The rapid scale-up of free antiretroviral therapy has lead to a decline in adult mortality at the population level and reduction of vertical transmission. Consequently, some couples living with HIV are maintaining their reproductive decisions; marrying and having children. This paper analyses policies and guidelines on HIV, AIDS and sexual and reproductive health in Malawi for content on marriage and childbearing for couples living with HIV. The authors report that analysis of guidelines and policies showed nonprescriptiveness on issues of HIV, AIDS and reproduction: they do not reflect the social cultural experiences of couples living with HIV. In addition, they found; lack of clinical guidelines, external influence on adoption of the policies and guidelines and weak linkages between HIV and AIDS and sexual and reproductive health services. The findings are argued to provide a strong basis for updating the policies and development of easy-to-follow guidelines in order to effectively provide services to couples living with HIV in Malawi.
Equity and HIV/AIDS
South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment. the authors argue there are two reasons for this. First, priority setting decisions on HIV treatment are argued to fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process without adequate participatory processes in place to incorporate stakeholders' views and evidence. They propose an alternative approach that integrates procedural fairness and a multi-criteria decision analysis that assesses feasibility, efficiency, and equity of programme options, including trade-offs.
This paper presents how the changes wrought by HIV have affected research, clinical practice, and policy. The AIDS epidemic provided the foundation for a revolution that upended traditional approaches to international health, replacing them with innovative global approaches to disease. Over the past half-century, historians have used episodes of epidemic disease to investigate scientific, social, and cultural change. Underlying this approach is the recognition that disease, and especially responses to epidemics, offers fundamental insights into scientific and medical practices, as well as social and cultural values.
This article presents part of the findings from a larger study that sought to assess the role that gender relations play in influencing equity regarding access and adherence to antiretroviral therapy (ART). Review of the literature has indicated that, in Southern and Eastern Africa, fewer men than women have been accessing ART, and the former start using ART late, after HIV has already been allowed to advance. The main causes for this gender gap have not yet been fully explained. To explore how masculinity norms limit men's access to ART in Dar es Salaam, the authors implemented a qualitative study, with a stratified purposive sampling and a thematic analysis. The findings revealed that men's hesitation to visit the care and treatment clinics can be related to norms of masculinity that require men to avoid displaying weakness. Since men are the heads of families and have higher social status, they reported feeling embarrassed at having to visit the care and treatment clinics. Specifically, male respondents indicated that going to a care and treatment clinic may raise suspicion about their status of living with HIV, which in turn may compromise their leadership position and cause family instability. Because of this tendency towards 'hiding', the few men who register at the public care and treatment clinics do so late, when HIV-related signs and symptoms are already far advanced. They argue that HIV control programmes need to factor in the deconstruction of such norms of masculinity.
An African proverb teaches us that “if you want to go fast, go alone—but
if you want to go far, go together”. The AIDS epidemic threatened to overcome Africa—but instead, Africa and the world have united to overcome AIDS, going farther than most ever thought possible. This special report presents in a graphical, compelling and accessible manner the many dimensions of progress on AIDS in Africa.
Whether it is relative wealth or relative poverty that drives the HIV epidemic in sub-Saharan Africa, is a controversial aspect of HIV/AIDS epidemiology. The authors suggest that the social epidemiology of HIV in Africa is changing. Previously, new infections were more rapidly acquired by those of relatively higher socioeconomic position (SEP). More recently, those of relatively low SEP are at greater risk. The authors explored in this paper whether the pattern would be compatible with the ‘inverse equity hypothesis’, that suggests that those of higher SEP benefit first from new health interventions. Using available evidence from the region, the authors suggest that in the early phase of the epidemic, HIV infections were concentrated among those of higher SEP in many countries. The inverse equity hypothesis suggests that new infections will increasingly concentrate among those of lower SEP. If further analysis confirms this hypothesis, the authors suggest that policy responses must be considered to ensure that interventions reach poorer groups and that structural approaches tackle the social determinants of HIV infection.
This paper examines some of the evidence linking structural factors to HIV risk; research gaps, including the pathways through which factors affect HIV vulnerability and interaction among factors; and explores the advantages of taking a “structurally informed” approach to HIV planning and implementation, namely the value of influencing clustered risk factors, the potential to influence multiple outcomes, and opportunities for co-financing. The authors argue that attention to structural forces that either heighten HIV vulnerability or create AIDS resiliency is an important but under-researched and under-programmed area of HIV prevention. There is long-standing evidence that demonstrates that a variety of social forces have both direct and indirect effects on HIV transmission, and undermine the effectiveness of proven biomedical prevention programmes. Intervening “upstream” yields multiple benefits: it allows programmes to potentially affect multiple risk factors at once (especially when they cluster), and it offers promise to influence a range of health and development outcomes through a single intervention. The authors argue that structural approaches to HIV prevention are an efficient and effective strategy in our current era of global fiscal austerity.
While global guidance for HIV prevention recognises the importance of structural HIV prevention, evidence for the effectiveness of these interventions, and their implementation, are lagging behind other areas of prevention. The challenges to implementation at the community and national levels are less well understood. This paper examines the United States (US) President’s Emergency Plan for AIDS Relief (PEPFAR)/US Agency for International Development (USAID) experience with implementing structural interventions in Zambia. Despite challenges to implementing, monitoring, and evaluating structural interventions, they can and have been implemented successfully and are necessary for a long-term and sustained response to both HIV and social and economic development needs, the authors argue. Better identification of causal pathways, involvement of key stakeholders and collaborators, and enhanced monitoring will strengthen implementation of structural interventions and provide the necessary data to understand their outcomes and impacts. Such efforts and stronger links between structural interventions and other biomedical and behavioural interventions will result in a true combination approach to HIV prevention, yielding better results.
According to this report, one reason that HIV prevention efforts have not kept pace has been insufficient attention to HIV’s “structural factors”, namely those areas beyond individual knowledge or awareness that shape risk and vulnerability to infection. Examples are often context-specific but can include economic inequality and livelihood insecurity, as well as hunger, gender inequality, and lack of education. These factors, many of which are rooted in various formal and informal types of marginalisation, underpin the diversity of HIV epidemics, helping to explain why some countries have a higher HIV burden than others. Structural factors have been demonstrated to influence treatment access and retention. The authors argue that action on structural factors can have multiple beneficial impacts not only on HIV-related goals but also on other health, development and human rights objectives. Implementing structural approaches requires a range of disciplinary perspectives that extend beyond the health sector, as well as cross-sector governance and financing.
The aim of this study was to assess the effectiveness of a community-based natural resource management programme that “mainstreamed” HIV awareness and prevention activities within rural communities in Namibia. The authors used data from two rounds of the Namibia Demographic and Health Surveys (2000 and 2006/2007), including a total of 117 men and 318 women in 2000, and 170 men and 357 women in 2006/2007. They found that community-based conservation in Namibia has significantly reduced multiple sexual partnerships, the main behavioural determinant of HIV and AIDS infection in Africa. They argue that their results demonstrate the effectiveness of holistic community-based approaches centred on the preservation of lives and livelihoods, and highlight the potential benefits of integrating conservation and HIV prevention programming in other areas of communal land tenure in Africa.