HIV discrimination : integrating the results from a six-country situational anaylsis in the Asia Pacific

The findings of the six independent studies on institutional forms of HIV discrimination in the Asia Pacific presented in this Special Issue of AIDS Care are integrated. At first glance, the general pattern of the results across the study sites suggests that discrimination is most pertinent in the domain of 'practice' rather than in the domains of law or institutional policy. On closer analysis, however, utilising the qualitative data, this conclusion does not take sufficient account of the cultural context within which the interpersonal interaction (practice) between the health carers and people living with HIV/AIDS occurs. Limitations on the use of anti-discrimination legislations and protective written policies for reducing discrimination in these contexts are discussed. The need for alternative approaches to thinking about discrimination intervention is raised and this is done through a consideration of the strategy of universal precautions.

Institutional and structural forms of HIV-related discrimination in health care : a study set in Beijing

This paper presents key findings of a situational analysis of institutional and structural levels of HIV/AIDS-related discrimination in Beijing, China, with a focus on the area of health care. Initially slow to respond to the presence of HIV, China has altered its approach and enacted strict legislative protection for people living with HIV/AIDS (PLWHA). In order to determine whether this has altered discrimination against PLWHA, this study examined existing legislation and policy, and interviewed key informants working in health care and PLWHA. The overall findings revealed that discrimination in its many forms continued to occur in practice despite China's generally strong legislative protection, and it is the actual practice that is hindering PLWHAs' access to health services. A number of legislative and policy gaps that allow discrimination to occur in practice were also identified and discussed. The paper concludes with a call to rectify specific gaps between legislation, policy and practice. An understanding of the underlying factors that drive discrimination will also be necessary for effective strategic interventions to be developed and implemented.

An Asia Pacific six-country study on HIV-related discrimination : introduction

This paper outlines a six-country study of institutionalised forms of HIV/AIDS-related discrimination in the Asia-Pacific region. Although recognised as a barrier to disease prevention and treatment, very limited data are available on the effects of institutionalised HIV-related stigma and discrimination. Understanding the forms of discrimination within the institutions where they occur is the first step to identifying effective ways of promoting compassionate, non-discriminatory treatment of PLWHA. Thus, the goal of this research project was to document institutional discrimination against PLWHA, as guided by the UNAIDS Protocol for the Identification of Discrimination Against People Living with HIV (2000), in six Asian countries: India, Thailand, Philippines, China, Vietnam and Indonesia. As a precursor to the six individual studies, this paper provides a brief overview of the literature on HIV discrimination, and then describes the UNAIDS Protocol and the shared methodological considerations relevant to all of the study sites. Commonalities in sampling, procedures and analysis are also discussed.

HIV, stigma, and rates of infections : a rumour without evidence

The modern concept of a social stigma comes from the work of American sociologist Erving Goffman, who described it as a response to a deeply discrediting attribute that devalues the person [1]. In the medical literature, stigma is almost inevitably written about in terms of adverse social sequelae of a disease—such as leprosy, tuberculosis, epilepsy, schizophrenia, or filariasis [2–6]—or a physical characteristic or functional loss, such as obesity, deafness, or paraplegia [7–9]. The consequences of stigma range from moderate opprobrium at one end of the spectrum to death [10].

Future research on structural and institutional forms of HIV discrimination

There is scant research into HIV discrimination, particularly structural and institutional forms of it. This appears, in part, to arise from a prevailing view that the solutions to HIV discrimination are known a priori and in the absence of additional data. The six country studies into HIV discrimination presented in this AIDS Care supplement suggest that this is not the case. There needs to be an acceptance that if the issue of HIV discrimination is to be tackled successfully and based on evidence, then incremental and effortful steps need to be taken to develop that evidence base. This is discussed.

The lived experience of gay men caring for others whith HIV/AIDS : resilient coping skills

There is a dearth of research conducted on the relationship aspect of gay men caring for gay men. This Australian research conducted in 2002 investigated the emotional effects of HIV/AIDS on the gay male carers of gay men with the disease. This study was phenomenological inquiry and employed van Manen's approach to content analysis. Twelve participants for the study were recruited. The results produced emergent themes relating to coping with HIV/AIDS, living day-to-day with HIV/AIDS, coping with the last phase of AIDS towards death, saying goodbye and remembrance. This research highlights the resilient coping style of carers of persons living with HIV/AIDS. The research also gives rise to recommendations for practice and educational contexts in terms of the support and care considerations for persons living with HIV/AIDS and their carers.

Thought processes associated with reluctance in gay men to be tested for HIV

This study explored the thought processes that are associated with reluctance in gay men to be tested for HIV antibodies. The sample comprised 97 men who had not been tested for at least four years; 69 had never been tested. They were asked to imagine that someone had suggested that they be tested very soon and to identify, from the list provided, any negative thoughts prompted by this suggestion. The most commonly reported thoughts were that testing was unnecessary because risks had not been taken, that it was unnecessary because there were no symptoms, and that there was no urgency to be tested. Data were explored by means of factor analysis and comparisons across subgroups differing in risk level. The results are interpreted as indicating the use of rationalizations to buttress a decision not to be tested, the powerful influence on HIV decision-making exerted by salient perceptible features, and the ‘status quo bias’. Techniques that could be used to encourage testing in gay men are discussed.

Markers and risk factors for HCV, HBV and HIV in a network of injecting drug users in Melbourne

Background and aims: Current injecting drug users (IDU) in major street drug markets within greater Melbourne were recruited to a longitudinal study on blood borne viruses. Here we investigated risk factors for hepatitis C virus (HCV), hepatitis B virus (HBV) and HIV infection in these IDU at the time of their recruitment.

Methods : Three hundred and eighty-two IDU completed detailed questionnaires on their drug use and risk behaviours, and provided blood samples for serology testing. These data were analysed using univariate and multivariate techniques.

Results : The overall prevalence of exposure to HCV, HBV and HIV was estimated at 70%, 34% and <1%, respectively. Independent predictors of HCV exposure were history of imprisonment (RR 1.34, 95% CI 1.19–1.52), use of someone else's needle or syringe (RR 1.23, 95% CI 1.07–1.42), >7.6 years length of time injecting (RR 1.21, 95% CI 1.07–1.37), and originating from Vietnam (RR 1.12, 95% CI 1.07–1.18). Independent predictors of HBV exposure were HCV exposure (RR 2.15, 95% CI 1.35–3.43), >7.6 years length of time injecting (RR 1.57, 95% CI 1.17–2.13) and originating from outside Australia (RR 1.60, 95% CI 1.22–2.10). Neither prison- nor community-applied tattoos predicted HCV or HBV exposure. Up to 31% of IDU who injected for 1 year or less were HCV antibody positive, as were 53% of those who injected for 2 years or less.

Conclusions : Ongoing engagement with young IDU, through the provision of harm reduction education and resources, is critical if we are to address blood borne viral infections and other health and social harms associated with injecting drug use.

Evaluation of a community-based mental health drug and alcohol nurse in the care of people living with HIV/AIDS

There is a growing need for advanced practice mental health and drug and alcohol nursing roles in the care of people living with HIV/AIDS; however, limited publications address these domains. This study evaluated a community-based mental health drug and alcohol nurse role caring for people living with HIV/AIDS (Mental Health D&A Nurse) in a large not-for-profit district nursing organization providing care to people living with HIV/AIDS in an Australian city. Outcomes from a client assessment and 6–8-week follow-up by the Mental Health D&A Nurse are presented as captured by the Depression Anxiety Stress Scales (DASS 21), Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Health of the Nation Outcome Scales (HONOS) and WHOQoL BREF. Mean scores and caseness were analysed, and significant differences were found on the 'impairment' and 'social problems' subscales of the HONOS. Results of semi-structured interviews with clients describe effective and supportive mental health care and health-promoting education following visits by the Mental Health D&A Nurse. These positive findings support continuing implementation of the role within this community setting and indicate that even greater benefits will ensue as the role develops further. Findings are of interest to clinicians and policy makers seeking to implement similar roles in community-based HIV/AIDS care.

Commercial sex work, survival sex, sexual violence and HIV/AIDS prevention in Arumeru District, Arusha region Of Tanzania

Objective: To examine the knowledge and practices about HIV/AIDS among female Tanzanian commercial sex workers (CSWs) and assess the contextual dynamics that prevent safer sexual behaviours.

Method: The study used mixed methods and was implemented in two phases. Phase one assessed the knowledge and practices about HIV/AIDS among CSWs. Data were obtained with 54 CSWs, who were selected by using a snowball sampling approach. Semi-structured, face-to-face interviews with the CSWs were undertaken to allow the research participants to describe and discuss their lived realities as they perceive and experience them. In phase two, three discrete focus group discussions, each comprising 6-10 women, were carried out with 26 of the 54 CSWs who were interviewed in phase one.

Results: There was exploitation and inequity in the women's lives due to the multiple and overlapping oppressions of poverty and patriarchy. Sexual violence was framed, legitimised and reinforced by structural and cultural inequities. Such exploitation impacted not only on CSWs' lives as sex workers, but on their previous and/or simultaneous lives as mothers, wives, girlfriends and daughters. The women practised ‘survival sex’ as CSWs and/or sexual partners of men, and experienced sexual violence from their clients/partners. This violence was either culturally legitimised within a patriarchal framework or manifested itself as ‘displaced aggressive sex’ by men experiencing marginalisation in socio-economic spheres.

Cost-effectiveness of adult circumcision in a resource-rich setting for HIV prevention among men who have sex with men

Background.  We examined the effects and cost‐effectiveness of 4 strategies of circumcision in a resource‐rich setting (Australia) in a population of men who have sex with men (MSM).

Method.  We created a dynamic mathematical transmission model and performed an economic analysis to estimate the costs, outcomes, and cost‐effectiveness of different strategies, compared with those of the status quo. Strategies included circumcision of all MSM at age 18 years, circumcision of all MSM aged 35–44 years, circumcision of all insertive MSM aged 18 years, and circumcision of all MSM aged 18 years . All costs are reported in US dollars, with a cost‐effectiveness threshold of $42,000 per quality‐adjusted life‐year.

Results.  We find that 2%–5% of human immunodeficiency virus (HIV) infections would be averted per year, with initial costs ranging from $3.6 million to $95.1 million, depending on the strategy. The number of circumcisions needed to prevent 1 HIV infection would range from 118 through 338. Circumcision of predominately insertive MSM would save $21.7 million over 25 years with a $62.2 million investment. Strategies to circumcise 100% of all MSM and to circumcise MSM aged 35–44 years would be cost‐effective; the latter would require a smaller investment. The least cost‐effective approach is circumcision of young MSM close to their sexual debut. Results are very sensitive to assumptions about the cost of circumcision, the efficacy of circumcision, sexual preferences, and behavioral disinhibition.

Conclusions.  Circumcision of adult MSM may be cost‐effective in this resource‐rich setting. However, the intervention costs are high relative to the costs spent on other HIV prevention programs.