Summaries
Track D: Social and Economic Issues

Experiences from programs in developing countries explicitly created to support PWAs economically documented valuable lessons. Problems in providing ARV therapy in developing countries remains a problem, although half of facilities in a province in South Africa are now ready to offer ART. In Botswana, introducing an ART program did increase the number of VCT clients and detection of postive cases. The feasibility of reaching the deaf has been successfully proven in Kenya.

HIV/AIDS is affecting the way in which health care providers work.. Stigma against HIV+ patients attending for services remains high, and providers often test suspeceted high-risk patients without informing them. Providers are also concerned about the risk of iatrogenic transmission and would like pre-operative testing, but the majority do not regularly follow basic infection prevention procedures. Although HIV+ doctors are more sympathetic to their HIV+ clients, they have problems in effectively communicating credible prevention messages. High levels of infection in a workforce do adversely affect productivity, but HAART can be introduced in the workplace and its introduction stabilizes costs to the company.

A growing proportion of elderly people are becoming infected, especially among those who had been more sexually active. ART can lead to amenorrhea which can appear as the menopause in older women. In many parts of Africa, the elderly become caregivers, and they worry about the quality of care they are able to provide, as well as resenting losing their social lives.

The benefits of PWAs being actively involved in desiging and implementing HIV/AIDS programs was strongly promoted, and several examples of how this can be done effectively were presented, including a hospital-based program, a literacy program, and increasing VCT and orphan care in a workplace program. Indeed, PWAs currently feel excluded from national efforts to design and implement HIV/AIDS programs, and as attempts are made to broaden participation in program development and access to resources they need to be included, as do civil rights groups, trade unions, etc. Inclusive leadership structures at the national level are critical if the large increases in donor funds are to be effectively harmonized and coordinated, as are a more diverse leadership to represent marginalized groups such as women, PWAs, and NGOs. Several presentations reflected on ways to strengthen leadership to ensure equity, efficiency and appropriate use of these increased resouces.


TUESDAY
13 July

Social and economic issues in relation to 'scaling up access to care' covered during this day included: strengthening families and communities for prevention and care: sexual violence and trafficking; culture and religion affecting vulnerability and prevention; social & economic issues of TB; evaluating impact on sexual behaviour; risk and protective factors of vulnerable populations; and the costs of failed commitments.

Strengthening families and communities for prevention and care requires nuanced approaches to account for the needs of different groups. Reaching men as a group with specific services was found to be feasible in Kenya and may benefit their families. Women value emotional support from their families but can be afraid to seek it for fear of rejection and loss. However, home-based care by families is not sustainable because of the costs and stress to the family, and so alternatives, such as mobile clinics together with volunteers, is recommended.

Encouraging condom use needs to take into account cultural beliefs, such as the role of semen in improving health, and engaging with the community to learn how to address these beliefs is needed to develop appropriate messages. Stigma against infected persons can be compounded by stigmas against certain behaviours, such as drug use and sex work, and so efforts at stigma reduction need to take these into account.

The TB and HIV epidemics are strongly associated in many populations, and so efforts to integrate screening and treatment for both are now being tested; examples from Malawi and among the homeless in New York were presented. Averting TB among HIV+ employees in South Africa was found to be more cost-effective than treating TB cases. This integrated approach will probably cost $250-450 million per year globally.

Certain populations are more vulnerable than others, and several papers considered the factors that increase their vulnerability. Among Ethiopian youth, low academic achievement and little parental communication or guidance contribute to higher risk behaviours. In Zambia, orphanhood results in earlier sexual debut, and thisis increased by orphanhood closer to adolescence. In South Africa, childhood trauma, including sexual abuse but also possibly orphanhood, is associated with several risk factors among women. Although women who have sex with women are usually considered to be a low risk group, their increased likelihood of using drugs and other risky behaviours puts them at a higher risk than women who have sex with men only in New York. Female drug users are more likely to become infected by their regular partner than through multiple sex partners because of high HIV rates among their partners and high levels of partner violence. Violence against sex workers is virtually universal in India and Bangladesh, but more needs to be known about its contribution to HIV risk. Treating rape survivors with PEP in societies with high prevalences of rape and of HIV is not only an issue of a basic right, but may well be cost-effective. School-based HIV education programs in developing countries can face problems of teachers applying culturally influenced opposition to condom use and focusing primarily on abstinence. Evaluations of such programmes showed that different definitions and messages around abstinence can cause confusion, that engaging teachers about the issue can lead to strategies being developed to enable teachers to begin to consider and include messages about condoms in their education classes.

Although significant increases in committed and actual funding for HIV have been made recently, reviews of commitments made that were not honoured, or inaction when it was possible indicate that these failures have exacerbated the current situation and may lead to larger economic and social losses in the future. Examples cited include delays in recognising the seriousness of the epidemic on African economies, the scaling back of earleir US commitments, insufficient funding for microbicide development, and the need for debt relief to facilitate scaling up.


WEDNESDAY
14 July

Social and economic issues in relation to 'ensuring access to youth and women" covered during this day included: research methodology, ethics and utilization; including RH programs as part of the response; caringfor children; older people; SRH services for youth; education for prevention; integrating gender and sexuality; and positive youth.

ncreasing numbers and proportions of youth, women, and especially young women, are now becoming infected. HIV/AIDS is now such an integral part of life in most parts of the world that there is a need to move from simply trying to control it through social and behavioural control mechanisms to beginning to re-organize social and economic structures.

Despite 50% of new infections being among young people, they are still excluded from most HIV/AIDS programs and decisions. Youth need more information about their rights and services to become empowered, and socially acceptable sexual violence against young women and men, including men against young men, needs to be addressed. Infected youth currently have little opportunity to become actively engaged. The education system clearly has a role to play here, and examples were shared. The effectiveness of various education programs remains uncertain, as does the sustainability of successful peer educator programs.

Traditional gender roles and relations that subjugate women increase their vulnerability, and although attention to gender issues are increasing, concerns remain that existing power structures aer co-opting efforts to mainstream gender. Those involved in sex work feel particularly vulnerable, as stigmatising language and laws further reduce their rights and access to resources. Empowerment through mobilization and networking does seem to enable some sex workers to become engaged in prevention and care activities.

Caring for infected children by older peole (over 50 yrs) is not adequately understood or addressed by programs. As they are usually a silent and under-represented group, it is often not realised that they are usually emotionally affected and are facing economic, physical and other demands they are not equiped to deal with. Efforts are needed to support them, both from within their communities as well as through organized programs that offer training and logistical support.

Issues around social and economic research discussed during the day included:

1. Methodological developments in understanding risky behavior among MSM; measuring condom use among brothel-based sex workers; and using ACASI to obtain more accurate information from PMTCT program participants.
2. Ethical issues discussed included: challenges of children participating in vaccine trials; developing culturally appropriate language in informed consent forms; and assessing whether treatments in RCTs meet standard of care norms.
3. Use of socio-cultural research to design and evaluate programs: local ethnographic data can contribute to program design with the assumption that it can produce more successful programs, but there is a lack of firm evidence to support this; socio-cultural concepts need to be appropriate locally and not imported from the west; and projects designed to address specific socio-cultural contexts can be difficult to fund as donors look to scale up activities to increase access.

Increasing access for women and youth to HIV/AIDS information and services can be enhanced by ensuring and increasing their access to quality SRH services. Despite the obvious links, and the numerous statements supporting and proposing ways of creating such links, there is still insufficient integration. Greater efforts are needed to move forward on implementing what is known to work, and to invest more in promising approaches, such as microbicides. Greater attention to the SRH needs of HIV+ women is critical. A recent UNFPA/UNAIDS "Call to Commitment" reinforces this need.


THURSDAY
15 July

Social and economic issues in relation to 'expanding options and access for prevention' covered during this day included: AIDS and orphaned/vulnerable children; access for the mobile and displaced; prevention among HIV+ people; and MSM in developing countries.

Orphans and vulnerable children (OVC) infected and affected by HIV/AIDS are an increasingly large population, especially in developing countries where the resources to look after them are also the most limited. Reports from NGO programmes in India, Kenya, Romania, Namibia and Uganda emphasised the importance of caring for their physical, emotional, economic and educational needs. None of the programmes distinguished between orphans directly affected by AIDS and needy children with living parents, and thus these programmes are wide-ranging in the services they offer and the way they are organized. Previously, OVC programmes have focused on current needs, but as the numbers of OVC grow and they get older, longer-term approaches that address their future needs and integration within society will be needed.

Sexuality in general, and transmission prevention in particular, among positive people is an area that urgently requires much more attention as the numbers of infected people increase and as they live longer. Positive people have an equal right to a full and satisfying sex life, and so ways in which this can be facilitated need to be explored and developed urgently. And from at least three perspectives: de-stigmatizing the idea that positive people should not have sex; ensuring that sex is fully protected; and support to (re)gain the emotional and physical capacity to have sex. Disclosure of status is sometimes mandatory, sometimes voluntary, but often ambiguously handled legally. As disclosure does not necessarily equate with prevention, the legal and ethical issues need to be handled carefully. Lowest levels of disclosure are found among pregnant women who learn through PMTCT, because they have the most to lose through informing their friends and family: violence, social rejection, and loss of economic support through being thrown out the family are all real possibilities. Poor, young, married positive women are thus once more the most disadvantaged group.

MSM in developing countries are becoming an increasingly recognised group, both because of personal vulnerability and because of the bridging role they play with the female population. Presentations from Africa, Asia and Latin America highlighted the fact that many MSM did not define themselves as homosexual. The diversity of contexts and behaviours relating to MSM in developing countries urgently needs more attention at the societal level to be able to reduce the stigma and thus develop appropriate support mechanisms for practising MSM.

Mobile and displaced populations are not only vulnerable to HIV infection because of the social and economic stresses caused by their situation, but how to provide prevention, care and treatment is also poorly understood. Presentations from Thailand, Uganda, Malaysia, UNHCR and DfID illustrated many issues facing migrants and those responsible for supporting them including: cultural differences in offering services; stigma, discrimination and lack of basic rights; limited acccess to economic resources and services; border restrictions on positive people; rapidly changing patterns, especially among displaced persons.

Expanding prevention requires reducing vulnerability, and examples from several countries were presented to illustrate the importance of mainstreaming HIV/AIDS into development efforts generally, rather than focusing only on vertical HIV/AIDS programmes. These means not only addressing medical and behavioural factors, but also developmental or structural determinants through interventions that reduce social and economic vulnerability.