The public health response to sexually transmitted infections, particularly HIV, has been and continues to be overwhelmingly focused on risk, disease and negative outcomes of sex, while avoiding discussion of positive motivations for sex like pleasure, desire and love. Recent advocacy efforts have challenged this approach and organisations have promoted the eroticisation of safer sex, especially in the context of HIV prevention.
This paper is a case study of one of these organisations – the Pleasure Project. The authors give a brief background on the public-health approach to sex and sexual health, and recommend an alternative approach that incorporates constructs of pleasure and desire into sexual health interventions. The Pleasure Project’s aims and unorthodox communications strategies are described, as are the response to and impact of its work, lessons learned and ongoing challenges to its approach. Despite the backdrop of sex-negative public health practice, there is anecdotal evidence that safer sex, including condom use, can be eroticised and made pleasurable, based on qualitative research by the Pleasure Project and other like-minded organisations. Yet there is a need for more research on the effectiveness of pleasure components in sexual health interventions, particularly in high-risk contexts, the authors argue. This need has become urgent as practitioners look for new ways to promote sexual health and as new prevention technologies (including female condoms and microbicides) are introduced or disseminated.
Equity and HIV/AIDS
Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. The authors estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs. For Hlabisa subdistrict, KwaZulu-Natal, they predicted the HIV epidemic dynamics, number on ART and programme costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. Calculations indicated that during the first five years, the new WHO treatment guidelines will require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years. The findings strengthen the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients.
The purpose of this study was to evaluate the relationship between the coping self-efficacy (CSE) scale and adherence to HIV medication in men and women enrolled in a large HIV treatment programme in Kenya. Data were collected from a sample of 354 volunteers attending Nazareth Hospital's nine satellite clinics located in parts of Nairobi, and the central province of Kenya. A social demographic survey, Adult Clinical Trials Group adherence questionnaire, and CSE scale were used to obtain information. Descriptive statistics and logistic regressions were performed to analyse data and to test study hypotheses. The researchers found that females were less likely to be nonadherent than males: the odds of adherence for females were 3.7 of the odds of adherence for males. When controlling for gender, CSE was found to be significant. Adherence to antiretroviral therapy can be partially explained by CSE, the authors conclude. Efforts aimed at building self-efficacy are likely to improve and maintain adherence to HIV and other medication, they argue.
Concurrent sexual partnerships are widely believed to be one of the main drivers of the HIV epidemic in sub-Saharan Africa. For this population-based cohort study, researchers used data from the Africa Centre demographic surveillance site in KwaZulu-Natal, South Africa, to try to find support for the concurrency hypothesis. A total of 2,153 sexually active men and 7,284 HIV-negative women from the surrounding local community were included in the study. During five years' follow-up, 693 new female HIV infections occurred and the researchers found that - after adjustment for individual-level sexual behaviour and demographic, socioeconomic and environmental factors associated with HIV acquisition - mean lifetime number of partners of men in the immediate local community was predictive of hazard of HIV acquisition in women. A high prevalence of partnership concurrency in the same local community was not associated with any increase in risk of HIV acquisition. The researchers argue that, in similar hyperendemic sub-Saharan African settings, there is a need for straightforward, unambiguous messages aimed at the reduction of multiple partnerships, irrespective of whether those partnerships overlap in time.
In 2008, the Capacity Project partnered with the Lesotho Ministry of Health and Social Welfare in a study of the gender dynamics of HIV and AIDS caregiving in three districts of Lesotho to account for men's absence in HIV and AIDS caregiving and investigate ways in which they might be recruited into the community and home-based care (CHBC) workforce. The researchers used qualitative methods, including 25 key informant interviews with village chiefs, nurse clinicians, and hospital administrators and 31 focus group discussions with community health workers, community members, ex-miners, and HIV-positive men and women. Study participants uniformly perceived a need to increase the number of CHBC providers to deal with the heavy workload from increasing numbers of patients and insufficient new entries. HIV and AIDS caregiving is a gender-segregated job, at the core of which lie stereotypes and beliefs about the appropriate work of men and women. This results in an inequitable, unsustainable burden on women and girls. The authors recommend that HIV and AIDS and human resources stakeholders must address occupational segregation and the underlying gender essentialism and male primacy if there is to be more equitable sharing of the HIV and AIDS caregiving burden and any long-term solution to health worker shortages.
Criminalisation and legal and policy barriers play a key role in increasing HIV vulnerability for men who have sex with men (MSM) and transgender people, says the World Health Organisation in this report. More than 75 countries currently criminalise same-gender sexual activity and transgender people lack legal recognition in most countries. These legal conditions force MSM and transgender people to risk criminal sanctions if they want to discuss their level of sexual risk with a service provider and also give police the authority to harass organisations that provide services to these populations. Long-standing evidence indicates that MSM and transgender people experience significant barriers to quality health care due to widespread stigma against homosexuality and ignorance about gender variance in mainstream society and within health systems. Social discrimination against MSM and transgender people has also been described as a key driver of poor physical and mental health outcomes in these populations across diverse settings. In addition to being disproportionately burdened by STI and HIV, MSM and transgender people experience higher rates of depression, anxiety, smoking, alcohol abuse, substance use and suicide as a result of chronic stress, social isolation and disconnection from a range of health and support services.
This cross-sectional facility-based survey was based on 70 structured face-to-face interviews combined with qualitative research that included two focus group discussions with pregnant women and five in-depth interviews with providers at antenatal care clinics in Marondera. Studies elsewhere have shown that the greatest barriers to the use of PMTCT services are linked to socio-cultural beliefs and influences, including fear of discrimination associated with testing and being HIV positive, and negative perceptions about the effectiveness of anti-retrovirals. None of these barriers were raised by participants in this study. Instead the main barriers were linked to the health system’s failure to meet the needs of pregnant women. Thus, SHIELD concludes, the main reasons why women cannot access PMTCT services are barriers faced in accessing antenatal services, including the cost and acceptability of these services. SHIELD makes a number of recommendations: remove or reduce the cost of antenatal care and delivery user fees for pregnant women, increase women’s access to reliable information, improve the quality of services, and provide training courses for health workers about how to engage with patients in a more acceptable manner.
In this study, researchers assessed whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. Ten communities participated in Project Accept in Tanzania, and eight in Zimbabwe. At each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT (SVCT), and the other community was assigned to receive community-based VCT (CBVCT) plus access to SVCT. The researchers found that the proportion of clients receiving their first HIV test during the study was higher in CBVCT communities than in SVCT communities in all three countries. Although HIV prevalence was higher in SVCT communities than in CBVCT communities, CBVCT detected almost four times more HIV cases than did SVCT across the three study sites. Repeat HIV testing in CBVCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. The researchers conclude that CBVCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing.
In this study, researchers investigated whether anti-retroviral therapy (ART) services for urban HIV-positive adults in two urban areas in South Africa are distributed in an equitable manner, in terms of socio-economic status and gender. HIV-positive people were found to be relatively poor. Over 60% of those with HIV fell into the poorest 40% of the South African population. The users of ART services were in general poorer than the HIV-positive population. Seventy percent of these users fell into the poorest 40% of the South African population. This finding was however not statistically significant, and the proportion of HIV-positive people that were women (or men) was no different to the sex distribution in the users of ART services. Taken together, these findings suggest that the use of ART services in urban South Africa is equitable. The researchers expressed hope that their study will add impetus to commitments to reaching and sustaining full coverage of ART for all in need.
Researchers speaking on the final day of the Sixth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention, held in Rome, Italy, from 17-20 July 2011, focused on the growing interest in the scientific path to an HIV cure. Discussions around an HIV cure have been growing over the past 12 months and are now gaining momentum with the establishment of an-IAS convened working group concentrating its initial efforts on establishing a global scientific strategy. IAS hopes to unveil their new global scientific strategy at the Seventh International AIDS Conference in Washington in 2012. Researchers also highlighted the need to scale up programmes that could more effectively address both the issues of injecting drug use linked HIV transmission and the still unacceptably high mortality rates amongst pregnant women and young children in sub-Saharan Africa.