This study explored how women’s and men’s gendered experiences from childhood to old age have shaped their vulnerability in relation to HIV both in terms of their individual risk of HIV and their access to and experiences of HIV services. It was a small scale-scale study conducted in urban and rural sites in Uganda between October 2011 and March 2012. The study used qualitative methods: in-depth interviews (with 31 participants) and focus group discussions (FGDs) with older women (2) and men (2) in urban and rural sites and 7 key informant interviews (KIIs) with stakeholders from government and non-government agencies working on HIV issues. Women’s position, the cultural management of sex and gender and contextual stigma related to HIV and to old age inter-relate to produce particular areas of vulnerability to the HIV epidemic among older women and men. Women report the compounding factor of gender-based violence marking many of their sexual relationships throughout their lives, including in older age. Both women and men report extremely fragile livelihoods in their old age. Older people are exposed to HIV through multiple and intersecting drivers of risk and represent an often neglected population within health systems. The author argues that research and interventions need to go beyond only conceptualising older people as ‘carers’ to better address their gendered vulnerabilities to HIV in relation to all aspects of policy and programming.
Equity and HIV/AIDS
In view of the high prevalence of HIV and AIDS in South Africa, particularly among adolescents, the South African Departments of Health and Education proposed a school-based HIV counselling and testing (HCT) campaign to reduce HIV infections and sexual risk behaviour. Through the use of semi-structured interviews, this qualitative study explored perceptions of parents regarding the ethico-legal and social implications of the proposed campaign. Despite some concerns, parents were generally in favour of the HCT campaign. However, they were not aware of their parental limitations in terms of the Children’s Act. Their views suggest that the HCT campaign has the potential to make a positive contribution to the fight against HIV and AIDS, but needs to be well planned. To ensure the campaign’s success, there is a need to enhance awareness of the programme. All stakeholders, including parents, need to engage in the programme as equal partners.
Africa is leading the world in expanding access to antiretroviral therapy, with 7.6 million people across the continent receiving antiretroviral therapy as of December 2012, including 7.5 million people in sub-Saharan Africa. Eastern and Southern Africa is scaling up faster, by more than doubling the number of people on treatment between 2006 and 2012. At least 10 countries (Botswana, Cape Verde, Eritrea, Kenya, Namibia, Rwanda,
South Africa, Swaziland, Zambia and Zimbabwe) reported reaching 80% or more
of adults eligible for antiretroviral therapy, under the 2010 WHO guidelines. However, new WHO guidelines on HIV treatment in 2013 have since made many more people eligible for treatment.
WHO and many other organisations are very interested in implementing treatment-as-prevention as a global policy to control the HIV pandemic.1 Widespread treatment of HIV-infected individuals with antiretroviral therapy will reduce HIV transmission, because it decreases viral load and hence infectiousness. To implement the rollout of treatment-as-prevention in an efficient manner, estimation of the number of HIV-infected individuals and where they live is needed. This assessment will be difficult to accomplish, particularly in areas of sub-Saharan Africa with severe HIV epidemics. The authors propose a solution to this problem by using geospatial statistical techniques and global positioning system (GPS) data.
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.
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.