Kiva: Using microfinancing to help people in developing countries

Paul Farmer, one of the founders of Partners in Health, describes the ‘great epi divide,’ the epidemiological divide that exists between developed countries and developing countries, between affluent neighborhoods and less well-off neighborhoods, between the haves and the have-nots. Morbidity and mortality associated with infectious diseases, Farmer notes, correlate well with economic disparities.

HIV/AIDS is no exception. Certainly, HIV can, and does, infect people of all walks of life. Increasingly, though, the HIV burden is highest among developing countries and the poor within developed countries. The reasons for this correlation are many. In economically challenged areas, medical care and treatment often are unavailable or unaffordable. In these areas, access to education may be limited. The list goes on.

One could argue, then, that improving the economic independence of people is the ultimate weapon against the spread of HIV. One group addressing the issue of economic independence in developing countries is KIVA. Kiva, Swahili for ‘agreement,’ is a non-profit organization designed to help people gain economic independence through microfinancing. Individuals can search the Kiva web site for people in Africa, central Asia, eastern Europe, and other parts of the world, who have great ideas, but need some initial capital. Through Kiva, one can make small, interest-free loans to these individuals. In some cases, a few hundred dollars may be all that a person needs to open a small bakery or expand a pottery shop.

The loans aren’t guaranteed; as a donor, you may never be repaid. But the results could be transformative. A little seed money may be all a person needs to become self-sufficient and cross the great epi divide.

Find out more about Kiva and help someone make their dreams a reality.

Until next time, I’m Dave Wessner.

HIV/AIDS in Prisons

Welcome to this installment of the AIDS Pandemic, a podcast hosted by Dave Wessner of the Department of Biology at Davidson College. I am Justin Fried.

Prisons have become a fertile ground for the HIV epidemic in the United States. In fact the Joint United Nation Programme on AIDS (UNAIDS) listed prisoners as one of the four "major at-risk and neglected populations" in the HIV/AIDS pandemic (2006 Report on the Global AIDS Epidemic). The other three categories included men who have sex with men, injection drug users, and sex workers (2006 Report on the Global AIDS Epidemic). Recent figures show that 2.3 percent of state prison inmates, and 1.0 percent of federal prison inmates in the United States are HIV positive, and an estimated 20 to 26 percent of people living with HIV have spent time in the correctional system (2006 Report on the Global AIDS Epidemic and Kantor 2006). The overcrowded and typically understaffed prisons in the United States are ideal breeding grounds for HIV. HIV is transmitted through bodily fluids with sharing needles and unprotected sex being the leading causes of virus transmission. Despite strict regulations against drugs in prisons, intravenous drug use still occurs. Clean needles are almost impossible to find and needles or improvised injection devices are often shared by inmates. These needles may also be shared for tattooing, another common practice in prisons. In addition to drugs, many inmates turn to sex to escape the boredom of prison life. Because distribution of condoms is prohibited in most penal institutions across the United States, safe sex is not even an option for most inmates. Sexual assault and rape, which are common intimidation tactics used by inmates, are also potential sources of transmission of HIV in correctional facilities (2006 Report on the Global AIDS Epidemic).

While high risk behaviors common to prisons put inmates at a higher risk for HIV infection while incarcerated, most HIV positive prisoners were infected before being sent to prison (HIV/AIDS Prevention). Indeed, the populations most vulnerable to the HIV infection are the same communities at high risk for criminalization and incarceration (HIV/AIDS Prevention). Fear of discrimination deters prisoners from accessing the voluntary HIV testing available in most prisons. Test result confidentiality is a major issue in a prison environment where even the suspicion of a positive test result can lead to stigmatization, bringing social isolation and violence from other inmates and sometimes even prison staff. The fear of stigmatization also discourages many inmates living with HIV from seeking medical services and treatment. Prison conditions also undermine the dosing schedules that are important for the effectiveness of antiretroviral therapy. Transfers of inmates to different correctional institutions or to and from courthouses can cause gaps in treatment. Searches for contraband may also result in medicine confiscation (Kantor 2006).

Addressing the problem of HIV and AIDS in prisons requires a multifaceted approach. UNAIDS believes that it is essential that prisoners be allowed access to prevention materials, including condoms, safer-sex supplies, and bleach kits for cleaning needles (HIV/AIDS Prevention). Increasing HIV and AIDS awareness through prisoner health education programs is crucial to decreasing the stigmatization of HIV inside prisons that prevents many inmates from seeking testing or treatment. For inmates living with HIV, provisions must be taken to ensure the regular interruptions of a prisoner’s life do not interrupt his or her antiretroviral therapy.

The Hampden County Correctional Facility in Massachusetts is a prison which is taking steps towards providing preventive education and effective health care to its inmates. This prison has adopted a health care program based on a public health model that provides inmates with a community-based standard of care (Kahn 2000). This program is based around five basic tenets: detection, effective and prompt treatment, education, prevention, and continuity of care. Prisoners undergo a three-day orientation upon admission and are given a full physical exam including tests for common communicable diseases. After attending an intensive peer-led educational session on HIV and AIDS, new inmates are encouraged to take an HIV test. Inmates that test positive for HIV then undergo additional tests to determine how best to proceed with treatment. Doctors, nurses, and case managers from the community are brought into the jail to deliver services to inmates. After the prisoners are released they have the option of continuing with the same primary care providers through a comprehensive discharge plan that includes Medicaid benefits and other supportive services (Kahn 2000).

The Hampden County Correctional facility is taking steps in the right direction, but fighting HIV in prisons is an uphill battle that will require revolutionizing prison health care. For changes to be made, Americans must first recognize that prisons are not isolated from the world, and that most inmates will eventually be released and infections acquired inside prison walls can be transmitted to the society outside. Preventing and treating HIV in prisons will benefit society as a whole and is important in the fight against AIDS.

Until next time, I am Justin Fried.
References

At Risk and Neglected: Four Key Populations. 2006 Report on the Global AIDS Epidemic. Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from http://data.unaids.org/pub/GlobalReport/2006/2006_GR_CH05_en.pdf

HIV/AIDS Prevention, Care, and Treatment in Prison Settings: A Framework for an Effective National Response. Health Organization and Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from
http://data.unaids.org/pub/Report/2006/20060701_HIV-AIDS_prisons_en.pdf.

Kahn, Stanya. Fire in the belly: A model program stresses community involvement. AIDS Info NYC. January 2000. Retrieved Dec 2, 2006 from http://www.aidsinfonyc.org/hivplus/issue6/report/model.html.

Kantor, Elizabeth. HIV Transmission and Prevention in Prisons. HIV Insight. April 2006. Retrieved Dec 2, 2006 from http://hivinsite.ucsf.edu/InSite?page=kb-07-04-13

Male Circumcision and HIV/AIDS

“When is it appropriate for public health practice to be on the side of an intervention that causes bodily injury?” (Franco)

I'm Erika Larson.

That is the question McGill’s Professor of Epidemiology, Eduardo Franco, asked when addressing circumcision as a possible method of reducing HIV prevalence. Circumcision has historically caused a polarizing debate across sectors of society including the pious, and the hygienic. Health workers have generally abstained from taking a side. However, new evidence that circumcision reduces infectivity of HIV may alter this precedent.

A recent study in the Journal of Infectious Diseases, Baeten et al. explore “Female to Male Infectivity of HIV-1 among Circumcised and Uncircumcised” in a cohort of Kenyan men. Unlike previous studies which did not isolate behavioral practices, this analysis designates per-sex act probabilities of HIV-1 transmission between circumcised and uncircumcised men.

Between 1993 and 1997, 745 Kenyan men, employed by six trucking companies around the Mombasa area, were recruited. After pre-counseling and informed consent, these men were examined for circumcision status, STD infection, and HIV-1 seropositivity using the ELISA antibody test. Follow-up visits included detailed accounts of sexual encounters and condom use. Each man attended a median of 4 follow-up visits over the span of 400 days. Risk reduction counseling and provision of free condoms accompanied follow-up visits.

Of the 95 uncircumcised men (13%), 11 experienced sercoconversion. Of the 650 circumcised men (87%), 32 seroconverted. Though the majority engaged in sexual activity with their wives, many were involved in extramarital sexual contact. The median number of sex acts per month (4.0) did not vary between circumcised and uncircumcised men. By using surveillance data to estimate prevalence for potential partners (wives, casual partners, and prostitutes), the researchers found an overall probability of acquiring HIV-1 through a single sex act was .0063. Female to male infectivity was higher for uncircumcised men than circumcised men (.0128 vs. .0051). Uncircumcised men were found to have over a 2-fold increased risk of HIV-1 infectivity per sex act.

Because the study could not trace the infection status or disease status of partners, some variants could not be isolated. However, ethnicity, occupation, and sexual risk behavior were statistically isolated. All results still revealed that uncircumcised men were at a higher risk for contracting HIV. The biological factors that cause this discrepancy could be the result of the thick skin that develops after circumcision which prevents HIV from targeting Langerhans cells.

Another study by French and South African researchers found results so dramatic that the control group was given the option to undergo the procedure. New research has created a wave of optimism in the scientific community. Dr. Seth Berkley, president of the International AIDS Vaccine Initiative, stated circumcision would be “an intervention that works over a person’s lifetime and could reduce HIV in a community setting.” Questions of acceptance as a risk-reduction policy were appeased in a recent South African study. In a survey of uncircumcised men, 70% stated they would undergo the procedure if it “proved to protect against sexually transmitted diseases.”

However optimism of community acceptance is marred by a false sense of security that circumcision could create. Increased risk behavior on the part of circumcised men could counter-act the benefits. For example 30% of uncircumcised men and 18% of circumcised men believed that the procedure would allow them to safely engage in sex with multiple partners.

Though we have already seen considerable risk-taking in prevention policy with needle exchange programs and safe injection facilities, circumcision continues to push the envelope on ethical approaches. Can we promote circumcision as a global policy to help weaken the horrifying forces of HIV? Is it feasible to pursue a worldwide circumcision effort especially in countries that rely on traditional practices (whose circumcision procedures may increase HIV-risk)? How can we prevent the unintentional consequences of viewing circumcision as a cure and the abandonment of safe-sex practices? Though circumcision does not affect HIV prevalence in men who have sex with men or IV drug users, it has huge possibilities on the African continent where heterosexual contact is the primary mode of transmission.