Suchergebnisse

In a country where quality HIV/AIDS prevention and care has been foremost on the national agenda, Brazil's extensive and diverse borders are one of the last unstudied potential hotbeds of HIV vulnerability. We carried out a rapid assessment of HIV-related services and the social context of HIV/AIDS at the Brazilian borders including current governmental and community response. The assessment was implemented in six frontier municipalities using the WHO's strategic approach methodology, which combines existing epidemiologic data with field-based qualitative data collection techniques, including observation of service delivery points and in-depth interviews and focus groups with local leaders, providers, and community members, in order to recommend context-specific HIV prevention strategies. This paper focuses on the qualitative findings regarding the role of the social context in shaping HIV vulnerability at the Brazilian borders. We documented a profound lack of governmental structure and response to HIV/AIDS at the borders as well as a notable absence of social cohesion and mobilization among the diverse population groups and communities situated at the borders with regard to HIV/AIDS. The weak governmental and community response is situated within a larger socio-political context of economic inequity and social division, which must be addressed if an effective response to HIV can be developed at Brazil's international borders. Possibilities for encouraging a collective response among the diverse border populations are explored.

Success in addressing HIV and AIDS among men who have sex with men, a key population in the global epidemic, is impeded by homophobia. Homophobia as a barrier to HIV prevention and AIDS treatment is a particularly acute problem in the prison setting. In this qualitative study, we explore HIV and AIDS, stigma, and homosexuality in the largest all male prison in Jamaica by conducting iterative in-depth interviews with 25 inmates. Participant narratives unveil a purposeful manipulation of beliefs related to homosexuality that impedes an effective response to HIV and AIDS both in prison and wider society. Findings indicate that homophobia is both a social construction and a tangible tool used to leverage power and a sense of solidarity in a larger political and economic landscape. This use of homophobia may not be unique to Jamaica, and is an important issue to address in other low and middle income post-colonialist societies.

Trust in health service providers and facilities is integral to health systems accountability. Understanding determinants of trust, a relational construct, in maternity settings necessitates exploring hierarchical perspectives of users, providers, and influencers in the care environment. We used a theoretically driven qualitative approach to explore trust determinants in a maternity setting across patient-provider, inter-provider, and community-policymaker interactions and relationships in peri-urban Kenya. Focus groups (n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews (n = 33) with WRB, health care providers and managers, and community health workers (CHWs) were conducted in 2013, soon after the national government's March 2013 introduction of a policy mandate for "Free Maternity Care." We used thematic coding, memo writing, and cross-perspective triangulation to develop a multi-faceted trust determinants framework. We found that determinants of trust in a maternity setting can be broadly classified into six types of factors, where each type of factor represents a cluster of determinants that may each positively or negatively influence trust: patient, provider, health facility, community, accountability, and structural. Patient factors are prior experiences, perceived risks and harms, childbirth outcomes, and maternal health literacy. Provider factors are empathy and respect, responsiveness, and perceived capability of providers. Health facility factors are "good services" as perceived by patients, physical environment, process navigability, provider collaboration and oversight, discrimination, and corruption. Community factors are facility reputation and history, information channels, and maternal health literacy. Accountability factors are alignment of actions with expectations, adaptations to policy changes, and voice and feedback. Structural factors are institutional hierarchies and policies in the form of professional codes. Trust ...

Trust in health service providers and facilities is integral to health systems accountability. Understanding determinants of trust, a relational construct, in maternity settings necessitates exploring hierarchical perspectives of users, providers, and influencers in the care environment. We used a theoretically driven qualitative approach to explore trust determinants in a maternity setting across patient-provider, inter-provider, and community-policymaker interactions and relationships in peri-urban Kenya. Focus groups (n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews (n = 33) with WRB, health care providers and managers, and community health workers (CHWs) were conducted in 2013, soon after the national government's March 2013 introduction of a policy mandate for "Free Maternity Care." We used thematic coding, memo writing, and cross-perspective triangulation to develop a multi-faceted trust determinants framework. We found that determinants of trust in a maternity setting can be broadly classified into six types of factors, where each type of factor represents a cluster of determinants that may each positively or negatively influence trust: patient, provider, health facility, community, accountability, and structural. Patient factors are prior experiences, perceived risks and harms, childbirth outcomes, and maternal health literacy. Provider factors are empathy and respect, responsiveness, and perceived capability of providers. Health facility factors are "good services" as perceived by patients, physical environment, process navigability, provider collaboration and oversight, discrimination, and corruption. Community factors are facility reputation and history, information channels, and maternal health literacy. Accountability factors are alignment of actions with expectations, adaptations to policy changes, and voice and feedback. Structural factors are institutional hierarchies and policies in the form of professional codes. Trust ...

AbstractIntroductionSouth Africa (SA) has the world's highest burden of HIV infection (approximately 7.2 million), yet it is estimated that 23.5% women and 31.5% of men are unaware that they are living with HIV. The 2015 national South African HIV testing guidelines mandate the universal offer of HIV testing services (HTS) in all healthcare facilities.MethodsA multi‐prong approach was used from January 2017 to June 2017 to evaluate the current implementation of HTS in ten facilities in the Ekurhuleni District of SA. First, we conducted patient exit interviews to quantify engagement in HTS services. Second, we systematically mapped the flow of individual patients through the clinic.ResultsWe conducted a total of 2989 exit interviews and followed 568 patients for value stream mapping. Overall self‐reported testing acceptance was high at 84.7% (244), but <10% of the patients (288) were offered testing. Female patients were more likely to be offered testing (233/2046, 11.4% vs. 55/943, 5.8% in males; chi‐square p < 0.005), and also more likely to accept testing (203/233, 87.1% vs. 41/55, 74.6% in males; chi‐square p = 0.02). Value stream mapping revealed that patients offered HIV testing had a total visit time of 51 minutes more (95% CI: 30‐72) compared to those not offered testing.ConclusionsThe poor delivery of HTS appears to be due to a failure to recommend HTS and the added time burden placed on those accepting testing. There were significant differences in both the offer and acceptance of testing by gender. Health system issues need to be addressed to improve HTS delivery.

Understanding the pregnancy experiences of female sex workers (FSWs), especially in the context of high rates of HIV and sexually transmitted infections (STIs), is essential to tailoring services to meet their needs. This study explores FSWs' experiences with intended pregnancy and access to antenatal care and HIV testing in two regions of Tanzania. Thirty in‐depth interviews and three focus group discussions were conducted. FSWs sought to become pregnant to gain respect as mothers, to avoid stigma, and/or to solidify relationships, sometimes posing risks to their own and their partners' health. Pregnant FSWs generally sought antenatal care (ANC) services but rarely disclosed their occupation, complicating provision of appropriate care. Accessing ANC services presented particular challenges, with health care workers sometimes denying all clinic services to women who were not accompanied by husbands. Several participants reported being denied care until delivery. The difficulties participants reported in accessing health care services as both sex workers and unmarried women have potential social and health consequences in light of the high levels of HIV and STIs among FSWs in sub‐Saharan Africa.

Objectives: We assessed the effectiveness of 2 environmental-structural interventions in reducing risks of HIV and sexually transmitted infections (STIs) among female sex workers in the Dominican Republic. Methods: Two intervention models were implemented over a 1-year period: community solidarity in Santo Domingo and solidarity combined with government policy in Puerto Plata. Both were evaluated via preintervention-postintervention cross-sectional behavioral surveys, STI testing and participant observations, and serial cross-sectional STI screenings. Results: Significant increases in condom use with new clients (75.3%-93.8%; odds ratio [OR] = 4.21; 95% confidence interval [CI] = 1.55, 11.43) were documented in Santo Domingo. In Puerto Plata, significant increases in condom use with regular partners (13.0%-28.8%; OR = 2.97;95% CI = 1.33, 6.66) and reductions in STI prevalence (28.8%-16.3%; OR = 0.50; 95% CI = 0.32, 0.78) were documented, as were significant increases in sex workers' verbal rejections of unsafe sex (50.0%-79.4%; OR = 3.86; 95% CI = 1.96, 7.58) and participating sex establishments' ability to achieve the goal of no STIs in routine monthly screenings of sex workers (OR = 1.17; 95% CI = 1.12, 1.22). Conclusions: Interventions that combine community solidarity and government policy show positive initial effects on HIV and STI risk reduction among female sex workers.

In the field of HIV prevention, there is renewed interest in operations research (OR) within an implementation science framework. The ultimate goal of such studies is to generate new knowledge that can inform local programmes and policies, thus improving access, quality, efficiency and effectiveness. Using four case studies from the USAID‐funded Research to Prevention (R2P) project, we highlight the strategic use of OR and the impact it can have on shaping the focus and content of HIV prevention programming across geographic and epidemic settings and populations. These case studies, which include experiences from several sub‐Saharan African countries and the Caribbean, emphasize four unique ways that R2P projects utilized OR to stimulate change in a given context, including: (1) translating findings from clinical trials to real‐world settings; (2) adapting promising structural interventions to a new context; (3) tailoring effective interventions to underserved populations; and (4) prioritizing key populations within a national response to HIV. Carefully crafted OR can bridge the common gap that exists between research‐generated knowledge and field‐based practice, lead to substantial, real‐world changes in national policies and programmes, and strengthen local organizations and the use of data to be more responsive to a given topic or population, ultimately supporting a locally tailored HIV response.

Capacity building in implementation science is integral to PEPFAR's mission and to meeting the 90–90–90 goals. The USAID funded Project SOAR sponsored a 4 day workshop for investigators and governmental and non-governmental partners from 12 African countries. The workshop was designed to address both findings from a pre-workshop online needs assessment as well as capacity challenges across the capacity building pyramid, from individual skills to institutional systems and resources. Activities were output-oriented and skill based. An online survey evaluated sessions and changes in perceptions of needs; a majority of respondents strongly agreed that after the workshop, they better understood their personal and institutional capacity strengthening needs. Participants 'strongly agreed' that workshop content was relevant to their jobs (90%) and that they left the workshop with a specific plan for conducting future research (65%). Workshop results suggest that skill-building should be done in conjunction with systems capacity building within the cultural context.

A recent Horizons study conducted jointly with two Dominican NGOs assessed the impact of two environmental-structural models in reducing HIV-related risk among female sex workers in the Dominican Republic and compared their cost-effectiveness. In the two cities studied, there were improvements from pre- to post-intervention in the key outcome variables, however the type and level of these changes varied by intervention approach. Based on our findings, program planners and policymakers involved in the study in the Dominican Republic agree that the integrated solidarity and policy model in conjunction with ongoing peer education and community mobilization activities is an appropriate, cost-effective, and ethical intervention package. The current dialogue is now focused on how to scale up this successful pilot experience in a way that continues to respect all members of the sex work community and to be effective in curbing the HIV epidemic.

Effective programs that avert new HIV infections among sex workers and their partners, and hence the general population, are critical components of national HIV-prevention strategies. Prevention efforts have frequently relied on interventions that reach members of these vulnerable groups as individuals, such as condom promotion and STI management. Now, many researchers and program implementers are increasingly turning to "environmental-structural" interventions that address the physical, social, and political contexts in which individual behavior takes place. A recent Horizons study conducted jointly with two Dominican NGOs—Centro de Orientación e Investigación Integral and Centro de Promoción e Solidaridad Humana—and the National Program for the Control of STDs and AIDS assessed the impact of two environmental-structural models in reducing HIV-related risk among female sex workers in the Dominican Republic and compared their cost-effectiveness. As detailed in this brief, the models, built on years of experience gained from sex worker peer education programs, drew from the strengths of both community solidarity and government policy initiatives and engaged community members in both program and policy development.