Dynamic intimate contact social networks and epidemic interventions

This article discusses dynamic intimate contact social networks and epidemic interventions

Herd Immunity/Herd Infection: Cultural Artifacts of Marginalization and the Dynamics of AIDS

We examine conditions under which high prevalence of infectious disease can become endemic within a community, in effect constituting a state of 'herd infection' inverse to epidemiological herd immunity. For something like AIDS, under such circumstances, a single behavioral lapse or adverse accident will probably be a death sentence

Inferring change points in the COVID-19 spreading reveals the effectiveness of interventions

As COVID-19 is rapidly spreading across the globe, short-term modeling forecasts provide time-critical information for decisions on containment and mitigation strategies. A main challenge for short-term forecasts is the assessment of key epidemiological parameters and how they change when first interventions show an effect. By combining an established epidemiological model with Bayesian inference, we analyze the time dependence of the effective growth rate of new infections. Focusing on the COVID-19 spread in Germany, we detect change points in the effective growth rate that correlate well with the times of publicly announced interventions. Thereby, we can quantify the effect of interventions, and we can incorporate the corresponding change points into forecasts of future scenarios and case numbers. Our code is freely available and can be readily adapted to any country or region.Comment: 23 pages, 11 figures. Our code is freely available and can be readily adapted to any country or region ( https://github.com/Priesemann-Group/covid19_inference_forecast/

Livelihood Risk from HIV in Semi-Arid Tropics of Rural Andhra Pradesh

This paper discusses the livelihood dynamics in the fragile landscape of the semi-arid tropics (SAT) of Andhra Pradesh. SAT is home to the poorest of the poor who live in conditions of persistent drought, subsistence agriculture and poor access to markets. This paper is a case study focusing particularly on labour migration, its role in influencing the health risk behaviour of migrants and in the spread of the HIV epidemic among SAT rural households. The most vulnerable population in these drought prone regions are the migrant labourers, and their vulnerability is influenced by three major factors—the vulnerability and unstable productivity in the degraded and marginal landscape, the caste system that has traditionally kept them backward and vulnerable, and experiences in the external environment to which they migrate. This study is based on a theoretical framework, whereby livelihood risks lead to health risks, particularly HIV infection—outlines the process that causes a further deterioration of the household and the occurrence of cyclical health risk. The paper calls for a multisectoral approach to tackle the issue of migrant vulnerability, and for interventions with a more migrant-need sensitive approach.

Livelihood Risk from HIV in Semi-Arid Tropics of Rural Andhra Pradesh

This paper discusses the livelihood dynamics in the fragile landscape of the semi arid tropics (SAT) of Andhra Pradesh. SAT is home to the poorest of the poor who live in conditions of persistent drought, subsistence agriculture and poor access to markets. This paper is a case study focusing particularly on labour migration, its role in influencing the health risk behaviour of migrants and in the spread of the HIV epidemic among SAT rural households. The most vulnerable population in these drought prone regions are the migrant labourers, and their vulnerability is influenced by three major factors?the vulnerability and unstable productivity in the degraded and marginal landscape, the caste system that has traditionally kept them backward and vulnerable, and experiences in the external environment to which they migrate. This study?based on a theoretical framework, whereby livelihood risks lead to health risks, particularly HIV infection?outlines the process that causes a further deterioration of the household and the occurrence of cyclical health risk. The paper calls for a multisectoral approach to tackle the issue of migrant vulnerability, and for interventions with a more migrant-need sensitive approach.labour migration, HIV risk behaviour, agriculture, health, semi-arid tropics

No. 24: Spaces of Vulnerability: Migration and HIV/AIDS in South Africa

Seventy per cent of the 36 million people infected worldwide with HIV live in Sub-Saharan Africa and within this region the countries of Southern Africa are the worst affected. The eight countries with the highest rates of infection are in Southern Africa, followed by six countries in East Africa, and then five other countries, only one outside Africa. The reasons why the highest rates of infection in the world occur in Southern Africa are unclear. Although the countries of the region have much in common, their histories over the last twenty years have been very different. A number of different factors have been advanced to explain the general picture of HIV/AIDS in South Africa including its rapid spread, high prevalence and uneven distribution. They include poverty and economic marginalization; differing strains of HIV; high rates of sexually transmitted disease and other opportunistic infection; sexual networking and patterns of sexual contact; the presence or absence of male circumcision; and the role of core-groups such as commercial sex workers. These factors are discussed in greater detail in the paper, reviewing the current state of knowledge about each in South Africa. The paper argues that a key neglected factor in explaining the rapid spread and prevalence of HIV/AIDS in Southern Africa over the last decade is human mobility. The paper therefore examines what is currently known about the connections between migration and HIV/AIDS. Although both migration and HIV have been examined separately in South Africa, we are still far from understanding in detail just how and to what extent migration affects the spread of HIV. Part of the reason for this is that studies of migration and disease tend to concentrate on the urban, or ‘receiving’ areas with little attention being paid to people living in the rural or ‘sending’ areas. Furthermore, there have been very few well-designed epidemiological studies documenting the relationship between migration and infectious diseases. Even more importantly, at this late stage of the Southern African HIV epidemic, there have been few intervention programmes, even on a small scale, which attempt to reduce transmission among migrants and their rural or urban partners. Without a proper understanding of the social, behavioural and psychological consequences of migration, it will not be possible to understand the consequences of migration for the spread of HIV and the particular vulnerability to infection of mobile populations. To effect this conceptual refocus on the social (and sexual) disruption that accompanies migration and mobility, a number of reorientations are required, including: A more detailed understanding of the complex and changing patterns of migrancy in its different forms; Appreciation of the particular vulnerabilities of migrants as migrants (and those with whom they interact) and hence the economic, social, sexual and gender regimes associated with migrancy; Since generic HIV/AIDS interventions seem to be having so little impact in migrant settings and situations of high mobility, there is a need to develop models of intervention that are sensitive to the circumstances of mobile people; As attention is increasingly directed towards models of care and the development of appropriate ‘toolkits’, there is a need to develop interventions appropriate to the situation of migrants and their divided households. The paper argues that none of these objectives can be adequately reached without attention to both the macro- and micro-geographies of mobility, social connectivity and sexual behaviour. The connections between migrancy and HIV/AIDS are more difficult to unravel because HIV/AIDS arrived in the region at a time when population mobility and systems of migrant labour were undergoing considerable change. Migrancy is, by its very nature, highly dynamic and has changed dramatically in scope, scale and diversity over the last two decades. Today it is much more difficult to map the prevalence and spread of disease onto spatial patterns of migration than it was in the past. Several important migration changes that coincided with the advent of HIV/AIDS need to be mentioned: The collapse of apartheid brought new opportunities and reasons for migration across borders within the region. Migrants from neighbouring countries and further afield see South Africa as a new place to trade, shop, seek essential services, work and seek asylum. South Africa’s formal trade with the rest of the continent has exploded, goods carried in the main by long-distance truckers. Informal sector cross-border trading has also expanded dramatically since the end of apartheid. Significant growth in levels of urbanization in South African cities. One consequence has been the displacement of the rural poor to the towns. The new gendering of migrancy. Women are becoming considerably more mobile, migrating for formal and informal work in ever-growing numbers and travelling more frequently for a variety of social and other reasons. The mining industry persists with its regional single-sex contract labour system but there are much higher levels of social contact between migrants miners and people living near the mines. The vulnerabilities to HIV of people (migrant and non-migrant, mobile and relatively immobile) associated with this changing regime of migrancy are poorly understood. The evidence seems to suggest that migrants and migrant households in town and countryside are particularly at risk. So too are the residents of non-migrant communities with whom migrant workers interact on a daily basis. After discussing the general evidence on the causal connections between HIV/AIDS and migration in South Africa, this paper seeks to move the South African debate from the macro- to the micro-scale. By reviewing the findings of research in three different settings the complexity of the connections between migration and HIV/AIDS begins to emerge. The case study areas are spaces of vulnerability, places in which to observe why migrants and those with whom they come into contact are highly susceptible to HIV infection, and hence to develop approaches to decreasing this vulnerability. If workable interventions, based on a sound understanding of local regimes of migration and sexuality, can be developed in disparate case studies such as these, then such best-practice models could have much wider relevance for resisting the ravages of the epidemic. Much can still be done to reduce the impact and the spread of HIV in South Africa. Mother-to-child transmission could be substantially reduced using standard drug regimens. Control of curable STIs would reduce transmission of HIV. The effective promotion of condoms and a reduction in high risk sexual behaviour would have an effect in the longer term. Tuberculosis prophylaxis could substantially reduce tuberculosis morbidity and mortality among those with HIV and this is particularly important in the context of gold mining. The public health implications of the provision of free anti-retroviral therapy to people who are HIV-positive need to be examined. And adequate resources must go to the development of a vaccine for HIV subtype C. None of these interventions are likely to be effective without a sound understanding of the reasons why Southern Africa is the worst affected region in the world, why the epidemic has spread in this region more rapidly than in any other, and why there are such great differences in the infection rates in different provinces, between men and women and critically between migrants and non-migrants. In addition, in all of these interventions special attention should be given to people at high risk of infection, which includes not only commercial sex workers, but also migrants and the partners of migrants. In this context, effort needs to go into the development of epidemiological models to understand the current state and the likely future course of the epidemic, to provide a context for planning and designing interventions, and to evaluate the effectiveness of such interventions. This paper highlights the current state of knowledge about the linkages between HIV/AIDS and migration but it is abundantly clear that there are large gaps in our knowledge of the extent to which migration, and the particular forms of migration that are found in Southern Africa, can explain why the levels of infection in this region are so much higher than anywhere else in the world. Areas in which more work is urgently needed include: Research on the dimensions and social and health impacts of cross-border and internal migration. To what extent does migration contribute to the overall spread of HIV and other STIs? What steps are being taken to ensure that all migrants, legal as well as undocumented, can readily access the treatment services for STIs and HIV prevention programmes? The economic consequences of out-migration from labour-sending areas have been studied in some depth. But what are the consequences of such migration for the sexual health of those who are left behind? As migrants return home with HIV, suffering from other opportunistic infections and soon to develop AIDS, what are the economic implications for their families and communities who will not only lose a bread winner but must also find the resources to provide some level of care for the dying men and women? As the gold mines, in particular, retrench more men and as the economy slows down and unemployment increases, there are indications that more and more women are migrating in search of work. Because of the highly discriminatory labour market, some will have no choice but to engage in commercial sex work. All are likely to be at increased risk of HIV. What kinds of public health interventions can be developed to assist women at such high risk? While it is certain that migration has fuelled the epidemic of HIV in Southern Africa, infections are now so widespread that it seems likely that migration is no longer driving the epidemic. However, programmes to control the epidemic will certainly be considerably less effective if migrant workers continue to spread infections. Programmes aimed at supporting migrants should be given the highest priority but much more work is needed to provide an understanding of the social, behavioural and sexual context of the lives of migrants Perhaps, most importantly, policy issues need to be addressed including the nature and extent of migration, the rights of migrant workers, and the kinds of services to which they have access. This must be done both for those in the formal and in the informal sector and even undocumented migrants must be able to access health services without fear of exposure. The epidemic of HIV/AIDS threatens to devastate much of Southern Africa. Dealing with the epidemic must be given the highest priority and treated with the greatest urgency. However, unless the issues of migration and disease are understood and dealt with effectively, it is unlikely that the greater struggle to control and manage AIDS can be won

Research report: "Using what you have to get what you want": Vulnerability to HIV and prevention needs of female post‐secondary students engaged in transactional sex in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents findings from a qualitative study examining vulnerability to HIV of female post‐secondary students engaged in transactional sex in Kumasi, Ghana and their prevention needs. The study was conducted by Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) as part of Project SEARCH funded by the United States Agency for International Development Ghana. Participants were recruited from five post‐secondary institutions in the greater Kumasi area. Our objective is to provide academic institutions, the Ghana AIDS Commission (GAC), the National AIDS Control Program, donors, and other stakeholders with rich data to inform research and programmatic efforts in Kumasi specifically, as well as academic institutions in general. We set out to document what forms of transactional sex female students are engaging in, who their partners are, and what motivates them to participate. We asked students about the individual and structural vulnerabilities for HIV reported by female post‐secondary students involved in transactional sex and what their prevention needs are. We also interviewed a small sample of faculty, residence hall matrons, and hotel staff to get their perspective on the behavior of female students practicing transactional sex that might put them at risk for HIV. The findings of this study can be used as well to inform the design of future studies of young women engaging in transactional sex in Ghana. With such limited understanding of HIV transmission among young female post‐secondary students engaged in transactional sex, research is needed to determine how this group contributes to the overall HIV epidemic. The Ghana AIDS Commission has recognized the need for further research among communities engaged in less well‐defined risky sex practices in the National Strategic Plan for Most‐at – Risk Populations (MARP) 2011‐2015.4 This study attempts to fill in gaps in the research regarding transactional sex, taking into account the complexities and nuances of the practice, in addition to examining the needs of female students for targeted HIV prevention programs.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Kaupapa Māori wellbeing framework: the basis for whānau violence prevention and intervention

With Māori over-represented in family violence statistics as both victims and perpetrators, this paper identifies some key considerations for implementing violence prevention and intervention initiatives. Key messages: Māori are over-represented in family violence statistics as both victims and perpetrators. The causes of whānau violence are acknowledged as complex and as sourced from both historical and contemporary factors. The impact of colonisation needs to be considered in order to respond effectively to whānau violence.  Western approaches have not curbed the epidemic of whānau violence. Multi-level approaches to whānau violence prevention and intervention are more likely to achieve the best results. Understanding the difference between whānau and family is critical in terms of any prevention and intervention practices, policies and legislation. The use of cultural imperatives, for example, whakapapa, tikanga, wairua, tapu, mauri, and mana, has the potential to inform wellbeing in intimate partner and whānau relationships, transform behaviours and provide alternatives to violence. Using these imperatives can guide transformative practices and inform strategies for whānau violence prevention and whānau wellbeing. They can also be seen as protective factors within whānau, hapū and iwi. Culturally responsive initiatives and programmes that restore and strengthen whānau and communities should be considered as well as the individual based interventions of mainstream for Māori whānau. Kaupapa Māori conceptual frameworks, for example the Mauri Ora framework, advocate for the development of Māori models that change the way whānau violence is understood and managed. Successful programmes are likely to have: - Māori population based responses that complement the work of Māori and other community-based intervention services. These should be grounded in te reo me ona tikanga (Māori language and culture), underpinned by Māori values and beliefs, Māori cultural paradigms and frameworks - Government agencies working in close collaboration with iwi organisations to facilitate the implementation of Māori whānau violence prevention initiatives that meet the needs, priorities and aspirations of iwi - Funding sufficient to (a) engage leaders and staff who have the nationally and locally recognised skills to ensure successful implementation of violence prevention initiatives, and (b) to allow for local consultation and subsequent responsiveness in planned activities and projects - Support for capacity building opportunities for both prevention and intervention staff, including opportunities for networking, advocacy, and training - Māori violence prevention initiatives that are funded for research and evaluation in a way that builds local knowledge within a Māori worldview

HCV epidemiology in high-risk groups and the risk of reinfection

Injecting risk behaviours among people who inject drugs (PWID) and high-risk sexual practices among men who have sex with men (MSM) are important routes of hepatitis C virus (HCV) transmission. Current direct-acting antiviral treatment offers unique opportunities for reductions in HCV-related liver disease burden and epidemic control in high-risk groups, but these prospects could be counteracted by HCV reinfection due to on-going risk behaviours after successful treatment. Based on existing data from small and heterogeneous studies of interferon-based treatment, the incidence of reinfection after sustained virological response range from 2-6/100 person years among PWID to 10-15/100 person years among human immunodeficiency virus-infected MSM. These differences mainly reflect heterogeneity in study populations with regards to risk behaviours, but also reflect variations in study designs and applied virological methods. Increasing levels of reinfection are to be expected as we enter the interferon-free treatment era. Individual- and population-level efforts to address and prevent reinfection should therefore be undertaken when providing HCV care for people with on-going risk behaviour. Constructive strategies include acknowledgement, education and counselling, harm reduction optimization, scaled-up treatment including treatment of injecting networks, post-treatment screening, and rapid retreatment of reinfections