"The group" in integrated HIV and livelihoods programming: opportunity or challenge?

HIV care and treatment providers across sub-Saharan Africa are integrating livelihood interventions to improve food security of their clientele. Many integrated HIV and livelihood programmes (IHLPs) require the formation and use of groups of HIV-infected/affected individuals as the operational target for programme interventions, indeed, virtually without exception the group is the focal point for material and intellectual inputs of IHLPs. We sought to critically examine the group approach to programming among IHLPs in Uganda, and to explore and problematise the assumptions underpinning this model. A case study approach to studying 16 IHLPs was adopted. Each IHLP was treated as a case comprising multiple in-depth interviews conducted with staff along the livelihood programme chain. Additionally, in-depth interviews were conducted with staff from The AIDS Support Organization (TASO), and with members of 71 HIV-infected TASO-registered client households. Our analysis reveals three important considerations in IHLP programming regarding the group-centred approach: (1) Group membership is widely held to confer benefits in the form of psycho-social and motivational support, particularly in empowering individuals to access HIV services and handle stigma. This is contrasted with the problem of stigma inherent in joining groups defined by HIV-status; (2) Membership in groups can bring economic benefits through the pooling of labour and resources. These benefits however need to be set against the costs of membership, when members are required to make contributions in the form of money, goods or labour; (3) Sharing of goods and labour in the context of group membership allow members to access benefits which would otherwise be inaccessible. In exchange, individual choice and control are diminished and problems of resources held in common can arise. While the group model can bring benefits to IHLP efficiency and by extension to food security, and other outcomes, its application needs to be carefully scrutinised at the individual programme level, in terms of whether it is an appropriate approach, and in terms of mitigating potentially adverse effects.

Spectrum of cancers among HIV-infected persons in Africa: the Uganda AIDS-Cancer Registry Match Study.

Although more than 25 million people in sub-Saharan Africa have human immunodeficiency virus (HIV) infection, little is known regarding their cancer risk. We investigated cancer risk among persons with HIV/AIDS in Uganda using record-linkage. We linked records of 12,607 HIV-infected persons attending The AIDS Support Organization (TASO) in Kyadondo County from October 1988 through December 2002 to the Kampala Cancer Registry. We calculated standardized incidence ratios (SIRs) to identify increased cancer risks in the early (4-27 months after TASO registration), late (28-60 months), or combined (4-60 months) incidence periods. We identified 378 cancers (181 prevalent, 197 incident) among TASO participants. Of incident cancers, 137 (70%) were AIDS-defining cancers. Risk was increased in the early-incident period, compared to the general population, for the AIDS-defining cancers: Kaposi sarcoma (SIR 6.4, 95%CI 4.8-8.4), non-Hodgkin lymphoma (6.7, 1.8-17), and cervical carcinoma (2.4, 1.1-4.4). These three cancers were also increased in the combined periods. Risks of five non-AIDS-defining cancers were increased in the combined periods: Hodgkin lymphoma (5.7, 1.2-17) and cancers of the conjunctiva (SIR 4.0; 1.5-8.7), kidney (16, 1.8-58), thyroid (5.7, 1.1-16), and uterus (5.5, 1.5-14). Cancers of the breast, nasopharynx, and lung were increased either in the early or late incident periods only. Among 407 children, seven cancers were observed, of which five were Kaposi sarcoma. The application of a record-linkage design in Africa broadens the repertoire of epidemiological tools for studying HIV-infected populations. We confirm the increased risks of AIDS-defining cancers and report increased risks of a few non-AIDS-defining cancers.