Search

Abstract This paper reviews the healthcare issues facing nations which have a substantial caseload of chronic HIV cases. It considers the challenges of extending antiretroviral coverage to an expanding caseload as supplier price rises and international trade agreements come into force to reduce the availability of affordable antiretrovirals just as the economic downturn restricts donor funding. It goes on to review the importance in this context of supporting adherence to drug regimens in order to preserve access to affordable antiretrovirals for those already on treatment, and of removing key barriers such as patient fees and supply interruptions. The demands of those with chronic HIV for health services other than antiretroviral therapy are considered in the light of the fearful or discriminatory attitudes of non-specialist healthcare staff due to HIV-related stigma, which is linked with the weakness of infection control measures in many health facilities. The implications for prevention strategies including those involving criminalisation of HIV transmission or exposure are briefly summarised for the current context, in which the caseload of those whose chronic HIV infection must be controlled with antiretrovirals will continue to rise for the foreseeable future.

Background: The human immunodeficiency virus (HIV) continues to be a major cause of maternal and infant mortality and morbidity in sub-Saharan Africa. Prevention of mother-to-child transmission of HIV (PMTCT) strategies have proven effective in decreasing the number of children infected in utero, intrapartum and during the breastfeeding period. This qualitative study explores knowledge and perceptions of HIV amongst pregnant women, healthcare workers' experiences of the national PMTCT services, and barriers to PMTCT, during a period of programme scale-up in urban Guinea-Bissau (2010-11). Methods: In-depth interviews were undertaken amongst 27 women and 19 key informants at local antenatal clinics and the national maternity ward in Bissau, Guinea-Bissau. Results: Amongst women who had been tested for HIV, awareness and knowledge of HIV and PMTCT remained low. Testing without informed consent was reported in some cases, in particular when the test was performed around the time of delivery. Possible drivers of inadequate counselling included lack of confidentiality, suboptimal healthcare worker training, lack of time, and perceived occupational risk. Demand-side barriers to PMTCT included lack of HIV and PMTCT knowledge, customary and cultural beliefs associated with HIV and ill-health, HIV stigma and discrimination, and fear of partnership dissolution. Conclusions: Socio-cultural and operational challenges, including HIV testing without informed consent, present significant barriers to the scale-up of PMTCT services in Bissau. Strengthening local capacity for effective counselling and testing in the antenatal setting is paramount. Further research into local customary beliefs relating to HIV is warranted. [ABSTRACT FROM AUTHOR]

Conscious of a paucity of evidence, and drawing upon a combination of historical documentary material, research literature and surveillance data, this paper offers a commentary on the social, historical and HIV contexts affecting men who have sex with men in Central Asia. The authors describe the history of men who have sex with men in the five Central Asian republics, before, during and after the Soviet-imposed legal prohibition, which continues in Turkmenistan and Uzbekistan, the only nations in the World Health Organization Europe region where sex between men remains illegal. This historical context frames contemporary responses to men who have sex with men. Despite long-established homoerotic traditions, modern attitudes to men who have sex with men are marked by great hostility, generating stigmatization of sex between men and discrimination against men suspected of it. The losses following public exposure can be severe: loss of employment; limited/lack of health-care access; and safety from physical and sexual assault. Such hostility creates an environment of increased HIV risk, and constrains the production of reliable HIV evidence. The authors argue that the generation of HIV risk, HIV-prevention responses and HIV evidence are products of their historical and social contexts, and call attention to the urgent need for HIV prevention and structural reforms to protect the health of men who have sex with men in Central Asia. [ABSTRACT FROM PUBLISHER]