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Indonesia’s HIV epidemic is concentrated among key populations. While prevalence among men who have sex with men (MSM) is high, transmission among young MSM (15–24-years-old) remains poorly understood. We conducted a respondent driven sampling survey of 211 young MSM in urban Bandung, Indonesia in 2018–2019 to estimate HIV prevalence and associated risk factors. Thirty percent of young MSM were HIV antibody positive. This is nearly 100-fold greater than Indonesia’s population prevalence and sevenfold higher than average estimates for young MSM across Asia and the Pacific Region. Individual risk factors associated with HIV infection were being 20–24 years old, having a steady partner and preferring the receptive position during sex. Issues of stigma, discrimination and social exclusion were common. Few young MSM who were open with friends and family members about their sexual identity. Among those that were, close to half reported experiencing feelings of aversion from these groups. Wider structural factors that reduce social tolerance, restrict the rights of young MSM and compel concealment of sexual identity are likely to fuel high-risk behaviors and limit access to essential testing care and support services including pre-exposure prophylaxis which is not yet widely available. Urgent health, social, legal and political actions are required to respond to these factors and reduce the disproportionate contribution of young MSM to Indonesia’s HIV epidemic. Supplementary Information The online version contains supplementary material available at 10.1007/s10461-021-03347-0.

ObjectiveTo assess the contribution of a digital health real-time monitoring platform towards the achievement of coverage targets during a national immunisation campaign in Indonesia.InterventionsA digital health platform was introduced to facilitate real-time reporting and data visualisation. Health workers submitted reports of children immunised each day by geolocation using mobile phones. Automated reports were generated for programme managers at all levels to enable early responses to coverage gaps.MethodsRisk profiles were generated for each district to assess precampaign immunisation programme performance. Digital health platform use and progress towards targets were monitored continuously throughout the campaign. Study outcomes were total coverage and time to achieve full (100%) coverage. Kaplan-Meier, Cox and linear regression analyses were used to estimate the associations and outcomes after adjusting for district risk profiles. A complementary qualitative assessment explored user experiences and acceptance through interviews with vaccinators and programme managers in provinces and districts selected through multistage random sampling.ResultsBetween August and December 2018, 6462 health facilities registered to use the digital health platform across 28 provinces and 395 districts. After adjusting for precampaign district risk profile and intracampaign delays due to vaccine hesitancy, districts with greater platform utilisation demonstrated higher coverage overall (R2=0.28, p75% reporting compliance; Risk Ratio 15.4, 95% CI 5.8 to 40.6). Stronger effects were observed among districts experiencing implementation delays due to vaccine hesitancy. Results from 106 key informant interviews conducted in 6 provinces and 18 districts suggest high degrees of acceptability, ease of use and satisfaction.ConclusionA digital health platform introduced for real-time monitoring of a national immunisation campaign in Indonesia was feasible, well liked and associated with improved problem solving and programme performance, particularly among districts affected by vaccine hesitancy.Trial registration numberISRCTN10850448.

We assessed Zika virus seroprevalence among healthy 1-4-year-old children using a serum sample collection assembled in 2014 representing 30 urban sites across Indonesia. Of 662 samples, 9.1% were Zika virus seropositive, suggesting widespread recent Zika virus transmission and immunity. Larger studies are needed to better determine endemicity in Indonesia.

Background Access to safe sanitation and the elimination of open defecation are pre-conditions for improved child health and nutrition and wider achievement of the Sustainable Development Goals (SDGs). While Indonesia has a solid policy framework, the country ranks third globally in terms of numbers of people practicing open defecation. Objectives Our aim was to assess the effectiveness of a five-year strategy to reduce open defecation through accelerating implementation of the national sanitation program across districts receiving variable levels of external support. Methods Among three provinces with poor sanitation program performance, districts were selected to receive one of three levels of external support. High intensity districts (n = 6) benefitted from enabling environment strengthening support including political and social mobilization, direct capacity development, and efforts to strengthen planning, budgeting, monitoring and supervision; learning districts (n = 16) benefitted from cross-district learning opportunities and political mobilization through provincial government advocacy efforts; and comparison districts (n = 58) were monitored under routine program conditions. Outcomes included open defecation free (ODF) status and new toilet facility construction and were assessed through village level monitoring systems across all districts. Negative binomial regression and multivariate analysis were used to assess associations between levels of intervention intensity and outcomes. Findings Among districts receiving high-intensity external support improvements in political commitment, planning, coordination, financing, monitoring and supervision were observed. Relative to comparison districts, high intensity districts were more likely to be ODF (aRR 4.65, CI 2.12–10.20) with greater increase in household toilet coverage (aRR 11.15 CI 1.04–119.82). Weaker non-significant associations with ODF were observed among learning districts relative to comparison districts. Interpretation Efforts to strengthen provincial and district government capacity to implement sanitation programming in Indonesia can yield substantial improvements in outcomes in a relatively short period of time., Highlights • The effectiveness of five-year sanitation strategies in Indonesia was assessed. • In high-intensity districts improvements in government systems were observed. • High-intensity districts were more likely to be open defecation free. • Sanitation outcomes can be improved when government systems are strengthened.

The sustainable development goals (SDGs) and updated Global strategy for women's, children's and adolescents' health (2016-2030) call upon countries and the global community to transform health systems and society. (1,2) Additional investments in women's, children's and adolescents' health are essential to achieve the ambitious agenda that has been set. Support for nationally-identified reproductive, maternal, newborn and child health priorities needs to be better coordinated and new mechanisms, such as the Global Financing Facility, need to be used to expand domestic financing and attract additional resources. (3,4) The relevant global frameworks have to be translated into actions at the country level and, for this, the lessons learnt from previous engagement with individual countries may give useful guidance. The Reproductive, Maternal, Newborn and Child Health Fund was established in 2013 to support countries with the highest burden of preventable maternal and child deaths and help direct such countries towards millennium development goals (MDGs) 4 and 5 (to reduce child mortality and to improve maternal health by 2015). The fund's main aims were to provide catalytic resources to fill the critical gaps identified by countries and facilitate greater integration of financing and intervention programmes. At the time of the fund's launch, integration was complicated by the proliferation of multiple new initiatives under the Every Woman Every Child umbrella--e.g. A Promised Renewed, Family Planning 2020 and the United Nations (UN) Commission on Life-Saving Commodities, etc. (5) In 2013, under the stewardship of heath ministries and with the support of the H4+ partnership, UN agencies and partners, a country engagement process was outlined to identify implementation gaps across the reproductive, maternal, newborn and child health spectrum. The objectives were to improve the alignment and integration of partners and programmes and to provide catalytic support for prioritized gaps. Using the latest relevant national and subnational data, a situation analysis was conducted to evaluate progress and identify key bottlenecks. Demand for reproductive, maternal, newborn and child health was then evaluated so that the interventions and strategies needed to achieve MDGs 4 and 5 could be determined. In many cases, the priorities identified had already appeared in existing national plans. In-country dialogues with key stakeholders then identified opportunities to strengthen national coordination and alignment. Forward-looking resource mapping was used to assess the financial resources that were--or might become--available to support reproductive, maternal, newborn and child health from domestic and external sources. Finally, prioritized gaps were identified against which further resource alignment could take place and new funding--e.g. from the Reproductive, Maternal, Newborn and Child Health Fund--mobilized. The country perspectives that we present in this article (Table 1) come from the health ministries, civil society organizations and partner agencies from 16 countries in sub-Saharan Africa that collectively received over 180 million United States dollars from the Reproductive, Maternal, Newborn and Child Health Fund (Box 1 and Box 2). These perspectives were generated from a synthesis of facilitated group discussions that took place, among representatives from all 16 focus countries, during a week-long workshop in October 2015. (6) By 2016, a range of lessons had been learnt from this country engagement process. There was a lack of enabling environment. At country level, there was persistent confusion around the multitude of global and regional initiatives on reproductive, maternal, newborn and child health. This resulted in high transaction costs for ministries and duplication and fragmentation in financing and programming. Although there was a compelling global discourse and commitment to improving alignment, this was not always mirrored by actions on the ground. …

In malaria elimination areas, malaria cases are sporadic and consist predominantly of imported cases. Plasmodium knowlesi cases have been reported throughout Southeast Asia where long-tailed and pig-tailed macaques and Anopheles leucosphyrus group mosquitoes are sympatric. The limitation of microscopic examination to diagnose P. knowlesi is well known. In consequence, no P. knowlesi case has previously been reported from routine health facility-based case finding activities in Indonesia. This report describes two clusters of unexpected locally acquired P. knowlesi cases found in an area where Plasmodium falciparum and Plasmodium vivax infection had been eliminated in Sabang Municipality, Aceh, Indonesia. The difficulties in diagnosis and response illustrate challenges that Southeast Asian countries will increasingly face as the formerly common malaria parasites P. falciparum and P. vivax are gradually eliminated from the region.

Objectives. To examine the acceptability, use, effects on early isolation, and contribution to Ebola virus disease (EVD) transmission of Community Care Centers (CCCs), which were rapidly deployed in Sierra Leone during an accelerated phase of the 2014–2015 EVD epidemic. Methods. Focus group discussions, triads, and key informant interviews assessed acceptability of the CCCs. Facility registers, structured questionnaires, and laboratory records documented use, admission, and case identification. We estimated transmission effects by comparing time between symptom onset and isolation at CCCs relative to other facilities with the national Viral Hemorrhagic Fever data set. Results. Between November 2014 and January 2015, 46 CCCs were operational. Over 13 epidemic weeks, 6129 patients were triaged identifying 719 (12%) EVD suspects. Community acceptance was high despite initial mistrust. Nearly all patients presented to CCCs outside the national alert system. Isolation of EVD suspects within 4 days of symptoms was higher in CCCs compared with other facilities (85% vs 49%; odds ratio = 6.0; 95% confidence interval = 4.0, 9.1), contributing to a 13% to 32% reduction in the EVD reproduction number (Ro). Conclusions. Community-based approaches to prevention and care can reduce Ebola transmission.

In Africa, older adults aged 50 and older are still sexually active and play a critical role as caregivers, yet little is known about their attitudes towards HIV and awareness of services. In this study, surveys were con- ducted in nine African sites. A multilevel model was fitted to evaluate the relationship between age and outcome variables. The study reveals that people aged 50 years and older have lower levels of HIV-related knowledge and awareness than those aged 25-49. Older adults were less likely to have been tested for HIV and women aged 50 and older showed particularly low levels of awareness.

OBJECTIVE: Assess the cost-effectiveness of an intervention combining microfinance with gender and HIV training for the prevention of intimate partner violence (IPV) in South Africa. METHODS: We performed a cost-effectiveness analysis alongside a cluster-randomized trial. We assessed the cost-effectiveness of the intervention in both the trial and initial scale-up phase. RESULTS: We estimated the cost per DALY gained as US$7688 for the trial phase and US$2307 for the initial scale-up. The findings were sensitive to the statistical uncertainty in effect estimates but otherwise robust to other key assumptions employed in the analysis. CONCLUSIONS: The findings suggest that this combined economic and health intervention was cost-effective in its trial phase and highly cost-effective in scale-up. These estimates are probably conservative, as they do not include the health and development benefits of the intervention beyond IPV reduction.

BACKGROUND: Health challenges faced by older people in developing countries are often neglected amidst a wide range of competing priorities. This is evident in the HIV field where the upper age limit for reporting HIV prevalence remains 49 years. However, the long latency period for HIV infection, and the fact that older people continue to be sexually active, suggests that HIV and AIDS are likely to affect older people. To better understand this, we studied mortality due to AIDS in people aged 50 and older in an area of rural Kenya with high rates of HIV infection. METHODS: A community health worker-administered verbal autopsy system was introduced in Nyanza Province, encompassing 63,500 people. Algorithms were used to determine cause of death. RESULTS: A total of 1228 deaths were recorded during the study period; 368 deaths occurred in people aged 50 years and older. AIDS was the single most common cause of death, causing 27% of all deaths. AIDS continued to be the main cause of death up to age 70 years, causing 34% of deaths in people aged 50-59 years and 23% of deaths in people aged 60-69 years. CONCLUSIONS: AIDS remains the principle cause of death among older people in Nyanza Province in western Kenya up until the age of 70 years. Greater efforts are needed to integrate older people into the HIV response and to better understand the specific vulnerabilities and challenges faced by this group.

The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) combines microfinance, gender/HIV training and community mobilization (CM) in South Africa. A trial found reduced intimate partner violence among clients but less evidence for impact on sexual behaviour among clients' households or communities. This process evaluation examined how feasible IMAGE was to deliver and how accessible and acceptable it was to intended beneficiaries during a trial and subsequent scale-up. Data came from attendance registers, financial records, observations, structured questionnaires (378) and focus group discussions and interviews (128) with clients and staff. Gender/HIV training and CM were managed initially by an academic unit ('linked' model) and later by the microfinance institution (MFI) ('parallel' model). Microfinance and gender/HIV training were feasible to deliver and accessible and acceptable to most clients. Though participation in CM was high for some clients, others experienced barriers to collective action, a finding which may help explain lack of intervention effects among household/community members. Delivery was feasible in the short term but both models were considered unsustainable in the longer term. A linked model involving a MFI and a non-academic partner agency may be more sustainable and is being tried. Feasible models for delivering microfinance and health promotion require further investigation.

Characteristics of sexual partnerships, as well as those of the individuals involved, might influence the use of condoms and risk of HIV transmission. We set out to identify characteristics of non-spousal sexual partnerships associated with condom use at last sex in the previous year and HIV infection in the previous three years among sexually active young people in rural South Africa. We conducted an analysis of follow-up data (collected in 2004) from a cohort of 14-35-year old men and women recruited to a cluster-randomised trial. Data on 1647 non-spousal sexual partnerships during the previous year were reported in 2004 and analysed alongside new HIV infections over the previous three years among 762 individuals who were HIV-negative in 2001. Structured interviews elicited information on sexual behaviour. HIV serostatus was assessed through oral-fluid ELISA. Condom use at last sex was reported for 615/1647 non-spousal sexual partnerships (37.3%) and was more commonly reported by individuals who were younger, more educated and aware of their HIV status. Condom use was more common in casual partnerships, those where the male partner was younger, where sex was less frequent and where the respondent believed the partner to have other sexual contacts. New HIV infection in the last three years was identified for 87/762 individuals (11.4%) and was more common among females and those out of school. Infection risk was associated with the age of the partners and was less common among individuals reporting less frequent intercourse in the previous year. Characteristics of sexual partnerships, as well as those of individuals, are important determinants of condom use and risk of HIV infection. Male characteristics may be particularly important because of their greater capacity to make decisions about HIV prevention. Established non-spousal sexual partnerships are an increasingly important context for HIV transmission in this setting.

Objective: To assess effects of a combined microfinance and training intervention on HIV risk behavior among young female participants in rural South Africa. Design: Secondary analysis of quantitative and qualitative data from a cluster randomized trial, the Intervention with Microfinance for AIDS and Gender Equity study. Methods: Eight villages were pair-matched and randomly allocated to receive the intervention. At baseline and after 2 years, HIV risk behavior was assessed among female participants aged 14‐35 years. Their responses were compared with women of the same age and poverty group from control villages. Intervention effects were calculated using adjusted risk ratios employing village level summaries. Qualitative data collected during thestudyexploredparticipants’responsestotheinterventionincludingHIVriskbehavior. Results: After 2 years of follow-up, when compared with controls, young participants had higher levels of HIV-related communication (adjusted risk ratio 1.46, 95% confidence interval 1.01‐2.12), were more likely to have accessed voluntary counseling and testing (adjusted risk ratio 1.64, 95% confidence interval 1.06‐2.56), and less likely to have had unprotected sex at last intercourse with a nonspousal partner (adjusted risk ratio 0.76, 95% confidence interval 0.60‐0.96). Qualitative data suggest a greater acceptance of intrahousehold communication about HIV and sexuality. Although women noted challenges associated with acceptance of condoms by men, increased confidence and skills associated with participation in the intervention supported their introduction in sexual relationships. Conclusions: In addition to impacts on economic well being, women’s empowerment and intimate partner violence, interventions addressing the economic and social vulnerability of women may contribute to reductions in HIV risk behavior. 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2008, 22:1659‐1665

OBJECTIVES:: To estimate HIV incidence and explore evidence for changing sexual behaviour over time among men and women belonging to different socioeconomic groups in rural South Africa. DESIGN AND METHODS:: A cohort study conducted between 2001 and 2004; 3881 individuals aged 14-35 years enumerated in eight villages were eligible. At least three household visits were made to contact each eligible respondent at both timepoints. Sexual behaviour data were collected in structured, respondent-focused interviews. HIV serostatus was assessed using an oral fluid enzyme-linked immunosorbent assay at each timepoint. RESULTS:: Data on sexual behaviour were available from 1967 individuals at both timepoints. A total of 1286 HIV-negative individuals at baseline contributed to the analysis of incidence. HIV incidence was 2.2/100 person-years among men and 4.9/100 person-years in women, among whom it was highest in the least educated group. Median age at first sex was lower among later birth cohorts. A higher number of previously sexually active individuals reported having multiple partners in the past year in 2004 than 2001. Condom use with non-spousal partners increased from 2001 to 2004. Migrant men more often reported multiple partners. Migrant and more educated individuals of both sexes and women from wealthier households reported higher levels of condom use. DISCUSSION:: HIV incidence is high in rural South Africa, particularly among women of low education. Some risky sexual behaviours (early sexual debut, having multiple sexual partners) are becoming more common over time. Condom use is increasing. Existing HIV prevention strategies have only been partly effective in generating population-level behavioural change.

Objectives. We sought to obtain evidence about the scope of women’s empowerment and the mechanisms underlying the significant reduction in intimate partner violence documented by the Intervention With Microfinance for AIDS and Gender Equity (IMAGE) cluster-randomized trial in rural South Africa. Methods. The IMAGE intervention combined a microfinance program with participatory training on understanding HIV infection, gender norms, domestic violence, and sexuality. Outcome measures included past year’s experience of intimate partner violence and 9 indicators of women’s empowerment. Qualitative data about changes occurring within intimate relationships, loan groups, and the community were also collected. Results. After 2 years, the risk of past-year physical or sexual violence by an intimate partner was reduced by more than half (adjusted risk ratio=0.45; 95% confidence interval=0.23, 0.91). Improvements in all 9 indicators of empowerment were observed. Reductions in violence resulted from a range of responses enabling women to challenge the acceptability of violence, expect and receive better treatment from partners, leave abusive relationships, and raise public awareness about intimate partner violence. Conclusions. Our findings, both qualitative and quantitative, indicate that economic and social empowerment of women can contribute to reductions in intimate partner violence.

Expanding access to voluntary counselling and testing (VCT) for HIV is an important first step in the development of a comprehensive package of HIV services. This article describes the introduction of VCT among five primary health care (PHC) facilities in a rural South African setting, alongside a multidimensional impact assessment as part of a national pilot programme. A baseline review of services demonstrated low levels of VCT, which were predominantly hospital-based. Twenty health workers in five PHC facilities were trained to provide VCT using rapid-testing assays. The feasibility of VCT introduction and its overall acceptability to clients and providers were evaluated using clinic testing registers, semi-structured interviews with counsellors and mock client encounters. One year after its introduction, a major increase in the quantity of HIV testing, the proportion of clients who receive their results, and the proportion who present voluntarily was observed. The majority of those presenting were women, and 20-40 year olds predominated. There was a high level of acceptance among health workers, and the quality of VCT was rated very good in mock client encounters. This work demonstrates one effective model for improving access to VCT through existing primary health care services in a rural South African context.

This paper reflects on current infectious disease control methods, their biomedical history and the management structures they are driven by. It asks whether a broader concept of 'infectious disease policy', with an emphasis on 'process' rather than outcomes, will help to re-frame the control discourse to ensure that infectious disease control is not only a method for preventing and treating infectious diseases, but is also a path for the creation of healthy communities.This paper reflects on current infectious disease control methods, their biomedical history and the management structures they are driven by. It focuses on the broader concept of "infectious disease policy" as a method for preventing and treating infectious diseases, and as a path for the creation of healthy communities. Infectious disease policy broadens the biological perspective of infectious disease control and highlights the common obstacles to policy and intervention, obstacles, which include poverty, inequity, environmental factors, access, and the interrelationship between individuals and communities with health structures. Developing such a policy will encourage a change in focus from purely biomedical program approach to a process-oriented policy approach, which will enable infectious disease control to be integrated, flexible, sensitive to global, national and local contexts, and directly involved in the creation of healthy communities.

In some societies, medical pluralism has been demonstrated to delay access to care. We identified sources of health care, and explored utilization patterns and triggers of care-seeking behavior among HIV/AIDS patients in rural South Africa. A longitudinal qualitative study consisting of in-depth interviews was conducted. We purposively sampled thirty-two adult HIV clinic attendees. A high degree of medical pluralism occurred among participants before initiation of antiretroviral treatment (ART). After ART initiation, participants predominantly used the HIV/ART clinic, and utilization of private and traditional facilities decreased. Patterns included both concurrent and sequential pathways to public, private and traditional health sectors. HIV diagnosis and treatment were delayed despite early contact with health systems. Therefore, use of multiple health care modalities before ART initiation can lead to delayed HIV testing and ART initiation. Integrated-care has the potential to mitigate the impact of medical pluralism on access to HIV-related services over the longer term.

This study investigated the relationship between highly active antiretroviral therapy (HAART) and instrumental activities of daily living (IADLs) among two clinical cohorts in South Africa. Between 2003 and 2008 structured questionnaires were administered to HIV-positive patients attending outpatient clinics at an urban hospital (Soweto, n = 3,081) and a rural hospital (Acornhoek, n = 1,247). Among those receiving help, an average of 4.8 and 5.1 h of assistance with IADLs daily was reported (rural and urban participants, respectively), with the patient’s mother and children assisting the most. Participants on HAART were 17 and 41% less likely to receive assistance with IADLs in the rural and urban cohorts, respectively, after adjusting for demographic characteristics, healthcare utilization, and CD4 counts. HAART significantly decreased the IADL assistance among patients in South Africa. Alongside clinical benefits, HAART has the potential to reduce the burden of HIV-related care, potentially extending wider social and economic gains to other family members.

OBJECTIVE: To demonstrate the feasibility acceptability and cost of home-based HIV testing and to examine the applicability of the model to high HIV prevalence settings. METHODS: Quantitative qualitative and cost data were collected during a home-based HIV testing program in a high-prevalence rural area of Kenya; data on age gender and marital status along with HIV test results were collected. This was complemented with qualitative research including key informant interviews with counselors and program managers to highlight experiences and challenges. Direct costs of the interventions were estimated through the review of budgets and monthly expenditure sheets. RESULTS: Of 3180 15-49-year olds exposed to a community awareness campaign 2033 (63.9%) agreed to be visited by counselors of whom 1984 (97.6%) agreed to be tested and receive the results. Adult HIV prevalence was 8.2% and married women were 4.8 times more likely to be HIV-positive than those never married. Counselors reported feeling welcomed and noted the enthusiasm of the community towards testing. The total cost of the exercise was $17569. The program cost was $2.60 for each of the 6750 community members $5.88 for each person tested and $84 per positive case detected. CONCLUSION: This study suggests that home-based HIV testing is feasible with high uptake and has the potential to substantially expand access to HIV testing services. There is a strong economic case for the extension of such a screening program to other communities.

Communication between parents and young people about sex has been identified as a positive influence on young people's sexual behavior. This article presents findings from South Africa, where a social intervention to reduce levels of HIV and intimate partner violence actively promoted sexual communication between adults and young people. We assessed this component of the program using quantitative and qualitative methods, collecting data through surveys, direct observation, interviews, and focus group discussions. Women participating in intervention activities reported sexual communication with children significantly more often than matched women in the control group (80.3% vs. 49.4%, adjusted risk ratio 1.59 (1.31-1.93). The content of communication with young people also appears to have shifted from vague admonitions about the dangers of sex to concrete messages about reducing risks. The congruence between these findings and existing literature on parent-child sexual communication suggests that conceptual frameworks and programs from developed settings can be adapted effectively for resource-poor contexts.

It has been argued that women's economic vulnerability and dependence on men increases their vulnerability to HIV by constraining their ability to negotiate the conditions, including sexual abstinence, condom use and multiple partnerships, which shape their risk of infection. In the face of escalating infection rates among women, and particularly young women, many have pointed to the potential importance of economic empowerment strategies for HIV prevention responses. Global evidence suggests that the relationship between poverty and HIV risk is complex, and that poverty on its own cannot be viewed simplistically as a driver of the HIV epidemic. Rather, its role appears to be multidimensional and to interact with a range of other factors, including mobility, social and economic inequalities and social capital, which converge in a particularly potent way for young women living in southern Africa. To date, there have been few interventions that have explicitly attempted to combine economic empowerment with the goal of HIV prevention, and even fewer that have been rigorously evaluated. This paper explores how programmes such as microfinance, livelihood training and efforts to safeguard women's food security and access to property have begun to incorporate an HIV prevention focus. Although such circumscribed interventions, by themselves, are unlikely to lead to significant impacts on a national or regional scale, they are useful for testing cross-sectoral partnership models, generating practical lessons and providing a metaphor for what might be possible in promoting women's economic empowerment more broadly. Despite numerous calls to 'mainstream AIDS' in economic development, cross-sectoral responses have not been widely taken up by government or other stakeholders. We suggest potential reasons for limited progress to date and conclude by presenting programme and policy recommendations for further exploring and harnessing linkages between economic empowerment and HIV prevention in Southern Africa.

While much descriptive research has documented positive associations between social capital and a range of economic, social and health outcomes, there have been few intervention studies to assess whether social capital can be intentionally generated. We conducted an intervention in rural South Africa that combined group-based microfinance with participatory gender and HIV training in an attempt to catalyze changes in solidarity, reciprocity and social group membership as a means to reduce women's vulnerability to intimate partner violence and HIV. A cluster randomized trial was used to assess intervention effects among eight study villages. In this paper, we examined effects on structural and cognitive social capital among 845 participants and age and wealth matched women from households in comparison villages. This was supported by a diverse portfolio of qualitative research. After two years, adjusted effect estimates indicated higher levels of structural and cognitive social capital in the intervention group than the comparison group, although confidence intervals were wide. Qualitative research illustrated the ways in which economic and social gains enhanced participation in social groups, and the positive and negative dynamics that emerged within the program. There were numerous instances where individuals and village loan centres worked to address community concerns, both working through existing social networks, and through the establishment of new partnerships with local leadership structures, police, the health sector and NGOs. This is among the first experimental trials suggesting that social capital can be exogenously strengthened. The implications for community interventions in public health are further explored.

A retrospective cohort study of mortality rates and potential predictors of death was conducted in public-sector patients initiating highly active antiretroviral therapy (HAART) between October 2005 and September 2007 in a rural, under-resourced region of South Africa. The aims were to determine the relative contribution of death to cohort exit and the causes and predictors of mortality among HAART initiators. A community outreach programme traced non-attenders. Patients categorised as dying at home underwent a verbal autopsy (by interviewing family members) and case-file review, and those dying in hospital a case-file review, to determine the probable cause of death. At 24 months 1131 (83.6%) patients were retained on treatment in the programme, 124 (9.2%) had died, 63 (4.7%) had transferred out, and 35 (2.6%) were lost to follow-up. The most common causes of death were tuberculosis (44.3%) and diarrhoeal diseases (24.5%). Death was the major reason for cohort exit. As experience is gained with rural HAART programmes mortality rates may decrease. These results draw attention to the need for early HIV diagnosis, increased access to HAART services with earlier treatment initiation, and routine screening and aggressive management of opportunistic infections, particularly tuberculosis.

OBJECTIVE: To explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone. METHODS: Cross-sectional data were derived from three randomly selected matched clusters in rural South Africa: (i) four villages with 2-year exposure to the Intervention with Microfinance for AIDS and Gender Equity (IMAGE), a combined microfinance-health training intervention; (ii) four villages with 2-year exposure to microfinance services alone; and (iii) four control villages not targeted by any intervention. Adjusted risk ratios (aRRs) employing village-level summaries compared associations between groups in relation to indicators of economic well-being, empowerment, intimate partner violence (IPV) and HIV risk behaviour. The magnitude and consistency of aRRs allowed for an estimate of incremental effects. FINDINGS: A total of 1409 participants were enrolled, all female, with a median age of 45. After 2 years, both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group. However, only the IMAGE group demonstrated consistent associations across all domains with regard to women's empowerment, intimate partner violence and HIV risk behaviour. CONCLUSION: The addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits. Donor agencies should encourage intersectoral partnerships that can foster synergy and broaden the health and social effects of economic interventions such as microfinance.

Objectives: To investigate whether the prevalence of HIV infection among young people, and sexual behaviours associated with increased HIV risk, are differentially distributed between students and those not attending school or college. Design: A random population sample of unmarried young people (916 males, 1003 females) aged 14–25 years from rural South Africa in 2001. Methods: Data on school attendance and HIV risk characteristics came from structured face-to-face interviews. HIV serostatus was assessed by oral fluid ELISA. Logistic regression models specified HIV serostatus and high-risk behaviours as outcome variables. The primary exposure was school attendance. Models were adjusted for potential confounders. Results: HIV knowledge, communication about sex and HIV testing were similarly distributed among students and non-students. The lifetime number of partners was lower for students of both sexes (adjusted odds ratio (aOR) for more than three partners for men 0.67; 95% CI 0.44 to 1.00; aOR for more than two partners for women 0.69; 95% CI 0.46 to 1.04). Among young women, fewer students reported having partners more than three years older than themselves (aOR 0.58; 95% CI 0.37 to 0.92), having sex more than five times with a partner (aOR 0.57; 95% CI 0.37 to 0.87) and unprotected intercourse during the past year (aOR 0.60; 95% CI 0.40 to 0.91). Male students were less likely to be HIV positive than non-students (aOR 0.21; 95% CI 0.06 to 0.71). Conclusions: Attending school was associated with lower-risk sexual behaviours and, among young men, lower HIV prevalence. Secondary school attendance may influence the structure of sexual networks and reduce HIV risk. Maximising school attendance may reduce HIV transmission among young people.

The role of social capital in promoting health is now widely debated within international public health. In relation to HIV, the results of previous observational and cross-sectional studies have been mixed. In some settings it has been suggested that high levels of social capital and community cohesion might be protective and facilitate more effective collective responses to the epidemic. In others, group membership has been a risk factor for HIV infection. There have been few attempts to strengthen social capital, particularly in developing countries, and examine its effect on vulnerability to HIV. Employing data from an intervention study, we examined associations between social capital and HIV risk among 1063 14 to 35-year-old male and female residents of 750 poor households from 8 villages in rural Limpopo province, South Africa. We assessed cognitive social capital (CSC) and structural social capital (SSC) separately, and examined associations with numerous aspects of HIV-related psycho-social attributes, risk behavior, prevalence and incidence. Among males, after adjusting for potential confounders, residing in households with greater levels of CSC was linked to lower HIV prevalence and higher levels of condom use. Among females, similar patterns of relationships with CSC were observed. However, while greater SSC was associated with protective psychosocial attributes and risk behavior, it was also associated with higher rates of HIV infection. This work underscores the complex and nuanced relationship between social capital and HIV risk in a rural African context. We suggest that not all social capital is protective or health promotive, and that getting the balance right is critical to informing HIV prevention efforts.

There has been growing interest in the application of institutionalist perspectives in the health economics literature. This paper investigates the institutionalist notion of social value and its use in economic evaluation with particular reference to a program to address HIV/AIDS and gender violence in Southern Africa (IMAGE). Institutions are the rules that govern the conduct between individuals, groups and organisations. Their social value stems from their capacity to reduce the uncertainty in human interactions thereby both reducing transaction costs and, importantly, enabling the initiation and sustainability of various activities (instrumental value). Furthermore, institutions tend to be formed around certain ethical positions and as a consequence, act in binding future decision making to these positions (intrinsic value). Incorporating such notions of social value within a conventional welfare-based measure of benefit is problematic as institutional development is not necessarily consistent with individual utility. An institutionalist approach allows for these additional domains to be factored into economic evaluation. IMAGE is an intervention to reduce gender violence and HIV through microfinance, health education and community development, and involves significant initial investment in institution-building activities, notably through training activities with program staff and community members. The key to employing an institutionalist approach to the evaluation of IMAGE is in understanding the nature of those actions that can be seen as institution-building and determining: (1) the instrumental value of follow-up activities by appropriate amortisation of transaction costs over an horizon that reflects the economies gained from the intervention; and (2) the intrinsic value of any transformation in the community through a cost-consequences approach informed by an a priori conceptual model. This case study highlights how health sector interventions can effect institutional changes and how these are captured within a theory-based economic evaluation framework.

Summary Background HIV infection and intimate-partner violence share a common risk environment in much of southern Africa. The aim of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study was to assess a structural intervention that combined a microfinance programme with a gender and HIV training curriculum. Methods Villages in the rural Limpopo province of South Africa were pair-matched and randomly allocated to receive the intervention at study onset (intervention group, n=4) or 3 years later (comparison group, n=4). Loans were provided to poor women who enrolled in the intervention group. A participatory learning and action curriculum was integrated into loan meetings, which took place every 2 weeks. Both arms of the trial were divided into three groups: direct programme participants or matched controls (cohort one), randomly selected 14–35-year-old household co-residents (cohort two), and randomly selected community members (cohort three). Primary outcomes were experience of intimate-partner violence—either physical or sexual—in the past 12 months by a spouse or other sexual intimate (cohort one), unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months (cohorts two and three), and HIV incidence (cohort three). Analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT00242957. Findings In cohort one, experience of intimate-partner violence was reduced by 55% (adjusted risk ratio [aRR] 0·45, 95% CI 0·23–0·91; adjusted risk difference −7·3%, −16·2 to 1·5). The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two (aRR 1·02, 0·85–1·23), and there was no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner (0·89, 0·66–1·19) or HIV incidence (1·06, 0·66–1·69) in cohort three. Interpretation A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in programme participants. Social and economic development interventions have the potential to alter risk environments for HIV and intimate-partner violence in southern Africa.

Structural interventions addressing macro-social determinants of risk have been suggested as potentially important adjuncts to biomedical and behavioural interventions for the prevention of HIV and other diseases. A few interventions of this type have been evaluated using randomised controlled trials (RCTs), the most rigorous design to evaluate the effects of biomedical and behavioural interventions. The appropriateness of applying RCTs to structural interventions is however debated. This paper considers whether issues of ethics, feasibility and utility preclude the use of RCTs in evaluations of structural interventions for HIV prevention. We conclude there is nothing particular to this category of interventions prohibiting use of RCTs. However, we suggest that RCTs may prove unacceptable, unfeasible or not useful in certain circumstances, such as where an intervention brings important benefits other than HIV prevention (such as increased income); where leaders of clusters do not allow decisions about macro-social policies to be determined randomly; where the unit of social organization addressed by an intervention is so large that recruitment of adequate numbers of clusters is impossible; and where the period required to trial interventions extends beyond practical decision-making time-scales. In such cases, alternative evaluative designs must be assessed for their ability to provide evidence of intervention effectiveness.

Although social gradients in morbidity and mortality from scrofula rickets and scarlet fever were noticed in England as early as 1845 current understanding of the relationship between poverty and ill health is still evolving. A detailed examination of the social determinants of health is the current focus of a World Health Organization Commission and a global agenda that addresses the overlapping vulnerabilities of poverty social exclusion and health recently has been articulated in the United Nations Millennium Development Goals (MDG) framework. Sub-Saharan Africa remains the area of the world at greatest risk of failing to meet any MDG targets. Some experts suggest that conditions of extreme deprivation characterizing much of the region create "poverty traps" that limit access to proven interventions and constrain potential gains in employment income food shelter and education carrying dire immediate and longer-term health consequences. The interdependence of poverty health and development might seem obvious but cross-sectoral experience on how and where to intervene remains limited. (excerpt)

More than 60% of the world’s HIV-infected population lives in sub-Saharan Africa,1 and South Africa, with a national antenatal HIV prevalence of 30.2%,2 is host to one of the world’s worst HIV epidemics. The predominant mode of HIV infection throughout southern Africa is unprotected heterosexual intercourse.3 Prevention programs that target secondary transmission between those known to be HIV-positive and their sexual partners have recently gained favor4 but are still underdeveloped in generalized epidemic settings.3,5,6 Better understanding patterns of sexual behavior among individuals who know their HIV status remains central to informing these efforts. Studies from industrialized countries suggest that some HIV-infected individuals, even after learning of their positive status, continue to engage in risky sexual behavior.7–12 In developing countries, experience is limited, although similar patterns are emerging. Research from West Africa and Uganda suggests that patterns of high-risk activity are common among those with known and unknown HIV status.13–16 In KwaZulu/Natal, South Africa, nearly 50% of HIV-infected patients in a single clinical setting were sexually active and 30% of those reported having unprotected sex in the previous 3 months.17 Increasing access to antiretroviral therapy (ART) has magnified the importance of addressing risk-taking behavior among HIV-infected adults. Few people in low- and middle-income countries were on ART before 2001; however, by the end of 2005, an estimated 1.3 million were on treatment, with 190,000 individuals on treatment in South Africa alone.1 Although the clinical benefits of ART are well established,18 the impact of treatment on preventing secondary transmission is less well understood. Although less infectious, people on treatment live considerably longer, thereby increasing the duration of potential exposure. Mathematic models predict that although high levels of ART coverage could potentially reduce HIV incidence, its benefits could be overshadowed by simultaneous increases in risky sexual behavior.6,19,20 In industrialized countries, concerns have emerged regarding increased risk behavior possibly attributable to ART treatment optimism21–23 and improving health; such data on the impact of care and support programs on patterns of sexual behavior are limited in developing countries.24 Furthermore, there are few available data on how these behaviors may differ in rural versus urban settings. This research assessed sexual behavior among HIV-positive South Africa patients attending a rural clinic and an urban clinic. We explored the determinants of and factors associated with safe sexual behavior, highlighting implications for prevention programs to reduce secondary transmission that target those living with HIV.