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1.  Structure, (governance) and health: authors reply 
This is a reply to the paper entitled Structure, (governance) and health: an unsolicited response by Daniel D Reidpath and Pascale Allotey
doi:10.1186/1472-698X-7-1
PMCID: PMC1790906  PMID: 17257404
2.  Indigenous well-being in four countries: An application of the UNDP'S Human Development Index to Indigenous Peoples in Australia, Canada, New Zealand, and the United States 
Background
Canada, the United States, Australia, and New Zealand consistently place near the top of the United Nations Development Programme's Human Development Index (HDI) rankings, yet all have minority Indigenous populations with much poorer health and social conditions than non-Indigenous peoples. It is unclear just how the socioeconomic and health status of Indigenous peoples in these countries has changed in recent decades, and it remains generally unknown whether the overall conditions of Indigenous peoples are improving and whether the gaps between Indigenous peoples and other citizens have indeed narrowed. There is unsettling evidence that they may not have. It was the purpose of this study to determine how these gaps have narrowed or widened during the decade 1990 to 2000.
Methods
Census data and life expectancy estimates from government sources were used to adapt the Human Development Index (HDI) to examine how the broad social, economic, and health status of Indigenous populations in these countries have changed since 1990. Three indices – life expectancy, educational attainment, and income – were combined into a single HDI measure.
Results
Between 1990 and 2000, the HDI scores of Indigenous peoples in North America and New Zealand improved at a faster rate than the general populations, closing the gap in human development. In Australia, the HDI scores of Indigenous peoples decreased while the general populations improved, widening the gap in human development. While these countries are considered to have high human development according to the UNDP, the Indigenous populations that reside within them have only medium levels of human development.
Conclusion
The inconsistent progress in the health and well-being of Indigenous populations over time, and relative to non-Indigenous populations, points to the need for further efforts to improve the social, economic, and physical health of Indigenous peoples.
doi:10.1186/1472-698X-7-9
PMCID: PMC2238768  PMID: 18096029
3.  Sexual behaviors and their correlates among young people in Mauritius: a cross-sectional study 
Background
Little is known about the HIV/AIDS epidemic in the Indian Ocean region, including Mauritius. National records suggest a prevalence of HIV in Mauritius of < 1% in the general population, which is one of the lowest prevalence rates in southern Africa. However, HIV-positive cases have been increasing recently in Mauritius. We conducted a cross-sectional survey in January 2003 to assess the prevalence of HIVrelated sexual behaviors and their correlates among young people aged 15–24 years in Mauritius.
Methods
We identified 1200 participants using two-stage cluster sampling. Demographic, social, sexual, and knowledge of HIV/AIDS data were obtained in face-to-face interviews using a structured questionnaire administered by trained interviewers. The prevalence of sexual behaviors was described in relation to gender, and the correlates of ever having had sex and nonuse of condom at last sex were analyzed using logistic regression.
Results
In the target population, 30.9% of males and 9.7% of females reported a history of sexual intercourse. Of the currently sexually active participants, 50.6% of men and 71.2% of women did not use condoms at their last sexual encounter. Logistic regression revealed that work experience and marijuana use were significantly associated with men's sexual experience, whereas being out of school and drinking experience were significantly associated with women's sexual experience. For both men and women, being Christian and visiting nightclubs were associated with having ever had sexual intercourse (P < 0.05). In addition, not using a condom at the first sexual encounter and lack of exposure to a nongovernmental organization (NGO) dealing with HIV/AIDS were associated with the nonuse of condoms at the last sexual encounter (P < 0.05).
Conclusion
Young people in Mauritius are at risk of a future HIV epidemic because behaviors predisposing to HIV infection are prevalent among sexually experienced youth. A focused prevention program targeting young people should be reinforced as part of the National AIDS Control Program, taking into account the predictors of sexual behaviors identified here.
doi:10.1186/1472-698X-7-8
PMCID: PMC2147008  PMID: 17919330
4.  Chagas disease: an impediment in achieving the Millennium Development Goals in Latin America 
Background
Achieving sustainable economic and social growth through advances in health is crucial in Latin America within the framework of the United Nations Millennium Development Goals.
Discussion
Health-related Millennium Development Goals need to incorporate a multidimensional approach addressing the specific epidemiologic profile for each region of the globe. In this regard, addressing the cycle of destitution and suffering associated with infection with Trypanosoma cruzi, the causal agent of Chagas disease of American trypanosomiasis, will play a key role to enable the most impoverished populations in Latin America the opportunity to achieve their full potential. Most cases of Chagas disease occur among forgotten populations because these diseases persist exclusively in the poorest and the most marginalized communities in Latin America.
Summary
Addressing the cycle of destitution and suffering associated with T. cruzi infection will contribute to improve the health of the most impoverished populations in Latin America and will ultimately grant them with the opportunity to achieve their full economic potential.
doi:10.1186/1472-698X-7-7
PMCID: PMC2034380  PMID: 17725836
5.  Alcohol use and extramarital sex among men in Cameroon 
Background
The spread of HIV in sub-Saharan Africa is believed to be driven by unsafe sex, and identification of modifiable risk factors of the latter is needed for comprehensive HIV prevention programming in the region. Some previous studies suggest an association between alcohol abuse and unsafe sexual behaviour, such as multiple concurrent sexual partnerships and inconsistent condom use in sex with non-spousal non-cohabiting partners. However, most of these studies were conducted in developed countries and the few studies in Africa were conducted among well-defined social groups such as men attending beer halls or sexually transmitted infection clinics. We therefore examined the association between alcohol and extramarital sex (a sign of multiple concurrent sexual partnerships) among men in a population-based survey in Cameroon; a low-income country in sub-Saharan Africa with a high rate of alcohol abuse and a generalised HIV epidemic.
Methods
We analyzed data from 2678 formally married or cohabiting men aged 15 to 59 years, who participated in the 2004 Cameroon Demographic and Health Survey, using a multivariate regression model.
Results
A quarter of the men (25.8%) declared having taken alcohol before their last sexual intercourse and 21% indicated that the last sex was with a woman other than their wife or cohabiting partner. After controlling for possible confounding by other socio-demographic characteristics, alcohol use was significantly associated with having extramarital sex: adjusted odds ratio (OR) 1.70, 95% confidence intervals (CI) 1.40 to 2.05. Older age (30–44 years: OR 3.06, 95%CI 2.16–4.27 and 45–59 years: OR 4.10, 95%CI 2.16–4.27), higher education (OR 1.25, 95%CI 1.10–1.45), and wealth (OR 1.71, 95%CI 1.50–1.98) were also significantly associated with higher odds of having extramarital sex. The men were more likely to have used a condom in their last sex if it was extramarital (OR 10.50, 95%CI 8.10–13.66). Older age at first sex (16–19 years: OR 0.81, 95%CI 0.72–0.90 and > 19 years: OR 0.74, 95% CI 0.65–0.87) and being the head of a household (OR 0.17, 95%CI 0.14–0.22) significantly decreased the odds of having sex outside of marriage. Religion and place of residence (whether urban or rural) were not significantly associated with extramarital sex.
Conclusion
Alcohol use is associated with having multiple concurrent non-spousal sexual partnerships among married men in Cameroon. We cannot infer a causal relationship between alcohol abuse and unsafe sex from this cross-sectional study, as both alcohol use and unsafe sexual behaviour may have a common set of causal personal and social factors. However, given the consistency with results of studies in other settings and the biologic plausibility of the link between alcohol intake and unsafe sex, our findings underscore the need for integrating alcohol abuse and HIV prevention efforts in Cameroon and other African countries with similar social profiles.
doi:10.1186/1472-698X-7-6
PMCID: PMC1959248  PMID: 17683541
6.  Community views about routine HIV testing and antiretroviral treatment in Botswana: signs of progress from a cross sectional study 
Background
The Botswana government began providing free antiretroviral therapy (ART) in 2002 and in 2004 introduced routine HIV testing (RHT) in government health facilities, aiming to increase HIV testing and uptake of ART. There have been concerns that the RHT programme might be coercive, lead to increased partner violence, and drive people away from government health services.
Methods
We conducted a household survey of 1536 people in a stratified random sample of communities across Botswana, asking about use and experience of government health services, views about RHT, views about ART, and testing for HIV in the last 12 months. Focus groups further discussed issues about ART.
Results
Some 81% of respondents had visited a government clinic within the last 24 months. Of these 92% were satisfied with the service, 96% felt they were treated with respect and 90% were comfortable about confidentiality. Almost all respondents said they would choose a government clinic for treatment of AIDS.
Nearly one half (47%) thought they were at risk of HIV. Those who had experienced partner violence within the last 12 months were more likely to think themselves at risk. One half of those who had visited a government facility in the last 24 months were offered HIV tests, and nearly half were tested. A few (8%) of those who were not asked thought they were tested. Most people (79%) had heard of RHT and 94% were in favour of it. Over one half (55%) of the entire sample had been tested for HIV within the last 12 months, one half of these through RHT. Women were more likely to have been tested.
Nearly everyone (94%) had heard of ART and thought it could help AIDS. Focus groups identified problems of access to ART due to distance from treatment centres and long queues in the centres.
Conclusion
Public awareness and approval of RHT was very high. The high rate of RHT has contributed to the overall high rate of HIV testing. The government's programme to increase HIV testing and uptake of ART is apparently working well. However, turning the tide of the epidemic will also require further concerted efforts to reduce the rate of new HIV infections.
doi:10.1186/1472-698X-7-5
PMCID: PMC1903358  PMID: 17559678
7.  Acceptability of HIV counselling and testing among tuberculosis patients in south Ethiopia 
Background
To benefit from available care and treatment options, patients should first be counselled and tested for HIV. Our aim was to assess the acceptability of HIV testing among tuberculosis patients under routine care conditions in south Ethiopia.
Methods
We interviewed all adult tuberculosis patients who were treated at Arba Minch Hospital in Ethiopia between January and August 2005. After recording socio-demographic information and tuberculosis treatment history, we referred those patients who showed initial willingness to a counsellor for HIV counselling and testing. Rapid test methods were used following a pretest counselling session. The results were disclosed during a post-test counselling session. We used the logistic regression method to assess factors associated with willingness and acceptability.
Results
190 adult tuberculosis patients were treated at the hospital and all of them consented to take part in the study. Their median age was 30 years (range, 15–68) and 52% of them were males. 49 patients (26%) were previously tested including 29 (59%) HIV positive. Of 161 patients (excluding the 29 already positive), 118 (73%) were willing to be tested and 58% (68/118) of those willing accepted the test. The overall acceptability rate was 35% (56/161). Fourteen (20.6%) were HIV positive and women were more likely to be HIV infected (p = 0.029). Unemployment and self-perceived high risk of HIV infection were associated with initial willingness (OR [95%CI]:2.6 [1.3–5.5] vs. 5.0 [1.1–22.4], respectively). However, only being unemployed was associated with accepting the test (OR = 4.2; 95%CI = 1.9–9.3).
Conclusion
The low acceptability of HIV counselling and testing among tuberculosis patients poses a challenge to the scale-up of TB/HIV collaborative efforts. There is a need for alternative counselling and testing strategies.
doi:10.1186/1472-698X-7-4
PMCID: PMC1892034  PMID: 17537265
8.  A participatory intervention to improve the mental health of widows of injecting drug users in north-east India as a strategy for HIV prevention 
Background
Manipur and Nagaland, in the north-east of India, are classified as high prevalence states for HIV, and intravenous drug use is an important route of transmission. Most injecting drug users (IDUs) are men, an estimated 40% are married, and death rates have been high in the last five years, consequently the number of widows of IDUs has increased. Many of these widows and their children are HIV-infected and experience poor health, discrimination, and impoverishment; all factors likely to be compromising their mental health. People with poor mental health are more likely to engage in HIV risk behaviours. Mental health can be promoted by public health actions with vulnerable population groups.
Methods
We designed an intervention study to assess the feasibility and impact of a participatory action process to promote the mental health and well-being of widows of IDUs in Manipur and Nagaland, as a strategy for reducing the risk of engagement in HIV risk behaviours. This paper describes the background and rationale for the study, the intervention, and the study methods in detail.
Results
Pending analysis.
Conclusion
This intervention study will make a significant contribution to the emerging evidence that supports associations between mental health and HIV. The concept of promoting mental health among women who are vulnerable to HIV infection or already infected as a strategy for HIV prevention in a development setting is breaking new ground.
doi:10.1186/1472-698X-7-3
PMCID: PMC1857694  PMID: 17442121
9.  Slum health: Diseases of neglected populations 
Background
Urban slums, like refugee communities, comprise a social cluster that engenders a distinct set of health problems. With 1 billion people currently estimated to live in such communities, this neglected population has become a major reservoir for a wide spectrum of health conditions that the formal health sector must deal with.
Discussion
Unlike what occurs with refugee populations, the formal health sector becomes aware of the health problems of slum populations relatively late in the course of their illnesses. As such, the formal health sector inevitably deals with the severe and end-stage complications of these diseases at a substantially greater cost than what it costs to manage non-slum community populations. Because of the informal nature of slum settlements, and cultural, social, and behavioral factors unique to the slum populations, little is known about the spectrum, burden, and determinants of illnesses in these communities that give rise to these complications, especially of those diseases that are chronic but preventable. In this article, we discuss observations made in one slum community of 58,000 people in Salvador, the third largest city in Brazil, to highlight the existence of a spectrum and burden of chronic illnesses not likely to be detected by the formal sector health services until they result in complications or death. Lack of health-related data from slums could lead to inappropriate and unrealistic allocation of health care resources by the public and private providers. Similar misassumptions and misallocations are likely to exist in other nations with large urban slum populations.
Summary
Continued neglect of ever-expanding urban slum populations in the world could inevitably lead to greater expenditure and diversion of health care resources to the management of end-stage complications of diseases that are preventable. A new approach to health assessment and characterization of social-cluster determinants of health in urban slums is urgently needed.
doi:10.1186/1472-698X-7-2
PMCID: PMC1829399  PMID: 17343758

Results 1-9 (9)