AIDS & public policy journal最新文献

Before introducing an HIV testing protocol into correctional facilities, the unique nature of these environments must be taken into account. We analyze three testing strategies that have been used in correctional settings--mandatory, voluntary, and routine "opt out" testing--and conclude that routine testing is most likely beneficial to inmates, the correctional system, and the outside community. The ethics of pre-release testing, and the issues surrounding segregation, confidentiality, and linking prisoners with community-based care, also play a role in determining how best to establish HIV testing strategies in correctional facilities. Testing must be performed in a manner that is not simply beneficial to public health, but also enhances the safety and health status of individual inmates. Longer-stay prison settings provide ample opportunities not just for testing but also for in-depth counseling, mental health and substance abuse treatment, and antiretroviral therapy. Jails present added complexities because of their shorter stay with respect to prisons, and testing, treatment, and counseling policies must be adapted to these settings.

Background: AIDS-related stigma discourages individuals who are aware of their HIV-positive status from sharing information about their status with their sexual partners and families, and makes it difficult to prevent the spread of the infection or to plan a secure future for surviving children and family members. It is essential that barriers to screening, prevention, and care are understood and removed so that persons living with HIV/AIDS can benefit optimally from available health and social services.

Objectives: The objectives of this article are to summarize the literature on barriers posed by stigma to HIV/AIDS prevention and care in sub-Saharan Africa, to analyze the contexts in which AIDS-related stigma and discrimination are manifested, and to suggest potential prevention strategies.

Methods: The authors collected and reviewed published studies from standard research databases and reference lists of relevant articles.

Results: The ways in which AIDS stigma is overtly or covertly expressed are shaped by a range of social, cultural, political, and economic factors. Stigma plays into existing social inequalities and is manifested at all levels: in the wider society, in institutions, in families, and at the individual level. IMPLICATIONS FOR POLICY AND PRACTICE: Influences on AIDS-related stigma and discrimination are rooted in the structure of communities and societies, and therefore effective interventions should be based on a sound theoretical foundation and include attention to individual as well social and structural barriers. Given the diversity of cultures among the various countries in Africa, interventions to reduce AIDS stigma are likely to be more effective if they are context-specific and sensitive to the prevailing sociocultural and economic environment of each country.

Background: As the number of persons living with HIV/AIDS (PLWHAs) continues to increase in Jamaica, concerns of discriminatory attitudes become more important.

Objective: To examine the attitudes of university students in Jamaica toward PLWHAs, including sympathy and support for PLWHAs in the workplace and in school.

Methods: The authors conducted a survey of 1,252 students between June 2001 and February 2002 using a 193-item questionnaire that measured HIV-related knowledge, attitudes, and behaviors.

Results: Less than half of the students who were surveyed reported sympathetic attitudes toward either homosexual males or female prostitutes living with HIV/AIDS (41 percent and 44 percent, respectively), while a majority reported sympathetic attitudes toward heterosexual males and non-prostitute females living with the disease (67 percent and 81 percent). Most students reported that HIV-positive teachers should be allowed to teach, and that HIV-positive children should be allowed to attend school (80 percent and 62 percent). Only a minority (36 percent) reported that HIV-positive nurses should be allowed to work. Students who were more sympathetic toward PLWHAs were more tolerant of PLWHAs in the workplace and in school, while those with inaccurate knowledge concerning HIV transmission risk were less tolerant.

Conclusion: Levels of discriminatory attitudes are high in Jamaica and warrant the attention of both individual- and societal-level interventions.

The authors report that individuals who are at highest risk of contracting HIV indicated the greatest concern about confidentiality and the greatest knowledge of local reporting laws. Although concern about confidentiality may not be cited as the most common reason to delay or defer testing, it is an important consideration for a minority of individuals--the very segment who are at highest risk of contracting HIV and are the most important targets of campaigns to encourage HIV testing. The particular concerns of this critical segment of the population at risk must be directly and carefully addressed and not lost in a general assessment of population-wide attitudes/concerns about HIV testing. Studies that examine individuals' concerns about HIV testing and privacy and do not stratify by level of HIV risk may obscure the important and heightened concerns of this most important subpopulation.

Any proposed surveillance system must be assessed according to what it reasonably can expect to accomplish in the promotion of behaviors we wish to encourage in HIV testing, treatment, and prevention. There is no reason to believe that the name reporting of persons with positive HIV test results will provide an accurate picture of the epidemic. Most public health experts believe that a significant number of people who are HIV positive avoid testing and have no idea of their status. And there is reason to believe that significant numbers of those considering testing, particularly those who are members of racial and sexual-preference minorities, will be deterred if they are required to provide their name.

A system of HIV surveillance based on AIDS case reporting is no longer adequate to monitor the epidemic of HIV/AIDS in the U.S. We are now faced with the challenge of designing an effective system of HIV surveillance. The "New Approaches to HIV Surveillance: Means and Ends" conference emphasized that there are several alternatives, each with strengths and limitations. The CDC has recommended that all states adopt a system of HIV surveillance based on case reporting. Although it has not specified that such systems need be name-based, CDC appears to reward states that adopt name-reporting systems. The rationale for this stance should be reviewed and made explicit. Name reporting may be superior in some respects to a system of case reports based on unique identifiers (UIs), especially in its greater ability to link surveillance activities to follow up at the individual level. Neither a name-reporting nor a UI approach to case reporting would provide HIV incidence data. The only currently envisioned means of providing incidence data is statistical estimation based on "snapshot estimates" of HIV incidence in sample cohorts. Calibration of this new instrument for HIV incidence estimation against existing data or through field trials is of critical importance.

The Yale-hosted conference, "New Approaches to HIV Surveillance: Means and Ends," is now over two years old; it is time for the public health and AIDS community to move beyond the debate on name reporting and focus on rethinking what we need from surveillance and how we might best get it. Rethinking the role and methods of surveillance is critical for HIV; but it will also show the way for public health in general.