Sharif Sawires

Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward

Although stigma is considered a major barrier to effective responses to the HIV/AIDS epidemic, stigma reduction efforts are relegated to the bottom of AIDS programme priorities. The complexity of HIV/AIDS-related stigma is often cited as a primary reason for the limited response to this pervasive phenomenon. In this paper, we systematically review the scientific literature on HIV/AIDS-related stigma to document the current state of research, identify gaps in the available evidence and highlight promising strategies to address stigma. We focus on the following key challenges: defining, measuring and reducing HIV/AIDS-related stigma as well as assessing the impact of stigma on the effectiveness of HIV prevention and treatment programmes. Based on the literature, we conclude by offering a set of recommendations that may represent important next steps in a multifaceted response to stigma in the HIV/AIDS epidemic.

Male circumcision and HIV/AIDS: challenges and opportunities

2enrolled in the respective studies. The Kenya and Uganda trials replicated the landmark fi ndings of the South African Orange Farm study, the fi rst randomised controlled trial to report a greater than 50% protective benefi t of male circumcision. 3 Before the availability of data from these three African randomised controlled trials, multiple observational studies correlated male circumcision with reduced risk of HIV infection. 4–9 Systematic reviews and meta-analysis of observational studies provide further evidence of the association of male circumcision with reduced risk of HIV infection 10–12 and a plausible explanation for the biological mechanism for reduced risk of infection has been suggested. 13 Recently released longitudinal evidence of the range of health benefi ts that male circumcision provides, 14

Men, HIV/AIDS, and human rights.

Though still limited in scale, work with men to achieve gender equality is occurring on every continent and in many countries. A rapidly expanding evidence base demonstrates that rigorously implemented initiatives targeting men can change social practices that affect the health of both sexes, particularly in the context of HIV and AIDS. Too often however, messages only address the harm that regressive masculinity norms cause women, while neglecting the damage done to men by these norms. This article calls for a more inclusive approach which recognizes that men, far from being a monolithic group, have unequal access to health and rights depending on other intersecting forms of discrimination based on race, class, sexuality, disability, nationality, and the like. Messages that target men only as holders of privilege miss men who are disempowered or who themselves challenge rigid gender roles. The article makes recommendations which move beyond treating men simply as “the problem”, and instead lays a foundation for engaging men both as agents of change and holders of rights to the ultimate benefit of women and men. Human rights and other policy interventions must avoid regressive stereotyping, and successful local initiatives should be taken to scale nationally and internationally.

Gender, Empowerment, and Health: What Is It? How Does It Work?

As the HIV/AIDS epidemic has progressed, the role of gender inequality in its transmission has become increasingly apparent. Nearly half of those living with the virus worldwide are women, and womens subordination to men increases their risk of infection and makes it harder for them to access treatment once infected. Men, too, suffer from harmful gender norms-the expectation that they will behave in ways that heighten their risk of HIV infection and that they will be cavalier about seeking health care increases their vulnerability to the disease. In the Middle East and North Africa, HIV infection rates are low, but changing gender norms have the potential to accelerate the spread of the disease if gender inequality is not addressed. Improving womens education, workforce participation, and social and political opportunities is crucial to strengthening health in the region. Work with men to shift gender imbalances is a further important task for the regions policy-makers and civil society groups.

Uncovering tensions and capitalizing on synergies in HIV/AIDS and antiviolence programs.

Research frequently points to the need to empower women to effectively combat the twin epidemics of HIV/AIDS and gender-based violence. Simultaneously, there has been increased attention given to working with men in gender equality efforts. The latter approach intervenes on masculinities as part of the fight against HIV/AIDS and violence. No research has considered these 2 lines of work side by side to address several important questions: What are the points of overlap, and the tensions and contradictions between these 2 approaches? What are the limitations and unintended consequences of each? We analyzed these 2 parallel research trends and made suggestions for how to capitalize on the synergies that come from bolstering each position with the strengths of the other.

Missed Opportunities for HIV Testing and Late-Stage Diagnosis among HIV-Infected Patients in Uganda

Background Late diagnosis of HIV infection is a major challenge to the scale-up of HIV prevention and treatment. In 2005 Uganda adopted provider-initiated HIV testing in the health care setting to ensure earlier HIV diagnosis and linkage to care. We provided HIV testing to patients at Mulago hospital in Uganda, and performed CD4 tests to assess disease stage at diagnosis. Methods Patients who had never tested for HIV or tested negative over one year prior to recruitment were enrolled between May 2008 and March 2010. Participants who tested HIV positive had a blood draw for CD4. Late HIV diagnosis was defined as CD4≤250 cells/mm. Predictors of late HIV diagnosis were analyzed using multi-variable logistic regression. Results Of 1966 participants, 616 (31.3%) were HIV infected; 47.6% of these (291) had CD4 counts ≤250. Overall, 66.7% (408) of the HIV infected participants had never received care in a medical clinic. Receiving care in a non-medical setting (home, traditional healer and drug stores) had a threefold increase in the odds of late diagnosis (OR = 3.2; 95%CI: 2.1–4.9) compared to receiving no health care. Conclusions Late HIV diagnosis remains prevalent five years after introducing provider-initiated HIV testing in Uganda. Many individuals diagnosed with advanced HIV did not have prior exposure to medical clinics and could not have benefitted from the expansion of provider initiated HIV testing within health facilities. In addition to provider-initiated testing, approaches that reach individuals using non-hospital based encounters should be expanded to ensure early HIV diagnosis.

Male Circumcision and HIV Prevention: Looking to the Future

Now that male circumcision has been shown to have a protective effect for men against HIV infection when engaging in vaginal intercourse with HIV-infected women, the research focus needs to shift towards the operational studies that can pave the way for effective implementation of circumcision programs. Behavioral research is needed to find out how people perceive the procedure and the barriers to and facilitators of uptake. It should also assess the risk of an increase in unsafe sex after circumcision. Social research must examine cultural perceptions of the practice, in Africa and beyond, including how likely uncircumcised communities are to access surgery and what messages are needed to persuade them. Advocates of male circumcision would benefit from research on how to influence health policy-makers, how best to communicate the benefits to the public, and how to design effective delivery models.

Framing Male Circumcision to Promote its Adoption in Different Settings

The effectiveness of male circumcision in preventing transmission of HIV from females to males has been established. Those who are now advocating its widespread use face many challenges in convincing policy-makers and the public of circumcision’s value. We suggest that frames are a useful lens for communicating public health messages that may help promote adoption of circumcision. Frames relate to how individuals and societies perceive and understand the world. Existing frames are often hard to shift, and should be borne in mind by advocates and program implementers as they attempt to promote male circumcision by invoking new frames. Frames differ across and within societies, and advocates must find ways of delivering resonant messages that take into account prior perceptions and use the most appropriate means of communicating the benefits and value of male circumcision to different audiences.

Gender and HIV in the Middle East and North Africa: lessons for low prevalence scenarios.

Over the quarter century since its discovery, HIV has not been considered a health threat in the Middle East and North Africa (MENA). However, despite the low prevalence in most countries of the region, there is increasing evidence suggesting that the epidemic is in motion. Since the identification of the first MENA region AIDS cases in the 1980s, the number of detected people living with HIV has been steadily on rise. Although geographic proximity and shared cultural factors interconnect the region, estimated HIV-related epidemiological profiles vary dramatically, ranging from low level to generalized epidemics. Despite the overall regional prevalence remaining low, the total number of AIDS deaths in the region increased by at least 6-folds since the early 1990s. Globally, gender norms that subordinate women and trap men in damaging patterns of risk behaviors are increasingly recognized as fundamental forces that increase population health vulnerabilities, and the MENA region is no exception. Gender is a social construct that refers to a complex framework affecting both men and women in the society. All cultures interpret the biological differences between women and men into a set of culturally normative behaviors and attitudes. In the community-oriented MENA societies, the family, rather than the individual, is the core focus of concern. Femininity and masculinity are often translated into raising women to be ‘‘caregivers’’ and men to be ‘‘breadwinners.’’ For both women and men, early marriage is encouraged, sexual relations outside marriage are prohibited, and sex education is a sensitive topic. The prevailing gender norms offer men greater social power and access to resources as compared with women. Furthermore, normative societal ideals for the interaction between women and men in the region may increase both women’s and men’s transmission risk and ability to access care for those who are infected. In the conservative societies of the MENA, cultural norms uphold the institution of marriage as the only legitimate context for sexual relations. Ideals of premarital chastity and lifelong fidelity are encouraged for women, whereas men’s experiences and multiple partners are often tolerated as part of the masculine ideals. Women face steep barriers to accessing accurate information about HIVand risk reduction and having a proactive role in negotiating safer sex because they are not expected to be sexually experienced. The region’s prevailing norms of masculinity provide men with more privileges and freedoms, often putting them at risk by preventing them from seeking accurate information or admitting their lack of knowledge about sexuality and risk reduction. Although a range of transmission modes exist in the region, unprotected sexual transmission is overwhelmingly responsible for new infections in the MENA. The growing population of injecting drug users is another major route of infection that is accelerating

Twenty-five years of HIV: lessons for low prevalence scenarios.

During the initial quarter century since the discovery of HIV, international response has focused on high prevalence scenarios and concentrated epidemics. Until recently, the theoretical underpinnings of HIV prevention were largely based on these responses-the assumption that inadequate responses to concentrated epidemics within low prevalence populations could rapidly lead to generalized epidemics. The limits of these assumptions for HIV prevention in low prevalence scenarios have become evident. While examples of rapid HIV diffusion in once low prevalence scenarios exist, emergence of generalized epidemics are less likely for much of the world. This paper reviews several key issues and advances in biomedical and behavioural HIV prevention to date and highlights relevance to low prevalence scenarios.