In a long-standing general population cohort in rural Uganda researchers assessed the prevalence of concurrency and investigated its association with socio-demographic and behavioural factors and with HIV prevalence, using the new recommended standard definition and methodological approaches. Among those eligible, 3,291 (66%) males and 4,052 (72%) females participated in the survey. Among currently married participants, 11% of men and 25% of women reported being in a polygynous union. Among those with a sexual partner in the past year, the proportion reporting at least one concurrent partnership was 17% in males and 0.5% in females. Polygyny accounted for a third of concurrency in men and was not associated with increased HIV risk. Among men there was no evidence of an association between concurrency and HIV prevalence (but too few women reported concurrency to assess this after adjusting for confounding). Regarding sociodemographic factors associated with concurrency, females were significantly more likely to be younger, unmarried, and of lower socioeconomic status than males. Behavioural factors associated with concurrency were young age at first sex, increasing lifetime partners, and a casual partner in the past year (among men and women) and problem drinking (only men). These findings are intended to provide a baseline for measuring changes in concurrency and HIV incidence in future surveys, and a benchmark for other studies.
Equity and HIV/AIDS
The notion that concurrent sexual partnerships are especially common in sub-Saharan Africa and explain the region's high HIV prevalence is accepted by many as conventional wisdom. This paper’s findings contradict that belief. The paper evaluated the quantitative and qualitative evidence offered by the principal proponents of the concurrency hypothesis and analysed the mathematical model they use to establish the plausibility of the hypothesis. It found that research seeking to establish a statistical correlation between concurrency and HIV prevalence either finds no correlation or has important limitations. Furthermore, in order to simulate rapid spread of HIV, mathematical models require unrealistic assumptions about frequency of sexual contact, gender symmetry, levels of concurrency, and per-act transmission rates. The paper considers qualitative evidence offered by proponents of the hypothesis as irrelevant since, among other reasons, there is no comparison of Africa with other regions. It concludes that promoters of the concurrency hypothesis have failed to establish that concurrency is unusually prevalent in Africa or that the kinds of concurrent partnerships found in Africa produce more rapid spread of HIV than other forms of sexual behaviour. Policy makers should turn attention to drivers of African HIV epidemics that are policy sensitive and for which there is substantial epidemiological evidence.
AIDS activists have reported that public health facilities in South Africa's Free State Province are experiencing serious shortages of condoms, with some clinics reporting complete stockouts. The Treatment Action Campaign (TAC), an AIDS lobby group, contacted 41 clinics in the province: four reported shortages of condoms and eleven said they had none at all. One clinic in the provincial capital, Bloemfontein, said the depot that normally supplied them with condoms had run out. Free State attracted controversy in November 2008 after the provincial health budget had been overspent to such an extent that the authorities stopped initiating HIV-positive patients on antiretroviral treatment. The national department of health blamed a countrywide shortage in December 2008 on a delay in awarding a new tender. TAC speculated that the delay might still be affecting supply, as it used to receive about one million condoms a month from the health department for distribution, but could now only get hold of about half that quantity.
Correct and consistent condom usage remains a pivotal strategy in reaching the target set by the South African government to reduce new HIV infections by 50% in the next 5 years. Studies have found that there has been an increase in condom usage by some categories of the population, but usage has not yet reached the desired levels in order to meet the target. This article reports on the findings of a study on condom usage in eight communities in the North West Province, which was part of a wider HIV and AIDS programme evaluation commissioned by the North West Provincial Department of Health. The main aim was to assess accessibility to condoms, and knowledge, attitudes and practices around condom use by four sampled communities in the North West Province. Eight focus group discussions were held and 50 households were interviewed. The study found positive results regarding accessibility and awareness of condoms. However, this often did not lead to the desired behavioural change of using condoms in risky sexual interactions. The majority of respondents still resisted condom usage, used condoms inconsistently, or were not in a position to negotiate protected sexual intercourse. The main reasons reported for this were: reduced pleasure, perceived and real physical side-effects, myths, lack of information, status, financial reasons, distrust in the efficacy of condoms, family planning, cultural reasons, gender-related reasons and trust. Many of the barriers to consistent condom use cannot be overcome by strategies that target the individual. Interventions need to address underlying developmental factors such as the non-biological factors that increase the susceptibility of women to HIV infection. As this falls outside of the scope of the mandate of the Department of Health, various partnerships with other key role players need to be established and/or strengthened, such as with local government, non-governmental organisations and faith-based organisations.
Thanks to the international recession, the author argues that external funders are either decreasing or opting not to increase their funding of AIDS treatment. Medecins Sans Frontieres (MSF) recently reported that two key international programmes supporting AIDS treatment in the developing world are not increasing their grants: For two successive years the Global Fund Against AIDS, Tuberculosis and Malaria has reduced funding for approved grants, while the American President’s Emergency Plan for AIDS Relief (PEPFAR) is now practicing what it calls ‘flat-funding’, which ‘basically means that you can only recruit when someone dies, when someone empties a seat or a treatment slot’, as explained by Dr Erci Goemaere, co-ordinator of MSF missions in South Africa and Lesotho. The authors warn that a funding crisis could lead to the reversal of gains made since the start of antiretroviral treatment in developing countries.
The authors of this study examined the association between young people's interests in the consumption of modern goods and their sexual behaviour in Antananarivo and Antsiranana, Madagascar. Their survey included 2, 255 youth ages 15-24. Overall, 7.3% of women and 30.7% of men reported having had multiple partners in the last year; and 5.9% of women reported ever practising transactional sex. This was associated with perceptions concerning the importance of fashion and a series of activities associated with modern lifestyles. For transactional sex, results suggested perceptions around fashion, nightclub attendance and getting to know a foreigner were key determinants. The authors found that peri-urban residence was more associated with transactional sex than urban residence; and ethnic origin was the strongest predictor of both outcomes for women. While they found some evidence of an association between sexual behaviour and interest in modern goods, or modern lifestyles, they caution that such processes did not single-handedly explain risky sexual behaviour among youth: these behaviours were also shaped by culture and conditions of economic uncertainty. These determinants must all be accounted for when developing interventions to reduce risky transactional sex and vulnerability to HIV.
AIDS drugs, some of them contaminated, diluted, or faked, are being sold at flea markets and hairdressing salons in the face of growing shortages in clinics linked to Zimbabwe's economic crisis, the health ministry said. State media quoted Minister of Health David Parirenyatwa on Monday appealing to people living with HIV or AIDS to buy their medicines from registered pharmacies, clinics, and hospitals only. "These fake drugs increase chances of one becoming resistant to treatment, and it becomes even more expensive for that person to remain on treatment," he was quoted as saying by the official Herald newspaper, which said that the "prohibitive" cost of antiretroviral drugs at private pharmacies had fueled the illegal market.
South Africa's Free State Province is again experiencing a crisis in the delivery of antiretroviral (ARV) treatment, with understaffed clinics, erratic drug supplies and long waiting lists preventing many dangerously ill patients from accessing the life-prolonging drugs, according to AIDS activists. Runaway overspending by the provincial health department in 2008 led to a moratorium on new patients starting ARV treatment that lasted from November until February 2009. The Southern African HIV Clinicians Society estimated that 30 people a day died during this three-month period because they could not access treatment. Now, several reports from the Free State suggest that many of the factors leading to last year's moratorium have not been addressed, and patients are again suffering the consequences. Trudie Harrison, director of the Anglican Church's Mosamaria AIDS Ministry, said that the crisis was the result of drug shortages and a dearth of health workers. At one ARV site she recently visited, normally staffed by three doctors, about 200 patients were waiting to see just one doctor.
Researchers in this study investigated reasons for clinical follow-up and treatment discontinuation among HIV-infected individuals receiving antiretroviral therapy (ART) in a public-sector clinic and in a workplace clinic in South Africa. Participants in a larger cohort study who had discontinued clinical care by the seventh month of treatment were traced using previously provided locator information. Those located were administered a semi-structured questionnaire regarding reasons for discontinuing clinical follow-up. Participants who had discontinued antiretroviral therapy were invited to participate in further in-depth qualitative interviews. Fifty-one of 144 (35.4%) in the workplace cohort had discontinued clinical follow-up by the seventh month of treatment. The median age of those who discontinued follow-up was 46 years and median educational level was five years. By contrast, only 16.5% (44/267) of the public-sector cohort had discontinued follow-up. Among them the median age was 37.5 years and median education was 11 years. Qualitative interviews were conducted with 17 workplace participants and 10 public-sector participants. The main reasons for attrition in the workplace were uncertainty about own HIV status and above the value of ART, poor patient–provider relationships and workplace discrimination. In the public sector, these were moving away and having no money for clinic transport. The authors argue that, in the workplace, efforts to minimise the time between testing and treatment initiation should be balanced with the need to provide adequate baseline counselling taking into account existing concepts about HIV and ART. In the public sector, earlier diagnosis and ART initiation may help to reduce early mortality, while links to government grants may reduce attrition.
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.