The Open Burning of Plastic Wastes is an Urgent Global Health Issue

The open burning of mixed wastes that contain plastics is a widespread practice across the globe, resulting in the release of gas emissions and ash residues that have toxic effects on human and environmental health. Although plastic pollution is under scrutiny as a pressing environmental concern, it is often conflated with plastic litter, and the contribution of the open burning of plastics to air, soil, and water pollution gets overlooked. Therefore, campaigns to raise awareness about plastic pollution often end up leading to increased open burning. Many countries or regions where open burning is prevalent have laws in place against the practice, but these are seldom effective. In this viewpoint, we direct attention to this critical but largely overlooked dimension of plastic pollution as an urgent global health issue. We also advocate interventions to raise awareness about the risks of open burning and emphasize the necessity of phasing out some particularly pernicious plastics in high-churn, single-use consumer applications.

Confident futures: Community-based organizations as first responders and agents of change in the face of the Covid-19 pandemic

This comparative study of community organizations serving marginalized youth in New York City and Amsterdam utilized a novel ethnographic approach called reverse engineering to identify techniques for social change that are active in each organization, adaptable and translatable to other contexts. It found that youth-serving organizations led flexible responses to the crisis of COVID-19 as it affected those marginalized by race, immigrant status, housing instability, religion and gender. The organizations employed techniques that they had previously developed to cultivate youth well-being – among them connectivity, safe space, and creativity – to mount tailored responses to COVID-19 related crises. In New York City, these groups addressed crises of material survival resources (personal protective equipment, food, housing) whereas in Amsterdam, youth-serving organizations focused on social connections and emotional well-being as the government met more of participants’ material needs.

The role of self-care interventions on men's health-seeking behaviours to advance their sexual and reproductive health and rights

BACKGROUND

Self-care interventions are influencing people's access to, expectation and understanding of healthcare beyond formal health delivery systems. In doing so, self-care interventions could potentially improve health-seeking behaviours. While many men proactively engage in maintaining and promoting their health, the focus on men's health comes from the recognition, at least partially, that male socialization and social norms can induce men and boys to have a lower engagement in institutionalized public health entities and systems around their sexual and reproductive health and rights, that could impact negatively on themselves, their partners and children.

MAIN TEXT

A research agenda could consider the ways that public health messaging and information on self care practices for sexual and reproductive health and rights could be tailored to reflect men's lived realities and experiences. Three examples of evidence-based self-care interventions related to sexual and reproductive health and rights that men can, and many do, engage in are briefly discussed: condom use, HIV self-testing and use of telemedicine and digital platforms for sexual health. We apply four core elements that contribute to health, including men's health (people-centred approaches, quality health systems, a safe and supportive enabling environment, and behaviour-change communication) to each intervention where further research can inform normative guidance.

CONCLUSION

Engaging men and boys and facilitating their participation in self care can be an important policy intervention to advance global sexual and reproductive health and rights goals. The longstanding model of men neglecting or even sabotaging their wellbeing needs to be replaced by healthier lifestyles, which requires understanding how factors related to social support, social norms, power, academic performance or employability conditions, among others, influence men's engagement with health services and with their own self care practices.

Are psychotic-like experiences related to a discontinuation of cannabis consumption in young adults?

OBJECTIVE

To assess changes in cannabis use in young adults as a function of psychotic-like experiences.

METHOD

Participants were initially recruited at age 14 in high schools for the longitudinal IMAGEN study. All measures presented here were assessed at follow-ups at age 19 and at age 22, respectively. Perceived stress was only assessed once at age 22. Ever users of cannabis (N = 552) gave qualitative and quantitative information on cannabis use and psychotic-like experiences using the Community Assessment of Psychic Experiences (CAPE). Of those, nearly all n = 549 reported to have experienced at least one psychotic experience of any form at age 19.

RESULTS

Mean cannabis use increased from age 19 to 22 and age of first use of cannabis was positively associated with a change in cannabis use between the two time points. Change in cannabis use was not significantly associated with psychotic-like experiences at age 19 or 22. In exploratory analysis, we observed a positive association between perceived stress and the experience of psychotic experiences at age 22.

CONCLUSION

Age of first use of cannabis influenced trajectories of young cannabis users with later onset leading to higher increase, whereas the frequency of psychotic-like experiences was not associated with a change in cannabis use. The observed association between perceived stress and psychotic-like experiences at age 22 emphasizes the importance of stress experiences in developing psychosis independent of cannabis use.

Chemical 24/7

This chapter shines a light on what happens in the dark: specifically, we present ethnographic insights from the nightlife economy and how chemicals enable youth to work “24/7.” Producers, promoters, DJs, hosts, artists, performers, drag queens, musicians, stage managers, bartenders, hospitality girls, and dancers from Amsterdam, Brooklyn, Bira (Indonesia), and Puerto Princesa (the Philippines) share with the ChemicalYouth team the various stimulants they use to stay awake and perform their jobs during non-typical working hours, and the other chemicals that they take in order to be able to sleep and recover afterwards. In Chemical 24/7 we compare and contrast the chemical practices of youth working at leisure industry sites in the global North to those of the low-income service sector and manual workers in the global South, and discuss how these different working conditions perpetuate chemical use. Our interlocutors rely on a range of chemicals for their work and social lives, and they develop practices to moderate their use in order to avoid adverse effects. Yet their practices differ depending on the availability, marketing, and policing of the substances.

‘The ethnography of everyday life’

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Experimental Trajectories of Young Users of Psycho-active Prescription Drugs in Urban Indonesia

In Indonesia, a country with stringent drug laws, psycho-active prescription drugs (PPDs) have become popular among urban youth as they are seen to be safe – both medically and in terms of the risks of being arrested. During the ChemicalYouth project, which involved a multi-sited ethnography in urban centers in South Sulawesi (Makassar, Gowa, and Maros) and in Yogyakarta, we found that young people encourage each other to try out different kinds of PPDs to determine which (combinations) work best for them. Sharing their experiences, they jointly build up knowledge that guides their ‘experimental trajectories’ (Raikhel and Garriott 2013). The experimental trajectories of youths are enabled by pharmacies, where young people can buy PPDs, and private sector doctors who sell and prescribe PPD prescriptions. When certain PPDs become harder to get, young people will try out new substances in their search for happiness, highs, and the confidence and stamina needed to perform precarious informal sector jobs such as sex work, street singing, and helping people park their cars. Across the sites, the researchers encountered young people realizing that they had become addicted to PPDs. Simultaneously, health workers lack instruments to prevent harm related to PPD use as they work in public sector harm reduction programs designed narrowly to address illicit heroin addiction. We argue that educational interventions need to address the desires and aspirations for good enough lives that are reflected in young people’s creative poly-drug use practices, and the iatrogenic effects of unregulated pharmaceutical markets that enable medicalization of precarious lives.

Beyond health: medicines, food supplements, energetics and the commodification of self-performance in Maputo

With an increasing range of products in global and local markets, more options are available for individuals to enhance their image and their (cognitive, social and physical) performance. These 'performance consumptions' relate to ideals of well-being and improvement, and are based on constructed desires, expectations and needs that go beyond the (often blurred) dichotomy of health and illness. Drawing from mixed-methods research in Maputo, Mozambique, this paper discusses individuals' use of medicines and other substances - pharmaceuticals, food supplements, traditional herbs, cosmetics and energy drinks - for managing different aspects of their everyday lives. Through an overview of the main consumption practices, we explore the underlying purposes and strategies of users, and the perceived legitimacy and risks involved when using a variety of products accessible through formal and informal exchange channels. From tiredness to sexual and aesthetic management, we show how the body becomes the locus of experimentation and investment to perform in accordance with socially expected roles, individual aspirations and everyday tasks. With insights from individuals' accounts in Maputo, we aim to add to discussions on pharmaceuticalisation of body management by showing how the emergence of new performance consumptions is articulated with the reconfiguration of more 'traditional' consumption practices.

Sexual and reproductive self care among women and girls: insights from ethnographic studies

Ethnographic studies examining how women manage their sexual and reproductive health can inform strategies to address unmet needs, say Anita Hardon and colleagues

Zoonotic Transmission of mcr-1 Colistin Resistance Gene from Small-Scale Poultry Farms, Vietnam

We investigated the consequences of colistin use in backyard chicken farms in Vietnam by examining the prevalence of mcr-1 in fecal samples from chickens and humans. Detection of mcr-1–carrying bacteria in chicken samples was associated with colistin use and detection in human samples with exposure to mcr-1–positive chickens.

Fluid Drugs: Revisiting the Anthropology of Pharmaceuticals

This review discusses a growing body of scholarship at the intersection of anthropology and science and technology studies (STS) that examines how drugs are rendered efficacious in laboratories, therapeutic settings, and everyday lives. This literature foregrounds insights into how commercial interests and societal concerns shape the kinds of pharmaceutical effects that are actualized and how some efficacies are blocked in response to moral concerns. The work brought together here reveals how regulatory institutions and health policy makers seek to stabilize pharmaceutical actions while, on the front lines of care, pharmacists, health workers, and users tinker with dosages and indications to tailor pharmaceutical actions to specific circumstances. We show that there is no pure (pharmaceutical) object that precedes its socialization. Pharmaceuticals are not “discovered”; they are made and remade in relation to shifting contexts. This review outlines five key areas of ethnographic and STS research that examines such fluid drugs.

Anthropology with algorithms?

Based on a study of more than twenty thousand reports on drug experiences from the online drug education portal Erowid, this article argues that the integration of ethnographic methods with computational methods and digital data analysis, including so-called big data, is not only possible but highly rewarding. The analysis of ‘natively’ digital data from sites like Facebook, message boards, and web archives can offer glimpses into worlds of practice and meaning, introduce anthropologists to user-based semantics, provide greater context, help to re-evaluate hypotheses, facilitate access to difficult fields, and point to new research questions. This case study generated important insights into the social and political entanglements of drug consumption, drug phenomenology, and harm reduction. We argue here that deep ethnographic knowledge, what we term ‘field groundedness’, is indispensable for thoroughly making sense of the resulting visualizations, and we advocate for seeing ethnography and digital data analysis in a symbiotic relationship.

Access for all: contextualising HIV treatment as prevention in Swaziland

This article explores how notions of the individual and population are evoked in two ongoing HIV treatment as prevention (TasP) implementation studies in Swaziland. By contrasting policy discourses with lived kinship experiences of people living with HIV, we seek to understand how TasP unfolds in the Swazi context. Data collection consisted of eight focus group discussions with people living with HIV who were members of support groups to examine their perspectives about TasP. In addition, 18 key informant interviews were conducted with study team members, national-level policy-makers and NGO representatives involved in the design of health communication messages about TasP in Swaziland. Thematic analysis was used to identify recurrent themes in transcripts and field notes. Policy-makers and people living with HIV actively resisted framing HIV treatment as a prevention technology but promoted it as (earlier) access to treatment for all. TasP was not conceptualised in terms of individual or societal benefits, which are characteristic of international public health debates; rather its locally situated meanings were embedded in kinship experiences, concerns about taking responsibility for one's own health and others, local biomedical knowledge about drug resistance, and secrecy. The findings from this study suggest that more attention is needed to understand how the global discourse of TasP becomes shaped in practice in different cultural contexts.

Anthropologists in Global Health Experiments

Can global health experiments be part of more flexible systems of knowledge generation, where different bodies of knowledge come together to provide understanding not only of the outcomes of new interventions but also of the mechanisms through which they affect people's well-being and health? Building past work in which they tried to transform how global health experiments are carried out and inspired by the articles in this special issue, the authors of this commentary argue that strategic collaboration is needed to break the hegemony of randomized controlled trials in designing global health technologies. More open-ended experiments are possible if anthropologists team up with innovative researchers in biomedicine to develop new conceptual models and to adopt novel observational techniques and 'smart' trials that incorporate ethnography to unravel complex interactions between local biologies, attributes of health systems, social infrastructures, and users' everyday lives.

Coming of age, becoming obese: a cross-sectional analysis of obesity among adolescents and young adults in Malaysia

BACKGROUND

Malaysians have become increasingly obese over recent years. The transition from adolescence to early adulthood is recognized as critical for the development of eating and activity habits. However, little obesity-related research focuses on this life stage. Drawing on data from a health and demographic surveillance site in Malaysia, this article describes obesity and overweight amongst adolescents and young adults in a multi-ethnic population.

METHODS

Data were collected at the South East Asia Community Observatory (SEACO) in Segamat District, Johor. In this dynamic cohort of approximately 40,000 people, 5,475 were aged 16-35 in 2013-2014. The population consists of Malay, Chinese, Indian and Indigenous (Orang Asli) families in proportions that reflect the national ethnic diversity. Data were collected through health profiles (Body Mass Index [BMI] measurements in homes) and self-report questionnaires.

RESULTS

Age and ethnicity were associated with overweight (BMI 25.0-29.9Kg/m2) and obesity (BMI ≥ 30Kg/m2). The prevalence of overweight was 12.8 % at ages 16-20 and 28.4 % at ages 31-35; obesity was 7.9 % and 20.9 % at the same age groups. The main ethnic groups also showed varied patterns of obesity and overweight at the different age groups with Chinese at lowest and Orang Asli at highest risk. Level of education, employment status, physical activity and frequency of eating out were poorly predictive of overweight and obesity.

CONCLUSION

The pattern of overweight and obesity in the 16-35 age group further highlights this as a significant period for changes in health-related behaviours. Further longitudinal research is however needed to confirm the observed pattern and investigate causal factors.

Educated Guesses and Other Ways to Address the Pharmacological Uncertainty of Designer Drugs: An Exploratory Study of Experimentation Through an Online Drug Forum

This study examines how experimentation with designer drugs is mediated by the Internet. We selected a popular drug forum that presents reports on self-experimentation with little or even completely unexplored designer drugs to examine: (1) how participants report their “trying out” of new compounds and (2) how participants reduce the pharmacological uncertainty associated with using these substances. Our methods included passive observation online, engaging more actively with the online community using an avatar, and off-line interviews with key interlocutors to validate our online findings. This article reflects on how forum participants experiment with designer drugs, their trust in suppliers and the testimonials of others, the use of ethno-scientific techniques that involve numerical weighing, “allergy dosing,” and the use of standardized trip reports. We suggest that these techniques contribute to a sense of control in the face of the possible toxicity of unknown or little-known designer drugs. The online reporting of effects allows users to experience not only the thrill of a new kind of high but also connection with others in the self-experimenting drug community.

Prevalence and risk factors for carriage of antimicrobial-resistant Escherichia coli on household and small-scale chicken farms in the Mekong Delta of Vietnam

OBJECTIVES

To describe the prevalence of antimicrobial resistance among commensal Escherichia coli isolates on household and small-scale chicken farms, common in southern Vietnam, and to investigate the association of antimicrobial resistance with farming practices and antimicrobial usage.

METHODS

We collected data on farming and antimicrobial usage from 208 chicken farms. E. coli was isolated from boot swab samples using MacConkey agar (MA) and MA with ceftazidime, nalidixic acid or gentamicin. Isolates were tested for their susceptibility to 11 antimicrobials and for ESBL production. Risk factor analyses were carried out, using logistic regression, at both the bacterial population and farm levels.

RESULTS

E. coli resistant to gentamicin, ciprofloxacin and third-generation cephalosporins was detected on 201 (96.6%), 191 (91.8%) and 77 (37.0%) of the farms, respectively. Of the 895 E. coli isolates, resistance to gentamicin, ciprofloxacin and third-generation cephalosporins was detected in 178 (19.9%), 291 (32.5%) and 29 (3.2%) of the isolates, respectively. Ciprofloxacin resistance was significantly associated with quinolone usage (OR = 2.26) and tetracycline usage (OR = 1.70). ESBL-producing E. coli were associated with farms containing fish ponds (OR = 4.82).

CONCLUSIONS

Household and small farms showed frequent antimicrobial usage associated with a high prevalence of resistance to the most commonly used antimicrobials. Given the weak biocontainment, the high prevalence of resistant E. coli could represent a risk to the environment and to humans.

Magic Power: changing gender dynamics and sex-enhancement practices among youths in Makassar, Indonesia

This paper examines changing sexualities and gender relations as they are reflected in the use of sexual enhancement products by young women and men in the eastern Indonesian city of Makassar. To examine the relationships between the use of these products and socially sanctioned gender roles, their 'gender scripts' were studied--the assumptions embedded in the products' design and advertising. What kinds of femininity and masculinity are expressed through their use? It was found that the most popular products--'magic tissues' that promise to prolong erections and a 'neotraditional' vaginal wash that promises to cleanse, perfume, and tighten vaginas--espouse the dual purpose of promoting sexual pleasure and hygiene. While it was found that the images in advertising to reflect changing gender relations in the field site, this research also points to enduring gender scripts in Indonesian culture: men should be virile, women should be clean and attractive.

Medical technologies: flows, frictions and new socialities

While social scientists often highlight the way medical technologies mediate biomedical hegemony, this special issue focuses on the creative and often unexpected ways in which medical technologies are appropriated by diverse actors in homes, clinics and communities. The authors highlight key insights from twelve ethnographic case studies conducted in North and South America, Western Europe, Sub-Saharan Africa and Southeast Asia. The case studies focus on, among other issues, how sperm donors in Denmark, despite being subjugated to medical surveillance, experience the act of donating sperm as liberating; how sex workers in Indonesia turn to psychoactive painkillers to feel confident when approaching clients; why some anorexic patients in the United States resist prescribed antidepressant drugs; and how adolescent sex education workshops in Ecuador are appropriated by mothers to monitor their daughters and shame their 'lying husbands'. Hardon and Moyer conclude that studies of medical technology need to be sensitive to the micro-dynamics of power, the specificities of local markets in which medical technologies generate value, the social and intergenerational relations in which they are embedded, and their intersections with class hierarchies.

Disclosure in times of ART: a relational analysis of social practices

The reach of HIV counseling and testing has grown rapidly since the 2000s, particularly since 2007 when provider-initiated counseling and testing was implemented alongside voluntary counseling and testing and testing for the prevention of mother-to-child transmission. Nevertheless, we still know little about the attendant practices of disclosing HIV-positive status. Persistently high rates of non-disclosure raise difficult ethical, public health and human rights issues. The articles in this special issue show that disclosure practices in Africa not only follow the public health rationality but are shaped by fears of stigma that favor secrecy. They show how practices of disclosure are embedded in social relationships. More specifically, they present disclosure practices at the intersection of five social spaces: international norms, national legislation and public health recommendations; household and family settings; couples' relationships; parental relationships; and relationships between health workers and PLWHA. The authors describe how people pursue strategies of disclosure in one or more of these social spaces, which sometimes allows them to avoid barriers (for instance when they choose to disclose only partially to certain 'significant others' in the household). One important finding is that counselors often do not support PLWHA to disclose their HIV status. Counselors themselves may be influenced by divergent logics and experience conflicts in values; they may also lack sufficient knowledge and skills to discuss sensitive issues based on rapidly changing medical data and public health recommendations.

Disclosure of HIV status between parents and children in Uganda in the context of greater access to treatment

While disclosure of HIV sero-status is encouraged in the management of the HIV and AIDS epidemic, it remains a challenge, especially among family members. This article examines the moral dilemmas and pragmatic incentives surrounding disclosure of HIV status in contemporary Uganda. Our findings are based on 12 in-depth interviews, 2 focus-group discussions, 6 key informant interviews with AIDS activists, and open-ended responses derived from 148 HIV-positive persons in a quantitative survey. The study was conducted in 2008-2009 in Kampala, Mpigi, and Soroti districts in Uganda. We found both parents and adult children facing dilemmas in disclosure, whether it was parents revealing their own HIV status to their children or the status of their perinatally infected children, or young people infected through sexual intercourse telling their parents. For both groups, there is fear of blame, stigma, discrimination, and shame and guilt related to unsafe sex, while young people also fear loss of privileges. On the other hand, there are practical imperatives for disclosure in terms of gaining access to care, treatment, and material resources. Faced with these dilemmas, HIV-positive people and their families require professional counselling to help them work through the emotional challenges encountered and identify mechanisms of support and coping.

Revealing the hidden agency of children in a clinical setting

BACKGROUND

Interactions with children in clinical settings are often criticized because parents and medical professionals speak for children rather than to them. Such approaches do not take the agency of children into account.

OBJECTIVE

First, to examine how children enact agency in a clinical encounter and draw lessons from this to improve health-care practices for children and, second, to explain how looking at agency might help to move the participation agenda forwards.

DESIGN

A qualitative study incorporating a range of methods, including participant observation, interviews and focus group discussions.

SETTING

Three hospitals in the Netherlands.

PARTICIPANTS

Children with diabetes type 1, between 8 and 12 years (n = 30), parents (n = 22) and medical professionals (n = 16).

RESULTS

Children do not simply accept the recurrent health education from medical professionals. Instead, they attribute their own personal meaning to their disease and treatment. Drawing from their years of experience with the disease and health care and the image of a passive and vulnerable child, they actively find ways to balance personal goals with medically defined goals.

CONCLUSION

Efforts to facilitate child participation should be based on insights into the ways in which children enact agency in the clinical encounter. Our data show that children already participate in health care and that their enactment of agency is based on a practical logic. Understanding of children's current participation and agency is needed to more successfully attune their treatment to their daily lives with diabetes. This is crucial for the success of treatment and the well-being of children.

Chemical sexualities: the use of pharmaceutical and cosmetic products by youth in South Sulawesi, Indonesia

Although young people in their everyday lives consume a bewildering array of pharmaceutical, dietary and cosmetic products to self-manage their bodies, moods and sexuality, these practices are generally overlooked by sexual and reproductive health programmes. Nevertheless, this self-management can involve significant (sexual) health risks. This article draws from the initial findings of the University of Amsterdam's ChemicalYouth project. Based on interviews with 142 youths, focus group discussions and participant observation in South Sulawesi, Indonesia, we found that young people - in the domain of sexual health - turn to pharmaceuticals and cosmetics to: (1) feel clean and attractive; (2) increase (sexual) stamina; (3) feel good and sexually confident; (4) counter sexual risks; and (5) for a group of transgender youths, to feminize their male bodies. How youth achieve these desires varies depending on their income and the demands of their working lives. Interestingly, the use of pharmaceuticals and cosmetics was less gendered than expected. Sexual health programmes need to widen their definitions of risk, cooperate with harm reduction programmes to provide youth with accurate information, and tailor themselves to the diverse sexual health concerns of their target groups.

On Coba and Cocok: youth-led drug-experimentation in Eastern Indonesia

The everyday lives of contemporary youths are awash with drugs to boost pleasure, moods, sexual performance, vitality, appearance and health. This paper examines pervasive practices of chemical 'self-maximization' from the perspectives of youths themselves. The research for this paper was conducted among male, female and transgender (male to female, so-called waria) sex workers in Makassar, Indonesia. It presents the authors' ethnographic findings on how these youths experiment with drugs to achieve their desired mental and bodily states: with the painkiller Somadril to feel happy, confident and less reluctant to engage in sex with clients, and contraceptive pills and injectable hormones to feminize their male bodies and to attract customers. Youths are extremely creative in adjusting dosages and mixing substances, with knowledge of the (mostly positive) 'lived effects' of drugs spreading through collective experimentation and word of mouth. The paper outlines how these experimental practices differ from those that have become the gold standard in biomedicine.

Socio-economic determinants of HIV testing and counselling: a comparative study in four African countries

OBJECTIVES

Research indicates that individuals tested for HIV have higher socio-economic status than those not tested, but less is known about how socio-economic status is associated with modes of testing. We compared individuals tested through provider-initiated testing and counselling (PITC), those tested through voluntary counselling and testing (VCT) and those never tested.

METHODS

Cross-sectional surveys were conducted at health facilities in Burkina Faso, Kenya, Malawi and Uganda, as part of the Multi-country African Testing and Counselling for HIV (MATCH) study. A total of 3659 clients were asked about testing status, type of facility of most recent test and socio-economic status. Two outcome measures were analysed: ever tested for HIV and mode of testing. We compared VCT at stand-alone facilities and PITC, which includes integrated facilities where testing is provided with medical care, and prevention of mother-to-child transmission (PMTCT) facilities. The determinants of ever testing and of using a particular mode of testing were analysed using modified Poisson regression and multinomial logistic analyses.

RESULTS

Higher socio-economic status was associated with the likelihood of testing at VCT rather than other facilities or not testing. There were no significant differences in socio-economic characteristics between those tested through PITC (integrated and PMTCT facilities) and those not tested.

CONCLUSIONS

Provider-initiated modes of testing make testing accessible to individuals from lower socio-economic groups to a greater extent than traditional VCT. Expanding testing through PMTCT reduces socio-economic obstacles, especially for women. Continued efforts are needed to encourage testing and counselling among men and the less affluent.

Client-provider interactions in provider-initiated and voluntary HIV counseling and testing services in Uganda

Background

Provider-initiated HIV testing and counselling (PITC) is based on information-giving while voluntary counselling and testing (VCT) includes individualised client-centered counseling. It is not known if the provider-client experiences, perceptions and client satisfaction with the information provided differs in the two approaches.

Methods

In 2008, we conducted structured interviews with 627 individuals in Uganda; 301 tested through PITC and 326 through voluntary counselling and testing (VCT). We compared client experiences and perceptions based on the essential elements of consent, confidentiality, counseling, and referral for follow-up care. We conducted multivariate analysis for predictors of reporting information or counselling as sufficient.

Results

In VCT, 96.6% (282) said they were asked for consent compared to 91.3% (198) in PITC (P = 0.01). About the information provided, 92.0% (286) in VCT found it sufficient compared to 78.7% (221) in PITC (P = <0.01). In VCT 79.9% (246) thought their results were kept confidential compared to 71.7% (200) in PITC (P = 0.02). Eighty percent (64) of HIV infected VCT clients said they were referred for follow-up care versus 87.3% (48) in PITC (p = 0.2). Predictors of perceived adequacy of information in PITC included an opportunity to ask questions (adj.RR 1.76, CI 1.41, 2.18) and expecting the test results received (adj.RR 1.18, CI 1.06, 1.33). For VCT significant factors included being given an opportunity to ask questions (adj.RR 1.62, CI 1.00, 2.60) and 3+ prior times tested, (adj.RR 1.05, CI 1.00, 1.09).

Conclusions

This study demonstrates good practices in the essential elements of HIV testing for both VCT and PITC. However, further quality enhancement is required in both testing approaches in relation to referral to HIV care post-test, client confidence in relation to confidentiality, and providing an opportunity to ask questions to address client-specific information needs.

Socio-economic determinants of HIV testing and counselling: a comparative study in four African countries

OBJECTIVES

Research indicates that individuals tested for HIV have higher socio-economic status than those not tested, but less is known about how socio-economic status is associated with modes of testing. We compared individuals tested through provider-initiated testing and counselling (PITC), those tested through voluntary counselling and testing (VCT) and those never tested.

METHODS

Cross-sectional surveys were conducted at health facilities in Burkina Faso, Kenya, Malawi and Uganda, as part of the Multi-country African Testing and Counselling for HIV (MATCH) study. A total of 3659 clients were asked about testing status, type of facility of most recent test and socio-economic status. Two outcome measures were analysed: ever tested for HIV and mode of testing. We compared VCT at stand-alone facilities and PITC, which includes integrated facilities where testing is provided with medical care, and prevention of mother-to-child transmission (PMTCT) facilities. The determinants of ever testing and of using a particular mode of testing were analysed using modified Poisson regression and multinomial logistic analyses.

RESULTS

Higher socio-economic status was associated with the likelihood of testing at VCT rather than other facilities or not testing. There were no significant differences in socio-economic characteristics between those tested through PITC (integrated and PMTCT facilities) and those not tested.

CONCLUSIONS

Provider-initiated modes of testing make testing accessible to individuals from lower socio-economic groups to a greater extent than traditional VCT. Expanding testing through PMTCT reduces socio-economic obstacles, especially for women. Continued efforts are needed to encourage testing and counselling among men and the less affluent.

Do support groups members disclose less to their partners? The dynamics of HIV disclosure in four African countries

BACKGROUND

Recent efforts to curtail the HIV epidemic in Africa have emphasised preventing sexual transmission to partners through antiretroviral therapy. A component of current strategies is disclosure to partners, thus understanding its motivations will help maximise results. This study examines the rates, dynamics and consequences of partner disclosure in Burkina Faso, Kenya, Malawi and Uganda, with special attention to the role of support groups and stigma in disclosure.

METHODS

The study employs mixed methods, including a cross-sectional client survey of counselling and testing services, focus groups, and in-depth interviews with HIV-positive individuals in stable partnerships in Burkina Faso, Kenya, Malawi and Uganda, recruited at healthcare facilities offering HIV testing.

RESULTS

Rates of disclosure to partners varied between countries (32.7% - 92.7%). The lowest rate was reported in Malawi. Reasons for disclosure included preventing the transmission of HIV, the need for care, and upholding the integrity of the relationship. Fear of stigma was an important reason for non-disclosure. Women reported experiencing more negative reactions when disclosing to partners. Disclosure was positively associated with living in urban areas, higher education levels, and being male, while being negatively associated with membership to support groups.

CONCLUSIONS

Understanding of reasons for disclosure and recognition of the role of support groups in the process can help improve current prevention efforts, that increasingly focus on treatment as prevention as a way to halt new infections. Support groups can help spread secondary prevention messages, by explaining to their members that antiretroviral treatment has benefits for HIV positive individuals and their partners. Home-based testing can further facilitate partner disclosure, as couples can test together and be counselled jointly.

Confronting diversity in the production of clinical evidence goes beyond merely including under-represented groups in clinical trials

There is increasing evidence that outcomes of health care differ by patient characteristics, such as gender and ethnicity. If evidence-based medicine is to improve quality of care for all patients, it is essential to take this diversity into account when designing clinical studies. So far, this notion has mainly been translated into recommendations for including minority populations in trials. We argue that a more comprehensive view of the production of diversity-sensitive clinical evidence is needed, one that takes heterogeneity as a starting point in research. We call for a mix of methodological approaches aimed at identifying diversity issues that matter and analysing the impact of these diversities on clinical outcomes. Institutional changes are necessary to support this methodological reform.

'What mother wouldn't want to save her baby?' HIV testing and counselling practices in a rural Ugandan antenatal clinic

Drawing on an exploratory qualitative case study investigating everyday practices within an antenatal clinic in rural Uganda, this paper investigates the dynamics of consent and counselling within a prevention of mother-to-child HIV transmission (PMTCT) programme, from the perspectives of various health professionals involved at different stages of the PMTCT trajectory. The paper contributes to the existing literature by focusing not on clients' views but, rather, by elucidating how different cadres of health workers view and practice the human rights principles of informed consent and opting out, that are reflected in Uganda's HIV testing policies. By investigating the roles and responsibilities of community counsellors, post-test counsellors, and midwives, we illustrate how the practice of counselling in PMTCT is influenced by two hegemonic discourses: the health of a child should be protected, and the health worker knows best. As a result, a directive form of counselling in PMTCT settings, with its focus on the health of the baby, silences women's right to opt out of HIV tests.

Home-based HIV counseling and testing: client experiences and perceptions in Eastern Uganda

BACKGROUND

Though prevention and treatment depend on individuals knowing their HIV status, the uptake of testing remains low in Sub-Saharan Africa. One initiative to encourage HIV testing involves delivering services at home. However, doubts have been cast about the ability of Home-Based HIV Counseling and Testing (HBHCT) to adhere to ethical practices including consent, confidentiality, and access to HIV care post-test. This study explored client experiences in relation these ethical issues.

METHODS

We conducted 395 individual interviews in Kumi district, Uganda, where teams providing HBHCT had visited 6-12 months prior to the interviews. Semi-structured questionnaires elicited information on clients' experiences, from initial community mobilization up to receipt of results and access to HIV services post-test.

RESULTS

We found that 95% of our respondents had ever tested (average for Uganda was 38%). Among those who were approached by HBHCT providers, 98% were informed of their right to decline HIV testing. Most respondents were counseled individually, but 69% of the married/cohabiting were counseled as couples. The majority of respondents (94%) were satisfied with the information given to them and the interaction with the HBHCT providers. Most respondents considered their own homes as more private than health facilities. Twelve respondents reported that they tested positive, 11 were referred for follow-up care, seven actually went for care, and only 5 knew their CD4 counts. All HIV infected individuals who were married or cohabiting had disclosed their status to their partners.

CONCLUSION

These findings show a very high uptake of HIV testing and satisfaction with HBHCT, a large proportion of married respondents tested as couples, and high disclosure rates. HBHCT can play a major role in expanding access to testing and overcoming disclosure challenges. However, access to HIV services post-test may require attention.

Associations between mode of HIV testing and consent, confidentiality, and referral: a comparative analysis in four African countries

BACKGROUND

Recommendations about scaling up HIV testing and counseling highlight the need to provide key services and to protect clients' rights, but it is unclear to what extent different modes of testing differ in this respect. This paper examines whether practices regarding consent, confidentiality, and referral vary depending on whether testing is provided through voluntary counseling and testing (VCT) or provider-initiated testing.

METHODS AND FINDINGS

The MATCH (Multi-Country African Testing and Counseling for HIV) study was carried out in Burkina Faso, Kenya, Malawi, and Uganda. Surveys were conducted at selected facilities. We defined eight outcome measures related to pre- and post-test counseling, consent, confidentiality, satisfactory interactions with providers, and (for HIV-positive respondents) referral for care. These were compared across three types of facilities: integrated facilities, where testing is provided along with medical care; stand-alone VCT facilities; and prevention of mother-to-child transmission (PMTCT) facilities, where testing is part of PMTCT services. Tests of bivariate associations and modified Poisson regression were used to assess significance and estimate the unadjusted and adjusted associations between modes of testing and outcome measures. In total, 2,116 respondents tested in 2007 or later reported on their testing experience. High percentages of clients across countries and modes of testing reported receiving recommended services and being satisfied. In the unadjusted analyses, integrated testers were less likely to meet with a counselor before testing (83% compared with 95% of VCT testers; p<0.001), but those who had a pre-test meeting were more likely to have completed consent procedures (89% compared with 83% among VCT testers; p<0.001) and pre-test counseling (78% compared with 73% among VCT testers; p = 0.015). Both integrated and PMTCT testers were more likely to receive complete post-test counseling than were VCT testers (59% among both PMTCT and integrated testers compared with 36% among VCT testers; p<0.001). Adjusted analyses by country show few significant differences by mode of testing: only lower satisfaction among integrated testers in Burkina Faso and Uganda, and lower frequency of referral among PMTCT testers in Malawi. Adjusted analyses of pooled data across countries show a higher likelihood of pre-test meeting for those testing at VCT facilities (adjusted prevalence ratio: 1.22, 95% CI: 1.07-1.38) and higher satisfaction for stand-alone VCT facilities (adjusted prevalence ratio: 1.15; 95% CI: 1.06-1.25), compared to integrated testing, but no other associations were statistically significant.

CONCLUSIONS

Overall, in this study most respondents reported favorable outcomes for consent, confidentiality, and referral. Provider-initiated ways of delivering testing and counseling do not appear to be associated with less favorable outcomes for clients than traditional, client-initiated VCT, suggesting that testing can be scaled up through multiple modes without detriment to clients' rights. Please see later in the article for the Editors' Summary.

Secrecy as embodied practice: beyond the confessional imperative

This introduction to this special issue of Culture, Health & Sexuality aims to intervene critically in debates in public health about sexual rights and ways of de-stigmatising HIV/AIDS, in which silence and secrets are seen to undermine well-being and perpetuate stigma. It presents key insights from collaborative studies on HIV/AIDS and youth sexual health, arguing that advocates of disclosure and sexual rights need to think more contextually and tactically in promoting truth-telling. The authors aim to enhance current thinking on secrecy, which examines it primarily as a social practice, by emphasising the centrality of the body and the experience of embodiment in the making and unmaking of secrets. To understand secrecy as embodied practice requires understanding how it simultaneously involves the body as subject - as the basis from which we experience the world - and the body as object - that can be actively manipulated, silenced and 'done'. The authors show how tensions emerge when bodies reveal reproductive mishaps and describe how the dissonances are resolved through a variety of silencing practices. The paper ends by discussing the implications of these insights for sexual-health programmes.

Concealment tactics among HIV-positive nurses in Uganda

This paper is based on two-and-a-half years of ethnographic fieldwork in two rural Ugandan health centres during a period of ART scale-up. Around one-third of the nurses in these two sites were themselves HIV-positive but most concealed their status. We describe how a group of HIV-positive nurses set up a secret circle to talk about their predicament as HIV-positive healthcare professionals and how they developed innovative care technologies to overcome the skin rashes caused by ART that threatened to give them away. Together with patients and a traditional healer, the nurses resisted hegemonic biomedical norms denouncing herbal medicines and then devised and advocated for a herbal skin cream treatment to be included in the ART programme.

"The Adopted Children of ART": expert clients and role tensions in ART provision in Uganda

The implementation of the greater involvement of people living with HIV (GIPA) principle in Ugandan AIDS care is described by focusing on the engagement of expert clients in two rural health centers during a time of antiretroviral therapy (ART) scale-up. We contrast how the expert clients help overburdened nurses to manage the well-attended ART programs in the public and in the nongovernmental organization clinic. They are unpaid, but acquire preferential status in the ART program because of their knowledge of AIDS medicines (and its adverse effects) and because of the compassionate care that they provide. Despite the assistance provided, nurses in the public facility felt threatened in their professional status by these expert clients, who were seen to overstep the boundaries of their role. We pay particular attention to the double burden for HIV-positive nurses, who fear stigma, and (unlike the expert patients) keep their HIV status secret.

Women's views on consent, counseling and confidentiality in PMTCT: a mixed-methods study in four African countries

BACKGROUND

Ambitious UN goals to reduce the mother-to-child transmission of HIV have not been met in much of Sub-Saharan Africa. This paper focuses on the quality of information provision and counseling and disclosure patterns in Burkina Faso, Kenya, Malawi and Uganda to identify how services can be improved to enable better PMTCT outcomes.

METHODS

Our mixed-methods study draws on data obtained through: (1) the MATCH (Multi-country African Testing and Counseling for HIV) study's main survey, conducted in 2008-09 among clients (N = 408) and providers at health facilities offering HIV Testing and Counseling (HTC) services; 2) semi-structured interviews with a sub-set of 63 HIV-positive women on their experiences of stigma, disclosure, post-test counseling and access to follow-up psycho-social support; (3) in-depth interviews with key informants and PMTCT healthcare workers; and (4) document study of national PMTCT policies and guidelines. We quantitatively examined differences in the quality of counseling by country and by HIV status using Fisher's exact tests.

RESULTS

The majority of pregnant women attending antenatal care (80-90%) report that they were explained the meaning of the tests, explained how HIV can be transmitted, given advice on prevention, encouraged to refer their partners for testing, and given time to ask questions. Our qualitative findings reveal that some women found testing regimes to be coercive, while disclosure remains highly problematic. 79% of HIV-positive pregnant women reported that they generally keep their status secret; only 37% had disclosed to their husband.

CONCLUSION

To achieve better PMTCT outcomes, the strategy of testing women in antenatal care (perceived as an exclusively female domain) when they are already pregnant needs to be rethought. When scaling up HIV testing programs, it is particularly important that issues of partner disclosure are taken seriously.