Robert Power

Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities

OBJECTIVES To assess factors influencing access to drug treatment among injecting drug users (IDUs) in two Russian cities. METHODS Eighty-six qualitative interviews were conducted with IDUs in Volgograd and Barnaul in 2003. IDUs were recruited through local drug treatment services, needle exchanges, and drug user networks. RESULTS Three main barriers to treatment assess were identified: financial constraints, fear to registration as a drug user, and perceived low efficacy of available treatment services. Registration of drug users was associated with loss of employment, breaches in confidentiality. and stigma. Some participants did not think that drug treatment services could respond appropriately and effectively to their treatment needs. CONCLUSIONS These findings highlight the importance of environmental factors in mediating IDUs access to drug treatment, which might suggest the need for social and structural interventions. Access to drug treatment services should be enhanced by reducing the financial burdens of drug treatment and minimizing the stigma associated with drug user registration. Russia should shift from a highly medicalised model of treatment toward a more holistic approach that recognises the diversity of treatment needs among IDUs. These priorities are especially timely given the urgent need to integrate drug treatment as part of wider HIV prevention responses in Russia.

A very low response rate in an on-line survey of medical practitioners

Objective: To report on the response rate achieved in a survey of medical practitioners and discuss the reasons for it.

The Regai Dzive Shiri Project: a cluster randomised controlled trial to determine the effectiveness of a multi-component community-based HIV prevention intervention for rural youth in Zimbabwe – study design and baseline results

Objective  To assess the effectiveness of a community‐based HIV prevention intervention for adolescents in terms of its impact on (1) HIV and Herpes simplex virus type 2 (HSV‐2) incidence and on rates of unintended pregnancy and (2) reported sexual behaviour, knowledge and attitudes.

The Regai Dzive Shiri project: results of a randomized trial of an HIV prevention intervention for youth

Background:HIV prevention among young people in southern Africa is a public health priority. There is little rigorous evidence of the effectiveness of different intervention approaches. We describe findings of a cluster randomized trial of a community-based, multicomponent HIV, and reproductive health intervention aimed at changing social norms for adolescents in rural Zimbabwe. Methods:Thirty rural communities were randomized to early or deferred implementation of the intervention in 2003. Impact was assessed in a representative survey of 18–22-year-olds after 4 years. Participants self-completed a questionnaire and gave a dried blood spot sample for HIV and herpes simplex virus-2 (HSV-2) antibody testing. Young women had a urinary pregnancy test. Analyses were by intention-to-treat and were adjusted for clustering. Findings:Four thousand six hundred and eighty-four, 18–22-year-olds participated in the survey (97.1% of eligible candidates, 55.5% women). Just over 40% had been exposed to at least 10 intervention sessions. There were modest improvements in knowledge and attitudes among young men and women in intervention communities, but no impact on self-reported sexual behavior. There was no impact of the intervention on prevalence of HIV or HSV-2 or current pregnancy. Women in intervention communities were less likely to report ever having been pregnant. Interpretation:Despite an impact on knowledge, some attitudes, and reported pregnancy, there was no impact of this intervention on HIV or HSV-2 prevalence, further evidence that behavioral interventions alone are unlikely to be sufficient to reverse the HIV epidemic. The challenge remains to find effective HIV prevention approaches for young people in the face of continued and unacceptably high HIV incidence, particularly among young women.

HIV/AIDS harm reduction in Iran.

A consultation on HIV prevention in injecting drug users was held in Tehran April 17--20 2006 organised by the Government of The Islamic Republic of Iran the World Bank the UN Office on Drugs and Crime and the Joint UN Programme on HIV/AIDS (UNAIDS). Participants represented the countries of the Golden Crescent (Pakistan Afghanistan Tajikistan Kyrgyzstan Uzbekistan and Iran) one of the major drug-producing areas and trafficking routes globally. The main aim was to review what works and to learn from the Iranian experiences of how to implement comprehensive harm-reduction programmes. There were about 13.2 million injecting drug users worldwide in 2004 of whom at least 200 000 were estimated to be in Iran alone. Because injecting drug users are often highly stigmatised and marginalised they are also difficult to reach with only 5% coverage by prevention interventions in Asia. The efficient transmission of HIV through the sharing of contaminated injecting equipment and the low coverage by prevention interventions have resulted in HIV epidemics in such users throughout Asia and eastern Europe. Epidemics fuelled by injecting drug use are further sustained through sexual transmission with potential for wider spread. (excerpt)

Health, health promotion, and homelessness

Contemporary health promotion emphasises the concepts of lifestyle, risk, and preventive health behaviour alongside the broader societal concerns of the environment, public policy, and culture.1 The recent green paper Our Healthier Nation stresses a more coordinated approach to health promotion for people who are socially excluded, emphasising behavioural change through targeted interventions at the level of the community.2 There have been extensive reviews of homelessness and health, 3 4 along with calls for urgent action,5–7 but little attention has been paid to the health promotion needs of homeless people, and there is no firm evidence base for practice. One challenge for health promotion is to develop and deliver appropriate initiatives to a heterogeneous population that is not always easy to categorise but has a wide range of needs. The healthcare priorities of a young man sleeping on the streets differ from those of a single mother in temporary accommodation. To be homeless means more than just the absence of secure accommodation. Homelessness has as much to do with social exclusion as with bricks and mortar, and demands a range of health promotion strategies. #### Summary points At one level, the health condition of homeless people is a product of housing policy.3 Over the past two decades in …

Factors associated with HIV seroconversion in gay men in England at the start of the 21st century

Objectives: To detect and quantify current risk factors for HIV seroconversion among gay men seeking repeat tests at sexual health clinics. Design: Unmatched case control study conducted in London, Brighton and Manchester, UK. Methods: 75 cases (recent HIV positive test following a negative test within the past 2 years) and 157 controls (recent HIV negative test following a previous negative test within the past 2 years) completed a computer-assisted self interview focused on sexual behaviour and lifestyle between HIV tests. Results: Cases and controls were similar in socio-demographics, years since commencing sex with men, lifetime number of HIV tests, reasons for seeking their previous HIV tests and the interval between last HIV tests (mean = 10.5 months). Risk factors between tests included unprotected receptive anal intercourse (URAI) with partners not believed to be HIV negative (adjusted odds ratio (AOR) and 95% confidence interval 4.1, 1.8 to 9.3), where increased risk was associated with concomitant use of nitrite inhalants, receiving ejaculate and increasing numbers of partners. Independent risk was also detected for unprotected insertive anal intercourse (UIAI) with more than one man (AOR 2.7, 1.3 to 5.5) and use of nitrite inhalants (AOR 2.4, 1.1 to 5.2). Conclusions: HIV serodiscordant unprotected anal intercourse remains the primary context for HIV transmission among gay men, with increased risk associated with being the receptive partner, receiving ejaculate and use of nitrite inhalants. Although the HIV transmission risk of URAI is widely acknowledged, this study highlights the risk of UIAI and that nitrite inhalants may be an important facilitator of transmission when HIV exposure occurs.

School based HIV prevention in Zimbabwe: feasibility and acceptability of evaluation trials using biological outcomes

ObjectiveTo determine the feasibility and acceptability of conducting a community randomized trial (CRT) of an adolescent reproductive health intervention (ARHI) using biological measures of effectiveness. SettingFour secondary schools and surrounding communities in rural Zimbabwe. MethodsDiscussions were held with pupils, parents, teachers and community leaders to determine acceptability. A questionnaire and urine sampling survey was undertaken among Form 1 and 2 pupils. Studies were undertaken to inform likely participation and follow up in a future CRT. A community survey of 16–19-year-olds was conducted to determine levels of secondary school attendance and likely HIV prevalence at final follow up in the event of a trial. ResultsForm 1 and 2 pupils aged 12–18 years (n = 723; median age, 15 years) participated in the research. Prevalences of HIV, Chlamydia and gonorrhoea were 3.6% [95% confidence interval (CI), 2.3–5.3%], 0.4% (95% CI, 0.1–1.3%) and 1.9% (95% CI, 1.0–3.3%) respectively. There was poor correlation between biological evidence of sexual experience and questionnaire responses, due to concerns about confidentiality. Only 13% (95% CI, 4–27%) of those infected with HIV and/or a sexually transmitted disease admitted to having had sex. In the community survey of 573 adolescents aged 16–19 years, 6.6% (95% CI, 3.9–10.3%) of females and 5.1% (95% CI, 2.9–8.2%) of males were HIV positive. High participation and retention rates are achievable within a trial in this setting. ConclusionsIt is acceptable and feasible to conduct randomized trials to establish the effectiveness of ARHIs. However, self-reported behavioural outcomes will probably be biased, emphasizing the importance of using externally validated biological outcome measures to determine effectiveness.

The role of qualitative research in HIV/AIDS.

Qualitative research, which is primarily inductive and descriptive, provides rich contextual data to further our understanding of social phenomena. Its value is firmly established in behavioural sciences and not merely as a complement to quantitative research [1]. Indeed, some have suggested that qualitative research is pivotal to our understanding of the sociobehavioural aspects of HIV disease [2]. In describing its role to date, this article will provide illustrations of the variety of methods used by qualitative researchers to gather data, but for the sake of clarity these will be described at the outset.

An evaluation of peer-led STD/HIV prevention work in a public sex environment.

This paper describes an independent evaluation of a peer-led STD/HIV prevention intervention conducted by Gay Men Fighting AIDS (GMFA) in a public sex environment (PSE). A variety of quantitative and qualitative research methods were employed to collect data on the intervention process as well as its outcomes. The main aim of the intervention was the distribution of condoms and safer sex literature to PSE users. During a five-month period, over 100,000 condoms and 2,200 safer sex information packs were distributed by GMFA volunteers to the PSE users. Condom provision was identified as the most needed health promotion activity in PSEs in a survey of gay and bisexual men (n = 688) conducted by the evaluators. Data collected showed that condoms provided by GMFA, as well as from other sources, were being used in the PSE. The peer-led focus of the intervention was acceptable to the PSE users. In addition, high levels of commitment and input from the volunteers contributed considerable added value to the intervention. The evaluation found that GMFA was successful in reaching the target population and addressing their needs and demands.