Eleanor MacPherson

Transactional sex and HIV: understanding the gendered structural drivers of HIV in fishing communities in Southern Malawi

In Southern Malawi, the fishing industry is highly gendered, with men carrying out the fishing and women processing, drying and selling the fish. Research has shown that individuals living in fishing communities in low‐income countries are particularly vulnerable to HIV infection. One of the key drivers of HIV in fishing communities is transactional sex. In the fishing industry this takes the form of “fish‐for‐sex” networks where female fish traders exchange sex with fishermen for access to or more favourable prices of fish. By controlling the means of production, the power dynamics in these exchanges favour men and can make it more difficult for women to negotiate safe sex.

Factors Shaping Initial Decision-Making to Self-test Amongst Cohabiting Couples in Urban Blantyre, Malawi

In sub-Saharan Africa, most new HIV infections occur in stable relationships, making couples testing an important intervention for HIV prevention. We explored factors shaping the decision-making of cohabiting couples who opted to self-test in Blantyre, Malawi. Thirty-four self-tested participants (17 couples) were interviewed. Motivators for HIV self-testing (HIVST) emerged at three main levels. Individual motivations included perceived benefits of access to treatment, and self-checking of serostatus in the hope of having been cured by prolonged treatment or faith-healing. HIVST was considered convenient, confidential, reassuring and an enabling new way to test with one’s partner. Partnership motivations included both positive (mutual encouragement) and negative (suspected infidelity) aspects. For women, long-term health and togetherness were important goals that reinforced motivations for couples testing, whereas men often needed persuasion despite finding HIVST more flexible and less onerous than facility-based testing. Internal conflict prompted some partners to use HIVST as a way of disclosing their previously concealed HIV positive serostatus. Thus, the implementation of community-based HIVST should acknowledge and appropriately respond to decision-making processes within couples, which are shaped by gender roles and relationship dynamics.

Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi

Linkage from HIV testing and counselling (HTC) to initiation of antiretroviral therapy (ART) is suboptimal in many national programmes in sub‐Saharan Africa, leading to delayed initiation of ART and increased risk of death. Reasons for failure of linkage are poorly understood.

Consent and community engagement in diverse research contexts: reviewing and developing research and practice

Consent and community engagement (CE) in health research are two aspects of a single concern—that research is carried out in a respectful manner where social value is maximized. There are important overlaps and interdependencies between consent and CE; for example, CE can provide insights into how best to tailor consent to context and can be an important component of consent processes. Engaging communities can also have intrinsic and instrumental value beyond consent; for example, as a means of showing respect and identifying appropriate ways of working respectfully. In this paper we critically examine how CE and consent processes are characterized, conducted, and evaluated in diverse health research contexts, and propose a preliminary research agenda to support future learning in these critical areas.Consent and community engagement (CE) in health research are two aspects of a single concern-that research is carried out in a respectful manner where social value is maximized. There are important overlaps and interdependencies between consent and CE; for example, CE can provide insights into how best to tailor consent to context and can be an important component of consent processes. Engaging communities can also have intrinsic and instrumental value beyond consent; for example, as a means of showing respect and identifying appropriate ways of working respectfully. In this paper we critically examine how CE and consent processes are characterized, conducted, and evaluated in diverse health research contexts, and propose a preliminary research agenda to support future learning in these critical areas.

Gender equity and sexual and reproductive health in Eastern and Southern Africa: a critical overview of the literature.

Background Gender inequalities are important social determinants of health. We set out to critically review the literature relating to gender equity and sexual and reproductive health (SRH) in Eastern and Southern Africa with the aim of identifying priorities for action. Design During November 2011, we identified studies relating to SRH and gender equity through a comprehensive literature search. Results We found gender inequalities to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Social and biological determinants combined to increase womens vulnerability to maternal mortality, HIV, and gender-based violence. Health systems significantly disadvantaged women in terms of access to care. Men fared worse in relation to HIV testing and care with social norms leading to men presenting later for treatment. Conclusions Gender inequity in SRH requires multiple complementary approaches to address the structural drivers of unequal health outcomes. These could include interventions that alter the structural environment in which ill-health is created. Interventions are required both within and beyond the health system.Background Gender inequalities are important social determinants of health. We set out to critically review the literature relating to gender equity and sexual and reproductive health (SRH) in Eastern and Southern Africa with the aim of identifying priorities for action. Design During November 2011, we identified studies relating to SRH and gender equity through a comprehensive literature search. Results We found gender inequalities to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Social and biological determinants combined to increase womens vulnerability to maternal mortality, HIV, and gender-based violence. Health systems significantly disadvantaged women in terms of access to care. Men fared worse in relation to HIV testing and care with social norms leading to men presenting later for treatment. Conclusions Gender inequity in SRH requires multiple complementary approaches to address the structural drivers of unequal health outcomes. These could include interventions that alter the structural environment in which ill-health is created. Interventions are required both within and beyond the health system.

Close to community health providers post 2015: Realising their role in responsive health systems and addressing gendered social determinants of health

Universal health coverage is gaining momentum and is likely to form a core part of the post Millennium Development Goal (MDG) agenda and be linked to social determinants of health, including gender;Close to community health providers are arguably key players in meeting the goal of universal health coverage through extending and delivering health services to poor and marginalised groups;Close to community health providers are embedded in communities and may therefore be strategically placed to understand intra household gender and power dynamics and how social determinants shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood;Enabling close to community health providers to realise their potential requires health systems support and human resource management at multiple levels.

Infectious disease and health systems modelling for local decision making to control neglected tropical diseases

Most neglected tropical diseases (NTDs) have complex life cycles and are challenging to control. The “2020 goals” of control and elimination as a public health programme for a number of NTDs are the subject of significant international efforts and investments. Beyond 2020 there will be a drive to maintain these gains and to push for true local elimination of transmission. However, these diseases are affected by variations in vectors, human demography, access to water and sanitation, access to interventions and local health systems. We therefore argue that there will be a need to develop local quantitative expertise to support elimination efforts. If available now, quantitative analyses would provide updated estimates of the burden of disease, assist in the design of locally appropriate control programmes, estimate the effectiveness of current interventions and support ‘real-time’ updates to local operations. Such quantitative tools are increasingly available at an international scale for NTDs, but are rarely tailored to local scenarios. Localised expertise not only provides an opportunity for more relevant analyses, but also has a greater chance of developing positive feedback between data collection and analysis by demonstrating the value of data. This is essential as rational program design relies on good quality data collection. It is also likely that if such infrastructure is provided for NTDs there will be an additional impact on the health system more broadly. Locally tailored quantitative analyses can help achieve sustainable and effective control of NTDs, but also underpin the development of local health care systems.

Fit for purpose: do we have the right tools to sustain NTD elimination?

Priorities for NTD control programmes will shift over the next 10-20 years as the elimination phase reaches the ‘end game’ for some NTDs, and the recognition that the control of other NTDs is much more problematic. The current goal of scaling up programmes based on preventive chemotherapy (PCT) will alter to sustaining NTD prevention, through sensitive surveillance and rapid response to resurgence. A new suite of tools and approaches will be required for both PCT and Intensive Disease Management (IDM) diseases in this timeframe to enable disease endemic countries to:1. Sensitively and sustainably survey NTD transmission and prevalence in order to identify and respond quickly to resurgence.2. Set relevant control targets based not only on epidemiological indicators but also entomological and ecological metrics and use decision support technology to help meet those targets.3. Implement verified and cost-effective tools to prevent transmission throughout the elimination phase.Liverpool School of Tropical Medicine (LSTM) and partners propose to evaluate and implement existing tools from other disease systems as well as new tools in the pipeline in order to support endemic country ownership in NTD decision-making during the elimination phase and beyond.

Mass Drug Administration and beyond: how can we strengthen health systems to deliver complex interventions to eliminate neglected tropical diseases?

Achieving the 2020 goals for Neglected Tropical Diseases (NTDs) requires scale-up of Mass Drug Administration (MDA) which will require long-term commitment of national and global financing partners, strengthening national capacity and, at the community level, systems to monitor and evaluate activities and impact.For some settings and diseases, MDA is not appropriate and alternative interventions are required. Operational research is necessary to identify how existing MDA networks can deliver this more complex range of interventions equitably.The final stages of the different global programmes to eliminate NTDs require eliminating foci of transmission which are likely to persist in complex and remote rural settings. Operational research is required to identify how current tools and practices might be adapted to locate and eliminate these hard-to-reach foci.Chronic disabilities caused by NTDs will persist after transmission of pathogens ceases. Development and delivery of sustainable services to reduce the NTD-related disability is an urgent public health priority.LSTM and its partners are world leaders in developing and delivering interventions to control vector-borne NTDs and malaria, particularly in hard-to-reach settings in Africa. Our experience, partnerships and research capacity allows us to serve as a hub for developing, supporting, monitoring and evaluating global programmes to eliminate NTDs.

Fragile and conflict affected states: report from the Consultation on Collaboration for Applied Health Research and Delivery

Fragile and Conflict Affected States present difficult contexts to achieve health system outcomes and are neglected in health systems research. This report presents key debates from the Consultation of the Collaboration for Applied Health Research and Delivery, Liverpool, June, 2014.