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.
Equity and HIV/AIDS
How AIDS Invented Global Health
Brandt AM: The New England Journal of Medicine 368(23): 2149-2152, 6 June 2013
Masculine attitudes of superiority deter men from accessing antiretroviral therapy in Dar es Salaam, Tanzania
Nyamhanga TM, Muhondwa EP and Shayo R: Global Health Action (6), 22 October 2013
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.
UNAIDS Special report: How Africa turned AIDS around
Michel Sidibe: African Union Summit | May 2013, UNAIDS Geneva
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.
Does the ‘inverse equity hypothesis’ explain how both poverty and wealth can be associated
Hargreaves JR, Davey C, White RG: J Epidemiol Community Health 67: 526–529, 2013
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.
Intervening Upstream: A Good Investment for HIV Prevention
Heise L and Watts C: AIDStarone, 2013
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.
Operationalising Structural Interventions for HIV Prevention: Lessons from Zambia
Bowa C and Mah TL: AIDStarone, 2013
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.
Policy and programme responses for addressing the structural determinants of HIV
Pronyk Paul and Lutz Brian: Aidstarone, June 2013
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.
Community-based conservation reduces sexual risk factors for HIV among men
Naidoo R and Johnson K: Globalization and Health 9(27): 9 July 2013
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.
Kenya launches National Strategy on HIV and AIDS and STI Programming along the Transport Corridors
International Organisation for Migration, Kenya: 4 June 2013
Kenya’s National AIDS Control Council (NACC) and the National AIDS and STI Control Programme (NASCOP) have launched an HIV and AIDS strategy for transport corridors that aims to reach out to high-risk mobile populations along transport corridors. It will help ensure provision of effective HIV and sexually transmitted infection (STI) prevention, treatment, care and support programmes for truckers, female sex workers, and men who have sex with men along with the communities they interact with such as border officials, police officers and the general population. The strategy will further provide a national framework within which HIV programming can be realised by various stakeholders providing HIV services along the transport corridors in Kenya.
Prevalence of Consensual Male–Male Sex and Sexual Violence, and Associations with HIV in South Africa: A Population-Based Cross-Sectional Study
Dunkle KL, Jewkes RK, Murdock DW, Sikweyiya Y and Morrell R: PLoS Medicine 10(6): e1001472, 18 June 2013
In this paper, the authors describe lifetime prevalence of consensual male–male sexual behaviour and male-on-male sexual violence (victimisation and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. The study was conducted in 2008 and included men aged 18–49 from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces, who provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimisation. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.