Structural interventions to encourage primary HIV prevention among people living with HIV

Re-visiting the relevance and importance of health psychology in South Africa

Health psychology as a discipline has existed for more than four decades and is primarily concerned with research, theory, and practice at the nexus of psychology and health. The discipline is well established across Europe, the United States, and Australia with health psychology societies, postgraduate programmes, conferences, and academic journals dedicated to the discipline in the majority of these countries. However, in South Africa, health psychology remains a broad umbrella term under which psychologists and other health care professionals conduct research. Health psychology is concerned with the biological, social, psychological, contextual, and structural drivers of health and illness, and relies on theory and empirically-driven research to identify and understand important links between health and behaviour. In South Africa, where a large proportion of the population faces multiple co-occurring disease epidemics, such as HIV/AIDS, TB, COVID-19, diabetes, and heart disease, there is a need for a uniting sub-discipline like health psychology to focus intervention efforts and to meet the sustainable development goals. The recent re-establishment of a special interest group in health psychology in the Psychological Society of South Africa (PsySSA) is an important first step. In this article, and as members of the newly re-established special interest group in health psychology, we call attention to the need to promote health psychology in South Africa. In this article, we describe the paradigmatic traditions and theoretical models that inform the discipline. We then argue why health psychology should be prioritised again and recommend future directions for health psychology in South Africa.

HIV epidemic in Mizoram, India: A rapid review to inform future responses

Background & objectives

Mizoram, a northeastern State of India bordering Myanmar, is home to several tribal clans under the ethnic group Mizo: Renthelei, Ralte, Paite, Lai, Hmar, Lusei, Mara, Thado and Kuki. Mizos also reside in the neighbouring northeastern States of Tripura, Assam, Manipur and Nagaland. The majority of Mizo people outside India live across the border in the neighbouring Chin State and Sagaing Region of Myanmar. Over the last decade, Mizoram witnessed a concerning level of rise in HIV prevalence among the general population. The present rapid review was conducted to identify various interventions that could help curb this rising trend.

Methods

An electronic search strategy with broad domains of 'HIV/AIDS', 'key population', 'community engagement' and 'interventions in Mizoram' using PubMed, Embase and Cochrane was adopted; grey literature were also accessed. Evidence, thus gleaned, were synthesized.

Results

Twenty eight resource materials comprising articles, reports and dissertations contributed to the current review. Changing tribal social support structure, early initiation of drugs, sexual debut at an early age and drug-sex interface were identified as factors associated with the progression of HIV epidemic in the State. Issues pertaining to the migration of people across the borders and easy access to drugs continue to be of concern. Churches and youth leaders have a strong influence on the society, at times even constraining access of key population groups to HIV prevention and care services. Tackling stigma and discrimination, ensuring uninterrupted HIV services and creation of an enabling environment in this context seems urgently needed. Incarcerated people in the State have been found with a high level of HIV infection and their linkages with prevention and care services need strengthening.

Interpretation & conclusions

This review underscores the importance of drawing upon successful intervention examples from the past such as 'Friends on Friday' and Red Ribbon Clubs. Active engagement of community-based organizations in programme planning, implementation and monitoring is essential. Establishment of harm reduction interventions for general and key populations paired with strategic communication appear to be the need of the hour.

Monitoring HIV-Related Laws and Policies: Lessons for AIDS and Global Health in Agenda 2030

The National Commitments and Policy Instrument (NCPI) has been used to monitor AIDS-related laws and policies for over 10 years. What can be learnt from this process? Analyses draw on NCPI questionnaires, NCPI responses, the UNAIDS Law Database, survey data and responses to a 2014 survey on the NCPI. The NCPI provides the first and only systematic data on country self-reported national HIV laws and policies. High NCPI reporting rates and survey responses suggest the majority of countries consider the process relevant. Combined civil society and government engagement and reporting is integral to the NCPI. NCPI experience demonstrates its importance in describing the political and legal environment for the HIV response, for programmatic reviews and to stimulate dialogue among stakeholders, but there is a need for updating and in some instances to complement results with more objective quantitative data. We identify five areas that need to be updated in the next iteration of the NCPI and argue that the NCPI approach is relevant to participatory monitoring of targets in the health and other goals of the UN 2030 Agenda for Sustainable Development.

Men Who have Sex with Men Who Believe that Their State has a HIV Criminal Law Report Higher Condomless Anal Sex than Those Who are Unsure of the Law in Their State

We assessed the effects of beliefs about state HIV criminal law on condomless anal sex (CAS < 3 months) among men who have sex with men (MSM) residing in 16 US states (n = 2013; M = 36 years old; 75 % White; 82 % HIV-negative) completing an online survey in 2010 and stratified by residency in a state with any or sex-specific HIV criminal law(s) or where a HIV-related arrest, prosecution, or sentence enhancement (APSE) had occurred. Three-quarters of MSM reported that they were unsure of the law in their state. Men who believed there was a HIV law in their state but lived in states without any or a sex-specific HIV criminal law(s) had higher probabilities of CAS compared to those who were unsure of their state's law; men who believed there was a HIV law in their state and lived in a state where an APSE had occurred had higher probabilities of CAS compared to those who were unsure of their state's law. Correct knowledge of state law was not associated with CAS. Findings suggest that HIV criminal laws have little or counter-productive effects on MSM's risk behavior.

Implications of HIV Disease for Oral Health Services

This paper, by means of a quality framework, reviews health services research in relation to people with HIV infection. The relevance of oral health care services to people’s needs is considered in terms of the goal of health services to reduce the burden of disease on the everyday life of the population. Dental services may therefore have a role in primary prevention in the HIV epidemic, passing on information about HIV and promoting health through the early diagnosis and treatment of oral disease. Effectiveness research of oral health care in HIV assesses the usefulness of oral diagnosis, whether care is safe, and whether treatment is clinically effective. Few data are available on the efficiency of services. People with HIV still have problems accessing dental care, due to the volume of care available in relation to their need and acceptability of care. Access problems in the US are compounded by social inequality. Health services research data are particularly sparse in resource-poor countries, and there is a need to translate the available information into treatment guidelines appropriate to these settings. The research community and funding agencies should place greater emphasis on the quality of oral health services for people with HIV.

Perceived barriers and facilitators to HIV testing in South African communities

We interviewed 15 South Africans seeking HIV testing to understand the factors that influenced their seeking an HIV test. Reasons in favour of testing included having had unprotected sex, availability of social support if testing HIV positive and modelling test-seeking behaviour to others. Reasons against seeking testing included fear testing HIV positive, the possibility of receiving treatment too late, HIV-related stigma and long distances to testing sites. Participants also discussed ways to increase the uptake of HIV testing, such as workplace testing, the role of the media and the role of cultural rituals such as male circumcision.

Health literacy as a process: caseworker perspectives on HIV health literacy

Health status and health literacy are interrelated. Previous research suggests that this relationship must be considered when providing services to HIV positive individuals. However, the pathways through which health literacy affects HIV remain unclear. This study seeks to understand the connections between health literacy and HIV from a caseworker perspective. Results suggest that caseworkers reject static definitions of health literacy by conceptualizing it as an emergent process. Caseworkers also expressed the need for development of subcomponents upon which health literacy is founded: (a) the building of trust, and (b) understanding clients' hierarchy of needs.

The Benefits of Youth Engagement in HIV-Preventive Structural Change Interventions

Youth are infrequently included in planning the health promotion projects designed to benefit them as many of the factors infringing upon youth's health and well-being also limit their engagement in community-based public health promotion projects. This article explores youth engagement in 13 coalitions implementing structural changes meant to reduce HIV transmission among adolescents. There was wide variation of youth membership and involvement across coalitions. Using analytic induction, the authors show that youth engagement was associated with the successful completion of structural change efforts. The authors also describe how youth engagement indirectly facilitated coalitions' success. The authors suggest that youth engagement in planning and conducting structural interventions is itself a valuable structural change.

The relationship between structural barriers to adherence to antiretroviral therapy, psychological distress, and health-related quality of life

We examined the relationship between structural barriers to antiretroviral therapy and quality of life among 291 antiretroviral therapy users in South Africa. We found significant relationships between structural barriers to clinical attendance and pill taking and various dimensions of quality of life. Psychological distress was not found to be a mediator between structural barriers to clinic attendance and indicators of health-related quality of life, although it was a potential mediator between structural barriers to pill taking and some dimensions of quality of life. Psychological distress partially mediated the relationship between structural barriers to pill taking and physical well-being and between structural barriers to pill taking and emotional well-being.

Early warning indicators for first-line virologic failure independent of adherence measures in a South African urban clinic

We sought to develop individual-level Early Warning Indicators (EWI) of virologic failure (VF) for clinicians to use during routine care complementing WHO population-level EWI. A case-control study was conducted at a Durban clinic. Patients after ≥ 5 months of first-line antiretroviral therapy (ART) were defined as cases if they had VF [HIV-1 viral load (VL)>1000 copies/mL] and controls (2:1) if they had VL ≤ 1000 copies/mL. Pharmacy refills and pill counts were used as adherence measures. Participants responded to a questionnaire including validated psychosocial and symptom scales. Data were also collected from the medical record. Multivariable logistic regression models of VF included factors associated with VF (p<0.05) in univariable analyses. We enrolled 158 cases and 300 controls. In the final multivariable model, male gender, not having an active religious faith, practicing unsafe sex, having a family member with HIV, not being pleased with the clinic experience, symptoms of depression, fatigue, or rash, low CD4 counts, family recommending HIV care, and using a TV/radio as ART reminders (compared to mobile phones) were associated with VF independent of adherence measures. In this setting, we identified several key individual-level EWI associated with VF including novel psychosocial factors independent of adherence measures.

Theorising beyond the individual: adherence to antiretroviral therapy in resource-constrained societies

Adherence to antiretroviral therapy, while often conceptualised as an individual or community-level concern, needs to be understood in the context of political and historical developments that have characterised many resource-constrained societies. This article identifies some of these dimensions of antiretroviral therapy adherence in South Africa and outlines the implications for community health psychology in taking this perspective. Using the conceptual apparatus of therapeutic citizenship, we demonstrate the importance of historical, political and other structural barriers to adherence. We conclude by examining the implications of these debates for community health psychology that go beyond the individual as the unit of intervention and analysis.

The development of an inventory to assess the structural barriers to clinic attendance and pill-taking amongst users of antiretroviral therapy

In addition to personal and psychological factors, structural factors may reduce the likelihood of optimal adherence to antiretroviral therapy (ART) among persons living with HIV. In this mixed-method study we report on the development of a scale to assess the salience of various structural barriers to ART adherence. After following conventional guidelines for scale development, two scales measuring structural barriers to adherence to clinic attendance and pill-taking were administered to 291 patients receiving ART at a public hospital in South Africa. Both exploratory and higher order factor analysis indicated that a single underlying general factor was appropriate for both scales. The final scales consisted of 12 items for the structural barriers to clinic attendance scale and 13 items for the structural barriers to medication-taking scale. Both scales displayed excellent internal consistency with Cronbach alpha coefficients above 0.80. Research to determine the construct validity of the scales may be a next step in this line of research.

Agents of change: peer mentorship as HIV prevention among HIV-positive injection drug users

This paper presents a qualitative investigation of peer mentoring among HIV seropositive injection drug users in a randomized controlled trial, the INSPIRE study. Qualitative analyses of 68 in-depth open-ended interviews conducted in 2005 in Baltimore, New York, Miami, and San Francisco revealed that these individuals conceptualized themselves as change agents through the identity of peer mentor at the three related domains of individual, interpersonal, and community-level change. Implications for program development and future research of peer mentoring as a mechanism for HIV prevention are discussed. This study was funded by the Centers for Disease Control and Prevention and Health Resources and Services Administration (HRSA).

Structural barriers to ART adherence in Southern Africa: Challenges and potential ways forward

Structural barriers to antiretroviral therapy (ART) adherence are economic, institutional, political and cultural factors, that collectively influence the extent to which persons living with HIV follow their medication regimens. We identify three sets of structural barriers to ART adherence that are salient in Southern Africa: poverty-related, institutional, and political and cultural. Examples of poverty-related barriers are competing demands in the context of resource-constrained settings, the lack of transport infrastructure, food insecurity, the role of disability grants and poor social support. Examples of institutional factors are logistical barriers, overburdened health care facilities, limited access to mental health services and difficulties in ensuring adequate counselling. Examples of political and cultural barriers are controversies in the provision of treatment for AIDS, migration, traditional beliefs about HIV and AIDS, poor health literacy and gender inequalities. In forging a way forward, we identify ways in which individuals, communities and health care systems may overcome some of these structural barriers. Finally, we make recommendations for further research on structural barriers to ART adherence. In all likelihood, enhancing adherence to ART requires the efforts of a variety of disciplines, including public health, psychology, anthropology, sociology and medicine.

Barriers to Adherence to Antiretroviral Treatment

Patient advocates were asked for their perspectives on the structural barriers to adherence to antiretroviral treatment among patients living with HIV. Poverty-related barriers were transport difficulties, food insecurity and patients’ receipt of a disability grant. Institutional barriers were long waiting times at clinics, negative experiences with clinic staff, low levels of health literacy and poor access to substance abuse treatment. Social and cultural barriers were the role of traditional healing practices, the influence of charismatic churches and perceived stigmatization. We offer a perspective on assisting patients living with HIV in addressing these key structural barriers to adherence.

Broadening Psychology’s Contribution to Addressing Issues of HIV/AIDS, Poverty and Nutrition

HIV/AIDS, more than any other public health problem, challenges dominant models of the role of psychology in health promotion and prevention. This paper focuses on poverty and resulting food insecurity as a structural risk factor for HIV infection. The paper considers the role of health psychology in global health concerns and argues that, while individual-based interventions are important, health psychology needs to shift to playing a proper role in broader level initiatives. Health psychology, in thinking about global health concerns such as HIV, needs to view an understanding of health, education and nutrition delivery programmes in low resourced contexts as at the core of the discipline.

Non-prescription syringe sales in California: a qualitative examination of practices among 12 local health jurisdictions

Legislation permitting non-prescription syringe sales (NPSS) was passed in 2004 in California as a structural intervention designed to expand access to syringes for injection drug users. As of December 2009, 19 of California's 61 local health jurisdictions (LHJs) have approved policies to authorize pharmacies to sell non-prescription syringes. The legislation faces termination in 2010 if current evaluation efforts fail to demonstrate outcomes defined in the legislation. Using qualitative methods, we examined the systems and procedures associated with implementation; identified facilitators and barriers to implementation among 12 LHJs, and documented the role of public health in initiating and sustaining local programs. We identified consistent activities that led to policy implementation among LHJs and discovered several barriers that were associated with failure to implement local programs. Factors leading to NPSS were public health leadership; an inclusive planning process, marketing the program as a public health initiative; learning from others' efforts, successes, and failures; and identifying acceptable syringe disposal options in advance of program implementation. Health departments that were confronted with political and moral arguments lost momentum and ultimately assigned a lower priority to the initiative citing the loss of powerful public health advocates or a lack of human resources. Additional barriers were law enforcement, elected officials, and pharmacy opposition, and failure to resolve syringe disposal options to the satisfaction of important stakeholders. The lessons learned in this study should provide useful guidance for the remaining LHJs in California without NPSS programs.

The role of HIV testing, counselling, and treatment in coping with HIV/AIDS in Uganda: a qualitative analysis

HIV/AIDS has had a devastating impact at individual, household and community levels. This qualitative research investigates the role of HIV voluntary counselling and testing (VCT) and treatment in enabling HIV-positive Ugandans to cope with this disease. Twelve predetermined focus group discussions (FGDs) were conducted; six with men and six with women. Half of the men and women's groups were receiving antiretroviral therapy (ART) and half were not. An FGD was held with the health care providers administering ART. Testing for HIV was perceived as soliciting a death warrant. Participants affirmed that the incentive for testing was the possibility of accessing free ART. They described experiencing gender-variant stigma and depression on confirming their HIV status and commended the role of counselling in supporting them to adopt positive living. For those receiving ART, counselling reinforced treatment adherence. The findings also revealed gender differences in treatment adherence strategies. ART was described to reduce disease symptoms and restore physical health allowing them to resume their daily activities. Additionally, ART was preferred over traditional herbal treatment because it had clear dosages, expiry dates and was scientifically manufactured. Those that were not receiving ART bore myths and misconceptions about the effectiveness and side effects of ART, delaying the decision to seek treatment. Stigma and the attached concern of HIV/AIDS-related swift death, is a major barrier for VCT. Based on this study's findings, ensuring the provision of quality assured and gender conscious VCT and ART delivery services will enhance positive living and enforce compliance to ART programmes.

Preventing mother-to-child transmission of HIV in resource-limited settings

Mother-to-child transmission (MTCT) before, during and after delivery may result in the acquisition of HIV for 30–35% of infants of HIV-infected mothers. Peripartum HIV transmission can be reduced to under 5% in resource-limited settings using a feasible prophylactic antiretroviral regimen. Reducing postnatal transmission through breastfeeding, whilst maintaining child survival, is an urgent priority, given that breastfeeding causes one-third to one-half of all infant HIV infections. Recent evidence highlights the impact of breastfeeding duration and pattern, and hazards associated with the avoidance of breastfeeding in different settings. New international guidelines on HIV and infant feeding have been published. Despite knowledge of how to reduce MTCT of HIV in resource-poor settings, an unacceptably low proportion of women access prevention of MTCT services (PMTCT); follow-up of women and children is poor. To improve survival of mothers and children, health services need to be strengthened, with the integration of PMTCT into existing maternal and child health services.

The virus stops with me: HIV-infected Ugandans' motivations in preventing HIV transmission

Few Positive Prevention interventions have been implemented in Africa; however, greater attention is now being paid to interventions that include messages of personal responsibility or altruism that may motivate HIV-infected individuals towards HIV prevention behaviors in Africa. We conducted 47 in-depth interviews in 2004 with HIV-infected men and women purposefully sampled to represent a range of sexual activities among clients of an AIDS support organization in Uganda. Qualitative interviews were selected from a cross-sectional survey of 1092 HIV-infected men and women. Clients were interviewed about their concerns around sexual HIV transmission, feelings of responsibility and reasons for these feelings, as well as about the challenges and consequences of actions to prevent HIV transmission. The reasons they provided for their sense of prevention responsibility revolved around ethical and practical themes. Responsibility toward sexual partners was linked to the belief that conscious transmission of HIV equals murder, would cause physical and emotional harm, and would leave children orphaned. The primary reason specific to preventing HIV transmission to unborn children was the perception that they are 'innocent'. Most participants felt that HIV-infected individuals held a greater responsibility for preventing HIV transmission than did HIV-uninfected individuals. Respondents reported that their sense of responsibility lead them to reduce HIV transmission risk, encourage partner testing, disclose HIV test results, and assume an HIV/AIDS educator role. Challenges to HIV preventive behavior and altruistic intentions included: sexual desire; inconsistent condom use, especially in long term relationships; myths around condom use; fear of disclosure; gender-power dynamics; and social and financial pressure. Our finding that altruism played an important role in motivating preventive behaviors among HIV-infected persons in Uganda supports the inclusion of altruistic prevention and counseling messages within Positive Prevention interventions.

Paucity of CD4+ CCR5+ T cells may prevent transmission of simian immunodeficiency virus in natural nonhuman primate hosts by breast-feeding

Simian immunodeficiency virus (SIV) persistence in wild populations of African nonhuman primates (NHPs) may occur through horizontal and vertical transmission. However, the mechanism(s) and timing of the latter type of transmission have not been investigated to date. Here we present the first study of SIV transmissibility by breast-feeding in an African NHP host. Six mandrill dames were infected with plasma containing 300 50% tissue culture infective doses of SIVmnd-1 on the day after delivery. All female mandrills became infected, as demonstrated by both plasma viral loads (VLs) and anti-SIVmnd-1 seroconversion. Neither fever nor lymphadenopathy was observed. At the peak of SIVmnd-1 viral replication (days 7 to 10 postinoculation), plasma VLs were high (8 x 10(6) to 8 x 10(8) RNA copies/ml) and paralleled the high VLs in milk (4.7 x 10(4) to 5.6 x 10(5) RNA/ml). However, at the end of the breast-feeding period, after 6 months of follow-up, no sign of infection was observed for the offspring. Later on, during a 4-year follow-up examination, two of the offspring showed virological evidence of SIVmnd-1 infection. Both animals seroconverted at least 6 months after the interruption of lactation. In conclusion, despite extensive viral replication in mandrill mothers and high levels of free virus in milk, no SIVmnd-1 transmission was detectable at the time of breast-feeding or during the following months. Since we observed a markedly lower expression of CCR5 on the CD4(+) T cells of young mandrills and African green monkeys than on those of adults, we propose that low levels of this viral coreceptor on CD4(+) T cells may be involved in the lack of breast-feeding transmission in natural hosts of SIVs.

Predictors of success in implementing HIV prevention in rural America: a state-level structural factor analysis of HIV prevention targeting men who have sex with men

Relatively few studies have examined the impact of modifying structural factors on HIV prevention efforts in the United States despite their high potential for lowering HIV prevalence rates. The aim of this study was to identify state-level characteristics of successful HIV prevention implementation. Structured interviews with 73 key informants in 13 rural states identified 'more successful' and 'less successful' states in HIV prevention. States were compared on demographic, religious, gay community, and funding variables. The 7 more successful states had both a wider variety and more MSM-targeted interventions. Overall funding, degree of epidemic, and "ruralness" were not significantly associated with success. Rather, successful states had less religious and Evangelical Protestant adherents and more 'gay community' infrastructure. They also spent a greater proportion of funds contracting community-based organizations and on MSM-targeted programming. Success in HIV prevention varies across rural states. Key demographic, social and economic indicators distinguish success in HIV prevention.

Why housing?

Housing/lack of housing and HIV are powerfully linked. Housing occupies an important place in the causal chains linking poverty and inequality, and HIV risk and outcomes of infection. The articles in this Special Supplement of AIDS and Behavior confirm the impact of homelessness, and poor or unstable housing, on HIV/AIDS, and challenge scientists to test and policy makers to implement the promise of housing as an innovative response to the epidemic. In order to influence the development of policies on housing to benefit at-risk or HIV-infected persons, however, proponents must justify why this association exists, and how housing can help end the epidemic as well as improve the care and health of persons living with HIV/AIDS. We introduce this supplement with a discussion of the "why" question.

HIV and housing assistance in four U.S. cities: variations in local experience

This paper provides an account of how young, HIV-positive women manage their lives on limited budgets in four United States cities: New York City, New Orleans, Miami, and Chicago. The study findings elucidate city-to-city variability in housing assistance, and how this manifests in locality specific differences in the experience of HIV. Our research suggests that the receipt of housing assistance has ramifications for women's engagement in care, and for their health. Women not receiving aid often move frequently in and out of homelessness, or "double up" with others in complex household arrangements to share costs. Women with long-term housing assistance, while still struggling financially, possess a stable base from which to approach daily life and HIV care. This account suggests a need for empirical research assessing the impact of local variations in housing assistance on specific health outcomes for those with HIV. It also highlights the importance of understanding local contexts when designing housing interventions at both the individual and structural levels.

The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review

Partner counseling and referral services (PCRS) are part of the spectrum of care for HIV-positive people and their sexual or needle-sharing partners. Referral includes notifying partners of exposure, after which they are (ideally) tested and receive prevention or risk reduction counseling or enter into care (if they test positive). Using The Guide to Community Preventive Services's methods for systematic reviews, the effectiveness of PCRS was evaluated, including partner notification, in identifying a population at high risk of HIV infection and in increasing testing in those populations. In this review, PCRS efforts using provider referral were found to be effective in reaching a population with a high prevalence of HIV. Nine studies qualified for the review. In these studies, a range of one to eight partners was identified per index case (a person newly diagnosed with HIV who has partners who should be notified); a mean of 67% of identified partners were found and notified of their potential exposure to HIV, and a mean of 63% of those notified were tested (previously known "positives" were not tested). Of those tested, a mean of 20% were HIV positive. Therefore, even given that not all partners could be found and notified and that some who could be found did not accept testing, 1% to 8% of people named as potentially exposed and not previously known to be HIV positive were identified as HIV positive through partner notification (although these people were not necessarily infected by the index case). Evidence was insufficient to determine whether PCRS, including partner notification, was also effective in changing behavior or reducing transmission because available studies did not generally report on these outcomes. Little empirical evidence was available to assess potential harm of the interventions, but current studies have not shown substantial harms. Based on Community Guide rules of evidence, sufficient evidence shows that PCRS with partner notification by a public health professional ("provider referral") effectively increases identification of a high-prevalence target population for HIV testing.

Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV

Twenty-three U.S. states currently have laws that make it a crime for persons who have HIV to engage in various sexual behaviors without, in most cases, disclosing their HIV-positive status to prospective sex partners. As structural interventions aimed at reducing new HIV infections, the laws ideally should complement the HIV prevention efforts of public health professionals. Unfortunately, they do not. This article demonstrates how HIV disclosure laws disregard or discount the effectiveness of universal precautions and safer sex, criminalize activities that are central to harm reduction efforts, and offer, as an implicit alternative to risk reduction and safer sex, a disclosure-based HIV transmission prevention strategy that undermines public health efforts. The article also describes how criminal HIV disclosure laws may work against the efforts of public health leaders to reduce stigmatizing attitudes toward persons living with HIV.

Policy perspectives on public health for Mexican migrants in California

This analysis focuses on public policies that affect primary HIV prevention and access to HIV care for Mexican migrants residing in California. Policy or structural level interventions, as opposed to behavioral or psychologic interventions, help to shape the environment in which people live. We use a conceptual model for policy analysis in public health to understand better the challenges faced by Mexican migrants. We assess potential policy level interventions that may serve as barriers to or facilitators of primary HIV prevention and care for Mexican migrants. Among potential barriers, we discuss restrictions on public health services based on legal immigration status, limits placed on affirmative action in education, and laws limiting travel and immigration. Under potential facilitators, we discuss community and migrant health centers, language access laws, and the use of community-based groups to provide prevention and treatment outreach. We also report on the limited research evaluating the implications of these public policies and ways to organize for more responsive public policies.

Methamphetamine-dependent gay men's disclosure of their HIV status to sexual partners

Disclosure of one's HIV status to a potential sexual partner has important HIV prevention implications. This paper qualitatively evaluates the social and sexual contexts that influence disclosure of HIV status among methamphetamine-dependent gay men enrolled in an outpatient drug treatment research program. As part of an open-ended, semi-structured interview, 34 HIV-positive and HIV-negative men discussed how, when, to whom and under what circumstances they reveal information about their HIV status. The four factors that influence participants' decision to disclose include: (1) an HIV-negative sexual partner's disclosure; (2) sexual venue (private versus public); (3) primary versus non-primary partner; and (4) the perceived risk of the sexual act. Sexual encounters among the men in this sample often occurred in public environments with non-primary partners, and involved use of illicit substances. In these social and sexual contexts, both HIV-positive and HIV-negative participants believed that it is HIV-negative rather than HIV-positive men who should initiate safer sex dialogue and safer sex practices. Findings are helpful in crafting HIV-prevention interventions targeting substance-using gay men whose sexual practices place them at high-risk for HIV-infection.

Estimating the net effect of HIV on child mortality in African populations affected by generalized HIV epidemics

For a given prevalence, HIV has a relatively higher impact on child mortality when mortality from other causes is low. To project the effect of the epidemic on child mortality, it is necessary to estimate a realistic schedule of "net" age-specific mortality rates that would operate if HIV were the only cause of child death observable. We assume that this net pattern would be independent of mortality from other causes. We used African studies that measured the survival of HIV-infected children (direct data) or survival of children of HIV-infected mothers (indirect data). We developed a mathematic procedure to estimate the mortality of infected children from indirect data sources and obtained net HIV mortality patterns for each study population. The net age-specific HIV mortality pattern for infected children can be described by a double Weibull curve fitted to empiric data; this gives a functional representation of age-specific mortality rates that decline after infancy and rise in the preteens. The fitted curve that we would expect if HIV were the only effective cause of death shows 67% net survival at 1 year and 39% at 5 years. The curve also predicts 13% net survival at 10 years using constraints based on survival of infected adults.

Cost-effectiveness of HIV screening for incarcerated pregnant women

Antiretroviral therapy (ART) initiated on a prenatal basis in HIV-infected pregnant women is a highly effective method for preventing mother-to-child HIV transmission. We developed a decision analytic model to project the clinical and economic outcomes of alternative HIV screening strategies (voluntary prenatal screening [VPS], routine prenatal screening [RPS], and mandatory newborn screening [MNS]) for a high-risk population of incarcerated pregnant women. Data for the decision model came from the HIV voluntary counseling and testing program at Connecticut's sole correctional facility for women and a comprehensive anonymously linked serosurvey of all inmates who entered the facility during the 2-year period beginning in October 1994. Based on serosurvey results, in the absence of any HIV screening program, 2.5 cases of pediatric HIV infection would be expected per 1000 pregnancies. Multiplied by the discounted lifetime cost per case of $247,000, this translates to a cost of $624 per testing-eligible prison entrant. Entrants were considered eligible if they were pregnant and their HIV status was unknown. MNS would save money, cost $364 per eligible entrant, and simultaneously reduce the rate of infections to 1.1 per 1000 pregnancies. Doing both MNS and RPS is most effective in reducing the rate of new infections (down to 0.2 per 1000 pregnancies). It would, however, increase costs to $430 per eligible entrant. This would result in an incremental cost of $73,603 per additional pediatric HIV case averted when compared with MNS alone. If mandatory newborn testing was not considered a feasible option, RPS would dominate VPS and would be cost-saving compared with no screening. RPS compares favorably with alternative uses of HIV prevention and treatment resources. In correctional facilities where voluntary newborn screening is already in place, our findings show that there remains a small marginal benefit to be realized from switching to RPS. In settings where HIV screening policies are not in place, however, the implementation of RPS can be expected to significantly reduce pediatric HIV cases and net health care expenditures.

Breast-feeding and Transmission of HIV-1

Breast-feeding substantially increases the risk of HIV-1 transmission from mother to child, and although peripartum antiretroviral therapy prophylaxis significantly decreases the risk of mother-to-child transmission around the time of delivery, this approach does not affect breast-feeding transmission. Increased maternal RNA viral load in plasma and breast milk is strongly associated with increased risk of transmission through breast-feeding, as is breast health, and it has been suggested that exclusive breast-feeding could be associated with lower rates of breast-feeding transmission than mixed feeding of both breast- and other milk or feeds. Transmission through breast-feeding can take place at any point during lactation, and the cumulative probability of acquisition of infection increases with duration of breast-feeding. HIV-1 has been detected in breast milk in cell-free and cellular compartments; infant gut mucosal surfaces are the most likely site at which transmission occurs. Innate and acquired immune factors may act most effectively in combination to prevent primary HIV-1 infection by breast milk.

HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa

OBJECTIVES

A cornerstone of HIV prevention in South Africa is voluntary HIV antibody counselling and testing (VCT), but only one in five South Africans aware of VCT have been tested. This study examined the relation between HIV testing history, attitudes towards testing, and AIDS stigmas.

METHODS

Men (n = 224) and women (n = 276) living in a black township in Cape Town completed venue intercept surveys; 98% were black, 74% age 35 or younger.

RESULTS

47% of participants had been tested for HIV. Risks for exposure to HIV were high and comparable among people tested and not tested. Comparisons on attitudes toward VCT, controlling for demographics and survey venue, showed that individuals who had not been tested for HIV and those tested but who did not know their results held significantly more negative testing attitudes than individuals who were tested, particularly people who knew their test results. Compared to people who had been tested, individuals who were not tested for HIV demonstrated significantly greater AIDS related stigmas; ascribing greater shame, guilt, and social disapproval to people living with HIV. Knowing test results among those tested was not related to stigmatising beliefs.

CONCLUSIONS

Efforts to promote VCT in South Africa require education about the benefits of testing and, perhaps more important, reductions in stigmatising attitudes towards people living with AIDS. Structural and social marketing interventions that aim to reduce AIDS stigmas will probably decrease resistance to seeking VCT.

Infant Feeding Practices of Women in a Perinatal HIV-1 Prevention Study in Nairobi, Kenya

OBJECTIVE

To determine feeding practices and nutritional status of infants born to HIV-1-infected women.

METHODS

Feeding plans and practices were evaluated by questionnaires and focus group discussions. Infants were weighed at 1 and 6 weeks and tested for HIV-1 at 6 weeks.

RESULTS

Of 128 women seen after delivery, 111 completed the study. Mothers who planned to breast feed were more likely to feed their infants as planned (86% vs. 55%; P < 0.001). Women opted to breast feed due to financial constraints, partner influence, and fear of losing confidentiality. Women who reported that their partners were willing to have HIV-1 testing were less likely to be breast feeding at 6 weeks (odds ratio [OR] = 0.3, 95% confidence interval [CI]: 0.1-0.8; P = 0.01). At 6 weeks, more infants were mixed fed (31% vs. 21%; P = 0.05) than at 1 week. Lower infant weight at 6 weeks was associated with not breast feeding (P = 0.001), HIV-1 infection (P = 0.05), birth weight <3000 g (P = 0.01), maternal employment (P = 0.02), and paying <$12.5 per month in house rent (among infants not breast fed; P = 0.05).

CONCLUSIONS

Replacement feeding was difficult, particularly without partner support in HIV-1 testing. Mixed feeding was common and increased by 6 weeks. Mothers of low socioeconomic status who opt not to breast feed require support to avoid nutritional compromise of infants.

Sex without disclosure of positive HIV serostatus in a US probability sample of persons receiving medical care for HIV infection

OBJECTIVES

We estimated the proportion of HIV-positive adults who have any sexual contact without disclosure and the proportion of their sexual partnerships that involve unprotected sex without disclosure.

METHODS

We drew participants from the HIV Cost and Services Utilization Study (n = 1421). Interviews assessed disclosure and sexual activities with up to 5 recent partners.

RESULTS

Overall, 42% of the gay or bisexual men, 19% of the heterosexual men, and 17% of all the women reported any sex without disclosure, predominately within nonexclusive partnerships (P <.001). Across all groups, 13% of serodiscordant partnerships involved unprotected anal or vaginal sex without disclosure, with no significant difference between groups.

CONCLUSIONS

Risky sex without disclosure of serostatus is not uncommon among people with HIV.

Breast-feeding and HIV-1 transmission in resource-limited settings

In many international settings, transmission of the HIV virus during lactation accounts for one third to one half of all HIV transmission from mothers to infants. Reduction of HIV transmission during lactation is one of the most pressing public health dilemmas confronting perinatal researchers, health policy makers, and HIV-infected women in many areas of the world. While results of clinical trials, laboratory and observational studies have increased our understanding of risk factors for breast-feeding transmission and the timing of postnatal transmission, there are no proven strategies known to reduce the risk of HIV transmission during breast-feeding for those HIV-infected women who opt to breast-feed in developing countries. Approaches to decreasing transmission of HIV through breast-feeding that will be studied include trials of combination antiretrovirals given to mothers during lactation. These research efforts using maternal antiretrovirals for perinatal HIV prevention during breast-feeding will interface with emerging plans for treatment programs in developing countries.

Estimating the efficacy of interventions to prevent mother-to-child transmission of HIV in breast-feeding populations: development of a consensus methodology

Postnatal transmission of HIV through breast milk complicates both the design of effective interventions to prevent mother-to-child transmission of HIV (PMTCT) and their evaluation. Estimated long-term efficacy in five African trials (four with peri-partum antiretrovirals and one with artificial feeding) varied from 25 to 50 per cent. This variation may be due, at least in part, to differences in analytical methodology. To facilitate direct comparison between trials, a methodological consensus approach to the analysis and presentation of the results of PMTCT trials was developed. The initial methodology used and results presented from African trials with available long-term efficacy data were reviewed during a workshop in Bordeaux, France, in September 2000. A consensus approach for evaluating efficacy applicable across PMTCT studies was developed. There are four typical situations defined by duration of follow-up (short versus long), and the available demographic (vital status) and biological data (single versus repeat HIV testing). Efficacy can be assessed from the risk of infection directly or from HIV-free survival by combining infection and death as a single endpoint. Studies should report results in a standardized format including infection, weaning, mortality and loss to follow-up. New statistical methods that account for the unknown date when a child would first test positive for HIV, for weaning as a competing risk for HIV infection, and for increased risk of death among HIV-infected children should be used in analysing data from PMTCT studies with repeat HIV testing. All estimates should be reported with confidence intervals. This standardized methodology that allows direct comparison between studies is now being applied to four randomized clinical trials.

Early detection of HIV: assessing the legislative context

Early detection of HIV has important implications for both prevention and treatment. Promoting HIV testing, and thereby early detection, however, is a complicated task that must balance the interests of public health, personal privacy, and legislative efforts to curb transmission. This article assesses the legislative context within which public health officials must operate to promote early HIV identification. Specifically, the article reviews United States laws regarding HIV testing passed over the course of 3 years, 1997 to 1999, at the state-not the federal-level. The new laws demonstrate such major themes as limiting confidentiality of HIV test results, mandating name-based HIV reporting, partner notification and newborn testing, and criminalizing nondisclosure of HIV status in sexual and needle-sharing situations. The article evaluates these new laws and their potentially negative impact on early detection, and assesses implications for practices such as informed consent for HIV testing. Outcome evaluations of newly implemented state laws are recommended. Policy makers must be aware that these policy changes can either encourage or discourage HIV testing.