DRAFT Report:Community Systems Strengthening Toward a Research Agenda

Communities have a long history of acting to preserve and promote the health of their members. Public health researchers, programmers, and funders are increasingly recognizing that community involvement is essential to improving health, especially among populations that are disproportionately affected by HIV. The Global Fund to fight AIDS, Tuberculosis and Malaria, together with civil society organizations and other development partners, created the Community Systems Strengthening (CSS) Framework to help Global Fund applicants frame, define, and quantify efforts to strengthen community contributions engagement (Global Fund 2011). Although the use of a CSS approach in health programming implementation shows promise, it lacks a theoretical framework to guide collaborations with communities. Additionally, it suffers from a paucity of program designs and evaluation practices, an incomplete evidence-based rationale for investing in CSS, and imprecise definitions (e.g., what is meant by “community” and “CSS”).The purpose of this paper is to highlight promising areas for future research related to CSS. Toward this objective, we propose to lay a foundation for a CSS research agenda by using theories and approaches relevant to CSS, reinforced with evidence from projects that employ similar approaches

Intermediate- and High-Velocity Ionized Gas toward zeta Orionis

We combine UV spectra obtained with the HST/GHRS echelle, IMAPS, and Copernicus to study the abundances and physical conditions in the predominantly ionized gas seen at high (-105 to -65 km/s) and intermediate velocities (-60 to -10 km/s) toward zeta Ori. We have high resolution (FWHM ~ 3.3-4.5 km/s) and/or high S/N spectra for at least two significant ions of C, N, Al, Si, S, and Fe -- enabling accurate estimates for both the total N(H II) and the elemental depletions. C, N, and S have essentially solar relative abundances; Al, Si, and Fe appear to be depleted by about 0.8, 0.3-0.4, and 0.95 dex, respectively. While various ion ratios would be consistent with collisional ionization equilibrium (CIE) for T ~ 25,000-80,000 K, the widths of individual high-velocity absorption components indicate that T ~ 9000 K -- so the gas is not in CIE. Analysis of the C II fine-structure excitation equilibrium yields estimated densities (n_e ~ n_H ~ 0.1-0.2 cm^{-3}), thermal pressures (2 n_H T ~ 2000-4000 cm^{-3}K), and thicknesses (0.5-2.7 pc) for the individual clouds. We compare the abundances and physical properties derived for these clouds with those found for gas at similar velocities toward 23 Ori and tau CMa, and also with several models for shocked gas. While the shock models can reproduce some features of the observed line profiles and some of the observed ion ratios, there are also significant differences. The measured depletions suggest that \~10% of the Al, Si, and Fe originally locked in dust in the pre-shock medium may have been returned to the gas phase, consistent with predictions for the destruction of silicate dust in a 100 km/s shock. The near-solar gas phase abundance of carbon, however, seems inconsistent with the predicted longer time scales for the destruction of graphite grains.Comment: 50 pages, 9 figures; aastex; accepted by Ap

Global and regional trends of people living with HIV aged 50 and over: Estimates and projections for 2000-2020.

BackgroundThe increasing numbers of people living with HIV (PLHIV) who are receiving antiretroviral therapy (ART) have near normal life-expectancy, resulting in more people living with HIV over the age of 50 years (PLHIV50+). Estimates of the number of PLHIV50+ are needed for the development of tailored therapeutic and prevention interventions at country, regional and global level.MethodsThe AIDS Impact Module of the Spectrum software was used to compute the numbers of PLHIV, new infections, and AIDS-related deaths for PLHIV50+ for the years 2000-2016. Projections until 2020 were calculated based on an assumed ART scale-up to 81% coverage by 2020, consistent with the UNAIDS 90-90-90 treatment targets.ResultsGlobally, there were 5.7 million [4.7 million- 6.6 million] PLHIV50+ in 2016. The proportion of PLHIV50+ increased substantially from 8% in 2000 to 16% in 2016 and is expected to increase to 21% by 2020. In 2016, 80% of PLHIV50+ lived in low- and middle-income countries (LMICs), with Eastern and Southern Africa containing the largest number of PLHIV50+. While the proportion of PLHIV50+ was greater in high income countries, LMICs have higher numbers of PLHIV50+ that are expected to continue to increase by 2020.ConclusionsThe number of PLHIV50+ has increased dramatically since 2000 and this is expected to continue by 2020, especially in LMICs. HIV prevention campaigns, testing and treatment programs should also focus on the specific needs of PLHIV50+. Integrated health and social services should be developed to cater for the changing physical, psychological and social needs of PLHIV50+, many of whom will need to use HIV and non-HIV services

Community voices: barriers and opportunities for programmes to successfully prevent vertical transmission of HIV identified through consultations among people living with HIV

Introduction: In 2010, two global networks of people living with HIV, the International Community of Women Living with HIV (ICW Global) and the Global Network of People living with HIV (GNP + ) were invited to review a draft strategic framework for the global scale up of prevention of vertical transmission (PVT) through the primary prevention of HIV and the prevention of unintended pregnancies among women living with HIV. In order to ensure recommendations were based on expressed needs of people living with HIV, GNP+ and ICW Global undertook a consultation amongst people living with HIV which highlighted both facilitators and barriers to prevention services. This commentary summarizes the results of that consultation. Discussion: The consultation was comprised of an online consultation (moderated chat-forum with 36 participants from 16 countries), an anonymous online e-survey (601 respondents from 58 countries), and focus-group discussions with people living with HIV in Jamaica (27 participants). The consultation highlighted the discrepancies across regions with respect to access to essential packages of PVT services. However, the consultation participants also identified common barriers to access, including a lack of trustworthy sources of information, service providers’ attitudes, and gender-based violence. In addition, participant responses revealed common facilitators of access, including quality counselling on reproductive choices, male involvement, and decentralized services. Conclusions: The consultation provided some understanding and insight into the participants’ experiences with and recommendations for PVT strategies. Participants agreed that successful, comprehensive PVT programming require greater efforts to both prevent primary HIV infection among young women and girls and, in particular, targeted efforts to ensure that women living with HIV and their partners are supported to avoid unintended pregnancies and to have safe, healthy pregnancies instead. In addition to providing the insights into prevention services discussed above, the consultation served as a valuable example of the meaningful involvement of people living with HIV in programming and implementation to ensure that programs are tailored to individuals’ needs and to circumvent rights abuses within those settings

Internalized stigma among people living with HIV: Assessing the Internalized AIDS-Related Stigma Scale in four countries

Objective: Measuring internalized stigma is critical to understanding its impact on the health and quality of life of people living with HIV (PLHIV). The aim of this study was to assess the performance of the Internalized AIDS-Related Stigma Scale (IA-RSS). Design: Secondary analysis of the six-item IA-RSS was conducted using data from four cross-sectional surveys implemented in Cambodia (n = 1207), the Dominican Republic (n = 891), Uganda (n = 391) and Tanzania (n = 529) between 2018 and 2019. Methods: IA-RSS scale item distribution was described. Multivariate regression models measured correlations between the IA-RSS and depression, antiretroviral therapy (ART) use and viral suppression. Confirmatory factor analysis assessed IA-RSS reliability and performance through analysis of standardized factor loadings and conditional probabilities of scale items. Analysis of qualitative interviews with PLHIV explored acceptability of IA-RSS item content. Results: Mean IA-RSS scores (possible 0–6) ranged from 2.06 (Uganda) to 3.84 (Cambodia), and internal consistency was more than 0.70 in each country (Kuder-Richardson 20), ranging from 0.71 to 0.83. Higher IA-RSS scores were strongly correlated with depression in (P \u3c 0.001 in all countries), and inversely associated with current ART use (Dominican Republic and Tanzania) and self-reported viral suppression (Uganda and Tanzania). Confirmatory factor analysis showed good model fit (all CFI ≥ 0.950), but also that the IA-RSS may summarize two domains related to HIV status disclosure (two items) and PLHIV feelings about themselves (four items). Conclusion: Strong performance across countries supports continued use of the IA-RSS. Further study is needed to explore potential item refinements and to better understand the relationship between internalized stigma and HIV treatment outcomes

The People Living with HIV Stigma Index 2.0: Generating critical evidence for change worldwide

Objective(s): To describe the process of updating the People Living with HIV (PLHIV) Stigma Index (Stigma Index) to reflect current global treatment guidelines and to better measure intersecting stigmas and resilience. Design: Through an iterative process driven by PLHIV, the Stigma Index was revised, pretested, and formally evaluated in three cross-sectional studies. Methods: Between March and October 2017, 1153 surveys (n = 377, Cameroon; n = 390, Senegal; n = 391, Uganda) were conducted with PLHIV at least 18 years old who had known their status for at least 1 year. PLHIV interviewers administered the survey on tablet computers or mobile phones to a diverse group of purposively sampled respondents recruited through PLHIV networks, community-based organizations, HIV clinics, and snowball sampling. Sixty respondents participated in cognitive interviews (20 per country) to assess if questions were understood as intended, and eight focus groups (Uganda only) assessed relevance of the survey, overall. Results: The Stigma Index 2.0 performed well and was relevant to PLHIV in all three countries. HIV-related stigma was experienced by more than one-third of respondents, including in HIV care settings. High rates of stigma experienced by key populations (such as MSM and sex workers) impeded access to HIV services. Many PLHIV also demonstrated resilience per the new PLHIV Resilience Scale. Conclusion: The Stigma Index 2.0 is now more relevant to the current context of the HIV/AIDS epidemic and response. Results will be critical for addressing gaps in program design and policies that must be overcome to support PLHIV engaging in services, adhering to antiretroviral therapy, being virally suppressed, and leading healthy, stigma-free lives

The People Living with HIV Stigma Index 2.0: generating critical evidence for change worldwide

Objective(s): To describe the process of updating the People Living with HIV (PLHIV) Stigma Index (Stigma Index) to reflect current global treatment guidelines and to better measure intersecting stigmas and resilience. Design: Through an iterative process driven by PLHIV, the Stigma Index was revised, pretested, and formally evaluated in three cross-sectional studies. Methods: Between March and October 2017, 1153 surveys (n = 377, Cameroon; n = 390, Senegal; n = 391, Uganda) were conducted with PLHIV at least 18 years old who had known their status for at least 1 year. PLHIV interviewers administered the survey on tablet computers or mobile phones to a diverse group of purposively sampled respondents recruited through PLHIV networks, community-based organizations, HIV clinics, and snowball sampling. Sixty respondents participated in cognitive interviews (20 per country) to assess if questions were understood as intended, and eight focus groups (Uganda only) assessed relevance of the survey, overall. Results: The Stigma Index 2.0 performed well and was relevant to PLHIV in all three countries. HIV-related stigma was experienced by more than one-third of respondents, including in HIV care settings. High rates of stigma experienced by key populations (such as MSM and sex workers) impeded access to HIV services. Many PLHIV also demonstrated resilience per the new PLHIV Resilience Scale. Conclusion: The Stigma Index 2.0 is now more relevant to the current context of the HIV/AIDS epidemic and response. Results will be critical for addressing gaps in program design and policies that must be overcome to support PLHIV engaging in services, adhering to antiretroviral therapy, being virally suppressed, and leading healthy, stigma-free lives