Mothers' knowledge of mother-to-child transmission of HIV and infant feeding practices in Juba, South Sudan

Introduction: While exclusive breastfeeding for the first six months of life is recommended for HIV-infected mothers, this may not be practiced fully in South Sudan; exclusive formula feeding, which is the best alternative to breastfeeding, may not be practical. Objective: To assess the knowledge of mother-to-child transmission of HIV (MTCT) and practices of feeding infants in the first six months of life among HIV-infected mothers attending Antiretroviral Therapy Centres in Juba Teaching Hospital (JTH) and Juba Military Hospital (JMH). Method: A cross-sectional study in which 304 HIV-infected mothers with children aged 6-18 months were interviewed between October and December 2016 using structured questionnaires. Key informant interviews (KIIs) and focus group discussions (FGDs) were also conducted using interview guides. Quantitative data was analysed using Statistics Package for Social Sciences software. Chi-square test was used to test the presence of significant association between the variables and the association is statistically significant when the p-value is < 0.05. Multiple logistic regression analysis was used to identify which predictor variables have major effect on the dependent variable. Qualitative data was transcribed in English and summarized according to the key themes, and the information obtained was used to supplement and interpret the findings of the quantitative data. Results: Only 120 (40%) of the HIV-infected mothers had a good knowledge of MTCT; 213 mothers (70.1%) practiced mixed feeding, 70 (23.0%) practiced exclusive breastfeeding and 20 (6.6%) practiced exclusive formula feeding. The factors that were found to have a positive effect on choice of infant feeding methods were having more than one child (odds ratio = 0.303, 95% Confidence interval: 0.161-0.571, p = 0.001) and participation in the prevention of motherto-child transmission of HIV programme (PMTCT) (odds ratio = 2.260, 95% Confidence interval: 1.251-4.084, p = 0.007). Stigma (p = 0.248) and mothers' knowledge of MTCT (p = 0.072) were not statistically significantly associated with the mothers' infant feeding practices. Conclusion: Knowledge of MTCT is low. Mixed feeding before six months of age is predominant among the HIV-infected mothers. It is therefore recomm;ended that HIV-infected mothers receive adequate information from counsellors regarding MTCT and exclusive breastfeeding for the first six months of an infant's life

HIV prevalence in young people and children living on the streets, Kenya

Objective To obtain an estimate of the size of, and human immunodeficiency (HIV) prevalence among, young people and children living on the streets of Eldoret, Kenya. Methods We counted young people and children using a point-in-time approach, ensuring we reached our target population by engaging relevant community leaders during the planning of the study. We acquired point-in-time count data over a period of 1 week betweethe hours of 08:00 and 23:00, from both a stationary site and by mobile teams. Participants provided demographic data and a finger print(to avoid double-counting) and were encouraged to speak with an HIV counsellor and undergo HIV testing. We used a logistic regression (model to test for an association between age or sex and uptake of HIV testing and seropositivity. Findings Of the 1419 eligible participants counted, 1049 (73.9%) were male with a median age of 18 years. Of the 1029 who spoke with a counsellor, 1004 individuals accepted HIV counselling and 947 agreed to undergo an HIV test. Combining those who were already aware of their HIV-positive status with those who were tested during our study resulted in an overall HIV seroprevalence of 4.1%. The seroprevalence was 2.7% (19/698) for males and 8.9% (23/259) for females. We observed an increase in seroprevalence with increasing age for both sexes, but of much greater magnitude for females. Conclusion By counting young people and children living on the streets and offering them HIV counselling and testing, we could obtain population-based estimates of HIV prevalence

Fighting against HIV and AIDS within a resource constrained rural setting: a case study of the Ruvheneko Programme in Chirumhanzu, Zimbabwe

Since reports of the first incidence of the HIV virus in Zimbabwe in 1985, the epidemic has negatively impacted on every facet of human security. Rural areas, by virtue of being the periphery and constrained in terms of resources and health care provision, bear the brunt of the epidemic. In light of the above background, this paper examined how the establishment of Ruvheneko Programme by the people of Chirumhanzu helped in mitigating on the impact of HIV and AIDS in the rural sphere. The paper analyses how the community of Chirumhanzu successfully engaged each other to the extent of coming up with such a vibrant programme. This is raised against the backdrop of failure usually associated with HIV and AIDS engagement projects. The study made use of field interviews and focus group discussions as data collection instruments. Participants were purposively selected on the basis of their knowledge and participation in the establishment and activities of Ruvheneko Programme. Selected were 5 St Theresa's Hospital Staff, 10 Roman Catholic Church members of which, 5 were from the St Anna's woman prayer group and 5 men from St Joseph's men prayer group, 1 village head and 2 elders from the same nearby village constituted key informants. Complementing the use of interviews and focus group discussions was the analysis of secondary data sources on HIV and AIDS in Zimbabwe as well as the Ruvheneko Programme. To understand the collective role of various sectors of the community in establishing Ruvheneko Programme, the paper derives insights from the perspective of social capital theory and its notion of commonality to strengthen communities. Findings from the study show that, unlike other HIV and AIDS programmes that are exported from the urban to the rural areas, Ruvheneko Programme demonstrates a grassroots-level response to HIV and AIDS. Again, social cohesion fostered by aspects such as religiosity, cultural ethos of Ubuntu, and a consultative approach played a key role in unifying people towards fighting HIV and AIDS in Rural Chirumhanzu

A weighted bootstrap approach to logistic regression modelling in identifying risk behaviours associated with sexual activity

The latest population estimates released by Statistics South Africa indicate that 25.03% of all deaths in 2017 in South Africa were AIDS-related. Along with these results, it is also reported that 7.06% of the population were living with HIV, with the HIV-prevalence among youth (aged 15­24) at 4.64% for 2017 (STATSSA. (2018). Retrieved from Statistics South Africa: http://www.statssa.gov.za/publications/P0302/P03022017.pdf). The data used in the study contained information related to the risk-taking behaviours associated with the sexual activity of entering first-year students at the University of the Western Cape. In this study, a logistic regression modelling procedure was carried out on those students that were determined to be sexually active, therefore, in the modelling procedure significant risk behaviours of sexually active first-year students could be identified. Of the 14 variables included in the modelling procedure, six were found to be significantly associated with sexually active students. The significant variables included; the age and race of the student, whether the student had ever taken an HIV test, the importance of religion in influencing the sexual behaviour of the student, whether the student consumed alcohol and lastly whether the student smoked. This study further investigated the impact of introducing sample weighting, bootstrap sampling as well as variable selection methods into the logistic regression modelling procedure. It is shown that incorporating these techniques into the modelling procedure produces logistic regression models that are more accurate and have an increased predictive capability. The bootstrapping procedure is shown to produce logistic regression models that are more accurate than those produced without a bootstrap procedure. A comparison between 200, 500 and 1000 bootstrap samples is also incorporated into the modelling procedure with the models produced from 200 bootstrap samples shown to be just as accurate those produced from 500 or 1000 bootstrap samples. Of the five variable selection methods used, it is shown that the Newton­Raphson and Fisher methods are unreliable in producing logistic regression models. The forward, backward and stepwise variable selection methods are shown to produce very similar results

Knowledge, attitudes and practices regarding the prevention of mother-to-child transmission of HIV among pregnant women in the Bosome Freho district in the Ashanti region of Ghana: a descriptive cross-sectional design

Introduction: the impact of HIV/AIDS on women and children has called for a higher increase in global commitment and response to the prevention of mother-to-child transmission (PMTCT). The study investigated the knowledge, attitudes and practices of pregnant women regarding PMTCT of HIV in Bosome Freho District in the Ashanti region of Ghana. Methods: a facility-based cross-sectional study was conducted in August of 2017, involving 339 pregnant women, selected through a multistage sampling technique. Data were collected through a structured pre-tested and validated questionnaire and analysed by using Stata SE version 12.0. Logistic regression analyses were used to test associations between background factors and the knowledge, attitudes and practices at 0.05 level of significance. Results: the level of knowledge was high (77.0%), attitudes were good (71.1%), and the practice of PMTCT was high (95.9%). However, the knowledge of participants on the importance of exclusive breastfeeding, the moments when HIV transmission occurs, and the merits of elective caesarean sections as an HIV preventive method were grossly insufficient. Knowledge was influenced by the level of education (AOR=19 (95% CI: 1.08-333.82); p=0.04); Attitudes were influenced by the level of knowledge regarding PMTCT (AOR=5.3 (95% CI: 2.76-10.35); p<0.001). Conclusion: interventions to improve the knowledge, attitudes and practices regarding PMTCT should focus more on women with less than Senior High School (SHS) level of education. Exclusive breastfeeding and elective caesarean sections, though effective in reducing transmission of HIV from the mother to the child, could be missed opportunities in reducing the burden of HIV in this community

Perceptions of why Malawians engage in concurrent sexual partnerships among a select population of radio listeners: findings from an exploratory study

Concurrent sexual partnerships have been identified as a potential driver in the HIV epidemic in Southern Africa. This study utilised an innovative approach to explore perceptions of why Malawians may engage in these relationships, and their suggestions for reducing the practice among a select population of radio listeners. Using radio listener feedback in the form of text messages, we analysed approximately 1 000 text messages sent by individuals who listened to a reality radio programme that included real stories, told by Malawians, on topics related to HIV/AIDS. Listeners suggested that lack of satisfaction with one's partner was the overarching reason why individuals had concurrent sexual partnerships. Within the context of lack of satisfaction, listeners cited alcohol use, poor communication and gendered norms as factors related to satisfaction. Listeners suggested that couple communication could increase satisfaction, which, in turn, could reduce concurrent sexual partnerships. Prevention efforts should consider how to utilise couple communication to improve satisfaction as an approach to reduce HIV risk in Southern Africa

Community perceptions of the socio-economic structural context influencing HIV and TB risk, prevention and treatment in a high prevalence area in the era of antiretroviral therapy

Following calls for targeted HIV prevention interventions in so-called "hotspots", we explored subjective perceptions of community members in places considered to be high HIV and tuberculosis (TB) transmission areas and those with low prevalence. Although more people now have access to antiretroviral therapy (ART), some areas are still experiencing high HIV transmission rates, presenting a barrier to the elimination of HIV. A rapid qualitative assessment approach was used to access a sample of 230 people who contributed narratives of their experiences and perceptions of transmission, treatment and prevention of HIV and TB in their communities. Theoretical propositions case study strategy was used to inform and guide the thematic analysis of the data with Research Department of Epidemiology & Public Health, University College London, London, UK. Our results support the concept of linking perceived control to health through the identification of structural factors that increase communities' sense of agency. People in these communities did not feel they had the efficacy to effect change in their milieu. The few socio-economic opportunities promote social mobility in search of better prospects which may have a negative impact on community cohesn and prevention strategies. Communities were more concerned with improving their immediate social and economic situations and prioritised this above the prevention messages. Therefore approaches that focus on changing the structural and environmental barriers to prevention may increase people's perceived control. Multifaceted strategies that address the identified constructs of perceived control may influence the social change necessary to make structural interventions successful

The demographic and clinical profiles of women presenting with vaginal discharge syndrome at primary care facilities in South Africa: Associations with age and implications for management

Background. Current South African guidelines for the management of vaginal discharge syndrome (VDS) do not recommend treatment for sexually transmitted infection (STI) pathogens for women aged ≥35 years whose partners do not have male urethritis syndrome. The guideline assumes that older women are unlikely to have an STI and that their partners do not have asymptomatic infections.Objectives. To describe the demographic, behavioural and clinical characteristics of women with VDS, comparing older women (≥35 years) with younger women, and to determine the performance of age alone as a criterion for predicting the presence of STI.Methods. This was a cross-sectional study at seven primary healthcare centres taking part in the aetiological surveillance of STIs between January 2015 and December 2016. Eligible women presenting with VDS were enrolled and completed a nurse-administered questionnaire. Genital swabs and blood specimens were collected for laboratory testing. Data were entered into surveillance-specific databases and exported into Stata 14 for analysis. Descriptive statistics were used to compare demographic and clinical profiles of older with younger women. A receiver operator curve (ROC) was used to determine the age cut-off that would best differentiate between women who had infection with STI pathogens and those without.Results. Of 757 women enrolled, 157 (20.7%) were aged ≥35 years. HIV positivity was 46.6%, and higher in older than younger women (54.9% v. 44.5%; p=0.02). Of those enrolled, 283 (37.4%) had bacterial vaginosis (BV) and/or Candida infection only, 232 (30.7%) had BV or Candida with STI pathogens detected, 98 (13%) were infected with STI pathogens only, and 144 (19.0%) did not have any detectable STI or non-STI causes. Although older women were less likely than younger women to have Neisseria gonorrhoeae, Chlamydia trachomatis or Mycoplasma genitalium infection (23.6% v. 38.2%; p<0.01), the burden in older women was not negligible. The area under the ROC for age was 57.5% (95% confidence interval 53.2 - 61.8%), which implies suboptimal performance.Conclusions. Although older women with VDS were less likely than younger women to have STIs, a significant proportion of them did have an infection with STI pathogens. Age alone was not a good criterion for discriminating between women with and without infection with STI pathogens. Other ways of improving the VDS algorithm performance are needed, as is better integration of HIV and STI prevention and treatment

Cultural competence: a framework for promoting voluntary medical male circumcision among VaRemba communities in Zimbabwe

Almost a decade after the formal introduction of voluntary medical male circumcision (VMMC) as an important technology for HIV prevention, its implementation is still fraught with acceptability challenges. This is especially true among ethnic groups where male circumcision is conducted as a rite of passage into adulthood. In this article we question why VMMC is being met with resistance despite widespread awareness of its promise to reduce HIV incidence in a culturally circumcising community in Zimbabwe. In-depth and key informant interviews were conducted with selected VaRemba initiation graduates and surgeons respectively in Mposi area in Mberengwa to explore why VMMC has not been readily accepted in their community. Findings suggest that male circumcision among VaRemba is not only the removal of prepuce but comprises a secretive and rich curriculum rooted in their culture and identity. Such a conceptualisation renders some social and programmatic impediments for VMMC uptake. To scale up VMMC uptake among VaRemba, we argue for a reorganisation and adaptation of VMMC services in a culturally competent way that accounts for local conceptions of circumcision and respect for the cultural beliefs and practices of VaRemba communities

HIV prevention needs for men who have sex with men in Swaziland

Men who have sex with men (MSM) have a high HIV burden and also often face multiple other challenges accessing HIV services, including legal and social issues. Although Swaziland recently started responding with interventions for MSM, significant gaps still exist both in information and programming. This study aimed to explore the HIV prevention needs of MSM in Swaziland, including factors elevating their risks and vulnerabilities to HIV infection; to find out what HIV prevention strategies exist; and to determine how best to meet the prevention needs of MSM. A total of 50 men who reported anal sex with other men in the past 12 months were recruited through simple respondent driven sampling. They completed either a structured quantitative survey (n = 35) or participated in a semi-structured qualitative interview (n = 15). Both quantitative and qualitative findings indicated perceived and experienced stigma among MSM. This predominantly manifested as internalised stigma, which may lead to alcohol abuse and sexual risky behaviours. At least 83% (29/35) of the quantitative sample had been labelled with derogatory terms because of their sexual orientation, while 66% (23/35) had experienced being avoided. There was limited knowledge of risk practices: When asked, 54% (19/35) of quantitative respondents reported that vaginal and anal sex carry an equal risk of HIV infection. Participants also had little knowledge on new HIV prevention methods such as pre-exposure prophylaxis (PrEP) and rectal microbicides. MSM needs included safe spaces in form of drop-in centres and non-hostile HIV services. Although Swaziland recently started interventions for key populations, including MSM, there is still a general lack on information to inform managers and implementers on the HIV prevention needs of MSM in Swaziland. Such information is crucial for designers of official and HIV programmes. Research is needed to increase knowledge on the HIV prevention needs for key populations, including MSM

Gendered childcare norms ­ evidence from rural Swaziland to inform innovative structural HIV prevention approaches for young women

Addressing discriminatory gender norms is a prerequisite for preventing HIV in women, including young women. However, the gendered expectation that women will perform unpaid childcare-related labour is rarely conceptualised as influencing their HIV risk. Our aim was to learn from members of a rural Swazi community about how gendered childcare norms. We performed sequential, interpretive analysis of focus group discussion and demographic survey data, generated through participatory action research. The results showed that gendered childcare norms were firmly entrenched and intertwined with discriminatory norms regarding sexual behaviour. Participants perceived that caring for children constrained young women's educational opportunities and providing for children's material needs increased their economic requirements. Some young women were perceived to engage in "transactional sex" and depend financially on men, including "sugar daddies", to provide basic necessities like food for the children they cared for. Our results suggested that men were no longer fulfilling their traditional role of caring for children's material needs, despite women's traditional role of caring for their physical and emotional needs remaining firmly entrenched. The results indicate that innovative approaches to prevent HIV in young women should incorporate structural approaches that aim to transform gendered norms, economically empower women and implement policies guaranteeing women equal rights

La prévention de la transmission du VIH de la mère à l'enfant (PTME) à Lubumbashi en République Démocratique du Congo. Résultats de 6 ans de pratique dans 5 maternités de référence

Objectif : Evaluer les activités de PTME depuis la sensibilisation au Dépistage Volontaire du VIH en consultation Prénatale jusqu'à la prise en charge des couples mère-enfant en période péripartum et néonatale précoce.Matériels et méthodes : Il s'agit d'une étude rétrospective de 16.253 accouchées dans 5 maternités de référence de la ville de Lubumbashi de 2007 à 2012.Les paramètres investigués : taux de sensibilisation au Dépistage Volontaire, d'adhésion au pré-test, séroprévalence VIH chez les dépistées, patientes non dépistées, prise en charge des couples mère-enfant en période péripartum et néonatale. Le test de Chi-carré était utilisé pour la comparaison des fréquences exprimées en pourcentage au seuil significatif de p < 0,05. Résultats : La majorité des accouchées (69,38%) a été sensibilisée au dépistage pendant la grossesse. De 2010 à 2012, le taux des sensibilisées est de 71,09% contre 64,37% avant 2010 (p = 0,000). Le taux d'adhésion est de 78,86% pour l'ensemble des sensibilisées : 95% entre 2007 et 2010 et 69% de 2011 à 2012, soit une décrue d'adhésion statistiquement significative (p = 0,000). La séroprévalence VIH chez les dépistées est de 4,15% pour la période étudiée, allant de 3,47% à 5,30%. L'analyse statistique ne montre pas de différence significative entre les taux périodiques sauf pour le taux de 2012 (3,58%) comparé à celui de 2007 (5,30%) (p = 0,02). La proportion des non-dépistées s'élève à 45,30%, soit 46,81% après 2009 et 40,82% antérieurement (p = 0,000). Enfin, la couverture PTME des gestantes diagnostiquées séropositives (369) atteint 51,49% (n = 190) ; leurs bébés ont bénéficié d'une thérapie antirétrovirale (TAR) en période néonatale précoce. Par rapport à l'effectif global des accouchées (16.253), au taux de 4,15% de séroprévalence, cette fraction (190) ne représente que 28,36% des séropositives potentielles (670 couples Mère-Enfant).Conclusion : Les résultats observés :Tendance au déclin dans l'adhésion au dépistage volontaire en CPN et inflation des accouchées non-dépistées malgré l'amélioration progressive des taux de sensibilisation (= faiblesse PTME) ; Taux paradoxalement bas de la couverture TAR parmi les séropositives ayant pourtant volontairement adhéré au dépistage (= faiblesse PTME),Appellent d'urgence une profonde réflexion sur les véritables raisons de ces faiblesses et la mise en place des politiques nouvelles et plus rentables de prise en charge

Involving parents from the start: formative evaluation for a large randomised controlled trial with Botswana junior secondary school students

While HIV prevention research conducted among adolescent populations may encounter parental resistance; the active engagement of parents from inception to trial completion may alleviate opposition. In preparation for implementing a large randomised controlled trial (RCT) examining the efficacy of a behavioural intervention targeting adolescent sexual risk behaviours; a formative evaluation was undertaken to assess parental reactions to the proposed trial. Six focus groups were conducted with parents of adolescents (aged 13-17) from rural; peri-urban and urban junior secondary schools in Botswana. Focus groups explored comprehension and acceptability among parents of the forthcoming trial including HSV-2 testing; the return of results to the adolescent (not the parent); trial information materials and the parental consent process. Parents welcomed the study and understood and accepted its moral and ethical considerations. Their reactions regarding return of HSV-2 results only to adolescents (not the parent) were mixed. Parents understood the consent process and most agreed to consent; while indicating their desire to remain informed and involved throughout the RCT. The focus group discussions (FGDs) provided valuable information and insights that helped strengthen the study. As a result of parents' feedback; counselling procedures were strengthened and direct linkages to local services and care were made. Informational materials were revised to increase clarity; and materials and procedures were developed to encourage and support parental involvement and parent-child dialogue. Ultimately; parental feedback led to a decision by the Government of Botswana to allow parents to access their child's HSV-2 test results

Gender inequality dynamics in the prevention of a heterosexual HIV epidemic in Sub-Saharan Africa

This paper critiques the approach to the elimination of gender inequality as an HIV prevention strategy in the just ended era of the Millennium Development Goals; with the aim of contributing to the formulation of policy guidelines for sub-Saharan Africa in the Sustainable Development Goals. The aim is to underscore the mutual responsibility of women and men in achieving a sustainable HIV response and ending the epidemic. While taking into account the real vulnerability of women; prevention programmes can reflect gender dynamics more accurately so that attention is given to the role of both sexes in propagating - or stemming - a predominantly heterosexual HIV epidemic. More emphasis could be given to the harm caused to both men and women by certain norms related to masculinity and sexuality; and the subsequent need for combined efforts in reducing intimate partner violence and concurrency. The empowerment and engagement of both women and men as agents of change would need to be dealt with more creatively

What does Sustainability Mean in the HIV and AIDS Response?

Immense progress has been made in the fight against HIV and AIDS. Achieving and exceeding the AIDS targets for the Millennium Development Goals (MDGs) was accomplished; in large part; due to an unprecedented financial investment from the international community. Following an $800 million dip in donor disbursements in 2010; the discourse has since shifted to the need for greater sustainability of funding. But what does sustainability mean? Current efforts focus heavily on fiscal imperatives such as increasing domestic funding. This is important - needs are increasing at a faster rate than donor funding; especially with increased treatment coverage. The problem is that measures of financial sustainability tell very little about the actual sustainability of specific programmes; disease trajectories or enabling environments. Recognising that current definitions of sustainability lack clarity and depth; we offer a new six-tenet conceptualisation of what sustainability means in the HIV and AIDS response: (1) financial; (2) epidemiological; (3) political; (4) structural; (5) programmatic; and (6) human rights. Based on these; we examine examples of donor transitions for their approach to sustainability; including PEPFAR in South Africa; the Global Fund in Eastern Europe; and the Bill and Melinda Gates Foundation in India (Avahan). We conclude that sustainability must be understood within a broader framework beyond funding stability. We also recommend that certain interventions; such as programming for key populations; may have to continue to receive external support even if affected countries can afford to pay

The promise andl imitations of cash transfer programs for HIV prevention

As the search for more effective HIV prevention strategies continues; increased attention is being paid to the potential role of cash transfers in prevention programming in sub-Saharan Africa. To date; studies testing the impact of both conditional and unconditional cash transfers on HIV-related behaviours and outcomes in sub-Saharan Africa have been relatively small-scale and their potential feasibility; costs and benefits at scale; among other things; remain largely unexplored. This article examines elements of a successful cash transfer program from Latin America and discusses challenges inherent in scaling-up such programs. The authors attempt a cost simulation of a cash transfer program for HIV prevention in South Africa comparing its cost and relative effectiveness - in number of HIV infections averted - against other prevention interventions. If a cash transfer program were to be taken to scale; the intervention would not have a substantial effect on decreasing the force of the epidemic in middle- and low-income countries. The integration of cash transfer programs into other sectors and linking them to a broader objective such as girls' educational attainment may be one way of addressing doubts raised by the authors regarding their value for HIV prevention

Developing and implementing global gender policy to reduce HIV and AIDS in low- and middle-income countries: policy makers' perspectives

Gender inequalities have been recognised as central to the HIV epidemic for many years. In response; a range of gender policies have been developed in attempts to mitigate the impact and transform gender relations. However; the effects of these policies have been less than successful. In March 2010 the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the Agenda for accelerated country level action on women; girls; gender equality and HIV (the Agenda); an operational plan on how to integrate women; girls and gender equality into the HIV response. This paper explores the perspectives of those involved in developing and implementing the Agenda to understand its strengths and limitations. In-depth one-on-one interviews were conducted with 16 individuals involved in the development and implementation of the Agenda. The data were analysed using thematic network analysis. Facilitators of the Agenda centred on the Agenda's ability to create political space for women and girls within the global HIV/AIDS response and the collaborative process of developing the Agenda. Barriers to the implementation and development of the Agenda include the limited financial and non-financial resources; the top-down nature of the Agenda's development and implementation and a lack of political will from within UNAIDS to implement it. We suggest that the Agenda achieved many goals; but its effect was constrained by a wide range of factors

Most at-risk populations: contextualising HIV prevention programmes targeting marginalised groups in Zanzibar, Tanzania

According to a 2009 UNAIDS report the HIV/AIDS prevalence rate in Zanzibar; Tanzania; is low in the general population (0.6); but high among vulnerable groups; specifically sex workers (10.8); injecting drug users (15.1; and men who have sex with men (12.3). In response to this concentrated epidemic; the Government of Zanzibar; international and local non-profit organisations have focused their prevention activities on these marginal populations. Although these efforts are beneficial in terms of disseminating information about HIV/AIDS and referring clients to health clinics; they fail to address how the socio-economic status of these groups places them at a greater risk for contracting and dying from the virus. Furthermore; there is an absence of qualitative research on these populations which is needed to understand the challenges these groups face and to improve the effectiveness of interventions. Through interviews with employees of government agencies and non-profit organisations; medical professionals; vulnerable populations and HIV/AIDS patients; this paper used a political economy of health and syndemic framework to examine how local realities inform and challenge HIV/AIDS programmes in Zanzibar

Reasons for the low uptake of adult male circumcision for the prevention of HIV transmission in Swaziland

Swaziland is currently experiencing the worst impact of HIV and AIDS of any country in the world. In an effort to curb further spread of the virus; the country adopted mass male circumcision (MC) as recommended by the World Health Organization in 2007. Despite intense campaigns to promote the procedure over the past three years; the uptake of circumcision remains very low for reasons that are not very clear. The purpose of this study was to explore the reasons for the low uptake of MC in Swaziland despite the massive national MC campaigns. A qualitative research design was used; in which all men who were targeted by the mass MC campaign were eligible. Participants were identified as they came for sexual and reproductive health services at the Family Life Association of Swaziland (FLAS) Clinic; Mbabane. In-depth; individual face-to-face unstructured interviews were conducted to elicit the reasons why men were not going for circumcision. A total of 17 men were interviewed. Results showed that these reasons include fear of the procedure and the possible outcome; perception of no significant benefit of the procedure; impatience about waiting for the procedure or the healing process; religious/cultural beliefs; and worries about the fate of the foreskin. These reasons were attributed to misconceptions and lack of accurate and specific information about some aspects of the circumcision strategy of HIV preventions. Physiological changes and economic activities associated with adulthood were also found to be hindrances to MC uptake. The study recommended that a comprehensive description of the procedure and more precise facts and scientific bases of the MC strategy be incorporated and emphasised in the MC campaigns. Involvement of religious leaders will also facilitate clarification of religious or cultural misunderstandings or misconceptions. A focus on neonatal MC would also help

Willingness to participate in future HIV prevention trials in Beira, Mozambique

In preparation for trials of new HIV prevention methods; willingness to participate (WTP) was assessed in Beira; Mozambique. A totla of 1 019 women participating in an HIV incidence study; and 97 men participating in a separate WTP survey; were interviewed. When comparing the answers to questions that were identical in the two studies; WTP was higher among women than men for all prevention methods. Among women; WTP was highest for trials evaluating daily oral pre-exposure prophylaxis (PrEP; 84.4 reporting very likely to participate); followed by vaccination (77.8); daily vaginal gel use (67.7); coital vaginal gel use (67.1) and monthly vaginal ring use (47.7). Among men; WTP was highest for trials evaluating vaccination (57.6); followed by daily vaginal gel use for female sexual partners (52.5); daily oral PrEP (49.5); coital vaginal gel use for female sexual partners (46.4) and monthly vaginal ring use for female sexual partners (39.4). Among men; the most important motivators for trial participation were social benefits; whereas personal risks (most notably receiving injections and/or blood draws) were deterrents; this was not assessed in women. Other important lessons learnt are that male circumcision and antiretroviral drugs were not generally recognised as ways to prevent HIV; that having to use hormonal contraception during trial participation will likely reduce WTP; and that evening clinics are not likely to be popular. The barriers reported in this and other studies may be challenging but are not impossible to overcome