Barriers and facilitators to HIV prevention and care for Venezuelan migrant/refugee women and girls in Colombia.

Venezuelan migrant and refugee women and girls (VMRWG) face risks of exposure to and infection from HIV and threats of multiple forms of violence (including GBV) during and after migration. Yet, there is a lack of evidence on barriers and facilitators to VMRWGs' access to HIV prevention and care services this population at all stages of their migration. We addressed this evidence gap by conducting a qualitative study composed of fifty-four semi-structured interviews with practitioners (n = 24) and VMRWG (n = 30) in the two largest receiving cities of migrants in Colombia. We sought to identify perceived barriers and facilitators to HIV prevention and care to inform policies and programmatic efforts. Analysis followed a theory-informed approach using the Socioecological Model. Findings describe multi-level barriers to access to HIV prevention and care related to discrimination, gender-based violence, rigid gender norms, lack of information and system fragmentation. Policies that integrate community-based networks and support intersectoral work are pivotal to breach the gaps between services and communities and develop a gender-sensitive approach that tackles the relationship between gender-based violence and HIV risk.

Attitudes towards involuntary incarceration for tuberculosis: a survey of Union members.

BACKGROUND: Policies involving the use of involuntary incarceration for tuberculosis (TB) are highly ethically controversial. To encourage ethical reflection within the International Union Against Tuberculosis and Lung Disease (The Union), the Ethics Advisory Group (EAG) surveyed members regarding their attitudes and values relating to involuntary incarceration for TB. METHODS: Members of the Union TB section were invited to respond to an anonymous web-based survey. The survey included both multiple choice questions describing a range of scenarios regarding involuntary incarceration, and free-text fields inviting respondents to provide general comments on ethical issues. RESULTS: The survey was completed by 194 participants, 33 (17%) of whom were opposed to involuntary incarceration on principle. The age and sex of the respondents was not associated with likelihood of principled opposition; respondents from North America were least likely to be opposed to involuntary incarceration (P = 0.02). Respondents were most likely to consider involuntary incarceration for persons with known multidrug-resistant TB or a history of previous treatment default, and least likely where people lived alone, were university-educated or the main income provider for their families. CONCLUSION: This survey found a wide range of viewpoints regarding involuntary incarceration, and highlights a number of key elements in ethical engagement with the tensions surrounding involuntary incarceration. We provide commentary on approaches to ethical policy making in the light of these findings.

Failing Siracusa: governments' obligations to find the least restrictive options for tuberculosis control.

One of the world's leading causes of death, tuberculosis (TB) remains a stigmatized and feared disease. Prevention, diagnosis, and adherence to TB treatment remain a challenge for many people, including migrants, those with alcohol and drug dependency, sex workers, people living with the human immunodeficiency virus, and individuals with disabilities. Low levels of TB treatment literacy and ignorance of transmission risks are common, and-along with inadequate funding for treatment support-contribute to patients' non-adherence to treatment. Recent cases involving the detention of individuals with TB in Kenyan and Canadian correctional facilities illustrate the circumstances under which individuals interrupt treatment and how health authorities seek restrictive measures to oversee and compel treatment. The legitimacy of restrictive measures is often defended by international public health authorities in relation to the non-binding Siracusa Principles. Yet in practice, as illustrated by examples from Kenya and Canada, government authorities and local laws sometimes do not fully meet, or entirely disregard, the requirements in the Siracusa Principles that restrictions on rights in the name of public health be strictly necessary and the least intrusive available to reach their objective. In addition, more specific standards are required at the international level to guide states' development and use of rights-restricting measures to address TB.

La tuberculose (TB), une des principales causes de décès dans le monde, reste une maladie stigmatisée et redoutée. La prévention, le diagnostic et l'adhésion au traitement de la TB restent un défi pour de nombreuses personnes, notamment les migrants, les sujets dépendants à l'alcool et aux drogues, les travailleurs du sexe, les sujets atteints par le virus de l'immunodéficience humaine et les individus atteints d'invalidité. Le faible taux de connaissance du traitement de la TB et l'ignorance des risques de transmission sont courants et contribuent, en plus d'un financement inadéquat pour le soutien au traitement, à la non-adhésion des patients au traitement. Des cas récents impliquant la détention d'individus atteints de TB dans les services correctionnels du Kenya et du Canada illustrent les circonstances dans lesquelles les individus interrompent le traitement et celles où les autorités de santé recourent à des mesures restrictives pour surveiller et imposer le traitement. La légitimité des mesures restrictives est souvent défendue par les autorités internationales de santé publique en lien avec les Principes non-contraignants de Syracuse. En pratique, comme l'illustrent les exemples du Kenya et du Canada, parfois les autorités gouvernementales et les lois locales ne répondent pas complètement, voire méconnaissent totalement les exigences des Principes de Syracuse selon lesquels les restrictions appliquées aux droits au nom de la santé publique doivent être strictement nécessaires et le moins intrusives possible pour atteindre leur objectif. En outre, des standards plus spécifiques s'imposent au niveau international pour orienter au niveau des Etats l'élaboration et l'utilisation de mesures restreignant les droits pour faire face à la TB.

La tuberculosis (TB), una de las principales causas de muerte en el mundo, representa aun una enfermedad estigmatizada y temida. La prevención y el diagnóstico de la TB y el cumplimiento con el tratamiento antituberculoso representan todavía un reto en muchas poblaciones, sobre todo en los inmigrantes, las personas con dependencia al alcohol o las drogas, los trabajadores del sexo, las personas aquejadas de infección por el virus de la inmunodeficiencia humana y las personas discapacitadas. Es frecuente la carencia de conocimientos en materia de tratamiento y se suelen ignorar los riesgos de transmisión, lo cual, aunado a la escasez de financiamiento destinado al apoyo del tratamiento, favorece el incumplimiento terapéutico de los pacientes. Los casos recientes de detención de personas con TB en centros correccionales en Kenia y Canadá constituyen un ejemplo de circunstancias en las cuales los pacientes interrumpen el tratamiento y las autoridades sanitarias ejercen medidas restrictivas con el fin de supervisar el tratamiento y forzar su continuación. Con frecuencia, las autoridades internacionales de salud pública defienden la legitimidad de las medidas restrictivas, en nombre de los Principios de Siracusa, los cuales no presentan un carácter vinculante. Sin embargo en la práctica, como lo pone de manifiesto el ejemplo de Kenia y Canadá, las autoridades gubernamentales y las legislaciones locales en ocasiones no cumplen a cabalidad las exigencias de los Principios de Siracusa o los desacatan totalmente; según estos principios, solo se pueden restringir los derechos en nombre de la salud pública cuando es estrictamente necesario y las restricciones aplicadas deben ser las menos intrusivas existentes que permitan lograr los objetivos. Además, se precisan normas más específicas a escala internacional, que orienten a los estados en la formulación y la ejecución de las medidas de restricción de los derechos encaminadas a luchar contra la TB.

Structural barriers and human rights related to HIV prevention and treatment in Zimbabwe.

There has long been recognition that individual risk factors can only partially explain vulnerability to HIV infection, and that a broader range of socioeconomic, cultural and political factors must be taken into account. More recently this understanding has been applied to addressing obstacles to accessing HIV treatment. Yet, while structural interventions aimed at contextual factors related to HIV prevention and treatment have been shown to be effective, they have not been widely implemented. Using the situation of Zimbabwe as an example, we will present an illustration of how contextual barriers can be understood in human rights terms, and how using a human rights analysis can specifically help define 'structural-rights' interventions and compel their implementation.

Is HIV/STD control in Jamaica making a difference?

OBJECTIVE: To assess the impact of the comprehensive HIV/STD Control Program established in Jamaica since the late 1980s on the HIV/AIDS epidemic. METHODS: AIDS case reports, HIV testing of blood donors, antenatal clinic attenders (ANC), food service workers, sexually transmitted disease (STD) clinic attenders, female prostitutes, homosexuals and other groups were used to monitor the HIV/AIDS epidemic. Primary and secondary syphilis and cases of congenital syphilis were also monitored. National knowledge, attitude and practice (KAP) surveys were conducted in 1988, 1989, 1992, 1994 and 1996. RESULTS: The annual AIDS incidence rate in Jamaica increased only marginally in the past three years from 18.5 per 100000 population to 21.4 in 1997. HIV prevalence in the general population groups tested has been about 1% or less. Among those at high risk, HIV prevalence rates have risen to 6.3% (95% confidence interval 5.0-8.0) in STD clinic attenders, around 10% and 21% in female prostitutes in Kingston and Montego Bay respectively and approximately 30% among homosexuals. Syphilis rates and congenital syphilis cases have declined. The proportion of men aged 15-49 years reporting sex with a non-regular partner declined from 35% in 1994 to 26% in 1996 (P< 0.001). Women ever having used condoms increased from 51% in 1988 to 62.5% in 1992 and 73% in 1994 and 1996 (P< 0.001), while condom use with a non-regular partner increased from 37% in 1992 to 73% in 1996 (P= 0.006). Condom use among men was high over the period: around 81% had ever used condoms and 77% used them with non-regular partners. Gay men, inner-city adults and adolescents aged 12-14 years all reported increases in condom use while condom sales and distribution increased from around 2 million in 1985 to 10 million in 1995. CONCLUSION: HIV/STD control measures appear to have slowed the HIV/AIDS epidemic in Jamaica, however a significant minority of persons continue to have unprotected sex in high risk situations.

Field experiences: measuring capacity building efforts in HIV/AIDS prevention programmes.

OBJECTIVE: To present a theoretical and practical means for the evaluation of organizational and institutional development (capacity building) in HIV/AIDS prevention programmes in developing countries. METHODS: Multiple frameworks, methodologies and paradigms for the evaluation of organizational and institutional development were reviewed and synthesized, resulting in this proposed pluralistic model for the measurement of capacity building efforts. Traditional forms of capacity building evaluation (self-assessment, case study, outcome, and impact evaluation) are presented and a framework for their integration at the level of interpretation and inference is provided. The review is based on experiences in measuring capacity building in more than 20 countries and 200 projects, ranging from communications and behavior change initiatives to condom social marketing to sexually transmitted disease/HIV clinical interventions with a range of international and local non-governmental organizations and ministries of health. RESULTS: From this experience, we have found that conducting a mixed method evaluation of capacity building efforts allows for a more insightful assessment of capacity building and a more comprehensive evaluation of HIV prevention programmes. CONCLUSIONS: The capacity building conceptual framework developed (linking strategies, variables and outcomes) provides an instructive paradigm for the evaluation of HIV prevention interventions worldwide.