The social and gender context of HIV disclosure in sub-Saharan Africa: A review of policies and practices

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or – in some cases – mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.Keywords: HIV testing, disclosure, policies, health providers, gende

Factors influencing uptake of voluntary counselling and testing services for HIV/AIDS in the Lower Manya Krobo Municipality (LMKM) in the Eastern Region of Ghana: a cross-sectional household survey

Background Voluntary counselling and testing (VCT) is one of the nine strategies recommended for prevention and control of HIV globally. In this study, we assessed the awareness and utilisation of VCT services among residents of the Lower Manya Krobo Municipality (LMKM) in the Eastern Region of Ghana. Methods A population-based descriptive cross-sectional survey was conducted with 200 participants, aged between 18 and 55 years. Participants were recruited using cluster and simple random techniques to take part in the survey. Data was analysed descriptively, as well as using regression analysis approach. Results Ninety-one percent of the respondents surveyed were aware of VCT services for HIV/AIDS. Seventy percent (70 %) have used VCT service in the last 12 months prior to the survey. Of this proportion, 97 % were satisfied with the quality of VCT services offered and indicated their willingness to recommend the service to others. Participants desire to know their HIV status (40 %), referral by health workers (25 %), and participants who wanted to get married (11 %) were the main reasons for increased uptake. Participants who had formal education, primary (OR = 1.8 (95 % CI 1.25–2.84)), junior high school (OR = 2.3 (95 % CI 1.54–3.37)), senior high school (OR = 2.8 (95 % CI 1.73–4.78)), and tertiary (OR = 3.4 (95 % CI 1.98–8.42)), had increased chance of using VCT service compared with participants who had no education (p < 0.001). Reasons for non-utilisation of VCT service were lack of awareness of the VCT service in the area (32 %), fear of being stigmatised (53 %), and the belief that HIV/AIDS cannot be cured and therefore the lack of need (5 %). Conclusions Although awareness and utilisation of VCT service rates were reportedly high, more efforts need to be done in order to increase awareness and promote utilisation. HIV/AIDS educational campaign programmes need to be strongly pursued, with emphasis on the benefits of VCT services. This has the potential of reducing stigma and increase utilisation

Clinical Ethics in Gabon: The Spectrum of Clinical Ethical Issues Based on Findings from In-Depth Interviews at Three Public Hospitals

Introduction Unlike issues in biomedical research ethics, ethical challenges arising in daily clinical care in Sub-Saharan African countries have not yet been studied in a systematic manner. However this has to be seen as a distinct entity as we argue in this paper. Our aim was to give an overview of the spectrum of clinical ethical issues and to understand what influences clinical ethics in the Sub-Saharan country of Gabon. Materials and Methods In-depth interviews with 18 health care professionals were conducted at three hospital sites in Gabon. Interview transcripts were analyzed using a grounded theory approach (open and axial coding),giving a qualitative spectrum of categories for clinical ethical issues. Validity was checked at a meeting with study participants and other health care experts in Gabon after analysis of the data. Results Twelve main categories (with 28 further-specified subcategories) for clinical ethical issues were identified and grouped under three core categories: A) micro level: "confidentiality and information","interpersonal, relational and behavioral issues","psychological strain of individuals",and "scarce resources";B) meso level: "structural issues of medical institutions","issues with private clinics","challenges connected to the family",and "issues of education, training and competence";and C) macro level: "influence of society, culture, religion and superstition","applicability of western medicine","structural issues on the political level",and "legal issues". Discussion Interviewees reported a broad spectrum of clinical ethical issues that go beyond challenges related to scarce financial and human resources. Specific socio-cultural, historical and educational backgrounds also played an important role. In fact these influences are central to an understanding of clinical ethics in the studied local context. Further research in the region is necessary to put our study into perspective. As many participants reported a lack of awareness of ethical issues amongst other health care professionals in daily clinical practice, we suggest that international organizations and national medical schools should consider infrastructure and tools to improve context-sensitive capacity building in clinical ethics for Sub-Saharan African countries like Gabon

Expanding HIV Testing Efforts in Concentrated Epidemic Settings: A Population-Based Survey from Rural Vietnam

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Programmatic Evaluation of a Combined Antigen and Antibody Test for Rapid HIV Diagnosis in a Community and Sexual Health Clinic Screening Programme

Background A substantial proportion of HIV-infected individuals in the UK are unaware of their status and late presentations continue, especially in low prevalence areas. Fourth generation antigen/antibody rapid test kits could facilitate earlier diagnosis of HIV in non-clinical settings but lack data on performance under programmatic conditions. Methods and Findings We evaluated the performance of Determine HIV-1/2 Ag/Ab Combo Test (Determine Combo), a rapid test with indicators for both HIV antibodies and p24 antigen, in participants recruited from community outreach and hospital-based sexual health clinics. HIV infection was confirmed using laboratory enzyme-linked immunosorbent assay (EIA), Line Immuno Assay (LIA) and quantitative polymerase chain reaction (PCR). In total, 953 people underwent HIV testing. HIV antibody (Ab) prevalence was 1.8% (17/953). Four false positive rapid tests were identified: two antibody and two p24 antigen (Ag) reactions. Of participants diagnosed as HIV Ab positive, 2/17 (12%) were recent seroconverters based on clinical history and HIV antibody avidity test results. However, none of these were detected by the p24 antigen component of the rapid test kit. There were no other true positive p24 Ag tests. Conclusion These data lend support to an increasing body of evidence suggesting that 4th generation rapid HIV tests have little additional benefit over 3rd generation HIV kits for routine screening in low prevalence settings and have high rates of false positives. In order to optimally combine community-based case-finding among hard-to-reach groups with reliable and early diagnosis 3rd generation kits should be primarily used with laboratory testing of individuals thought to be at risk of acute HIV infection. A more reliable point of care diagnostic is required for the accurate detection of acute HIV infection under programmatic conditions

Knowledge of HIV status prior to a community HIV counseling and testing intervention in a rural district of south Africa: results of a community based survey

<p>Abstract</p> <p>Background</p> <p>The low uptake of facility-based HIV counseling and testing (HCT) in South Africa, particularly amongst men and youth has hindered attempts to increase access to effective treatment and prevention strategies. Many barriers to HIV testing have been described including long waiting times, transport to reach facilities, fear of lack of confidentiality and health systems factors such as stock outs of HIV test kits. The aim of this study was to undertake a community survey to determine rates of HCT in a rural area in order to plan a community intervention.</p> <p>Methods</p> <p>A community-based survey was undertaken in 16 communities in Sisonke district, KwaZulu-Natal between September and November 2008. A total of 5821 individuals participated in the survey of which 66% were females. Gender specific mixed effects logistic regression models were used to describe differences in socio-economic characteristics, and their association with HIV testing histories.</p> <p>Results</p> <p>Overall 1833 (32%) individuals in this rural area knew their HIV status. Prior testing was higher amongst women (39%) than amongst men (17%). Older men (> 24 years) were more likely to report having tested for HIV previously, with the highest likelihood (adjusted OR = 4.02; 95% CI: 2.71-5.99) among men in age group, 35-49 years. For women, age group 25-34 years had the highest likelihood of having been previously tested (adjusted OR = 1.30; 95% CI: 1.05-1.66). Being currently pregnant (adjusted OR 3.31; 95% CI: 2.29 - 4.78) or having a child under five (adjusted OR 7.00; 95% CI: 5.84 - 8.39) were also associated with prior HIV testing amongst women.</p> <p>Conclusions</p> <p>Overall, knowledge of HIV status in this rural sub-district is low. The relatively higher uptake of HIV testing among women is encouraging as it shows that PMTCT services are well functioning. However, these data suggest that there is an urgent need for scaling up HIV testing services in rural communities specifically targeting men and youth.</p

Missed Opportunities for HIV Testing and Late-Stage Diagnosis among HIV-Infected Patients in Uganda

BACKGROUND: Late diagnosis of HIV infection is a major challenge to the scale-up of HIV prevention and treatment. In 2005 Uganda adopted provider-initiated HIV testing in the health care setting to ensure earlier HIV diagnosis and linkage to care. We provided HIV testing to patients at Mulago hospital in Uganda, and performed CD4 tests to assess disease stage at diagnosis. METHODS: Patients who had never tested for HIV or tested negative over one year prior to recruitment were enrolled between May 2008 and March 2010. Participants who tested HIV positive had a blood draw for CD4. Late HIV diagnosis was defined as CD4≤250 cells/mm. Predictors of late HIV diagnosis were analyzed using multi-variable logistic regression. RESULTS: Of 1966 participants, 616 (31.3%) were HIV infected; 47.6% of these (291) had CD4 counts ≤250. Overall, 66.7% (408) of the HIV infected participants had never received care in a medical clinic. Receiving care in a non-medical setting (home, traditional healer and drug stores) had a threefold increase in the odds of late diagnosis (OR = 3.2; 95%CI: 2.1-4.9) compared to receiving no health care. CONCLUSIONS: Late HIV diagnosis remains prevalent five years after introducing provider-initiated HIV testing in Uganda. Many individuals diagnosed with advanced HIV did not have prior exposure to medical clinics and could not have benefitted from the expansion of provider initiated HIV testing within health facilities. In addition to provider-initiated testing, approaches that reach individuals using non-hospital based encounters should be expanded to ensure early HIV diagnosis

An exploratory study of Muslim adolescents' views on sexuality: Implications for sex education and prevention

<p>Abstract</p> <p>Background</p> <p>This paper describes the results of an exploratory qualitative study on Muslim adolescents' views on sexuality in the Netherlands.</p> <p>Methods</p> <p>Data were gathered from an Internet forum on which 44 Muslim and 33 non-Muslim adolescents discussed sexuality as it relates to Islam. These discussions were subsequently analyzed for content using Nvivo 2.0.</p> <p>Results</p> <p>Our analysis revealed several issues that are relevant for the design of future sex education programs targeting Muslim youth. Apart from some expected outcomes regarding, for example, taboos on sexuality, sex outside marriage, abortion, homosexuality and conservative gender roles, our analyses showed that in cases of disputes 1) discussions were polarized, 2) opponents used the same Qur'anic passages to support their views, and 3) the authority of an Imam was questioned when his interpretation of Qur'anic passages was not in line with the views of participants.</p> <p>Conclusions</p> <p>Our findings show that current approaches to sex education among Muslim youth are likely to be unsuccessful given the rigidity of sexual norms in Muslim society. In addition, we also identified new barriers to sex education among Muslim youth (e.g. lack of respect for an Imam who opposes a youth's views on sexuality).</p