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.
Equity and HIV/AIDS
According to this paper, a growing number of studies highlight men's social disadvantage in making use of HIV services. Drawing on the perspectives of 53 ARV users and 25 healthcare providers, researchers examined qualitatively how local constructions of masculinity in rural Zimbabwe impact on HIV testing and treatment uptake. They found that informants reported a clear and hegemonic notion of masculinity that required men to be and act in control, to have know-how, be strong, resilient, disease free, highly sexual and economically productive. However, such traits were in direct conflict with the 'good patient' persona who is expected to accept being HIV positive, take instructions from nurses and engage in health-enabling behaviours such as attending regular hospital visits and refraining from alcohol and unprotected extra-marital sex. This conflict between local understandings of manhood and biopolitical representations of 'a good patient' can provide a possible explanation to why so many men do not make use of HIV services in Zimbabwe. The researchers urge HIV service providers to consider the obstacles that prevent many men from accessing their services.
This paper describes the development of a family-centred, structured intervention to support mothers to disclose their HIV status to their HIV-negative school-aged children in rural South Africa, an area with high HIV prevalence. The intervention was piloted with 24 Zulu families, all mothers were HIV-positive and had an HIV-negative child aged 6–9 years. Lay counsellors delivered the six session intervention over a six to eight week period. Qualitative data were collected on the acceptability, feasibility and the effectiveness of the intervention in increasing disclosure, health promotion and custody planning. All mothers disclosed something to their children: 11/24 disclosed fully using the words "HIV" while 13/24 disclosed partially using the word "virus". This pilot study found the intervention was feasible and acceptable to mothers and counsellors, and provides preliminary evidence that participation in the intervention encouraged disclosure and health promotion. The pilot methodology and small sample size has limitations and further research is required to test the potential of this intervention. A larger demonstration project with 300 families is currently underway.
An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. The authors of this study evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region. Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills. The authors conclude that MEMS-bottle use was readily accepted by patients, but patients need to be more explicitly instructed to continue MEMS-use when travelling. In addition, even if HIV clinics have sufficient staff and free medication, supplying an insufficient amount of pills may impose adherence barriers on patients.
A two-day joint meeting of SADC Ministers of Health and Ministers responsible for HIV and AIDS was officially opened in Mbabane, Swaziland, on 12 November 2009, by the Right Honourable Sibusiso Dlamini, prime minister of Swaziland. In his address, the prime minister urged SADC member states to implement SADC policy documents on HIV and AIDS, TB and malaria. The ministers approved a number of policy documents, including the Draft HIV and AIDS Strategic Framework 2010-2015. Ministers urged member states who are in the process of updating their frameworks to align them with the regional framework. The ministers also approved the SADC HIV and AIDS Business Plan and Budget, which emphasises multi-sector and inter-programme links reflecting the inter-relationships between HIV and AIDS, poverty, conflict, governance, socio-cultural and economic development and the SADC HIV and AIDS Fund. On the control of communicable diseases, HIV and AIDS, Tuberculosis and Malaria, the ministers approved the functions and minimum standards for national reference laboratories in the SADC region; functions and minimum standards for supranational reference laboratory and regional centres of excellence; and the proposed selection criteria for supranational reference laboratory and regional centres of excellence. The ministers further approved the regional minimum standards for HIV testing and counselling and urged member states to adhere to them.
Within the HIV public health domain, interest is growing in universal test and treat (UTT) strategies. This refers to the expansion of antiretroviral therapy (ART) in order to reduce onward transmission and incidence of HIV in a population, through a “treatment as prevention” (TasP). This paper focuses on how masculinity influences engagement with HIV care in the context of an on-going TasP trial. Data were collected in January–November 2013 using 20 in-depth interviews, 10 of them repeated thrice, and 4 focus group discussions, each repeated four times. The accounts detailed men’s unwillingness to engage with HIV testing and care, seemingly tied to their pursuit of valued masculinity constructs such as having strength and control, being sexually competent, and earning income. Given fears regarding getting an HIV-positive diagnosis, men preferred traditional medicine. Further primary health centres were not seen to be welcoming to men discouraging their readiness to test for HIV. These tensions were amplified by masculinity norms. Men struggled with disclosing their HIV status, and used various strategies to avoid or postpone disclosing, or disclose indirectly. In contrast women were found to access care readily. The authors argue that UTT and TasP promotion should use health service delivery models that address these tensions.
Women comprise nearly half of the HIV-infected population worldwide, but these 15.5 million women tend to be under-represented in clinical trials of anti-HIV drug therapies, according to this study. The authors used the US Food and Drug Administration (FDA) database created from 40 clinical studies to assess gender differences in the efficacy of antiretroviral treatments. They found that women represented only about 20% of the subjects in randomised clinical trials submitted to the FDA between 2000 and 2008. When they compared the effectiveness of anti-HIV drug regimens reported for women versus men overall and among various subgroups, they found no statistically or clinical significant differences between women and men in outcomes with regard to viral load after 48 weeks. However, they did report significant gender differences favouring males based on subgroup analyses. They argue that this is a critical area of research in terms of developing new HIV therapies, as mounting evidence indicates that metabolism of certain drugs varies in men vs. women, and side effects that interfere with adherence to these medications may also be manifested differently.
The consequences of HIV and AIDS are exponential in Kenya, touching not only the health of those infected, but also depleting socioeconomic resources of entire families. Access to financial services is one of the important ways to protect and build economic resources. Unfortunately, the norm of financial viability discourages microfinance institutions from targeting people severely impacted by HIV and AIDS. Thus, HIV- and AIDS-service NGOs have been increasingly getting involved in microcredit activity in recent years for economic empowerment of their clients. Despite limited human resources and funding in the area of microcredit activity, these NGOs have demonstrated that nearly 50% of their microcredit beneficiaries invested money in income-generating activities, resulting in enhancement in their livelihood security. In the short term these NGOs need to improve their current practices. However, this does not mean launching microfinance initiatives within their AIDS-focused programmes, as financial services are best provided by specialised institutions. Longer-term cooperation between microfinance institutions and other HIV- and AIDS-service organisations and donors is necessary to muster appropriate and rapid responses in areas experiencing severe impacts of the disease.
Do the gains in confidence and economic well being that can come from participation in a microfinance programme reduce clients’ vulnerability to HIV infection? Until now practical experience and an evidence base relating to such activities have been limited. This article reviews the evidence supporting an enhanced role for microfinance in HIV prevention activities. It describes the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) – a South African case study that has been specifically designed to explore these relationships. The paper discusses the operational integration of microfinance and HIV prevention – highlighting challenges, emerging lessons and limitations in the light of international best practice and several years of field experience.
This study of six countries, including Zimbabwe, Kenya and Uganda, indicates that new investment in AIDS services has exposed existing fragilities in health systems. In some cases it has placed increasing burdens on these systems by expanding demand and stretchied already overextended human resources. The report, which provides some of the first on-the-ground research documenting the impacts of the AIDS service scale up, shows that the AIDS response has attracted the biggest share of health financing, increased the number of trained medical personnel, improved the management of people living with the virus, and supported the establishment of HIV clinics that treat TB and other opportunistic infections.