AIDS & public policy journal最新文献

Background: Controversy remains about perinatal HIV testing in many clinical settings. We sought to examine the attitudes and health beliefs among drug users about mandatory HIV testing of newborns and about voluntary versus mandatory testing of pregnant women. We also examined to what extent negative experiences and stigmatization affected attitudes toward HIV testing.

Methods: To establish a baseline, we examined 610 structured interviews conducted from 1997 to 2001, of active drug users who were recruited using respondent-driven sampling. We then conducted five focus groups of five subjects per group to further analyze responses in September 2003. The responses of the members of the focus groups were transcribed, coded, and analyzed using Microsoft Word 2000.

Results: Quantitative Longitudinal Cohort Studies. Of the 610 drug users interviewed in the two longitudinal cohort studies conducted from 1997 to 2001, nearly all (89 percent) had been previously tested for HIV Nearly all subjects (91 percent) believed that pregnant women should be tested for HIV. More subjects who had prior HIV testing believed all pregnant women should be tested for HIV (92.9 percent versus 82.6 percent, p = 0.008). Although 86 percent of the subjects agreed that all newborns should be tested, only 57 percent of all of the subjects believed that it should be mandatory. Among the female subjects, however, more injectors than non-injectors would avoid prenatal care if HIV testing was required during pregnancy (16.2 percent versus 6.1 percent, p < 0.01). Of the 499 subjects who reported that they had a usual site for care, 31.8 percent believed that "certain types of people" received better treatment than others. Not using drugs, being of a certain race/ethnicity, and having private insurance were associated with receiving better care. The majority of subjects believed that being a drug user resulted in receiving suboptimal care from the healthcare establishment. Qualitative Focus Group Study. In the focus groups, arguments against mandatory testing of pregnant women included the loss of choice, the right not to know one's HIV status, and the belief that mandatory testing was both a means of provoking rebellion and promoting discrimination. Concern for a baby's health was the primary reason for supporting mandatory testing. Perceived discrimination by the healthcare system was cited as a barrier to acceptance of testing strategies, as it was in the structured interviews.

Conclusions: The current practice of mandatory newborn and voluntary prenatal screening for HIV in the State of Connecticut appears to have been acceptable to a population of highly stigmatized drug users who have been or were at risk for HIV. Despite this acceptance, perceived discrimination by the healthcare system persists and may result in adverse outcomes for a minority of high-risk women, particularly where drug

In the late 1980s, New York State faced projected shortages in the supply of clinicians to meet the burgeoning HIV epidemic. In 1990, the New York State Department of Health AIDS Institute (AI), in collaboration with selected academic, medical center-based Designated AIDS Centers, responded by developing a two-year fellowship training program that provides skills training in the management of HIV disease and the public health aspects of the HIV epidemic. Its primary goal is to increase the number of highly qualified, broadly trained physicians, nurse practitioners, physician assistants, and dentists who can assume leadership roles in HIV-related direct care and program administration in New York State. In May 2002, each of the 74 scholars who had completed the full two-year program was mailed a survey that assessed the degree to which program goals had been met. Of the 48 survey respondents, 96 percent (46) had worked in HIV care at some time after completing the program and 90 percent were employed in HIV clinical settings. Of the 25 respondents with no HIV care experience prior to entering the program, 22 (88 percent) pursued careers in the field of HIV care after completing the program and remained in those jobs at the time of the survey. Of the 48 respondents, 42 (88 percent) held leadership positions (as program directors or medical directors), filled leadership roles as members of advisory boards, had published articles in professional journals, or had made presentations at national and international HIV/AIDS conferences; 91 percent of the respondents rated the overall quality of their training experience as "good" or "very good," the highest possible rating. The survey results indicate that this clinical training and leadership development program successfully met its primary goal of building the HIV/AIDS clinical healthcare workforce in New York State. Its success demonstrates that a state-funded, targeted clinical education program can address acute shortages in the public healthcare professional workforce in the absence of other privately or publicly funded professional development initiatives.

Congress enacted the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act in 1990 to address the unmet health needs of persons living with HIV (PLWH) by funding primary healthcare and support services to enhance access to and retention in care. The CARE Act was amended and reauthorized in 1996 and in 2000, and again in December 2006. As originally enacted, the CARE Act was a compromise across a wide political divide. A structure was established that distributed Ryan White CARE Act (RWCA) funds through five federal titles, with different parameters set for each title. Some funds were placed under federal control, while others were controlled locally and distributed to cities and states. Some funds were earmarked for specific services or populations, such as medications; others could be assigned according to a community's priorities. Title IV, the section of the RWCA dedicated to serving women, children, youth, and families who are infected with and affected by HIV/AIDS, is unique, even given the diversity of the other titles. The Title IV program was first implemented in 1988 as the Pediatric AIDS Demonstration Program. It became part of the CARE Act in 1994, and its purpose was expanded at that time to create better links between medical and support services. Although it is the smallest of the titles, with less than 4 percent of the RWCA budget, it may have the broadest mission: providing medical, logistical, psychosocial, and developmental care not just to persons living with the virus, but to entire families. In addition to its focus on this target population, Title IV is unique in its recognition of the need for, and historic support of, comprehensive systems of care to improve, expand, and coordinate service delivery, HIV-prevention efforts, and clinical research. Title IV was excluded from a 10 percent administrative cap on administrative expenses, which enables its funded programs to accomplish this mission. As of 2003, Title IV supported 74 family projects in 34 states (including Puerto Rico, the District of Columbia, and the Virgin Islands), which was a 28 percent increase in funded grantees and a 35 percent increase in participating states since 1999. However, the program's expansion was not matched with a comparable examination of its impact. Rather, the U.S. Health Resources and Services Administration (HRSA), the agency responsible for administering the RWCA, has focussed its evaluation interests on developing goals to use in evaluating its overall RWCA program and in evaluating shorter-term demonstration projects that have more-limited goals. Previous assessments of HIV/AIDS provider networks have examined the following: The process of network development and the determinants of successful implementation, The feasibility of collecting data from network providers, and The mechanisms of agency collaboration and care coordination at the provider level. Only recently has HRSA begun work on developing theoretical frameworks

Unlabelled: BACKGROUND; AIDS-related stigma is one of the biggest obstacles in the fight to prevent HIV transmission. Since stigma deters people from seeking treatment or getting tested for HIV, determining the factors that underpin AIDS-related stigmatization may be key to finding new ways to improve care and support for people living with HIV/AIDS (PLWHA) and to reduce new infections.

Setting: The town of Lucea and surrounding communities in the parish of Hanover, Jamaica.

Method: Cross-sectional questionnaire survey of 195 individuals from health centers and households in Hanover.

Results: Of the 195 respondents, 28 percent felt the names of HIV-positive people should be public information. We found three constructs (avoidant behavior, social contact stigma, and blame stigma) that underpin stigmatization of PLWHA. The factors that influence avoidance behavior were education and being married. The factors associated with social contact stigma were being married and having no acquaintance with PLWHA. The factor that influenced blame stigma was not owning a home.

Conclusion: Public health campaigns to reduce stigmatization must address individuals on the basis of their socio-demographic characteristics. A critical appraisal of current anti-stigma measures is warranted, and appropriate anti-stigma interventions are needed. Interventions with community members should address the social context of stigma, particularly the arenas of community norms, through education, information, and legislative measures to promote interaction with, and positive attitudes toward, PLWHA.

The first candidate topical microbicides--products designed to reduce women's risk of HIV infection--are now in the final stages of efficacy testing, and, if successful, could start to be available by the end of the decade. Advocates in public health and international development are already discussing how to expedite access to this new technology in countries where it could have the largest public health impact. The World Health Organization (WHO), World Bank, and the European Union support the integration of family planning and HIV programs. Such integration is impeded by U.S. policy, funding restrictions, and reluctance to integrate family planning and HIV/AIDS funding. This article describes how these policies weaken, rather than strengthen, the capacity of distribution networks to play an urgently needed role in microbicide roll-out when the time comes.

The rapid scale-up (that is, full implementation) of programs to provide antiretroviral therapy (ART) for HIV in resource-poor settings has become a major objective for many less-developed nations and the agencies that provide funding to them. The success and sustainability of ART programs will depend upon durable viral suppression, the long-term maintenance of the infected on first-line treatment regimes. This article considers the data policy that will be required to achieve durable viral suppression. The UNAIDS (Joint United Nations Programme on HIV/AIDS) "Three Ones" doctrine calls for one national health information strategy for countries that are scaling-up ART. This article provides a framework for standardizing national data policy. The need for standardization must be balanced with recognition that ART programs are still evolving and that excess standardization (imposing forms and electronic systems) should be avoided while best practices are developed and proven. This independent assessment of data policy for ART may be useful in the further development of routine program monitoring and targeted evaluation of durable viral suppression.