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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.

The presence of Zika virus (ZIKV) in Indonesia has been recognized since the 1970s, but its transmission dynamics there have been poorly understood. To understand more fully the geographic distribution and burden of ZIKV infection, we performed retrospective serological tests on specimens collected from asymptomatic children age 5 to 9 years old living at 30 sites in 14 provinces. Of 870 serum samples tested, 9.2% were found to be positive for anti-ZIKV antibodies, as confirmed by plaque reduction neutralization assays. This was the same overall prevalence reported previously for 1- to 4-year-old children collected at the same sites at the same time. Together with geographic differences in seroprevalence between the age groups, these data suggest that, although ZIKV might be endemic in Indonesia, its occurrence has been focal and episodic.

Background: Child anaemia continues to represent a major public health challenge in lower-and-middle income countries. It has serious long-term consequences for child growth and development. In Indonesia, there was a 10% increase in the national prevalence of child anaemia between 2013 and 2018. Aim: This study aims to assess the prevalence of, and factors associated with anaemia among children aged one to three years in eight districts in Aceh Province, Indonesia. Methods: A cross-sectional study was conducted on a sample of 1148 mother-child dyads aged one to three years between November and December 2018. The sampling process involved a three-stage cluster sampling design using the probability proportionate to size methodology. Anaemia status was determined using haemoglobin level (Hb

Background In 2012, the UN Commission on Life Saving Commodities (UNCoLSC) articulated a series of recommendations to expand access to 13 life-saving reproductive, maternal, newborn and child health (RMNCH) commodities with the greatest potential to reduce preventable deaths. We conducted a five-year longitudinal assessment of progress towards achieving these recommendations among countries in sub-Saharan Africa and Southeast Asia. Methods Between 2013 and 2017, national reviews were undertaken at two time points among 14 countries with a high burden of preventable maternal-child deaths who were receiving support from a multi-UN agency RMNCH technical support and financing mechanism. Data were drawn from national health documentation (e.g. strategic plans, policies, guidelines); logistics management information systems; national household and health facility surveys; and interviews with governments and development partners. Results Over time, the percent of health facilities with stock availability showed a statistically significant increase of five percentage points from 69% to 74% (median). Recent training at health facility also displayed a significant increase of eight percentage points from 38% to 46% (median). National RMNCH coordination mechanisms, treatment guidelines, and national training curricula and job-aids were near fully redressed. However, countries continue to face persistent supply chain challenges including national stock-outs, tracking commodities throughout the supply chain, and strengthening medicine control laboratories. Conclusions While substantial progress has been made in improving access to life-saving commodities, including stock availability and workforce training at health facilities, additional efforts are required to improve regulatory efficiency, enhance commodity quality and safety, and reduce supply chain fragmentation.

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.

We conducted an evaluation of healthcare accessibility among patients taking antiretroviral treatment (ART) after they were ‘down-referred’ from hospital-based programmes to primary healthcare (PHC) centres in a rural South African setting. A cross-sectional design was used to study 109 PHC users compared to a randomly selected control group of 220 hospital-based users. Both groups were matched for a minimum duration on ART of six months. Using a comprehensive healthcare-accessibility framework, the participants were asked about availability, affordability and acceptability of their ART care in structured exit interviews that were linked to their ART-clinic record reviews. Unadjusted and adjusted regression models were used. Down-referral was associated with reduced transportation and meal costs (p ≤ 0.001) and travel time to an ART facility (p = 0.043). The down-referred users were less likely to complain of long queues (adjusted odds ratio [AOR] 0.06; 95% confidence interval [95% CI]: 0.01–0.29), were more likely to feel respected by health providers (AOR 4.43; 95% CI: 1.07–18.02), perceived lower stigma (AOR 0.25; 95% CI: 0.07–0.91), and showed a higher level of ART adherence (AOR 8.71; 95% CI: 1.16–65.22) than the hospital-based users. However, the down-referred users preferred to consult with doctors rather than nurses (AOR 3.43; 95% CI: 1.22–9.55) and they were more likely to visit private physicians (AOR 7.09; 95% CI: 3.86–13.04) and practice self-care (AOR 4.91; 95% CI: 2.37–10.17), resulting in increased health-related expenditure (p ≤ 0.001). Therefore, the results indicate both gains and losses in ART care for the patients, and suggest that down-referred patients save time and money, feel more respected, perceive lower stigma and show better adherence levels. However, unintended consequences include increased costs of using private physicians and self-care, highlighting the need to further promote the potential gains of down-referral interventions in resource-poor settings.Keywords: adherence, affordability, antiretroviral therapy, HIV/AIDS, primary healthcare, programme evaluation, resourcepoor settings, rural communitiesAfrican Journal of AIDS Research 2011, 10(4): 393–401

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: In light of increasing access to HAART in sub-Saharan Africa we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIVinfected South Africans in urban and rural primary care clinics. Design: Prospective observational cohort. Methods: We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003 to 2010 representing 19703 clinic visits. The primary outcomes were being sexually active unprotected sex and more than one sex partner and were evaluated at 6 monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors. Results: Among 6263 HIV-infected men and women over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up visits while receiving HAART were associated with a decrease in those reporting being sexually active [adjusted odds ratio: 0.86 (95% confidence interval: 0.78–0.95)]. Unprotected sex and having more than one sex partner were reduced at visits following HAART initiation compared to pre-HAART visits [adjusted odds ratio: 0.40 (95% confidence interval: 0.34–0.46) and adjusted odds ratio: 0.20 (95% confidence interval: 0.14-0.29) respectively]. Conclusion: Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.

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.

Aims: To utilize the Agincourt health and demographic surveillance system (HDSS) platform to assess the burden of pulmonary tuberculosis (PTB) in a rural South African sub-district. Methods: During 1999, data from three sources were combined to estimate disease prevalence amongst a non-migrant adult population: (1) passive case-finding (PCF) through hospital register data; (2) active case finding (ACF) using a systematic household assessment of chronic coughers; and (3) verbal autopsy (VA) data on cause of death. Results: Of 66,840 residents, 38,251 permanent adult residents were included in the analysis. A total of 102 cases of PTB were detected through PCF. ACF sweep detected 366 chronic coughers with 6 cases of confirmed PTB. Among 28 PTB deaths detected by VA, 13 (46%) were not previously identified by the health service. The total PTB prevalence was 157/100,000; 110/100,000 of prevalent cases were detected by PCF. Among undetected cases, 24/ 100,000 were identified through ACF, while 23/100,000 were detected by the VA process. Conclusions: Amongst prevalent PTB cases in the permanent adult population, 70% were detected by the health service; 15% of cases were undiagnosed in the community, while an equal proportion died of PTB prior to diagnosis. The latter groups contributed disproportionately to infectiousness in the community through prolonged duration of symptoms. As most of these cases presented to the health service on a number of occasions, strengthening early case detection should remain the cornerstone of TB control efforts. Strategies to strengthen the application of health & demographic surveillance systems to disease surveillance are discussed.

Summary. — We applied a mixed-methods approach to participatory wealth ranking (PWR) to identify the number of poor households in eight villages of rural South Africa and describe how poor they are. We generated a household wealth index on the basis of the ranking process and statements made on standard of living. Descriptions from PWR identified households as ‘‘very poor,’’ ‘‘poor, but a bit better off,’’ or ‘‘doing OK.’’ Of 9,671 households, 3,113 (32.2%) could be considered ‘‘very poor’’ or ‘‘poor.’’ The paper presents a novel approach to wealth ranking that generates a rich appraisal of poverty.

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 paper describes the process of implementing a low-cost 'real-time' vital registration and verbal autopsy system integrated within an electronic medical record within the Millennium Village cluster in rural Ghana. Using MGV-Net, an open source health information architecture built around the OpenMRS platform, a total of 2378 births were registered between January 2007 and June 2009. The percentage of births registered in the health facility under supervision of a skilled attendant increased substantially over the course of the project from median of 35% in 2007 to 64% in 2008 and 85% midway through 2009. Building additional clinics to reduce distance to facility and using the CHEWs to refer women for delivery in the clinics are possible explanations for the success in the vital registration. The integration of vital registration and verbal autopsies with the MGV-Net information system makes it possible for rapid assessment of effectiveness and provides important feedback to local providers and the Millennium Villages Project.

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.

Background The World Health Organization recommends isoniazid preventive therapy (IPT) for preventing tuberculosis in HIV-infected adults, although few countries have instituted this policy. Both IPT and highly active antiretroviral therapy (HAART) used separately result in reductions in tuberculosis risk. There is less information on the combined effect of IPT and HAART. We assessed the effect of IPT, HAART or both IPT and HAART on tuberculosis incidence in HIV-infected adults in South Africa.

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.