A qualitative analysis of SNAP and minimum wage policies as experienced by workers with lower incomes.

Work-related policies, including minimum wage and food assistance work requirements, can affect food security for people with lower incomes. This study conducted 112 qualitative interviews to understand participant policy experiences in two contexts (Raleigh, North Carolina and Minneapolis, Minnesota). Participants experienced frequent, destabilizing changes to their United States Department of Agriculture Supplemental Nutrition Assistance Program benefits, which they identified as part of a broader safety net. Raleigh workers described an unsupportive policy environment; Minneapolis workers reaped few benefits from an ongoing wage increase. Many workers face complex financial tradeoffs; more sophisticated evaluations should consider broader policy contexts and long-range effects.

"If You Report Your Dad, How are You Going to Survive": Health Practitioner Perspectives on Quality of Care for Survivors of Sexual Violence and the Challenge of Family Interference.

This study examined the experiences and perspectives of health practitioners facing the challenges of providing services to female survivors of sexual violence. Interviews were conducted with 28 health practitioners, from eight post-rape care facilities located in Nairobi, Kenya. Data were analyzed using the Colaizzi's 1978 analytical model. The analysis of the results was guided by four domains of the ecological framework: individual, interpersonal, community/cultural, and public policy. The study documented a myriad of detail about the challenges faced by women before reporting the crime as well as the actual process of reporting. One key finding from this study was that health practitioners perceived family interference as a barrier to reporting, access to care, and to the pursuit of justice for survivors, particularly if the perpetrator was a relative. Family interference was also identified as a factor with implications for health practitioners' ability to ensure quality of care as it resulted in patients loss to follow-up and added to the negative emotional toll on health practitioners providing post-rape care. Three main themes emerged in practitioner responses related to this issue: (a) fear of consequences of reporting and care seeking, including economic vulnerability, family conflict, and retaliation such as divorce or further violence, (b) the trend toward out-of-court settlements rather than intervention through formal health and criminal justice sector challenges, and (c) attitudes toward sexual violence and survivors, normalization of rape, and victim-blaming attitudes. The study adds to our understanding of the obstacles faced by health practitioners providing post-rape care and provides a unique set of insights from the front lines on underlying factors contributing to these challenges.

The Impact of Macroeconomic Policies on Healthcare Delivery in Kenya: An Analysis of the National Sexual Violence Prevention and Care Response.

Sexual violence is one of the most common forms of violence against women in Kenya. This study documents the care of sexual violence survivors from the perspective of health care practitioners based on an analytic framework developed in studies of the political-economy of health to examine the effects of International Financial Institutions' conditionalities on the allocation of national fiscal resources. The study documented the working conditions of practitioners and myriad challenges that they experience in providing quality services to sexual violence survivors. The issues reflected in the results are grounded in social structural inequities driven by the global political economic policies that perpetuate poverty and dependency throughout Africa and the developing world. Macro-level variables associated with health care provision are assessed with a focus on global macroeconomic policies established by the International Monetary Fund and World Bank, their impact on Kenya's health economy and their ultimate impact on the capacity of the health system to meet the complex needs of survivors of sexual violence. In this paper, study results are analysed within the context of these macroeconomic policies and their legacy.

"She Is NOT a Genuine Client": Exploring Health Practitioner's Mistrust of Rape Survivors in Nairobi, Kenya.

Sexual violence is one of the most common forms of violence against women in Kenya. Recognizing this, the Kenyan government introduced health care sector guidelines for survivors of sexual violence. This study explores the care of rape survivors from the perspective of health-care practitioners and identifies a number of recommendations for improving the quality of care. Qualitative interviews were conducted with 28 health practitioners from eight post-rape care facilities located in Nairobi, Kenya. Data were analyzed using the Colaizzi's 1978 analytical model. The study uncovered a troubling tendency of health practitioners questioning the authenticity of a woman's claim, deeming some not to be genuine rape survivors. Doubts about the veracity of the client's story led to additional emotional drain on health practitioners. This judgment negatively impacted the quality of care for rape survivors and in some cases, leading practitioners to deny services and exposing survivors to secondary victimization.

Assessment of Prevention of Mother-to-Child Transmission HIV Services in the Bantey Meanchey Province in Cambodia.

BACKGROUND: Elimination of pediatric HIV requires a robust program for the prevention of mother-to-child transmission (PMTCT). The goal of this study was to assess the implementation of these services in Cambodia. METHODS: This prospective study was conducted in Bantey Meanchey at 2 sites. Staff reviewed daily clinic and laboratory registration logs to gather data on PMTCT service access among antenatal women. RESULTS: A total of 12 140 pregnant women received antenatal care. Only 4034 (33.2%) received pre-HIV test counseling. Of which 3407 (84.5%) received an HIV test. Eighteen (94.7%) of 19 women testing HIV-seropositive received triple-combination antiretroviral (ARV) medication. Fifteen HIV-exposed infants were delivered during the study. One infant tested HIV positive and is on ARV medication. CONCLUSION: Acceptance for HIV testing was high among women who received pretest counseling. An increase in the number of counselors may improve the rates of HIV testing. Follow-up mechanisms targeting mother-baby pairs should focus on increasing timely service uptake in the public sector.

Implementation and Operational Research: Scaling Up the Provision of the PMTCT Services, Using the Linked Response Approach in Cambodia From 2008 to 2012.

INTRODUCTION: In Cambodia, the Linked Response (LR) approach for strengthening linkages between HIV and reproductive health services, especially for the prevention of mother-to-child transmission of HIV (PMTCT), was scaled up in 2009. This article describes the LR scale-up and the concomitant evolution of key PMTCT indicators at the national level. METHODS: A descriptive analysis of routine LR, PMTCT programme data, and national laboratory data from 2008 to 2012 was conducted. RESULTS: LR data show that between 2008 and 2012, the number of LR/PMTCT sites increased from 67 to 956 (of 1004) public health facilities to cover 74 (of 77) operational districts. In LR operational districts, the number of pregnant women (PW) tested for HIV increased from 41,800 in 2009 to 269,935 [of whom 375 (0.14%) were newly tested positive for HIV] in 2012; the number of PW living with HIV and exposed infants receiving antiretrovirals increased from 49 and 44 in 2009 to 720 and 551 in 2012, respectively. Concomitantly, national PMTCT programme data showed that the percent of PW tested for HIV increased from 34.4% (117,832 of 342,929 estimated PW) in 2008 to 86.1% (324,996 of 377,340) in 2012. In 2012, 65.3% (862 of 1321) of estimated HIV-positive PW and 72.7% (960 of 1321) of exposed infants received antiretrovirals. By 6-8 weeks postpartum, 7.4% (8 of 108) and 1.5% (6 of 409) of DNA-polymerase chain reaction tested positive in 2008 and in 2012, respectively. CONCLUSIONS: The LR approach provided a model, which catalyzed increased access of PW to HIV testing and treatment, thereby contributing to the scale-up of PMTCT service provision and improved coverage in Cambodia.

Achieving universal access and moving towards elimination of new HIV infections in Cambodia.

INTRODUCTION: In the mid-1990s, Cambodia faced one of the fastest growing HIV epidemics in Asia. For its achievement in reversing this trend, and achieving universal access to HIV treatment, the country received a United Nations millennium development goal award in 2010. This article reviews Cambodia's response to HIV over the past two decades and discusses its current efforts towards elimination of new HIV infections. METHODS: A literature review of published and unpublished documents, including programme data and presentations, was conducted. RESULTS AND DISCUSSION: Cambodia classifies its response to one of the most serious HIV epidemics in Asia into three phases. In Phase I (1991-2000), when adult HIV prevalence peaked at 1.7% and incidence exceeded 20,000 cases, a nationwide HIV prevention programme targeted brothel-based sex work. Voluntary confidential counselling and testing and home-based care were introduced, and peer support groups of people living with HIV emerged. Phase II (2001-2011) observed a steady decline in adult prevalence to 0.8% and incidence to 1600 cases by 2011, and was characterized by: expanding antiretroviral treatment (coverage reaching more than 80%) and continuum of care; linking with tuberculosis and maternal and child health services; accelerated prevention among key populations, including entertainment establishment-based sex workers, men having sex with men, transgender persons, and people who inject drugs; engagement of health workers to deliver quality services; and strengthening health service delivery systems. The third phase (2012-2020) aims to attain zero new infections by 2020 through: sharpening responses to key populations at higher risk; maximizing access to community and facility-based testing and retention in prevention and care; and accelerating the transition from vertical approaches to linked/integrated approaches. CONCLUSIONS: Cambodia has tailored its prevention strategy to its own epidemic, established systematic linkages across different services and communities, and achieved nearly universal coverage of HIV services nationwide. Still, the programme must continually (re)prioritize the most effective and efficient interventions, strengthen synergies between programmes, contribute to health system strengthening, and increase domestic funding so that the gains of the previous two decades are sustained, and the goal of zero new infections is reached.

Uptake of interventions for preventing mother-to-child HIV transmission in 11 operational districts in Cambodia.

INTRODUCTION: To achieve the global goal of eliminating mother-to-child transmission of HIV, retention of HIV-positive women and their babies throughout the cascade of prevention of mother-to-child transmission of HIV (PMTCT) services is necessary. Little evidence has been published on coverage of the cascade in resource-limited settings. Along with PMTCT service expansion in Cambodia, a national routine reporting system was developed. This study examines coverage of six PMTCT interventions to improve our understanding of retention throughout the cascade. METHOD: WE DEVELOPED INDICATORS TO MONITOR COVERAGE OF THE SIX KEY INTERVENTIONS: (1) maternal antiretroviral treatment or prophylaxis; (2) delivery in a health facility; (3) infant ARV prophylaxis at birth; (4) infant co-trimoxazole prophylaxis at six weeks; (5) first infant DNA-PCR test at six weeks; and (6) second infant DNA-PCR test at 30 weeks. Programme data from April 2008 to December 2011 in 11 operational districts were used to identify those eligible for each intervention. RESULTS: Women eligible for maternal antiretroviral treatment or prophylaxis in the study were aged 18 to 48 with a median age of 30 years. Coverage of the six interventions were: (1) 79.9% (258/323); (2) 92.2% (236/256); (3) 69.9% (179/256); (4) 73.3% (184/251); (5) 85.7% (215/251); and (6) 61.6% (135/219). Among those eligible, 29.7% (65/219) received all six interventions. DISCUSSION: This study revealed critical gaps in PMTCT service delivery under routine conditions in Cambodia. Service optimization by reducing gaps will help eliminate HIV infection among infants and improve maternal survival. Further operational studies are needed to identify determinants of service uptake.

Uptake of interventions for preventing mother-to-child HIV transmission in 11 operational districts in Cambodia

Introduction: To achieve the global goal of eliminating mother-to-child transmission of HIV, retention of HIV-positive women and their babies throughout the cascade of prevention of mother-to-child transmission of HIV (PMTCT) services is necessary. Little evidence has been published on coverage of the cascade in resource-limited settings. Along with PMTCT service expansion in Cambodia, a national routine reporting system was developed. This study examines coverage of six PMTCT interventions to improve our understanding of retention throughout the cascade. Method: We developed indicators to monitor coverage of the six key interventions: (1) maternal antiretroviral treatment or prophylaxis; (2) delivery in a health facility; (3) infant ARV prophylaxis at birth; (4) infant co-trimoxazole prophylaxis at six weeks; (5) first infant DNA-PCR test at six weeks; and (6) second infant DNA-PCR test at 30 weeks. Programme data from April 2008 to December 2011 in 11 operational districts were used to identify those eligible for each intervention. Results: Women eligible for maternal antiretroviral treatment or prophylaxis in the study were aged 18 to 48 with a median age of 30 years. Coverage of the six interventions were: (1) 79.9% (258/323); (2) 92.2% (236/256); (3) 69.9% (179/256); (4) 73.3% (184/251); (5) 85.7% (215/251); and (6) 61.6% (135/219). Among those eligible, 29.7% (65/219) received all six interventions. Discussion: This study revealed critical gaps in PMTCT service delivery under routine conditions in Cambodia. Service optimization by reducing gaps will help eliminate HIV infection among infants and improve maternal survival. Further operational studies are needed to identify determinants of service uptake.