepting their own faith, disclosing their HIV status to family, and joining AIDS support groups. These strategies can be situated within the "living positively" discourse, which helped to create a sense of optimism to combat the HIV epidemic among the women. Additionally, the acceptance of their HIV status played an essential role in the meaning-making process because it assisted the women in sustaining the equilibrium of their emotional well-being.

Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Female sex workers are a population who are at heightened risk of HIV infection secondary to biological, behavioural, and structural risk factors. However, three decades into the HIV pandemic, understanding of the burden of HIV among these women remains limited. We aimed to assess the burden of HIV in this population compared with that of other women of reproductive age.

METHODS

We searched PubMed, Embase, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine for studies of female sex workers in low-income and middle-income countries published between Jan 1, 2007, and June 25, 2011. Studies of any design that measured the prevalence or incidence of HIV among female sex workers, even if sex workers were not the main focus of the study, were included. Meta-analyses were done with the Mantel-Haenszel method with a random-effects model characterising an odds ratio for the prevalence of HIV among female sex workers compared with that for all women of reproductive age.

FINDINGS

Of 434 selected articles and surveillance reports, 102 were included in the analyses, representing 99,878 female sex workers in 50 countries. The overall HIV prevalence was 11·8% (95% CI 11·6-12·0) with a pooled odds ratio for HIV infection of 13·5 (95% CI 10·0-18·1) with wide intraregional ranges in the pooled HIV prevalence and odds ratios for HIV infection. In 26 countries with medium and high background HIV prevalence, 30·7% (95% CI 30·2-31·3; 8627 of 28,075) of sex workers were HIV-positive and the odds ratio for infection was 11·6 (95% CI 9·1-14·8).

INTERPRETATION

Although data characterising HIV risk among female sex workers is scarce, the burden of disease is disproportionately high. These data suggest an urgent need to scale up access to quality HIV prevention programmes. Considerations of the legal and policy environments in which sex workers operate and actions to address the important role of stigma, discrimination, and violence targeting female sex workers is needed.

FUNDING

The World Bank, UN Population Fund.

Drug policy in Vietnam: a decade of change?

BACKGROUND

Driven by the rapid spread of HIV, Vietnam's response to drug use has undergone significant transformation in the past decade. This paper seeks to identify and analyse factors that prompted these changes and to investigate their impact on the lives of people who use drugs.

METHOD

This policy analysis is based on a review of Vietnamese Government documents, peer-reviewed publications and the authors' knowledge of and involvement in drug policy in Vietnam.

RESULTS

The last decade has witnessed a progressive change in the mindset of political leaders in Vietnam around illicit drug use and HIV issues. This has led to adoption of evidence-based interventions and the evolution of drug policy that support the scale up of these interventions. However, HIV prevalence among drug users at 31.5% remains high due to limited access to effective interventions and impediments caused by the compulsory treatment centre system.

CONCLUSIONS

The twin epidemics of HIV and illicit drug use have commanded high-level political attention in Vietnam. Significant policy changes have allowed the implementation of HIV prevention and drug dependence treatment services. Nevertheless, inconsistencies between policies and a continued commitment to compulsory treatment centres remain as major impediments to the provision of effective services to drug users. It is critical that Vietnamese government agencies recognise the social and health consequences of policy conflicts and acknowledge the relative ineffectiveness of centre-based compulsory treatment. In order to facilitate practical changes, the roles of the three ministries directly charged with HIV and illicit drug use need to be harmonised to ensure common goals. The participation of civil society in the policymaking process should also be encouraged. Finally, stronger links between local evidence, policy and practice would increase the impact on HIV prevention and drug addiction treatment programming.

Factors associated with methadone treatment among injection drug users in Bangkok, Thailand

Little is known about the characteristics of injection drug users (IDU) who take methadone treatment in Thailand. We examined prevalence and correlates of methadone treatment among a community-recruited sample of IDU in Bangkok, Thailand. Among 273 participants, 143 (52.4%) reported accessing methadone treatment within the previous 6 months. Older age (adjusted odds ratio [AOR] = 1.90, 95% confidence interval [CI] = 1.10-3.30) and more than weekly midazolam injection (AOR = 1.85, 95% CI = 1.04-3.29) were positively associated, whereas alcohol use (AOR = 0.34, 95% CI = 0.18-0.63) and noninjection methamphetamine use (AOR = 0.49, 95% CI = 0.29-0.85) were negatively associated with methadone treatment. In subanalyses, 98.6% of IDU on methadone continued to inject drugs, and the most common reason for stopping methadone was becoming incarcerated (49%). Evidence-based addiction treatment in the form of methadone maintenance therapy, with attention paid to concomitant midazolam injection in this setting, should be implemented.

Conceptual and methodological challenges to measuring political commitment to respond to HIV

Background

Researchers have long recognized the importance of a central government’s political “commitment” in order to mount an effective response to HIV. The concept of political commitment remains ill-defined, however, and little guidance has been given on how to measure this construct and its relationship with HIV-related outcomes. Several countries have experienced declines in HIV infection rates, but conceptual difficulties arise in linking these declines to political commitment as opposed to underlying social and behavioural factors.

Methods

This paper first presents a critical review of the literature on existing efforts to conceptualize and measure political commitment to respond to HIV and the linkages between political commitment and HIV-related outcomes. Based on the elements identified in this review, the paper then develops and presents a framework to assist researchers in making choices about how to assess a government's level of political commitment to respond to HIV and how to link political commitment to HIV-related outcomes.

Results

The review of existing studies identifies three components of commitment (expressed, institutional and budgetary commitment) as different dimensions along which commitment can be measured. The review also identifies normative and ideological aspects of commitment and a set of variables that mediate and moderate political commitment that need to be accounted for in order to draw valid inferences about the relationship between political commitment and HIV-related outcomes. The framework summarizes a set of steps that researchers can follow in order to assess a government's level of commitment to respond to HIV and suggests ways to apply the framework to country cases.

Conclusions

Whereas existing studies have adopted a limited and often ambiguous conception of political commitment, we argue that conceiving of political commitment along a greater number of dimensions will allow researchers to draw a more complete picture of political commitment to respond to HIV that avoids making invalid inferences about the relationship between political commitment and HIV outcomes.

Is a HIV vaccine a viable option and at what price? An economic evaluation of adding HIV vaccination into existing prevention programs in Thailand

Background

This study aims to determine the maximum price at which HIV vaccination is cost-effective in the Thai healthcare setting. It also aims to identify the relative importance of vaccine characteristics and risk behavior changes among vaccine recipients to determine how they affect this cost-effectiveness.

Methods

A semi-Markov model was developed to estimate the costs and health outcomes of HIV prevention programs combined with HIV vaccination in comparison to the existing HIV prevention programs without vaccination. The estimation was based on a lifetime horizon period (99 years) and used the government perspective. The analysis focused on both the general population and specific high-risk population groups. The maximum price of cost-effective vaccination was defined by using threshold analysis; one-way and probabilistic sensitivity analyses were performed. The study employed an expected value of perfect information (EVPI) analysis to determine the relative importance of parameters and to prioritize future studies.

Results

The most expensive HIV vaccination which is cost-effective when given to the general population was 12,000 Thai baht (US$1 = 34 Thai baht in 2009). This vaccination came with 70% vaccine efficacy and lifetime protection as long as risk behavior was unchanged post-vaccination. The vaccine would be considered cost-ineffective at any price if it demonstrated low efficacy (30%) and if post-vaccination risk behavior increased by 10% or more, especially among the high-risk population groups. The incremental cost-effectiveness ratios were the most sensitive to change in post-vaccination risk behavior, followed by vaccine efficacy and duration of protection. The EVPI indicated the need to quantify vaccine efficacy, changed post-vaccination risk behavior, and the costs of vaccination programs.

Conclusions

The approach used in this study differentiated it from other economic evaluations and can be applied for the economic evaluation of other health interventions not available in healthcare systems. This study is important not only for researchers conducting future HIV vaccine research but also for policy decision makers who, in the future, will consider vaccine adoption.

Engaging local businesses in HIV prevention efforts: the consumer perspective

Participation of different community sectors, including the private business sector, is necessary to fight the HIV/AIDS epidemic. Local businesses may be reluctant to participate in HIV prevention because of fear of negative customer reactions and loss of revenue. This study examines the extent to which residents of two communities in San Diego, California, would support HIV prevention initiatives in local businesses. A population-based household survey (N = 200) is conducted in two communities with higher versus lower risk for HIV. The survey includes questions regarding the acceptability of HIV prevention activities, such as condom and brochure distribution in businesses, and history of exposure to HIV prevention activities in local businesses. Most residents agree that (a) business involvement in prevention activities would reduce HIV (92%), (b) free or low-cost condoms available in businesses could prevent the spread of HIV (90.9%) and increase condom accessibility (87%), and (c) they would prefer to shop at businesses that supported HIV prevention versus those that did not (87.4%). These findings suggest that HIV prevention in local businesses would be supported by residents and would be unlikely to adversely affect business profits. This information could be used to design interventions to engage local businesses in HIV-prevention efforts.

Intergenerational relationships within families of HIV-infected adults under antiretroviral treatment in Northern Thailand

Thailand has been severely affected by AIDS/HIV. The epidemic has undermined the health of the population of working age, placing stress on intergenerational relations and threatening the social fabric. Older people in families affected by the disease, although not the main victims, have experienced major changes in relationships with their adult children and grandchildren. However, the availability of antiretrovirals has transformed HIV infection from a lethal to a chronic disease. Intergenerational relationships are analysed with data from a quantitative survey of HIV-infected adults currently receiving antiretroviral treatment in Northern Thailand. The introduction of antiretroviral treatment has eased the pressure on families. Where HIV-infected adults are more dependent on their older parents, it is because they are single and childless or single parents. While ageing parents remain a source of support for their adult children, the introduction of antiretroviral treatment has radically changed the prospects for HIV-infected adults and their regained health allows them to work, take care of their family and fulfil their filial duties as expected in Thai society. If Thailand's original aim in introducing health policies in this area was to curtail the HIV epidemic, its positive impact on intergenerational relations is an additional benefit.

The role of brothels in reducing HIV risk in Sonagachi, India

High rates of empowerment, HIV-related knowledge, and condom use among sex workers in Sonagachi, India have been attributed to a community-led intervention called the Sonagachi HIV/AIDS Intervention Program (SHIP). In this research we examined the crucial role of brothels in the success of the intervention. In-depth, semistructured interviews were conducted with 55 participants of SHIP. The results indicate that brothels help sex workers reduce HIV risk by (a) serving as targeted sites for SHIP's HIV intervention efforts, (b) being operated by madams (women managers of brothels) who participate in SHIP's intervention efforts and promote healthy regimes, (c) structuring the economic transactions and sexual performances related to sex work, thus standardizing sex-related behavior, and (d) promoting community empowerment among brothel residents. Implications of these results are discussed for future efforts to replicate SHIP's success in other sex work communities.

HIV/AIDS-Related Stigma and Discrimination: A Study of Health Care Providers in Bangladesh

People living with HIV/AIDS (PLWHA) are stigmatized and looked at negatively by people at large. Stigma, discrimination, and prejudice extend its reach to people associated with HIV-positive people such as health providers, hospital staff, as well as family member and friends. Studies demonstrate that, in low-income countries, especially in South Asia and sub-Saharan Africa, health providers' views toward the HIV-positive individuals is not very much different from the general population. The study has been qualitative in nature and conducted among health providers such as physicians and nurses attached to different hospitals. The study was conducted from March 2005 to May 2007. The study shows that 80% of the nurses and 90% of the physicians' behavior with the HIV-positive individuals were discriminatory. They talk to their patients standing far from them. The interview revealed that the spouses of the physicians and nurses in charge of the HIV-positive individuals put pressure to stop serving the patient or even quit the job. The notion that HIV is only transmitted through sexual activities is prevalent among them. Interestingly, although the physicians know well about the routes of transmission, they do not believe it by heart. Therefore, their fear of being infected makes them discriminate against the HIV-positive individuals. HIV-related stigma remains a barrier to effectively fighting this pandemic. Fear of discrimination often prevents people from seeking treatment publicly. There are evidences that they were evicted from home by their families and rejected by their friends and colleagues. The stigma attached to HIV/AIDS can extend into the next generation, placing an emotional burden on them.

Human rights and HIV prevention, treatment, and care for people who inject drugs: key principles and research needs

Efforts to provide HIV prevention, treatment, and care to injecting drug users (IDU) are shaped by tensions between approaches that regard IDU as criminals and those regarding drug-dependent individuals as patients deserving treatment and human rights. Advocates for IDU health and human rights find common cause in urging greater attention to legal frameworks, the effects of police abuses, and the need for protections for particularly vulnerable populations including women and those in state custody. Arbitrary detention of drug users, and conditions of pretrial detention, offer examples of how HIV prevention and treatment are adversely impacted by human rights abuse. National commitments to universal access to prevention and treatment for injecting drug users, and the recognition that users of illicit substances do not forfeit their entitlement to health services or human dignity, offer a clear point of convergence for advocates for health and rights, and suggest directions for reform to increase availability of sterile injection equipment, opiate substitution treatment, and antiretroviral therapy. For IDU, protection of rights has particular urgency if universal access to HIV prevention and treatment is to become an achievable reality.

How HIV treatment could result in effective prevention

As the number of HIV infections continues to surpass treatment capacity, new HIV prevention strategies are imperative. Beyond individual clinical benefits, by rendering an individual less infectious, expanding access to highly active antiretroviral therapy (HAART) could also have a larger public health impact of curbing new HIV infections. Recent guidelines have moved towards initiating HAART at higher CD4 cell counts, thus increasing the number of individuals in need of treatment. A new treatment strategy is wanting that can simultaneously curb the epidemic and provide necessary treatment to those most in need. A recent debate has centered on whether an expansion of free and universal treatment, regardless of CD4 cell count, could be a means of HIV prevention. In light of the growing access to HAART in resource-limited settings and increasing evidence suggesting the clinical and prevention benefits of initiating treatment at higher CD4 cell counts, it is conceivable that, in the future, HAART will be an integral part of both individual-level clinical treatment programs as well as public health-based HIV prevention interventions.

Pilot study assessing HIV vaccine trial readiness among female sex workers, injection and non-injection drug users, and men who have sex with men in Spain

The purpose of this study was to assess HIV risk and willingness to participate in HIV vaccine trials in three high risk populations in Spain. Eight hundred and forty-four participants, comprising female sex workers, injection and non-injection drug users (IDUs and NIDUs, respectively), and men who have sex with men were tested for HIV and surveyed for risk and willingness to participate in future preventive HIV vaccine trials. HIV seroprevalence was 3.8% (95% CI: 2-11). HIV infection was associated with transgender identification, IDU in the past year, and sex with an IDU or other drug-using partner. The majority (82%) expressed their willingness to participate in HIV vaccine trials. Substantial sexual and parenteral risk in all groups and concomitant willingness to participate in vaccine trials was found, particularly among women and IDUs. Additional longitudinal cohort studies in Spain are needed to plan future vaccine efficacy trials.

Sex trafficking, sexual risk, sexually transmitted infection and reproductive health among female sex workers in Thailand

BACKGROUND

The trafficking of women and girls for sexual exploitation is an internationally recognised form of gender-based violence, and is thought to confer unique sexual and reproductive health vulnerabilities. To date, little research has compared sexual risk or health outcomes among female sex workers (FSWs) on the basis of experiences of sex trafficking.

AIM

To compare experiences of sexual risk and sexual and reproductive health outcomes among FSWs on the basis of experiences of trafficking as an entry mechanism to sex work.

METHODS

Data from a national sample of FSWs in Thailand (n=815) was used to assess (a) the prevalence of sex trafficking as an entry mechanism into sex work and (b) associations of sex trafficking with sexual risk and health outcomes.

RESULTS

Approximately 10% of FSWs met criteria for trafficking as an entry mechanism to sex work. Compared with their non-trafficked counterparts, sex-trafficked FSWs were more likely to have experienced sexual violence at initiation to sex work (adjusted risk ratio (ARR) 2.29, 95% CI 1.11 to 4.72), recent workplace violence or mistreatment (ARR 1.38, 95% CI 1.13 to 1.67), recent condom failure (ARR 1.80, 95% CI 1.15 to 2.80), condom non-use (ARR 3.35, 95% CI 1.49 to 7.52) and abortion (ARR 2.83, 95% CI 1.48 to 5.39).

DISCUSSION

Both the prevalence of sex trafficking as an entry mechanism to sex work and the threats to sexual and reproductive health observed on the basis of trafficking status show the need for comprehensive efforts to identify and support this vulnerable population. Moreover, existing STI/HIV-prevention programming may be stymied by the limited condom-use capacity and high levels of violence observed among those trafficked into sex work.

The Chinese government's response to drug use and HIV/AIDS: a review of policies and programs

Illicit drug use has become popular in China. Acknowledging the challenge of illicit drug use, China has adopted several new policies on the management of illicit drug use in recent years. This study reviews the current policies on drug use and assesses the harm reduction interventions among drug users in China. The review documents that the new policies on drug use provide a variety of choices of detoxification treatment for drug users. The methadone maintenance treatment and needle exchange programs have been adopted as harm reduction models in China. Most of the reviewed harm reduction programs have been successfully implemented and yielded positive effects in reducing drug related risk behaviors among drug users. Although there remain barriers to the effective implementation of policies on drug use and harm reduction programs, Chinese government has shown their commitment to support the expansion of harm reduction interventions for drug users throughout the country.

Gender and access to HIV testing and antiretroviral treatments in Thailand: why do women have more and earlier access?

In the recent scale-up of antiretroviral treatment, gender differences in access to treatment have been reported. In Thailand, as the HIV epidemic became more generalised, there has been a shift from men being disproportionately affected to increased vulnerability of women. In 2007, the Living with Antiretrovirals (LIWA-ANRS 12141) study investigated the gender distribution of all adult patients receiving antiretroviral therapy (N=513 patients) in four community hospitals in northern Thailand and factors influencing the disparities observed. From this retrospective life-event history survey, we found that proportionately more women (53%) were receiving antiretroviral therapy than men, an unexpected result for a country with a higher proportion of infections among men. They were more likely to initiate treatment within one year of diagnosis and were at a more advanced stage of the disease compared to women. This gender distribution is partly explained by the evolving dynamics of the HIV epidemic, initial prioritization of mothers for treatment and earlier access to HIV testing for women. These issues are also entangled with gender differences in the reasons and timing to HIV testing at the individual level. This study found that the majority of men underwent HIV testing for health reasons while the majority of women were tested following family events such as a spouse/child death or during pregnancy. Further qualitative research on gender specific barriers to HIV testing and care, such as perceived low risk of infection, poor access to medical care, lack of social support, actual or anticipated HIV/AIDS-related stigma would provide greater insight. In the meantime, urgent efforts are needed to increase access to voluntary counselling and testing inside and outside the family setting with targeted interventions for men.

AIDS and the stigma of sexual promiscuity: Thai nurses' risk perceptions of occupational exposure to HIV

This paper examines the culturally shaped meanings of AIDS and perceptions of accidental occupational exposure to HIV among a group of twenty nurses in Bangkok, Thailand. The findings are based on data collected as a part of a larger mixed-methods study that examined how perceptions of risk behaviours (including sexual promiscuity) shape health workers' perceptions of patients living with HIV/AIDS. Nurses' narratives revealed that despite acknowledgement of the low probability of occupational exposure to HIV, the fear of HIV infection remained and was largely driven by the enormity of the anticipated social (rather than the health) consequences of being HIV-positive. The perceived certainty of social ostracism was reinforced by participants' observations of the social rejection experienced by people living with HIV/AIDS both within and outside clinical settings. For female nurses, the dominant social perception that women living with HIV/AIDS were violators of gender norms, and thus 'guilty' victims, was an issue central to their self-identities. Ways of improving care for people living with HIV in the light of the nurses' concerns and future research are discussed.

Challenge and co-operation: civil society activism for access to HIV treatment in Thailand

Civil society has been a driving force behind efforts to increase access to treatment in Thailand. A focus on HIV medicines brought civil society and non-governmental and government actors together to fight for a single cause, creating a platform for joint action on practical issues to improve care for people with HIV/AIDS (PHA) within the public health system. The Thai Network of People with HIV/AIDS, in partnership with other actors, has provided concrete support for patients and for the health system as a whole; its efforts have contributed significantly to the availability of affordable generic medicines, early treatment for opportunistic infections, and an informed and responsible approach towards antiretroviral treatment that is critical to good adherence and treatment success. This change in perception of PHA from 'passive receiver' to 'co-provider' of health care has led to improved acceptance and support within the healthcare system. Today, most PHA in Thailand can access treatment, and efforts have shifted to supporting care for excluded populations.

Evaluation design for large-scale HIV prevention programmes: the case of Avahan, the India AIDS initiative

BACKGROUND

Closing the HIV prevention gap to prevent HIV infections requires rapid, worldwide rollout of large-scale national programmes. Evaluating such programmes is challenging and complex, requiring clarity of evaluation purpose and evidential approaches substantively different to those employed for pilots and small programmes.

OBJECTIVES

This paper describes the evaluation design for the implementation phase of Avahan, the India AIDS initiative, a large HIV prevention programme funded by the Bill and Melinda Gates Foundation. Avahan, which began in December 2003, has a 10-year charter to impact the Indian epidemic and its response by implementing an HIV prevention programme targeting core and bridge groups in 83 districts of six Indian states, transferring the programme to the Government of India, and disseminating programme learning.

METHODS

The foundation commissioned an external process to design Avahan's evaluation framework. An independent advisory group oversees and guides course corrections in the execution of this framework.

RESULTS

Avahan's evaluation framework comprises: trend and synthetic analysis of data from core, bridge and household biobehavioural surveys in a subset of intervention districts, denominator estimates and programme monitoring from all intervention districts, and government's antenatal surveillance (two sites per district in all districts); bespoke transmission dynamics modelling to estimate infections averted (subset of districts); cost effectiveness studies (subset of districts). In addition, there are other knowledge-building and quality-monitoring activities.

CONCLUSION

Rather than a small set of monofocal outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution.

[Community-based intervention to control STD/AIDS in the Amazon region, Brazil]

OBJECTIVE

To describe a case study of community-based intervention, developed in a constructionist-emancipatory framework to control STD/AIDS.

METHODS

Descriptive study developed in the town of Manacapuru, in the state of Amazonas, from 1997 to 2004, focusing on procedures designed in collaboration with government agents, health professionals and the community. Data on the dynamics of prostitution and condom sales in this town, preventive practices and STD/AIDS care and process assessment were collected. Actions targeting STD prevention and care in the public healthcare system, a testing center, an epidemiological surveillance system and sex workers' qualification were established concomitantly.

RESULTS

It was observed the strengthening of sex workers as peer educators and their legitimization as citizens and health agents in projects involving transvestites, homosexuals and students. There was an increase in condom sales in town, as well as in condom use among sex workers; reduction in bacterial STD; and stabilization of the incidence of HIV/AIDS infections and congenital syphilis. The sustainability of the intervention program studied, organized within the sphere of action of the Sistema Unico de Saúde (National Health System), was promoted by a political pact, which guaranteed headquarters and municipal law-regulated budget, as well as by the constant debate over the process and program results.

CONCLUSIONS

The study strengthened the notion that effective control of STD/AIDS depends on a synergic approach that combines interventions on individual (biological-behavioral), sociocultural and programmatic levels.

Universal Access to HIV prevention, treatment and care: assessing the inclusion of human rights in international and national strategic plans

Rhetorical acknowledgment of the value of human rights for the AIDS response continues, yet practical application of human rights principles to national efforts appears to be increasingly deficient. We assess the ways in which international and national strategic plans and other core documents take into account the commitments made by countries to uphold human rights in their efforts towards achieving Universal Access. Key documents from the Joint United Nations Programme on HIV and AIDS (UNAIDS), the World Health Organization (WHO), the World Bank, the Global Fund to Fight AIDS, TB and Malaria (GFATM) and the US President's Emergency Plan for AIDS Relief (PEPFAR) were reviewed along with 14 national HIV strategic plans chosen for their illustration of the diversity of HIV epidemic patterns, levels of income and geographical location. Whereas human rights concepts overwhelmingly appeared in both international and national strategic documents, their translation into actionable terms or monitoring frameworks was weak, unspecific or absent. Future work should analyse strategic plans, plans of operation, budgets and actual implementation so that full advantage can be taken, not only of the moral and legal value of human rights, but also their instrumental value for achieving Universal Access.

Condom availability inTaiwanese gay bathhouses: the right things in the wrong places

Gay bathhouses were identified as public venues where men having sex with men are more likely to engage in risky sexual behaviors. This study applied Binson and Woods's (Journal of Homosexuality, 44, 2003) theoretical framework of risk environment/bathhouse setting to (a) describe four domains of bathhouse environments, (b) investigate condom availability in bathhouses, and (c) identify barriers of condom distribution. An ethnographic study was conducted at eight gay bathhouses in Taiwan, including environmental observations, interviews of 16 staff members, and self-administered questionnaires of 409 bathhouse patrons. Condoms were provided upon request in eight bathhouses. Environmental observations showed a poor match between the places where condoms were distributed and where men had sex. Cost and police harassment were two barriers of condom distribution in bathhouses. Our findings highlight the importance of the extension of condom distribution at places where men have sex in gay bathhouses.

Women's reports of condom use in Thai couples under intensive and regular STI/HIV risk reduction counseling

The objective of this study was to determine factors affecting condom use and condom use rates among Thai couples. A cohort of 1,391 reproductive aged women who attended seven family planning clinics in all regions of Thailand and met study eligibility were followed at 3-month intervals for 15-24 months. At each visit, the woman was interviewed about sexual risk behaviors and counseled for sexual risk reduction and condom use. Condoms were provided free of charge. The women were classified into 3 groups according to contraceptive use at baseline: single contraceptive method group, dual methods consisting of contraceptives with condoms, and condoms only. We found that condom use rates were generally low in all contraceptive groups. Significant factors affecting condom use in multivariate analyses included, contraceptive method at baseline, polygynous marriage, higher education, engaging in commercial sex work, multiple sex partners, sex during menses, more frequent sex, laboratory confirmed STIs, husbands spending nights away from home, husbands having sex with other women, and penile ulcers or sores.

AIDS denial in Asia: dimensions and roots

AIDS denial has long been viewed as the obstacle to forging effective response in many Asian countries. This article examines the dimensions and roots of this phenomenon. It identifies seven types of views, attitudes, or tendencies that can be described as denial, dissent, disagreements, or doubts. Three major factors underlying the AIDS denial are discussed. These are (1) historical impressions that STDs are Western diseases, (2) desire of some Asian leaders to forge Eastern points of view, and (3) long-held negative image towards the peoples or groups who happened to be at the front-line of the population groups exposed to the epidemic. The third factor is the most important source of denial. AIDS denial is not a new and isolated phenomenon but the one shaped by the global and historical institutions. Asian AIDS denial reflects the authoritarian and moralist grievances arising from the perceived deterioration of traditional moral order.