This study was developed to evaluate differences in sexual behaviors and incident bacterial sexually transmitted diseases (STDs) between older HIV-infected individuals and their middle-aged and younger counterparts. We conducted a prospective cohort study of HIV-infected individuals ≥ 18 years who had completed an annual standard of care assessment. Analyses were performed to examine differences in sexual behaviors and incident STDs between age groups: (30%) were 18–35 years (younger), (46%) were 36–49 years (middle-aged) and (24%) were ≥ 50 years (older). 541 individuals completed the assessment. Older individuals were most likely to be male and Caucasian with longest time since HIV diagnosis, greatest receipt of HAART and highest rates of HIV RNA < 50 copies/mL (all p<0.001). Reports of recent sexual activity decreased with age, (56% younger vs. 43% middle-aged vs. 27% older) (p<0.001), the median number of sex partners was 1 (range 1–25) and 68% overall reported using condoms consistently. The number of sexual partners and consistency of condom use did not differ by age group. The STD incidence rate was 8% (gonorrhea [9], chlamydia [7] and syphilis [20]) and was higher among younger than older individuals (11% younger vs. 7% middle-aged vs. 3% older) (p=0.02). Our results demonstrated that reported sexual activity decreases with advancing age but did not improve consistency of condom use. Regardless of age, STDs continue to be identified and this finding reinforces the need for secondary prevention efforts among all individuals living with HIV/AIDS.

Disclosure of positive HIV status in Sub-Saharan Africa has been associated with safer sexual practices and better antiretroviral therapy (ART) adherence, but associations with psychosocial function are unclear. We examined patterns and psychosocial correlates of disclosure in a Zimbabwean community. Two hundred HIV positive women at different stages of initiating ART participated in a cross-sectional study examining actual disclosures, disclosure beliefs, perceived stigma, self-esteem, depression, and quality of life. Ninety-seven percent of the women disclosed to at least one person, 78% disclosed to their current husband/partner, with an average disclosure of 4.0 persons per woman. The majority (85–98%) of disclosures occurred in a positive manner and 72–95% of the individuals reacted positively. Factors significantly correlated with HIV disclosure to partners included being married, later age at menses, longer duration of HIV since diagnosis, being on ART, being more symptomatic at baseline, ever having used condoms, and greater number of partners in the last year. In multivariate analysis, being married and age at menses predicted disclosure to partners. Positive disclosure beliefs, but not the total number of disclosures, significantly correlated with lower perceived stigma (rho=0.44 for personalized subscale and rho=0.51 for public subscale, both p<0.0001), higher self-esteem (rho=0.15, p=0.04), and fewer depressive symptoms (rho=−0.14, p=0.05). In conclusion, disclosure of positive HIV status among Zimbabwean women is common and is frequently met with positive reactions. Moreover, positive disclosure beliefs correlate significantly with psychosocial measures, including lower perceived stigma, higher self-esteem, and lower depression.

Depression is common in people with cardiovascular diseases (CVD) and those with HIV, and is a risk factor for CVD-related mortality. However, little is known about whether HIV influences the relationship between depression and cardiovascular risk. 526 HIV-infected and 132 uninfected women from the Women’s Interagency HIV Study were included in an analysis of women who completed twice-yearly study visits over 9.5 years. CVD risk was calculated at baseline and approximately 9.5 years later using the Framingham Risk Score (FRS). Chronic depressive symptoms were defined as Center for Epidemiologic Studies Depression Scale scores of 16 or greater at ≥75% of study visits. Over the follow-up period, 22.8% of HIV-infected women and 15.9% of HIV-uninfected women had chronic depressive symptoms (p=0.08). Baseline FRS were similar between HIV infected and uninfected women (M=−5.70±SE=0.30 vs. M=−6.90± SE=0.60, p=0.07) as was follow-up FRS (M=0.82±SE=0.30 vs. M=−0.44± SE=0.73, p=0.11). Among HIV-infected and uninfected women, together, follow-up FRS were higher among women with chronic depressive symptoms as compared to those without (M=1.3± SE=0.6 vs. M=−0.3± SE=0.40, p<0.01), after adjusting for baseline FRS and other covariates. HIV status did not modify the relationship between chronic depressive symptoms and FRS. Chronic depressive symptoms accelerated CVD risk scores to a similar extent in both HIV infected and uninfected women. This implies that the diagnosis and treatment of depression may be an important consideration in CV risk reduction in the setting of HIV-infection. The determination of factors that mediate the depression/CVD relationship merits further study.

The objective of this study is to conduct a quantitative risk assessment of multiple factors influencing HIV/AIDS transmission through unprotected sexual practices among HIVseropositive men. A knowledgebase was developed by reviewing different published sources. The data was collected from different sources including Centers for Disease Control and Prevention (CDC), selected journals, and reports. The risk pathway scenario tree was developed based on a comprehensive review of published literature. The variables are organized into nine major parameter categories. Monte Carlo simulations for the quantitative risk assessment of HIV/AIDS transmission was executed with the software @Risk 4.0 (Palisade Corporation) Results show that the value for the likelihood of unprotected sex due to having less knowledge about HIV/AIDS and negative attitude towards condom use and safer sex ranged from 1.24 × 10−5 to 8.47 × 10−4 with the mean and standard deviation of 1.83 × 10−4 and 8.63 × 10−5 respectively. The likelihood of unprotected sex due to having greater anger-hostility, anxiety, less satisfied with aspects of life and greater depressive symptoms ranged from 2.76 × 10−9 to 5.34 × 10−7 with the mean and standard deviation of 5.23 × 10−8 and 3.58 × 10−8 respectively. The findings suggest that HIV/AIDS research and intervention programs must be focused on behavior, and the broader setting within which individual risky behaviors occur.

Youth who engage in early and premarital sex are at risk of HIV and sexually transmitted infections. Most prevention programs ignore the mediating influence of the threat and experience of violence on these outcomes. Using nationally representative data from Lesotho, Malawi, Zimbabwe, Kenya, Tanzania, and Uganda, multivariate analyses examined the association between individual and community-level tolerance of spouse abuse on the age and circumstances of sexual debut among female youth. The youth sample sizes ranged from a high of 5,007 in Malawi to a low of 3,050 in Lesotho. In the study countries, there were between 521 and 367 communities included in the analysis. Youth who approved of spouse abuse were more likely to have sexually debuted at each age. In Kenya, youth from communities with high female spouse abuse tolerance were more likely to have initiated sex at each age. In Malawi and Zimbabwe, youth from high tolerance communities were less likely to have sexually debuted at each age or to have had premarital sex; the same effect on premarital sex was found for men's tolerance in Kenya and Tanzania. Programs are needed to reduce violence risk and increase youth negotiating power and delayed sexual debut with the objective of reducing young people's risk of negative outcomes.

Findings to date indicate that it is feasible to deliver a brief behavioral risk reduction/medication adherence group intervention to HIV-infected IDUs in a community-based setting. HIV infection and substance abuse can result in neurocognitive impairment and this is directly relevant to intervention development because a significant number of people living with HIV/AIDS have a positive history of substance abuse and being able to successfully participate in behavioral interventions often requires a relatively high level of cognitive performance. The aim of the current study was to evaluate if changes in information, motivation and behavior skills with respect to medication adherence, sex- and drug-risk behavior outcomes from baseline to post-intervention is predicted by cognitive impairment following the brief 4-session Holistic Health for HIV intervention for HIV-infected Drug Users (3H+). Significant associations were found between change in motivation and certain neurocognitive performance domains. Findings suggest that it may be helpful to specifically tailor such behavioral interventions to accommodate cognitive impairment.

Knowing at antiretroviral therapy (ART) initiation which patients might be at greatest risk for failure to achieve viral suppression would enable providers to target patients most in need and tailor their care appropriately. This study involved multilevel modeling of data from a randomized controlled trial among outpatients in Seattle, WA, USA. The 224 participants initiating or switching ART at baseline were 24% female, 34% heterosexual, and 47% Caucasian. Of 24 baseline demographic and psychosocial patient-level variables modeled in separate generalized estimating equations, only employment predicted changes in HIV-1 RNA viral load or CD4 lymphocyte count over the course of the 9-month trial. Although the findings require replication, they suggest adherence support strategies should emphasize close monitoring and support for all patients initiating ART.

Objective

Geographic location may be related to the receipt of quality HIV healthcare services. Clinical outcomes and healthcare utilization were evaluated in rural, urban and peri-urban patients seen at high-volume U.S. urban-based HIV care sites.

Methods

Zip codes for 8,773 HIV patients followed in 2005 at 7 HIV Research Network sites were categorized as rural (population<10K), peri-urban (10K – 100K) and urban (>100K). Clinical and demographic characteristics, inpatient and outpatient (OP) utilization, AIDS defining illness rates, receipt of highly active antiretroviral therapy (HAART), opportunistic infection (OI) prophylaxis usage and virologic suppression were compared among patients, using Χ2 tests for categorical variables, t-tests for means, and logistic regression for HAART utilization.

Results

HIV-infected rural (n=170) and peri-urban (n=215) patients were less likely to be Black or Hispanic than urban HIV patients. Peri-urban subjects were more likely to report MSM as their HIV risk factor than rural or urban subjects. Age, gender, CD4 or HIV-RNA distribution, virologic suppression, HAART usage or OI prophylaxis did not differ by geographic location. In multivariate analysis, rural and peri-urban patients were less likely to have ≥4 annual outpatient visits than urban patients. Rural patients were less likely to receive HAART if they were Black. Overall, geographic location (as defined by home zip code) did not affect receipt of HAART or OI prophylaxis.

Conclusion

Although demographic and healthcare utilization differences were seen among rural, peri-urban, and urban HIV patients, most HIV outcomes and medication use were comparable across geographic areas. As with HIV care for urban-dwelling patients, areas for improvement for non-urban HIV patients include access to HAART among minorities and IDUs.

Based on combined methods, this study investigated substance use and HIV risk behaviors among kathoey sex workers (KSWs) in Bangkok, Thailand. The study found that only half of the KSW participants reported having been tested for HIV, and that except for one participant, all others had not seen health care providers in the past 12 months. About one third of the participants reported having engaged in unprotected anal sex with customers in the past 6 months. Almost all participants reported alcohol use, as well as having had sex with customers under the influence of alcohol. The prevalence of marijuana and ecstasy use in the past 12 months was high (32% and 36%, respectively); as was for ketamine (20%) and non-injecting methamphetamine (yaba) use (10%). A multiple regression analysis showed that the participants who were post-operative status, had used illicit drugs, or had been abused by their father and brothers were less likely to use condoms for anal sex with customers. Three quarters of the participants sent money to their families and 35% of the participants expressed their willingness to engage in unsafe sex when customers offer extra money. The qualitative interviews revealed that many identified as girl or kathoey in early age and had been exposed to transphobia and violence from father and brothers. Some reported support for gender transition from their mothers. More than half of the participants currently had difficulties in living as kathoey, such as challenges in job market and relationship with family members. Family obligation for sending money and the Buddhist concept of karma were discussed in relation to risk behaviors among KSWs. The study provided implications for facilitating HIV testing and developing future HIV prevention intervention programs for KSWs in Thailand.

The objectives of the project were 1) to determine the extent to which HIV-positive persons living in Michigan were aware of and understood Michigan's criminal HIV exposure law, 2) to examine whether awareness of the law was associated with seropositive status disclosure to prospective sex partners, and, 3) to examine whether awareness of the law was associated with potential negative effects of the law on persons living with HIV (PLWH) including heightened HIV-related stigma, perceived societal hostility toward PLWH, and perceived need to conceal one's HIV infection.

The study design was cross-sectional. A statewide sample of 384 PLWH in Michigan completed anonymous pen and paper surveys in 1 of 25 data collection sessions.

A majority of participants were aware of Michigan's HIV exposure law. Awareness of the law was not associated with increased seropositive status disclosure to all prospective sex partners, decreased HIV transmission risk behavior, or increased perceived responsibility for HIV transmission prevention. However, awareness of the law was significantly associated with disclosure to a greater proportion of sex partners prior to respondents’ first sexual interaction with that partner. Awareness of the law was not associated with increased HIV-related stigma, perceived societal hostility toward PLWH, or decreased comfort with seropositive status disclosure.

Evidence of an effect of Michigan's HIV exposure law on seropositive status disclosure was mixed. Further research is needed to examine the various forms of HIV exposure laws among diverse groups of persons living with or at increased risk of acquiring HIV.

Among HIV-negative men who have sex with men (MSM), any incident of unprotected anal intercourse (UAI) between casual partners is usually regarded as risky for HIV transmission. However, men are increasingly using knowledge of their casual partner’s HIV-status to reduce HIV risk during UAI (i.e., serosorting). Since familiarity between casual partners may lead to higher levels of UAI and serosorting, we examined how often men have UAI and practice serosorting with three types of casual partnerships that differ in their degree of familiarity.

We included 240 HIV-negative men of the Amsterdam Cohort Study among MSM. We distinguished three types of casual partnerships: one-night stand (‘met by chance and had sex only once’); multiple-time casual partner (‘met and had sex with several times’); and the ‘regular’ casual partner (‘sex buddy’). Serosorting was defined as UAI with an HIV-concordant partner. GEE analyses were used to examine the association between type of casual partnership and sexual risk behaviour.

Analyses revealed that men with a sex buddy were more likely to have UAI than men with a one-night stand (OR[95%CI] 2.39 [1.39–4.09]). However, men with a sex buddy were also more likely to practice serosorting than men with a one-night stand (OR[95%CI] 5.20 [1.20–22.52]).

Men with a sex buddy had more UAI but also reported more serosorting than men with a one-night stand. As a result, the proportion of UAI without serosorting is lower for men with a sex buddy, and therefore men might have less UAI at risk for HIV with this partner type. However, the protective value of serosorting with a sex buddy against HIV transmission needs to be further established. At this time, we suggest that a distinction between the one-night stand and the sex buddy should be incorporated in future studies as men behave significantly different with the two partner types.

Adherence is integral to improving and maintaining the health and quality of life of people living with HIV. Two-hundred HIV-positive adults recruited from teaching hospitals and non-governmental organizations (NGOs) in Rio de Janeiro City were assessed on socio-demographic factors, adherence to antiretroviral therapy (ART) and psychosocial factors hypothesized to be associated with ART. Predictors of non-adherence were analyzed using bivariate and multivariate analyses. Self-reported medication adherence was high (82% had adherence > 90%). Non-adherence was associated with personal factors (i.e. sexual orientation, self-efficacy), physical factors (i.e. loss of appetite) and interpersonal factors (i.e. doctor-patient relationship). Adherence in Brazil is as good, if not better, than that seen in the US and western Europe, which is noteworthy since the sample was derived predominantly from public healthcare settings. It is possible that the connection to NGOs in Rio de Janeiro City played a helpful role in achieving high levels of adherence in this sample of people living with HIV and AIDS. Recommendations, based on study findings, include enhancing and sustaining supportive services for NGOs, promoting patient self-efficacy and behavioral skills for adherence, increasing social network support and having healthcare providers directly address patients’ medication beliefs, attitudes and experience with side effects.

Studies of depression and hepatitis C virus (HCV) infection in HIV-infected patients have been contradictory and often not addressed key differences between HCV-infected and uninfected individuals including substance use. This cross-sectional observational study from the University of Washington HIV Cohort examined associations between HCV, symptoms, and depression in HIV-infected patients in routine clinical care. Patients completed instruments measuring depression, symptoms, and substance use. We generated depression severity scores and used linear regression to examine the relationship with HCV accounting for demographic and clinical characteristics. We conducted sensitivity analyses in which we removed depression somatic items (e.g. fatigue) from depression scores, and sensitivity analyses in which we also adjusted for non-depression somatic symptom items to examine the role of somatic and non-somatic symptoms in the association between depression and HCV. Of 764 HIV-infected patients, 160 (21%) were HCV-infected. In adjusted analysis, HCV-infected patients had worse depression severity (p=0.01) even after adjusting for differences in substance use. HCV remained associated with depression severity in secondary analyses that omitted the depression somatic PHQ-9 items (p = 0.01). However, when non-depression somatic symptoms were included as covariates in multivariate analyses, HCV was no longer associated with depression (p = 0.09).

Conclusions

We found a high prevalence and severity of depression among HIV-infected patients in routine care, particularly among those with HCV. The association between HCV and depression persisted even when depression somatic PHQ-9 items were omitted suggesting the association was not due to misclassification of HCV-related somatic symptoms like fatigue as depression. However, in models that also adjusted for non-depression somatic symptoms, the association disappeared highlighting the strong relationship between symptom burden and depression. Longitudinal studies are needed to assess the degree symptoms mediate the association between HCV and depression, and whether increased symptom burden is due in part to depression.

This study aimed to determine the level of antiretroviral (ART) adherence and factors associated with adherence among patients receiving free ART at one clinic in Tanzania. Adult patients were recruited into the cross-sectional study and completed a survey that included self-reported adherence over four days and over one month. Less than 95% adherence on either measure was considered “poor”. Factors associated with adherence in unadjusted analyses (α=0.10) were included in a logistic regression model. 340 patients participated in the study, and 5.9% (20/340) reported poor adherence. The final model found poor adherence associated with: being young (OR=4.03) or old (OR=6.68); having lower perceived quality of patient-provider interaction (OR=2.75); and ever missing a clinic appointment (OR=3.13). Results highlight good adherence, but suggest the importance of addressing: 1) age-specific challenges of adherence through counseling and support; 2) client-focused care and quality of patient-provider interaction; and 3) clinic appointment reminder systems.

The objective of this study was to design and assess measurement instruments that accurately measure the levels of stigma among individuals with a primarily collectivist culture. A cross-sectional study was conducted among middle school students and their parents or guardians in a rural area of China. Exploratory and confirmatory factor analyses were used to examine and determine the latent factors of the sub-scales of stigma respectively among students and their parents. Factor analyses identified three sub-scales: HIV public stigma (7 items), drug-use public stigma (9 items), and fear of HIV infection (7 items). There were no items with cross-loading onto multiple factors, supporting the distinctness of the constructs that these scales were meant to measure. Goodness of fit indices indicated that a three-factor solution fit the data at an acceptable level in the student sample (χ2/degree ratio = 1.98, CFI = 0.92, RMSEA = 0.055, SRMR = 0.057) and in the parent sample (χ2/degree ratio = 1.95, CFI = 0.91, RMSEA = 0.06, SRMR = 0.059). Reliability of the three scales was excellent (Cronbach’s alpha: 0.78–0.92 for students; 0.80–0.94 for parents or guardians) and stable across split samples and for the data as a whole. The scales are brief and suitable for use in developing countries where the collectivist culture prevails.

United States HIV treatment guidelines delineate preferred antiretroviral regimens (ART) and discourage use of subpotent, toxic, or adversely interacting combinations. It is unclear how often patients receive guideline concordant ART and what factors are correlated with receiving guideline-inconsistent ART. The objective of this study was to assess ART reported by participants of the Women's Interagency HIV Study (WIHS) and the Multicenter AIDS Cohort Study (MACS) to determine whether gender is associated with receipt of guideline-inconsistent ART. ART reported by WIHS and MACS participants from 1/1/2001 – 12/31/2007 was assessed for concordance with HIV guidelines. Logistic regression with generalized estimating equations estimated the crude and adjusted odds ratios and 95% confidence intervals associated with guideline-inconsistent regimens. Of 2937 participants, 463 subjects (WIHS n=263; MACS n=200) reported guideline-inconsistent ART during the study period. Age greater than 50 years (aOR = 2.22, 95% CI 1.14, 4.33) and HIV-1 RNA (aOR=1.17, 95% CI 1.08, 1.25) but not participant gender (aOR= 1.21, 95% CI 0.88, 1.65) were associated with guideline-inconsistent ART. The prevalence of guideline inconsistent ART peaked in 2004, however there was not a statistically significant increase or decrease over time. Guideline inconsistent ART was not related to gender, but was often used by older patients, and patients with higher viral loads. Monitoring ART quality based on concordance with expert guidelines could improve treatment outcomes in a substantial number of patients.

This paper explores how perceived stigma and layered stigma related to injection drug use and being HIV positive influence the decision to disclose one’s HIV status to family and community and experiences with stigma following disclosure among a population of HIV positive male injection drug users (IDUs) in Thai Nguyen, Vietnam. In qualitative interviews conducted between 2007 and 2008, 25 HIV positive male IDUs described layered stigma in their community but an absence of layered stigma within their families. These findings suggest the importance of community level HIV prevention interventions that counter stigma and support families caring for HIV positive relatives.

It is estimated that 5.6% of the Tanzanian population ages 15–49 are infected with HIV, but only 30% of adults have ever had an HIV test. Couples’ testing has proven to increase testing coverage and introduce HIV prevention, but barriers include access to testing services and unequal gender dynamics in relationships. Innovative approaches are needed to address barriers to couple’s testing and increase uptake of HIV testing. Using qualitative data collection methods, a formative study was conducted to assess the acceptability of a home-based couples counseling and testing (HBCCT) approach. Eligible study participants included married men and women, HIV-infected individuals, health care and home-based care providers, voluntary counseling and testing counselors, and community leaders. A total of 91 individuals participated in focus group discussions (FGDs) and in-depth interviews conducted between September 2009 and January 2010 in rural settings in Northern Tanzania. An HBCCT intervention appears to be broadly acceptable among participants. Benefits of HBCCT were identified in terms of access, confidentiality, and strengthening the relationship. Fears of negative consequences from knowing one’s HIV status, including stigma, blame, physical abuse, or divorce, remain a concern and a potential barrier to the successful provision of the intervention. Lessons for implementation highlighted the importance of appointments for home visits, building relationships of confidence and trust between counselors and clients, and assessing and responding to a couple’s readiness to undergo HIV testing. HBCCT should addresses HIV stigma, emphasize confidentiality, and improve communication skills for disclosure and decision-making among couples.

Pregnant women who fear or experience HIV-related stigma may not get care for their own health or medications to reduce perinatal transmission of HIV. This study examined factors associated with anticipating and experiencing HIV-related stigma among 1,777 pregnant women attending antenatal care clinics in rural Kenya. Women were interviewed at baseline, offered HIV testing and care, and a sub-set was re-interviewed at 4–8 weeks postpartum. Women who were older, had less education, whose husbands had other wives, and who perceived community discrimination against people with HIV had significantly greater adjusted odds of anticipating HIV stigma. Over half of the HIV-positive women interviewed postpartum reported having experienced stigma, much of which was self-stigma. Women experiencing minor depression, and those whose family knew of their HIV status had significantly greater adjusted odds of experiencing stigma. Lack of women’s empowerment, as well as depression, may be important risk factors for HIV-related stigma and discrimination.

International health experts agree that China is on the verge of an AIDS crisis. In response, the Chinese government initiated the “Four Frees and One Care” policy in 2003 to decrease economic barriers and increase access to antiretroviral therapies for people with HIV. However, long-term treatment success requires not only access, but high rates of medication adherence. This qualitative interview study with 29 persons receiving HIV care at Beijing’s Ditan Hospital identified barriers to and facilitators of medication adherence. The interviews were guided by an a priori conceptual model of adherence with four components: access, knowledge about medications, motivation, and proximal cues to action. Barriers to adherence were related to stigma and fear of discrimination; the medications themselves (including side effects and complicated dosing regimens); and other economic issues (i.e., costs of transportation, lab tests, and hospitalizations). Facilitators included participants’ strong will to live, use of electronic reminders, and family support. These results support the conceptual model and suggest that successful interventions must minimize stigma as it negatively affects all components of the model for adherence.

Many adults in the United States enter primary care late in the course of HIV infection, countering the clinical benefits of timely HIV services and missing opportunities for risk reduction. Our objective was to determine if perceived social support was associated with delay entering care after an HIV diagnosis. Two hundred sixteen patients receiving primary care at a large, university-based HIV outpatient clinic in North Carolina were included in the study. Dimensions of functional social support (emotional/informational, tangible, affectionate and positive social interaction) were quantified with a modified Medical Outcomes Study Social Support Scale and included in proportional hazard models to determine their effect on delays seeking care. The median delay between diagnosis and entry to primary care was 5.9 months. Levels of social support were high but only positive social interaction was moderately associated with delayed presentation in adjusted models. The effect of low perceived positive social interaction on the time to initiation of primary care differed by history of alcoholism (no history of alcoholism, hazard ratio (HR): 1.43, 95% confidence interval (CI): 0.88, 2.34; history of alcoholism, HR: 0.71, 95% CI: 0.40, 1.28). Ensuring timely access to HIV care remains a challenge in the southeastern United States. Affectionate, tangible, and emotional/informational social support were not associated with the time from diagnosis to care. The presence of positive social interaction may be an important factor influencing care seeking behavior after diagnosis.

There are limited data on quality of life (QOL) in untreated HIV-infected children who do not have severe HIV symptoms. Moreover, such data do not exist for Asian children. Poor QOL could be a factor in deciding if antiretroviral therapy (ART) should be initiated. Thai and Cambodian children (n=294), aged 1–11 years, naïve to ART, with mild to moderate HIV symptoms and CD4 15–24% were enrolled. Their caregivers completed the Pediatric AIDS Clinical Trials Group QOL questionnaire prior to ART commencement. Six QOL domains were assessed using transformed scores that ranged from 0 to 100. Higher QOL scores indicated better health. Mean age was 6.1 (SD 2.8) years, mean CD4 was 723 (SD 369) cells/mm3, 57% was female, and % CDC N:A:B was 2:63:35%. One-third knew their HIV diagnosis. Mean (SD) scores were 69.9 (17.6) for health perception, 64.5 (16.2) for physical resilience, 84.2 (15.6) for physical functioning, 77.9 (16.3) for psychosocial well-being, 74.7 (28.7) for social and role functioning, 90.0 (12.1) for health care utilization, and 87.4 (11.3) for symptoms domains. Children with CD4 counts above the 2008 World Health Organization (WHO) ART-initiation criteria (n=53) had higher scores in health perception and health care utilization than those with lower CD4 values. Younger children had poorer QOL than older children despite having similar mean CD4%. In conclusion, untreated Asian children without severe HIV symptoms had relatively low QOL scores compared to published reports in Western countries. Therapy initiation criteria by the WHO identified children with lower QOL scores to start ART; however, children who did not fit ART-initiation criteria and those who were younger also displayed poor QOL. QOL assessment should be considered in untreated children to inform decisions about when to initiate ART.

The present study reports sexual risk factors associated with HIV infection among men attending two sexually transmitted disease (STD) clinics in Pune, India and compares these behaviours between young and older men. Between April 1998 and May 2000, 1,872 STD patients were screened for HIV infection. Data on demographics, medical history and sexual behaviour were collected at baseline. The overall HIV prevalence was 22.2%. HIV risk was associated with being divorced or widowed, less educated, living away from the family, having multiple sexual partners and initiation of sex at an early age. The risk behaviours in younger men were different to older men. Younger men were more likely to report early age of initiation of sex, having friends, acquaintances or commercial sex workers as their regular partners, having premarital sex and bisexual orientation. Young men were more educated and reported condom use more frequently compared with the older men. Similar high HIV prevalence among younger and older men highlights the need for focused targeted interventions aimed at adolescents and young men and also appropriate interventions for older men to reduce the risk of HIV and STD acquisition.

The roll-out of accessible and affordable antiretroviral (ARV) drugs for people living with HIV in low-income countries is drastically changing the nature of HIV-related healthcare. The Zimbabwean Ministry of Health has renewed efforts to make antiretroviral treatment (ART) for HIV free and publically available across the country. This paper describes the findings from a multi-method qualitative study including interviews and a focus group with healthcare workers (mostly nurses), totalling 25 participants, and field notes from over 100 hours of ethnographic observation in three rural Zimbabwean health centres. These health centres began providing free ARV drugs to HIV-positive people over one year prior to the research period. We examined sources of motivation and frustration among nurses administering ART in these resource-poor health centres. The findings suggest that healthcare workers administering ART in challenging circumstances are adept at drawing strength from the dramatic physical and emotional recoveries made possible by ART and from their personal memories of the suffering caused by HIV/AIDS among close friends or family. However, healthcare staff grappled with extreme resource shortages, which led to exhaustion and frustration. Surprisingly, only one year into ART provision, healthcare workers did not reference the professional challenges of their HIV work before ART became available, suggesting that medical breakthroughs such as ART rapidly come to be seen as a standard element of nursing. Our findings provide a basis for optimism that medical breakthroughs such as ART can reinvigorate healthcare workers in the short term. However, we caution that the daily challenges of nursing in poor environments, especially administering an ongoing and resource-intensive regime such as ART, must be addressed to enable nurses to continue delivering high-quality ART in sub-Saharan Africa.

The Indian government provides free antiretroviral treatment (ART) for people living with HIV. To assist in developing policies and programs to advance equity in ART access, we explored barriers to ART access among kothis (men who have sex with men whose gender expression is feminine) and aravanis (transgender women, also known as hijras) living with HIV in Chennai. In the last quarter of 2007, we conducted six focus groups and four key-informant interviews. Data were explored using framework analysis to identify categories and derive themes. We identified barriers to ART access at the family/social-level, healthcare system-level, and individual-level; however we found these barriers to be highly interrelated. The primary individual-level barrier was integrally linked to the family/social and healthcare levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one’s HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgenders, and HIV stigma prevalent in families, the healthcare system, and the larger society. HIV stigma was present within kothi and aravani communities as well. Consequences of disclosure, including rejection by family, eviction from home, social isolation, loss of subsistence income, and maltreatment (although improving) within the healthcare system, presented powerful disincentives to accessing ART. Given the multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, healthcare providers, and the kothi and aravani communities. India needs a national policy and action plan to address barriers to ART access at family/social, healthcare system, and individual levels for aravanis, kothis, other subgroups of men who have sex with men and other marginalized groups.