Refusal Bias in the Estimation of HIV Prevalence

In 2007, UNAIDS corrected estimates of global HIV prevalence downward from 40 million to 33 million based on a methodological shift from sentinel surveillance to population-based surveys. Since then, population-based surveys are considered the gold standard for estimating HIV prevalence. However, prevalence rates based on representative surveys may be biased because of nonresponse. This article investigates one potential source of nonresponse bias: refusal to participate in the HIV test. We use the identity of randomly assigned interviewers to identify the participation effect and estimate HIV prevalence rates corrected for unobservable characteristics with a Heckman selection model. The analysis is based on a survey of 1,992 individuals in urban Namibia, which included an HIV test. We find that the bias resulting from refusal is not significant for the overall sample. However, a detailed analysis using kernel density estimates shows that the bias is substantial for the younger and the poorer population. Nonparticipants in these subsamples are estimated to be three times more likely to be HIV-positive than participants. The difference is particularly pronounced for women. Prevalence rates that ignore this selection effect may be seriously biased for specific target groups, leading to misallocation of resources for prevention and treatment.     

Internalized Homophobia,HIV Knowledge,and HIV/AIDS Personal Responsibility Beliefs: Correlates of HIV/AIDS Discrimination among MSM in the Context of Institutionalized Stigma

ABSTRACT

There exists a paucity of research on the psychosocial risk factors of HIV/AIDS among men who have sex with men (MSM) in settings where they are stigmatized or face prosecution. The present study investigates discrimination against people living with HIV (PLHIV), internalized homophobia, HIV/AIDS personal responsibility beliefs and HIV knowledge in a purposive sample of 106 self-identified MSM obtained through a web-based survey disseminated by two voluntary welfare organizations. Results indicate that internalized homophobia is positively associated with discrimination against PLHIV. Internalized homophobia also substantially mediates the effect of HIV/AIDS personal responsibility beliefs on discrimination against PLHIV, highlighting the confounded nature of HIV/AIDS and homosexual stigma in a setting where stigma is deep-rooted and institutionalized. Internalized homophobia may thus serve as a barrier to the effectiveness of HIV prevention efforts among MSM in Singapore.     

Ministry of Health Maps Out Goals for Prevention of Mother-to-Child Transmission

In a recently circulated document calledImplementation Plan (Trial) for Prevention ofMother-to-Child HIV Transmission, the Ministry ofHealth vowed to step up efforts to cut off mother-to-child transmission and improve maternal and childhealth.Specifically, the ministry seeks to make voluntarycounseling and testing available to 90% of pregnantwomen and new mothers, as well as other groupswho receive pre-marital medical care; providepreventive services to HIV-infected pregnant…     

PrEP Whores and HIV Prevention: The Queer Communication of HIV Pre-Exposure Prophylaxis (PrEP)

ABSTRACT

HIV pre-exposure prophylaxis (PrEP) has been introduced as another biomedical tool in HIV prevention. Whereas other such tools—including post-exposure prophylaxis (PEP) and interruption of perinatal transmission—have been embraced by those impacted by HIV, PrEP has been met with more conflict, especially within the gay community and HIV organizations. The “PrEP whore” has come to designate the social value and personal practices of those taking PrEP. This study examines the “PrEP whore” discourse by using queer theory and quare theory. Within these theoretical vantage points, the study explicates four discursive areas: slut shaming, dirty/clean binaries, mourning the loss of condoms, and reclaiming the inner whore. The study illuminates possible discursive strategies that lie outside of the domains of public health and within the individual and community.     

HIV/AIDS and Urbanization

It is well known that levels of HIV prevalence tend to be appreciably higher inurban areas. This article considers the reasons for this and shows that within world regions that are relatively homogeneous with respect to their experience of HIV/AIDS, variation in the level of urbanization corresponds to about one‐third of variation in estimated HIV prevalence. Furthermore, for populations in the world's worst‐affected area—eastern and southern Africa—there are signs that, partly by differentially raising urban death rates and depressing urban birth rates, HIV/AIDS is slowing the pace of urbanization. Finally, in countries with very high levels of HIV infection and relatively low birth rates, such as in South Africa, the urban sector will soon constitute a “demographic sink”—with death rates exceeding birth rates.     

Part 1: HIV as'the line in the sand'

There is a growing rift between HIV-positive and HIV-negative gay men, which finds expression in social, economic, structural and political divisiveness that, if not resolved, may 'kill' the "gay liberation movement." While disasters generally tend to create organizational solidarity, the AIDS crisis has operated in reverse, spawning a variety of competitive AIDS service organizations, alienating seropositive gays from the mainstream gay community, and in turn disenfranchising seronegative gay men as human and financial resources are redirected toward persons living with HIV and AIDS. Serostatus has become a social marker of societal status, operating in a bimodal discriminatory manner. Seronegative gay men experience discrimination from within the gay community as funding for and services to this sector diminish. Seropositive gay men (and the organizations that provide for some of their needs) have culturally, economically and socially dismissed the socio/psychological needs of seronegative gay men (survivor guilt, safer sex education, etc.) in favour of providing social and resource-based services to seropositive gay men. As the disparities in service and advocacy increase, the social distance between the gay movement and the AIDS movement correspondingly increases. If this trend continues, the social gap will serve further to push HIV-positive and HIV-negative gay men into polarized camps, resulting in a wider separation of the gay movement and the AIDS movement. The stigmatization of HIV-positive people will subsequently increase both within and outside the gay movement, and any ability to present a unified Gay Liberation front will correspondingly diminish. Additionally, the emergent notion within and without the gay communities that to be gay is to be HIV-positive will solidify. This will (a) further stigmatize all gay men in the eyes of the non-gay population, and (b) exacerbate the rift between HIV-positive and HIV-negative gay men within the gay community, reversing the stigma of HIV such that to be HIV-negative will be a marker of non-gay identity. In short, seropositivity will become the defining element of gayness.     

Late marriage and the HIV epidemic in sub-Saharan Africa

The causes of large variation in the sizes of HIV epidemics among countries in sub-Saharan Africa are not well understood. Here we assess the potential roles of late age at marriage and a long period of premarital sexual activity as population risk factors, using ecological data from 33 sub-Saharan African countries and with individual-level data from Demographic and Health Surveys (DHS) in Kenya and Ghana in 2003. The ecological analysis finds a significant positive correlation between HIV prevalence and median age at first marriage, and between HIV prevalence and interval between first sexual intercourse and first marriage. The individual-level analysis shows that HIV infection per year of exposure is higher before than after first marriage. These findings support the hypothesis of a link between a high average age at marriage and a long period of premarital intercourse during which partner changes are relatively common and facilitate the spread of HIV.     

HIV/AIDS and Cross-National Convergence in Life Expectancy

This article analyzes the effect of HIV/AIDS on the cross-national convergence in life expectancy as well as infant and child survival rates by comparing three scenarios. One is based on historical and future best-guess estimated values given the existence of the epidemic. The second scenario assumes that the effect of the epidemic is much worse than expected. The final scenario is based on hypothetical values derived from estimations where the mortality caused by the epidemic is removed. For life expectancy, convergence becomes stalled in the late 1980s (without weighting by country population size) or 1990s (with weighting). Convergence in infant and child survival rates does not become stalled, but slows down. These results are mainly attributable to the epidemic since all signs of stalled convergence or even divergence disappear in the “No AIDS scenario.” Given the existence of the epidemic, however, the reduced degree of inequality in life expectancy attained by 1985 is only expected to be achieved again by 2015 at the earliest. If the epidemic turns out much worse than expected, divergence could continue to 2050. No divergence is to be expected in infant and child survival rates in any of the scenarios.     

Exploration of Safe Mobility and HIV Prevention Model in Northern China

正The former National Population and Family Planning Commission implemented the United Nations Development Programme(UNDP)regional project'Safe mobility and HIV Prevention in northern China'(the Project)in 2005-2011.This article summaries the achievements of the project and provides reference on HIV prevention intervention targeting     

The Impact of HIV/AIDS on Adult Mortality in Zimbabwe

In June 2000, an estimated 25 percent of adults in Zimbabwe were living with HIV/AIDS. Statistical data on the impact of the epidemic, though problematic in many ways, are better for Zimbabwe than for many other countries in sub‐Saharan Africa. This analysis presents estimates of adult mortality in Zimbabwe based on multiple sources, including registered deaths adjusted for incomplete reporting, estimated at approximately 50 percent. Comparison of estimates from different data sources shows that they are subject to substantial errors. At the same time, the estimates leave no doubt that adult mortality risks in Zimbabwe more than doubled between 1982 and 1997. The evidence that this rise is due to AIDS deaths is circumstantial, but very strong; there is no credible competing explanation.     

中国老年艾滋病的流行状况分析

艾滋病在中国的迅速流行已是不争的事实,但是人们普遍认为“艾滋病是年轻人的病”。调查资料显示,50岁及以上的老年艾滋病病毒感染者报告人数已达到全国感染者的1/10,并呈快速增长趋势。老年感染人群的主要感染渠道以既往有偿献血感染为主。老年艾滋病病毒(HIV)感染者和艾滋病(AIDS)病人增多无论对家庭还是对社会均产生严重的后果,在艾滋病预防和控制战役中,老年是一个不可忽略的人群,应引起高度重视。     

Health Selection,Migration, and HIV Infection in Malawi

Despite its importance in studies of migrant health, selectivity of migrants—also known as migration health selection—has seldom been examined in sub-Saharan Africa (SSA). This neglect is problematic because several features of the context in which migration occurs in SSA—very high levels of HIV, in particular—differ from contextual features in regions that have been studied more thoroughly. To address this important gap, we use longitudinal panel data from Malawi to examine whether migrants differ from nonmigrants in pre-migration health, assessed via SF-12 measures of mental and physical health. In addition to overall health selection, we focus on three more-specific factors that may affect the relationship between migration and health: (1) whether migration health selection differs by destination (rural-rural, rural-town, and rural-urban), (2) whether HIV infection moderates the relationship between migration and health, and (3) whether circular migrants differ in pre-migration health status. We find evidence of the healthy migrant phenomenon in Malawi, where physically healthier individuals are more likely to move. This relationship varies by migration destination, with healthier rural migrants moving to urban and other rural areas. We also find interactions between HIV-infected status and health: HIV-infected women moving to cities are physically healthier than their nonmigrant counterparts.     

Migration,Marital Change,and HIV Infection in Malawi

Research on the relationship between migration and HIV infection in sub-Saharan Africa often suggests that migrants are at higher risk of HIV infection because they are more likely to engage in HIV risk behaviors than nonmigrants, and they tend to move to areas with a relatively higher HIV prevalence. Although migration may be a risk factor for HIV infection, I instead focus on the possibility that the HIV positive are more likely to migrate. Using a longitudinal data set of permanent rural residents and migrants from Malawi, I find that migrants originating from rural areas are indeed more likely than nonmigrants to be HIV positive and to have engaged in HIV risk behaviors. The increased HIV risk among migrants may be due to the selection of HIV-positive individuals into migration; I find that HIV-positive individuals are more likely to migrate than those who are HIV negative. The explanation for this phenomenon appears to be marital instability, which occurs more frequently among HIV-positive individuals and leads to migration after marital change.     

Marital strategies for regulating exposure to HIV

In a setting where the transmission of HIV occurs primarily through heterosexual contact and where no cure or vaccine is available, behavioral change is imperative for containing the epidemic. Abstinence, faithfulness, and condom use most often receive attention in this regard. In contrast, this article treats marriage as a resource for HIV risk management via mechanisms of positive selection (partner choice) and negative selection (divorce of an adulterous spouse). Retrospective marriage histories and panel data provide the evidence for this study and results indicate that men and women in Malawi increasingly turned to union-based risk-avoidance strategies during the period that the threat of HIV/AIDS materialized. Although both sexes strategize in a similar fashion, men are better equipped than women to deploy these strategies to their advantage. The article concludes with reflections on the long-term and population-level implications of these coping mechanisms.     

HIV transmission: Men are the solution

In the nation of Uganda, the cumulative total cases of clinical AIDS is 15,569, but out of the 13,984 adult AIDS cases, 6,394 are women aged 13–49 years. AIDS has been reported in all districts of Uganda ranging from 4 cases in Kapchorwa district to 2,808 and 4,232 cases in Masaka and Kampala districts, respectively (AIDS Control Program Report 1990). The age distribution is: 0 – 5 years = 10% 6 – 15 years = 0% 16 – 40 years = 80% 40 + years = 10%Heterosexual contact accounts for over 90% of the transmission. Evidence suggests that prior exposure to sexually transmitted diseases (STD) such as herpes, gonorrhea, and syphilis enhances susceptibility to transmission. Blood transmission and mother-to-newborn transmission cases account for about 1% and 10%, respectively. The majority of the cases are in the productive and reproductive age group. Men dominate in the 30–34 age group. Most women affected are in the childbearing range of 15–49 years. The peak incidence of AIDS is among 20–29 year-old women. The women affected are 5 years younger than the men. The average age of the affected is 27 years for women compared with 32 years for men.     

HIV and fertility in Africa: first evidence from population-based surveys

The historical pattern of the demographic transition suggests that fertility declines follow mortality declines, followed by a rise in human capital accumulation and economic growth. The HIV/AIDS epidemic threatens to reverse this path. We utilize recent rounds of the demographic and health surveys that link an individual woman’s fertility outcomes to her HIV status based on testing. The data allow us to distinguish the effect of own positive HIV status on fertility (which may be due to lower fecundity and other physiological reasons) from the behavioral response to higher mortality risk, as measured by the local community HIV prevalence. We show that although HIV-infected women have significantly lower fertility, local community HIV prevalence has no significant effect on noninfected women’s fertility.     

HIV testing in pregnancy: Using women's voices to inform policy

BackgroundIn Canadian provinces with opt-out policies for maternal HIV screening, pregnant women are told HIV screening is routine and are provided with the opportunity to refuse. In Newfoundland and Labrador an opt-out screening policy has been in place since 1997.PurposeThis research study aimed to (1) obtain an increased understanding of the information women receive about HIV/AIDS during the opt-out screening process and (2) to advance the policy related dialogue around best practices in HIV screening within the province of Newfoundland and Labrador.MethodsTwelve women who were between 14 and 35 weeks gestation participated. Interviews were transcribed verbatim and a thematic analysis was carried out.FindingsThe major themes are that women have difficulty obtaining clear information about maternal HIV screening, are often not told they have the right to refuse maternal screening, and experience paternalism from physicians.ConclusionWe recommend that physicians and other health care providers in be reminded that that current opt-out testing requires women's consent and that women must be given the option to refuse the test.     

Designing appropriate intervention strategies for HIV/AIDS in southern Africa

This research was supported by the U.S. Agency for International Development.