“Someone who is in this thing that I am suffering from”: The role of peers and other facilitators for task sharing substance use treatment in South African HIV care

South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a “siloed treatment experience”), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.     

Characteristics of substance abuse treatment programs providing services for HIV/AIDS, hepatitis C virus infection, and sexually transmitted infections: the National Drug Abuse Treatment Clinical Trials Network

Illicit drug users sustain the epidemics of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), hepatitis C (HCV), and sexually transmitted infections (STIs). Substance abuse treatment programs present a major intervention point in stemming these epidemics. As a part of the “Infections and Substance Abuse” study, established by the National Drug Abuse Treatment Clinical Trials Network, sponsored by National Institute on Drug Abuse, three surveys were developed; for treatment program administrators, for clinicians, and for state and District of Columbia health and substance abuse department administrators, capturing service availability, government mandates, funding, and other key elements related to the three infection groups. Treatment programs varied in corporate structure, source of revenue, patient census, and medical and non-medical staffing; medical services, counseling services, and staff education targeted HIV/AIDS more often than HCV or STIs. The results from this study have the potential to generate hypotheses for further health services research to inform public policy.     

Holistic Native network: integrated HIV/AIDS, substance abuse, and mental health services for Native Americans in San Francisco

The Holistic Native Network provides a model for integrated HIV/AIDS, substance abuse and mental health services in a cultural context. Funded in 2002 by a grant from the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) initiative, the Holistic Native Network is a collaboration of the Native American Health Center and Friendship House Association of American Indians, two community-based organizations with facilities in San Francisco and Oakland. Substance abuse and mental health services are integrated into primary HIV/AIDS medical care. San Francisco has the largest population of Native Americans with HIV/AIDS in the country. Since its inception, 45 Native Americans with HIV/AIDS have been enrolled in the Holistic Native Network. These clients were surveyed upon admission and at three months in treatment. The results indicated positive changes in quality of life. The success of this program lies in the way that culture and community is included at every stage of service provision. From outreach to case management to substance abuse and mental health services, the Holistic Native Network meets the spiritual, medical and psychosocial needs of HIV+ Native Americans.     

探索社区网格化管理下开展艾滋病知识的健康促进

目的 探索在社区网格化管理下开展艾滋病知识的健康促进的可行性.方法 在社区网格化管理下为居民建立健康档案过程中,为居民的六位一体的服务中,由社区医务人员传授艾滋病的相关知识一年,随机抽取1200名金花街居民调查艾滋病知识知晓率,与本社区2010年调查居民艾滋病相关知识知晓率的调查结果进行比较.结果 金花街社区居民艾滋病相关知识知晓率为84.39％,2010年居民艾滋病相关知识知晓率的平均正确率为65.39％,差异有统计学意义（P＜0.05）.结论 在社区网格化管理下开展艾滋病知识的健康促进的服务模式具有创新意义,适合在各社区服务中心开展.     

The changing epidemiology of prevalent diagnosed HIV infections in Taiwan, 1984-2005

By the end of 2005, there were 10,158 reported cases of HIV infections in Taiwan, of them, 2,403 had developed full blown AIDS, and 1,333 had died. It represented an average annual increase of 15% in HIV diagnoses before 2003. The most common route of transmission is through men having sex with men followed by heterosexual contact, while infections through injecting drug use (IDUs) remained low. However, the number of newly reported HIV infections has been rising sharply since 2003, mainly among IDUs. The consequences of this HIV/IDU epidemic include a rapid increase in female HIV/AIDS patients and a decreased mean age of HIV/AIDS cases. Only 2% of patients in the IDU group have been diagnosed with AIDS, suggesting that most IDU cases are in the early stage of HIV infections.HIV/AIDS patients are provided with free medical care by the government in Taiwan, including anti-retroviral treatment. The case fatality rate of AIDS cases declined gradually from 64% in 1996 to 8.9% in 2005. Patients in the IDU group seek medical care less frequently than patients in the sexual contact group. Statistics show that 61.4% of patients in the IDU group did not seek HIV-related medical care, significantly higher compared to the sexual contact group.The Taiwanese government implemented a trial “Harm Reduction Programme,” which involved a needle-syringe programme (NSP) and substitution treatment, in August 2005. After 1 year's pilot study, the HIV incidence in cities with NSP decreased from 13.9 to 13.3 per 100,000 persons compared to an incidence increase from 11.5 to 15.3 per 100,000 persons in cities without NSP. We scaled up the programme to cover the whole of Taiwan in July 2006 and are expecting to see the efficacy in the near future.     

Determinants of vct uptake among pregnant women attending two ANC clinics in Addis Ababa City: unmatched case control study

BACKGROUND: With HAART PMTCT interventions can reduce the risk of MTCT below 2%. However, low uptake of VCT is challenging effectiveness of PMTCT programs in sub-Saharan Africa. The aim of this study is to identify factors that determine VCT uptake among pregnant women attending ANC services. METHODS: A case-control study was conducted from August 30, 2005 - November 30, 2005 among pregnant women attending ANC PMTCT services at Teklehaimanot Health Center and Gandhi memorial Hospital in Addis Ababa City. Cases were pregnant mothers who accepted VCT (n=202) and controls were pregnant mothers who refused VCT (n=200). Data was collected by counselor nurses working at the respective services RESULTS: Factors that determine VCT acceptance were women's perceived ability to cope with a positive result (OR = 5.5, 95% CI 3.5-8.5, MHOR = 6.3, 95% CI 3.9-10.2); perceived favorable reaction of husband's after sharing positive test result (OR = 2.7 95% CI 1.4-5.1, MHOR = 2.9, 95% CI 1.4-5.7); perceived positive community response (OR = 2.2 95% CI 1.1-4.2, MHOR = 2.6 95% CI 1.3-5.2); perceived ability to get continuous medical care if found out to be positive (OR = 2.0, 95% CI 1.2-3.5, MHOR = 2.4, 95% CI 1.3-4.5). CONCLUSION: Women's perceived ability to cope with a positive result, accesses to medical care, fear of husband's negative reaction and the stigma and discrimination following a positive test result were key determinants of uptake of VCT. Therefore, increasing uptake of VCT/PMTCT services needs policy makers and service providers' effort to promote couple counseling, intensifying the fight against stigma and discrimination and ensuring continuous HIV/AIDS related medical care.     

Breaking the silence: an HIV-related educational intervention for medical students in Zimbabwe

PROBLEM: A culture of silence surrounding HIV is a major contributor to continued HIV transmission and poor care for people living with HIV/AIDS. AIM: To encourage medical leadership in addressing stigma and fear related to HIV at individual and community levels OBJECTIVE: To pilot a mini-course for final year medical students in Zimbabwe that demonstrates stigma-reduction knowledge and skills needed to communicate information about HIV to patients, to address ethical implications of testing versus not testing for HIV, to increase awareness of the medical and preventive benefits of knowing one's HIV status and showing people how to cope with the emotional burden of dealing with HIV everyday. DESIGN: Methods of proven effectiveness for training medical students in ethics and communication skills were used such as presentations by well respected role models and opinion leaders, role-playing, small group discussions, accompanied by materials indicating local resources, in three afternoon teaching sessions. SETTING: University of Zimbabwe College of Medicine. PARTICIPANTS: 60 medical students, six lecturers, two facilitators and a group of actors. MAIN OUTCOME MEASURES: Evaluation of the course by students showed appreciation of the course as measured on a scale of one to five for content and usefulness with requests for further inputs into the curriculum; model of mini-course that can be used by other medical schools in the southern Africa region and other areas of emerging HIV epidemics. CONCLUSIONS: A brief educational intervention can help medical students to cope with the extraordinary challenge of providing care in high HIV prevalence countries and may contribute towards better leadership in addressing HIV epidemics.     

Access to medical care and service utilization among injection drug users with HIV/AIDS

Access to care and optimal service utilization among 287 low income African American former and current drug injectors was examined. Results indicated suboptimal outpatient care, and no evidence of alternative use of hospital services. Participation in drug treatment and case management were associated with greater access to care and use of outpatient services, even after controlling for current drug use, gender, and insurance. AIDS and physical functioning limitation were associated with emergency room (ER) use and hospitalization. Participation in drug treatment and case management and an AIDS diagnosis were associated with optimal outpatient service use. Daily alcohol use was associated with ER as the usual facility for care. Integration of substance abuse treatment, case management, and medical services delivery may contribute to improved HIV care for this population.     

African-American injection drug users: tensions and barriers in HIV/AIDS prevention.

This exploratory study utilized a focus group methodology to explore tensions and barriers in HIV/AIDS prevention among African-American injection drug users. Participants discussed HIV infection risks, national/community HIV prevention effectiveness, prevention barriers, ideas on barrier removal, and the tensions which exist between users and the larger African-American community. Recognizing the inevitability of continued drug use for many injectors, participants requested basic harm-reduction supplies including condoms, needle exchange programs, additional drug user treatment services, and the use of culturally- and gender-matched peer-led prevention and treatment outreach. Preliminary recommendations are made for consideration in HIV/AIDS prevention among African-American IDUs.     

Use and cost of hospital and community service provision for children with HIV infection at an English HIV referral centre

OBJECTIVE: To describe the use of hospital and community services for children infected with HIV and estimate the cost per patient-year by stage of HIV infection during the era of antiretroviral monotherapy. DESIGN: Data on the use of hospital services were collected from case notes; the use of statutory and nonstatutory community services was recorded through diaries and interviews. Total cost estimates were calculated from unit costs from relevant hospital departments and community organisations. SETTING: Children managed at St. Mary's Hospital (London, England) between 1 January 1986 and 31 December 1994, some of whom used statutory and nonstatutory community services in South East England between 1 November 1994 and 31 May 1996. PATIENTS AND PARTICIPANTS: 118 children with positive HIV antibody status. MAIN OUTCOME MEASURES AND RESULTS: Mean inpatient days, outpatient visits, tests and procedures performed, drugs prescribed, community services used, associated unit costs and average cost estimates per patient-year by stage of HIV infection (1995/1996 values), and lifetime costs. Service provision during the study period was predominantly hospital-based. The use of services increased for different stages of HIV infection and increased with increasing severity of HIV infection. A shift from an inpatient-based to an outpatient-based service was seen between the periods 1986 to 1991 and 1992 to 1994. As symptoms evolved, children used more hospital inpatient services, with an accompanying shift in the use of community services from general services, such as schooling, to increased use of nurses, social care and home help. The estimated total cost of hospital and community care was 18,600 Pounds per symptomatic non-AIDS patient per year and 46,600 Pounds per AIDS patient per year. Similar estimates for children with indeterminate HIV infection and asymptomatic infection amounted to 8300 Pounds and 4800 Pounds per patient-year, respectively. Nondiscounted lifetime costs for hospital care amounted to 152,400 Pounds (44,300 Pounds to 266,800 Pounds) compared with discounted lifetime costs of 122,700 Pounds (42,000 Pounds to 182,200 Pounds); nondiscounted lifetime costs for community care amounted to 24,300 Pounds (7900 Pounds to 41,600 Pounds) compared with discounted lifetime costs of 21,000 Pounds (6800 Pounds to 32,000 Pounds). CONCLUSIONS: The continued emphasis on the use of hospital services may be due to the small number of children infected with HIV, most of whom lived in the London metropolitan area where specialist care was concentrated in a few centres. A shift from an inpatient- to an outpatient-based service was observed over time; the advent of the use of combination antiretroviral therapy in this population may further facilitate a shift in service provision and promote shared care between specialist centres, local hospital and community-based services.     

三级医院与社区卫生服务机构双向转诊的实践与体会

目的:了解三级医院与社区卫生服务机构双向转诊中存在的问题并探讨其解决方法。方法:选取2012年1月—2012年6月山西医科大学第二医院与其对口支援的社区卫生服务机构双向转诊的患者(上转241例,下转78例)为研究对象,通过问卷调查了解双向转诊中存在的主要问题。双向转诊工作由山西医科大学第二医院的社区卫生服务指导中心负责。结果:患者对双向转诊的总体满意度得分为(57.91±9.53)分,总体满意度水平不高。上转患者的满意度得分、对社区医务人员技术水平的认可度高于下转患者(P<0.01);但下转患者对药物和医保使用便利情况的得分高于上转患者(P<0.01),差异有统计学意义。上、下转诊患者对三级医院的技术水平、社区医疗环境的认可度差异无统计学意义(P>0.05)。结论:三级医院与社区卫生服务机构双向转诊呈现上转容易下转难的现象,主要与双向转诊制度不健全、患者对社区卫生服务机构的医疗技术水平认可度低、医保和药物的区域性限制等因素有关。因此,健全相关政策法规、完善社区卫生指导中心的双向转诊职能、建立三级医院与社区卫生服务机构良性互动机制是落实双向转诊的关键。     

HIV risk reduction and service delivery strategies in criminal justice settings

Because of the HIV risk behaviors of substance abusers, particularly injection drug users and those who exchange sex for drugs, and the large numbers who are already infected with HIV or showing symptoms of AIDS, significant service delivery issues are associated with their criminal justice processing. Many strategies have been implemented in correctional settings in an effort to prevent and control the transmission of HIV. A number of these are for the purpose of lowering transmission risk in institutions, whereas others have been structured for the sake of offering prevention/intervention to inmates before they return to the free community. As such, prisons and jails represent opportune settings for HIV prevention and education. The most common HIV control/prevention/education strategies include mandatory testing of inmates for HIV, segregating infected inmates from the general prison population, establishing special health care units for HIV positive and AIDS symptomatic inmates, offering HIV prevention and risk reduction programs, and granting medical parole for the terminally ill. Because drug abuse treatment results in substantial declines in the use of heroin, cocaine, and other drugs, treatment per se can play a significant role in reducing the spread of HIV and AIDS among those coming to the attention of the criminal justice system. Most promising are continuous and integrated treatment services that are tied to the stages of correctional supervision: primary treatment while incarcerated; secondary treatment while on work release, halfway house or community supervision; and, tertiary treatment in ongoing aftercare.     

Illicit drug use among Bangladeshi women living in the United Kingdom: An exploratory qualitative study of a hidden population in East London

This explorative study focused on Bangladeshi women using illicit drugs in the London Borough of Tower Hamlets, which has a large Bangladeshi population. The study was designed to: examine Bengali women's perceptions of their drug use and perception of treatment services; identify the cultural determinants of service utilization; examine the concept of izzat (honour) and its role in contributing to the secrecy surrounding Bengali women's drug use; examine the pressures that have contributed to Bengali women accessing drug treatment services in Tower Hamlets; and examine barriers to the utilization of drug treatment services.

 Eight Bengali female drug users were recruited via two treatment settings and one by snowballing methods and data gathering was through qualitative discourse.

 The findings revealed that Bengali female drug users constitute a hidden population that is engaging in high-risk behaviours, especially unsafe sex. Cultural constructs, such as shame about drug use, antipathy towards injecting and stigmatization of drug use in the community are all present in this group. Gender role expectations are particularly pronounced for this group and they face greater gender discrimination from within their community in respect of substance use and misuse than their male counterparts. They experience profound barriers to treatment, which prevent them from accessing services at an earlier stage in their drug use. Their presentation to drug services frequently involves a coercive element whether from family members or social services.

 Service provision should include targeted hepatitis- and HIV-prevention programmes.     

昭通市艾滋病流行现状与防治策略

目的了解昭通市艾滋病流行特征,为制定有效的防治策略提供依据。方法回顾性分析昭通市1996～2010年艾滋病疫情、监测和流行病学资料。结果截至2010年12月底,昭通市累计报告HIV/AIDS共计1619例,其中AIDS患者309例,死亡报告186例;传播途径的构成中性传播占39.87%,注射吸毒39.57%,母婴传播1.09%,义务献血人群0.42%,不详19.06%;外出流动人口感染者占总数的44.09%。结论传播途径以性传播为首,艾滋病流行由高危人群向普通人群扩散,感染者以外出人群为主,提高外出流动人口对艾滋病的防护意识,切实加强外出流动人口高危行为干预措施是当前昭通市防治艾滋病主要策略。     

Knowledge and stigma regarding methadone maintenance treatment among personnel of methadone maintenance treatment and non-methadone maintenance treatment addiction facilities in Israel

Stigma attached to methadone maintenance treatment is very common. The objective of the current article is to evaluate the presence of stigma and its relation to the extent of knowledge about methadone maintenance treatment. The authors conducted a survey among methadone maintenance treatment and non-methadone maintenance treatment addiction therapists from different treatment centers in Israel, including methadone maintenance treatment clinics (Ministry of Health) and non-methadone maintenance treatment addiction facilities (Ministry of Social Services), using an anonymous questionnaire about methadone maintenance treatment stigma and knowledge. There were 63 therapists from methadone maintenance treatment clinics (63%) and 46 therapists from the social services department (SSD) non-methadone maintenance treatment addiction facilities (9.2%) who responded. Methadone maintenance treatment versus social services department personnel were older (42.7 ± 12.8 versus 37.5 ± 8.2 years; p = 0.03), with fewer females (48 versus 75%; p = 0.006), and 50% were social workers compared to 100% social workers in the SSD group (p < 0.0005). Stigma score was lower among methadone maintenance treatment personnel compared to the social services department personnel (3 ± 2.5 versus 5.0 ± 3.5; p = 0.0001), while the knowledge score about methadone maintenance treatment was higher among the methadone maintenance treatment personnel (10.3 ± 2.9 versus 7.7 ± 2.8; p < 0.0005). The difference in both the stigma and knowledge scores remained significant after controlling for age, gender, and profession. There was a negative correlation between the stigma and knowledge scores among both the methadone maintenance treatment (R = –0.5, p < 0.0005) and the social services department personnel (R = –0.33, p = 0.03). These results revealed a significant correlation between the presence of stigma and the extent of education and knowledge about methadone maintenance treatment, with ignorance and stigma against methadone maintenance treatment being more pronounced among social services department personnel. An educational intervention, especially among social services department personnel, may benefit people who use opioids and improve the overall quality of treatment for opioid addiction in Israel.     

AFRICAN-AMERICAN INJECTION DRUG USERS: TENSIONS AND BARRIERS IN HIV/AIDS PREVENTION

This exploratory study utilized a focus group methodology to explore tensions and barriers in HIV/AIDS prevention among African-American injection drug users. Participants discussed HIV infection risks, national/community HIV prevention effectiveness, prevention barriers, ideas on barrier removal, and the tensions which exist between users and the larger African-American community. Recognizing the inevitability of continued drug use for many injectors, participants requested basic harm-reduction supplies including condoms, needle exchange programs, additional drug user treatment services, and the use of culturally- and gender-matched peer-led prevention and treatment outreach. Preliminary recommendations are made for consideration in HIV/AIDS prevention among African-American IDUs. [Translations are provided in the International Abstracts Section of this issue.]     

Assessment of quality of post abortion care in government hospitals in Addis Ababa, Ethiopia

BACKGROUND: Unsafe abortion is the leading cause of maternal death in Ethiopia. It is also known to cause several acute and long-term complications leading to disabilities. In countries like Ethiopia where there is no access to safe abortion, improvement of the available postabortion care services is an important strategy. OBJECTIVES: The aim of the study is to assess the quality of health services with respect to postabortion care in hospitals in Addis Ababa, Ethiopia. METHODS: A cross sectional survey on quality of postabortion care was conducted among 422 postabortion patients attending four hospitals in Addis Ababa. Additionally, 42 service providers involved in providing postabortion care services were interviewed. Direct service delivery observation and inventory of equipment and supplies were also conducted. The data were analyzed using Statistical Package for Social Sciences. RESULTS: Interaction between service providers and patients was found to be satisfactory whereas information provision on important aspects of care such as danger signs and follow-up needs were very limited. Only about 20% and 3% received family planning counseling and contraceptive methods respectively. Other reproductive health related issues such as STIs and HIV/AIDS were rarely raised by the service providers during caring for the patients. Overall 92.3% of the patients responded that they were satisfied with the services they have received. CONCLUSION: The study has shown several missed opportunities and indicated important areas for future service delivery improvement.     

Efficacy evidences in prevention of HIV infection in developing countries. A critical appraisal from population-based studies

For generalised HIV/AIDS sub-Saharan African epidemics emphasis has been placed on the three established pillars of HIV prevention: condom promotion and distribution, Voluntary Counselling and Testing (VCT) and treatment of other sexually transmitted infections (STIs). Experiences in several countries support the positive results of Ugandan prevention politics called Abstinence, Be faithful, Condom (ABC), based on Primary Behaviour Change (PBC). Polemics tending to label this approach as “confessional based” have been recently intensified after Pope Benedict XVI recalled how the sole use of condoms cannot be considered the solution for HIV/AIDS in Africa. An honest and scientific approach to the dramatic reality of HIV/AIDS in Africa may yet require a reconsideration of the Western positions towards HIV prevention, accepting the potential challenge of a multifaceted strategy that uses all valid approaches, with particular regard to PBC: the elusive goal of vaccine, the simplistic trust in condoms, or acritical enthusiasm in drugs (either as therapy, postexposure or preventive treatment), mathematical modelling. All these are pieces of a complex puzzle. Synergy between treatment and prevention needs to be implemented in a realistic way, never forgetting that behaviour change is a process, not an event, involving human freedom and will. The need of a really participating community, with a prevention coming from below to the top and not from external over-imposing criteria, is also mandatory.