Journal articles on the topic 'HIV-positive persons – Counseling of – Zimbabwe'

As the AIDS epidemic continues to claim lives, the issues of testing, confidentiality, and refusal to care for seropositive patients generate increasing debate and concern among health care workers, legislators, and the general public. Protecting the uninfected from exposure to HIV, providing adequate medical care and counseling to HIV-positive persons, and preventing discrimination are necessary and immediate goals. Adherence by practitioners to both the current legislation on AIDS and the ethical imperatives of the health professions will facilitate adequate access to health care for all persons with AIDS. It will also provide necessary guidelines for issues of confidentiality.

We investigated how follow-up counselling had increased linkage to HIV care in a trial of referral to care and follow-up counseling, compared to referral to care only, for participants diagnosed as HIV-positive through home-based HIV counseling and testing. We carried out a cross-sectional qualitative study. Using random stratified sampling, we selected 43 trial participants (26 [60%] in the intervention arm). Sample stratification was by sex, distance to an ART facility, linkage, and nonlinkage to HIV care. Twenty-six in-depth interviews were conducted with participants in the intervention arm: 17 people who had linked to HIV care and 9 who had not linked after 6 months of follow-up. Home-based follow-up counseling helped to overcome worries resulting from an HIV-positive test result. In addition, the counseling offered an opportunity to address questions on HIV treatment side effects, share experiences of intimate partner violence or threats, and general problems linking to care. The counselling encouraged early linkage to HIV care and use of biomedical medicines, discouraging alternative medicine usage. Home-based follow-up counseling also helped to promote HIV sero-status disclosure, facilitating linkage to, retention in and adherence to HIV care and treatment. This study successfully demonstrated that home-based follow-up counselling increased linkage to care through encouragement to seek care, provision of accurate information about HIV care services and supporting the person living with HIV to disclose and manage stigma.

We evaluated the efficacy of a brief motivational intervention (MI) counseling in reducing alcohol consumption among persons living with HIV/AIDS in Kampala, Uganda. Persons living with HIV/AIDS with Alcohol Use Disorders Identification Tool (AUDIT) score ≥3 points were randomized to either standardized positive prevention counseling alone or in combination with alcohol brief MI counseling. The mean change in AUDIT-C scores over 6 months was compared by treatment arm. The mean (standard deviation [SD]) AUDIT-C scores were 6.3 (2.3) and 6.8 (2.3) for control and MI arms ( P = .1) at baseline, respectively, and change in mean AUDIT-C score was not statistically different between arms over the 6 months ( P = .8). However, there was a statistically significant decrease in mean AUDIT-C score (−1.10; 95% confidence interval: −2.19 to −0.02, P = .046) among women in the MI arm. There was a nondifferential reduction in alcohol consumption overall, but MI appeared effective among women only. Studies with more than 1 counseling session and evaluation of gender differences in treatment response are needed.

The United States has the world’s highest prison population, and an estimated one in seven HIV-positive persons in the USA passes through a correctional facility annually. Given this, it is critical to develop innovative and effective approaches to support HIV treatment and retention in care among HIV-positive individuals involved in the criminal justice (CJ) system. Information and communication technologies (ICTs), including mobile health (mHealth) interventions, may offer one component of a successful strategy for linkage/retention in care. We describe CARE+ Corrections, a randomized controlled trial (RCT) study now underway in Washington, that will evaluate the combined effect of computerized motivational interview counseling and postrelease short message service (SMS) text message reminders to increase antiretroviral therapy (ART) adherence and linkage and retention in care among HIV-infected persons involved in the criminal justice system. In this report, we describe the development of this ICT/mHealth intervention, outline the study procedures used to evaluate this intervention, and summarize the implications for the mHealth knowledge base.

Introduction/Aim: Voluntary and confidential counseling and testing (VCCT) means getting information about HIV, ways of transmission, recognizing, reducing or avoiding risks for HIV infection, about safe sexual relations, the place where people can be tested, and what they should do depending on the test results in order to protect themselves and other people. The aim of this study was to examine differences in demographic characteristics, risky behavior and HIV status between men and women who were voluntarily and confidentially counseled and tested at the Counseling Center for HIV/AIDS of the Institute of Public Health in Belgrade. Methods: This research was conducted as a cross-sectional study and it included 3,480 persons (43.2% of women and 56.8% of men), who were counseled and tested at the Counseling Center for HIV/AIDS of the Institute of Public Health in Belgrade from 2017 to 2019. ch2 or Fisher's test was used for the statistical analysis of data. Results: The majority of women (42.1%) and men (42.5%) who were counseled and tested were in the age group 21-30 years. Men used DPST services significantly more often than women. HIV positive status was significantly more frequent in men (2.5%) than in women (0.3%). Women came significantly more often to voluntary counseling and testing due to the possible exposure to HIV infection by heterosexual contact (84.9%), accident (11.1%) and raping (1.0%), while men were counseled and tested due to heterosexual contact (59.3%), homosexual and bisexual contact (33.6%) and intravenous drug abuse (1.1%). Men used condoms always or often (40.1%) and had two or more partners (53.2%) more frequently during the last 12 months in comparison to women (24.2% and 20.6%). Conclusion: Voluntary and confidential counseling and testing is necessary in the fight against HIV infection, especially from the perspective of early discovering of people with this infection and education of HIV negative persons about risky sexual behavior and possible prevention measures.

Background German statutory health insurance began covering the costs associated with HIV PrEP in September 2019; however, to bill for PrEP services, physicians in Germany must either be certified as HIV-specialists according to a nationwide quality assurance agreement, or, if they are non-HIV-specialists, have completed substantial further training in HIV/PrEP care. Given the insufficient implementation of PrEP, the aim of our study was to explore the potential to increase the number of non-HIV-specialists providing PrEP-related services. Methods We conducted an anonymous survey among a random sample of internists, general practitioners, dermatologists and urologists throughout Germany using a self-developed questionnaire. We calculated a knowledge score and an attitudes score from individual items in these two domains. Both scores ranged from 0–20, with high values representing good knowledge or positive attitudes. We also asked participants about the proportion of PrEP advice they provided proactively to men who have sex with men (MSM) and trans-persons who met the criteria to be offered PrEP. Results 154 physicians completed the questionnaire. Self-assessed knowledge among HIV-specialists was greater than among non-HIV-specialists [Median knowledge score: 20.0 (IQR = 0.0) vs. 4.0 (IQR = 11.0), p<0.001]. Likewise, attitudes towards PrEP were more positive among HIV-specialists than non-HIV-specialists [Median attitudes score: 18.0 (IQR = 3.0) vs. 13.0 (IQR = 5.25), p<0.001]. The proportion of proactive advice on PrEP provided to at-risk MSM and trans-persons by HIV-specialists [Median: 30.0% (IQR = 63.5%)] was higher than that provided by non-HIV-specialists [Median: 0.0% (IQR = 11.3%), p<0.001]. However, the results of our multiple regression suggest the only independent predictor of proactive PrEP advice was the knowledge score, and not whether physicians were HIV-specialists or non-HIV-specialists. Conclusions These findings point to opportunities to improve PrEP implementation in individuals at risk of acquiring HIV. Targeted training, particularly for non-HIV-specialists, and the provision of patient-centered information material could help improve care, especially in rural areas.

When COVID-19 was declared a pandemic, there was concern that TB and HIV services in Zimbabwe would be severely affected. We set up real-time monthly surveillance of TB and HIV activities in 10 health facilities in Harare to capture trends in TB case detection, TB treatment outcomes and HIV testing and use these data to facilitate corrective action. Aggregate data were collected monthly during the COVID-19 period (March 2020–February 2021) using EpiCollect5 and compared with monthly data extracted for the pre-COVID-19 period (March 2019–February 2020). Monthly reports were sent to program directors. During the COVID-19 period, there was a decrease in persons with presumptive pulmonary TB (40.6%), in patients registered for TB treatment (33.7%) and in individuals tested for HIV (62.8%). The HIV testing decline improved in the second 6 months of the COVID-19 period. However, TB case finding deteriorated further, associated with expiry of diagnostic reagents. During the COVID-19 period, TB treatment success decreased from 80.9 to 69.3%, and referral of HIV-positive persons to antiretroviral therapy decreased from 95.7 to 91.7%. Declining trends in TB and HIV case detection and TB treatment outcomes were not fully redressed despite real-time monthly surveillance. More support is needed to transform this useful information into action.

Background: Clinical presentations of Tuberculosis (TB) vary with in HIV positive and HIV negative individuals. Smear negative tuberculosis is the leading cause of death of HIV patients. Objective: To examine the relationship between bacteriological status of TB cases and TB symptoms in HIV patients. Methods: A cross-sectional analytical study was conducted during January 2004 and August 2005 in a representative sample of 100 HIV infected persons visiting different Voluntary Counseling and Testing Centers (VCT) and HIV/AIDS care centers located in Kathmandu. Laboratory investigation of Tuberculosis was done by AFB staining and culture in ogawa medium. Data obtained through pre structured questionnaire and laboratory investigation were entered into SPSS 11.5 and analyzed. Results: Twenty three percent prevalence of TB is observed in HIV patients. Eighty one percent of the total TB cases were smear negative cases. Significant relationship was observed between the TB symptoms and Smear positive TB cases (χ2 =4.01, p<0.05, at 1 degree of freedom) but no significant relationship could be established between TB symptoms and smear negative cases (χ2 =0.82, p>0.05, at 1 degree of freedom). Mycobacterium avium complex (40.9%) was predominant followed by M. tuberculosis (27.3%) Conclusion: In HIV patients, the utility of direct microscopy of AFB stained smear is limited because most of these patients were smear negative and are asymptomatic. So, direct microscopy in combination with Culture is recommended for higher case finding of TB in HIV patients. Key words: Asymptomatic; smear negative TB; HIV/AIDS; Kathmandu DOI: 10.3126/saarctb.v5i1.3077 SAARC J. Tuber. Lung Dis. HIV/AIDS 2008 Vol.5(1) 7-12

Abstract Background The South Florida Metropolitan Statistical Area has for several years recorded the highest HIV incidence in the nation, and prevalence in the top three of all counties. To address the alarming disparity in HIV impact, we developed a survey study to learn about the beliefs, attitudes, and perspectives of persons who accessed services at an HIV community-based organization in South Florida. Methods Surveys were administered in English and Spanish to 109 persons who visited a community-based HIV service provider (Latinos Salud) at any of its three South Florida sites in April 2019. The survey evaluated the participants’ perspectives on different avenues for HIV counseling, screening, and accessing HIV medications for prevention or treatment. Results The majority of survey participants were male (90%), homosexual/gay/queer (75%), and Hispanic/Latino (56%; Table 1). Participants’ self-reported their HIV status as negative (64%), positive (30%), or unknown (6%; Table 1). Of those not currently living with HIV, 77% reported having been tested within the past 6 months, and 81% reported recent engagement in high-risk activities (Table 1). Most participants considered using social media to promote awareness of HIV and related services a good idea (Table 2). Large proportions of participants endorsed receiving HIV counseling through in-person conversations with clinicians (91%), staff at community-based organizations (83%), friends (83%), telehealth visits (69%), conversations with teachers (63%), or church members (56%; Table 2). Most participants endorsed a range of both clinical (e.g. local health clinic) and non-clinical (e.g. mobile van) locations as acceptable settings for HIV testing (Table 2). Large proportions of participants endorsed receiving medications to prevent or treat HIV immediately after testing (82%), by home delivery (78%), or through telehealth (60%; Table 2). Meaningful associations were found between certain patient demographics (race/ethnicity, testing history, or insurance status) and the participants’ perspectives on specific strategies (Table 3). Table 1. Participant Characteristics Table 2. Participants’ Views on Strategies for HIV Counseling, Testing, and Access to Medications Table 3. Participants’ Views on Strategies for HIV Counseling, Testing, and Access to Medications Stratified by Patient Characteristics Conclusion These real-world findings can be used to inform clinic- and community-based interventions tailored to individual patient characteristics. Disclosures Tamar Sapir, PhD, Gilead Sciences, Inc. (Other Financial or Material Support, Independent medical education grant)

This study investigates Vocational Rehabilitation (VR) services related to competitive employment closure among non-Hispanic Blacks (NHB), non-Hispanic Whites (NHW), and Hispanics with HIV/AIDS and substance use disorder (SUD). Data of 4150 was extracted from the Rehabilitation Services Administration (RSA-911) database. Descriptive statistics and multi-variate analysis showed consumers who received SSI and Medicare were less likely to be employed than those who did not, and, NHW who received rehabilitation counseling and guidance benefited the most compared to NHB who did not. Rehabilitation counselors can assist minorities with HIV/AIDS and SUD secure employment given the positive effects of employment for this population. Health professionals should consider incorporating employment, using VR services in their treatment strategies, while making sure clients with different racial ethnicity background benefit equally from all VR services.

Setting: Nineteen health facilities in rural, southeastern Malawi.Objective: To describe the implementation and results of a 6-week intervention to accelerate human immunodeficiency virus (HIV) case finding.Design: Six HIV testing strategies were simultaneously implemented. Routinely collected data from Ministry of Health registers were used to determine the number of HIV tests performed and of new cases identified. The weekly averages of the total number of tests and new cases before and during the intervention were compared. Testing by age group and sex was described. The percentage yield of new cases was compared by testing strategy.Results: Of 29 703 HIV tests conducted, 1106 (3.7%) were positive. Of the total number of persons tested, 69.5% were women and 75.5% were aged >15 years. The yield of positive test results was 3.5% among women, 4.3% among men, 4.4% among those aged >15 years and 1.5% among those aged 15 years. The average weekly number of tests increased 106.7% from 3337 to 6896 (P = 0.002). The average weekly number of positive cases identified increased 51.9% from 158 to 240 (P = 0.017). The testing strategy with the highest yield resulted in a 6.0% yield; the lowest was 1.3%. The yield for all strategies, except one, was highest in adult men.Conclusion: A multi-strategy approach to HIV testing and counseling can be an effective means of accelerating HIV case finding.

Introduction: The Human Immunodeficiency Virus (HIV) infection is a global pandemic affecting principally the sexually active and economically productive population of any country. Additionally the dual epidemic of HIV and TB infection is of growing concern in Asia, where nearly two-third of TB-infected individuals live and where tuberculosis now accounts for 40 percent of HIV/AIDS deaths. Keeping this in mind, a study was conducted to understand the profile of HIV/AIDS patients attending Integrated Counseling and Testing Center (ICTC) located at Primary Health Centre, Palam in Delhi.Methodology: This was a descriptive record based study undertaken at ICTC, PHC PALAM, New Delhi. Records of all HIV seropositive patients identified in reference period (January 2010 to December 2014) were analyzed retrospectively to assess the socio-demographic and clinical profile including possible route of transmission, CD4 counts at the time of first reporting to the Anti Retroviral Treatment (ART) centre and the presence of co-infections including tuberculosis were recorded. Total 77 HIV seropositive patients were identified.Results: Mean Age of presentation of male was 31.18 ± 8.85 years (12-60 years) and female 30.30 ± 10.07 years (7-53 years). Majority of HIV+ persons were married (16% of males and 6% females were unmarried).24% of women were widows. Majority of HIV+ males and females had only primary schooling. 11% males and 21% females were illiterate. Main occupations of HIV+ males were daily wages labor and salaried service or other unspecified four out of 5 HIV+ women were housewives 70% of subjects were either referred from RNTCP or were self reporting. Heterosexual route was the most common route of transmission. Mean CD4 counts Males: 190.48 ± 180.52, Females: 286.21 ± 220.25 (t=2.09; p=0.039, significant).At the time of first reporting to ART centers, mean CD4 count was significantly higher in HIV+ females as compared to males. More than 50% of HIV+ males and 30% of females had co-infection of HIV & TB. CD4 count was associated with gender and co-infection with TB. Significantly higher odds of HIV-TB co-infection among male as compared to females (chi-square=4.49, p=0.034) and odds Ratio=2.76(1.07 – 7.14)Conclusions: Low literacy and some occupations carry higher risk of HIV. CD4 count was associated with gender and co-infection with TB. Odds of co-infection with TB were higher in males. Analysis of information at ICTC & ART centre should be used to monitor and plan HIV prevention and control in the area.SAARC J TUBER LUNG DIS HIV/AIDS, 2017; XIV(1), page: 22-26

Abstract Background The restriction of reproductive rights of HIV-positive couples in low-resource settings could be related to the attitudes and skills of health workers. We assessed health workers’ knowledge of safer conception and their attitudes toward the reproductive rights of HIV-positive couples in a tertiary hospital in Nigeria. Methods A cross-section of health workers (n=294) was interviewed using structured questionnaires. Knowledge and attitude scores were analyzed. Logistic regression was employed to generate adjusted odds ratios (AORs) for predictors of attitude. Results Safer conception methods mentioned by respondents included timed unprotected intercourse with (27.9%) and without antiretroviral pre-exposure prophylaxis (37.4%), in vitro fertilization plus intracytoplasmic sperm injection (26.5%), and sperm washing and intrauterine insemination (24.8%). The majority (94.2%) of health workers acknowledged the reproductive rights of HIV-infected persons, although (64.6%) strongly felt that HIV-infected couples should have fewer children. Health workers reported always/nearly always counseling their patients on HIV transmission risks (64.1%) and safer conception (59.2% and 48.3% for females and males, respectively) (p<0.05). Among health workers, being older (30–39 vs <30 y) (AOR=1.33, 95% CI=1.13–2.47), married (AOR=2.15, 95% CI=1.17–5.58) and having a larger HIV-positive daily caseload (20–49 vs <20) (AOR=1.98, 95% CI=1.07–3.64) predicted positive attitude towards reproductive rights of HIV-affected couples. Conclusions Health workers had limited knowledge of safer conception methods, but were supportive of the reproductive rights of HIV-positive couples. Health workers in Nigeria require training to effectively counsel couples on their reproductive rights, risks and options.

Abstract Background In our urban, underserved patient population, Human Immunodeficiency Virus (HIV) is hyper-endemic, and HIV screening is frequently performed. Although HIV screening tests have high specificity, false positives can occur. Numerous reasons for false positive testing have been cited, including vaccinations, autoimmune diseases, and viral infections. In 2019, Philadelphia experienced a large Hepatitis A outbreak, during which time false positive HIV screening tests were discovered. Our aim was to further describe these patients who had been diagnosed with acute Hepatitis A infection and in whom false positive HIV testing had occurred. Methods We conducted a retrospective chart review of adult patients admitted to our hospital between January 2017 and December 2019 who had a positive Hepatitis A Virus (HAV) IgM. Demographics, HIV tests, viral hepatitis tests, and liver tests were recorded. False positive HIV was defined as a positive HIV screen (p24 antigen and HIV-1 and 2 antibody combo), followed by a negative differentiation assay for HIV-1 and 2 antibodies, combined with a negative HIV PCR. Results A total of 156 unique patients were found to have acute HAV, with 138 cases identified in 2019. Of these, 3 patients had confirmed false positive HIV testing, and 1 patient had suspected false positive HIV testing (HIV-2 differentiation assay indeterminate, with very low local prevalence of HIV-2), for a false positive test rate of 2.6% (4/156). Ages ranged from 36-47 years, 3 were male, and 2 were persons who injected drugs (PWID). Three patients had prior negative HIV testing. Two patients had fevers during admission, but none of the four were febrile at the time of HIV test collection. Three patients had elevated transaminases, and two had abnormal coagulation testing. Coinfection with Hepatitis C was found in three patients. One patient had follow-up HIV testing performed, which was negative. Conclusion To our knowledge, this is the first report of false positive HIV testing related to acute HAV. Prevalence of false positives was low, but awareness can facilitate patient counseling. With low sample size, conclusions cannot be drawn about risk factors related to false positive testing. Disclosures All Authors: No reported disclosures

Abstract Background The Southeastern United States bears a disproportionate burden of HIV infection, accounting for nearly half of all new cases. The Centers for Disease Control and Prevention released routine opt-out testing recommendations in 2006. Our emergency department collaborated with our infectious diseases clinic (ECU-ID) to implement suggested guidelines among adults since March 2017. Methods Our primary aim was to implement routine, opt-out HIV testing in the Vidant Medical Center Emergency Department (ED) for patients between 18 and 65 years of age who have blood work completed, and have not had a test documented in the electronic medical record (EMR) in the last year. A secondary aim was to successfully link HIV-positive patients to care at ECU-ID or preferred clinic. Methods defining programmatic success included developing nurse directed opt-out ordering protocol, integrating testing into normal ED workflow, utilizing the existing EMR to prompt testing, and hiring a linkage coordinator to initiate post-test counseling and linkage-to-care. Results Since March 2, 2017, a total of 7,109 HIV tests were performed; an average of 592 monthly tests conducted compared with a previous average of 10 stat tests. Testing increased 5,820% compared with 2015. Of the 21 HIV-positive patients found, 16 were newly diagnosed. Among those newly diagnosed, 14 (87.5%) were linked to care; and among the five known positives, two (40%) were linked to care. Reasons why patients could not be linked included incarceration, refusal to link to care, and re-location. Conclusion Joined with the implementation of a routinized ED HIV testing program, a seamless process was developed to link persons found to be positive in the ED to HIV care services; therefore, establishing a systems-level prevention model. Future plans include expanding testing to adolescents and utilizing similar methods to integrate Hepatitis C testing. Disclosures All Authors. Gilead Sciences, Inc.: Grant Investigator, Grant recipient and Salary.

HIV prevalence in Kenya remains steady at 5.6% for adults 15 years and older, and 0.9% among children aged below 14 years. Parents and children are known to practice unprotected sex, which has implications for continued HIV spread within the country. Additionally, due to increased accessibility of antiretroviral therapy, more HIV-positive persons are living longer. Therefore, the need for HIV disclosure of a parent’s and/or a child’s HIV status within the country will continue for years to come. We conducted a qualitative phenomenological study to understand the entire process of disclosure from the time of initial HIV diagnosis of an index person within an HIV-affected family, to the time of full disclosure of a parent’s and/or a child’s HIV status to one or more HIV-positive, negative, or untested children within these households. Participants were purposively selected and included 16 HIV-positive parents, seven HIV-positive children, six healthcare professionals (physician, clinical officer, psychologist, registered nurse, social worker, and a peer educator), and five HIV-negative children. All participants underwent an in-depth individualized semistructured interview that was digitally recorded. Interviews were transcribed and analyzed in NVivo 8 using the modified Van Kaam method. Six themes emerged from the data indicating that factors such as HIV testing, living with HIV, evolution of disclosure, questions, emotions, benefits, and consequences of disclosure interact with each other and either impede or facilitate the HIV disclosure process. Kenya currently does not have guidelines for HIV disclosure of a parent’s and/or a child’s HIV status. HIV disclosure is a process that may result in poor outcomes in both parents and children. Therefore, understanding how these factors affect the disclosure process is key to achieving optimal disclosure outcomes in both parents and children. To this end, we propose an HIV disclosure model incorporating these six themes that is geared at helping healthcare professionals provide routine, clinic-based, targeted, disclosure-related counseling/advice and services to HIV-positive parents and their HIV-positive, HIV-negative, and untested children during the HIV disclosure process. The model should help improve HIV disclosure levels within HIV-affected households. Future researchers should test the utility and viability of our HIV disclosure model in different settings and cultures.

Objectives Correctional settings (prisons, jails, detention facilities) provide a unique opportunity to screen for sexually transmitted infections (STIs) among correctional populations with a high prevalence of infection. Immigrant detainees are a distinct and poorly described correctional population. The main objective of this study was to determine the feasibility of a national STI screening program for immigrant detainees. Methods and Materials We developed an opt-out STI testing program that included electronic health record integration, patient education, and staff member training. We piloted this program from June 22 through August 19, 2018, at 2 detention facilities with different operational requirements and detainee demographic characteristics. We assessed STI test positivity rates, treatment outcomes, estimated cost to conduct testing and counseling, and staff member perceptions of program value and challenges to implementation. Results Of 1041 immigrant detainees approached for testing, 526 (50.5%) declined. Of 494 detainees who were tested, 42 (8.5%) tested positive for at least 1 STI; the percentage positivity rates were 6.7% (n = 33) for chlamydia, 0.8% (n = 4) for syphilis, 0.8% (n = 4) for gonorrhea, 0.6% (n = 3) for hepatitis B, and 0.2% (n = 1) for HIV. The estimated cost to detect any STI ranged from $500 to $961; the estimated cost to identify 1 person infected with HIV ranged from $22 497 to $43 244. Forty of 42 persons who tested positive began treatment before release from custody. Medical staff members had positive views of the program but had concerns about workload. Practice Implications STIs are prevalent among immigrant detainees. A routine screening program is feasible if operational aspects are carefully considered and would provide counseling, education, and treatment for this vulnerable population.

Background Pre-exposure prophylaxis (PrEP) is highly effective and an important prevention tool for African adolescent girls and young women (AGYW), but adherence and persistence are challenging. PrEP adherence support strategies for African AGYW were studied in an implementation study. Methods and findings HIV Prevention Trials Network (HPTN) 082 was conducted in Cape Town, Johannesburg (South Africa) and Harare (Zimbabwe) from October 2016 to October 2018 to evaluate PrEP uptake, persistence, and the effect of drug level feedback on adherence. Sexually active HIV–negative women ages 16–25 were offered PrEP and followed for 12 months; women who accepted were randomized to standard adherence support (counseling, 2-way SMS, and adherence clubs) or enhanced adherence support with adherence feedback from intracellular tenofovir-diphosphate (TFV-DP) levels in dried blood spots (DBS). PrEP uptake, persistence through 12 months (no PrEP hold or missed visits), and adherence were assessed. The primary outcome was high adherence (TFV-DP ≥700 fmol/punch) at 6 months, compared by study arm. Of 451 women enrolled, median age was 21 years, and 39% had curable sexually transmitted infections (STIs). Most (95%) started PrEP, of whom 55% had uninterrupted PrEP refills through 12 months. Of those with DBS, 84% had detectable TFV-DP levels at month 3, 57% at month 6, and 31% at month 12. At 6 months, 36/179 (21%) of AGYW in the enhanced arm had high adherence and 40/184 (22%) in the standard adherence support arm (adjusted odds ratio [OR] of 0.92; 95% confidence interval [CI] 0.55, 1.34; p = 0.76). Four women acquired HIV (incidence 1.0/100 person-years), with low or undetectable TFV-DP levels at or prior to seroconversion, and none of whom had tenofovir or emtricitabine resistance mutations. The study had limited power to detect a modest effect of incentives on adherence, and there was limited awareness of PrEP at the time the study was conducted. Conclusions In this study, PrEP initiation was high, over half of study participants persisted with PrEP through month 12, and the majority of young African women had detectable TFV-DP levels through month 6 with one-fifth having high adherence. Drug level feedback in the first 3 months of PrEP use did not increase the proportion with high adherence at month 6. HIV incidence was 1% in this cohort with 39% prevalence of curable STIs and moderate PrEP adherence. Strategies to support PrEP use and less adherence-dependent formulations are needed for this population. Trial registration ClinicalTrials.gov NCT02732730.

Introduction: The Medical Monitoring Project (MMP) is a national, multi-site population-based supplemental HIV/AIDS surveillance project of persons receiving HIV/AIDS care. We compared California MMP data by region. Demographic characteristics, medical care experiences, HIV treatment, clinical care outcomes, and need for support services are described. Methods: HIV-infected patients 18 years or older were randomly selected from medical care facilities. In person structured interviews from 2007 - 2008 were used to assess sociodemographic characteristics, self-reported clinical outcomes, and need for supportive services. Pearson chi-squared, Fisher’s exact and Kruskal-Wallis p-values were calculated to compare regional differences. Results: Between 2007 and 2008, 899 people were interviewed: 329 (37%) in San Francisco (SF), 333 (37%) in Los Angeles (LA) and 237 (26%) in other California counties. Significant regional sociodemographic differences were found. Care received and clinical outcomes for patients in MMP were positive and few regional differences were identified. HIV case management (36%), mental health counseling (35%), and dental services (29%) were the supportive services patients most frequently needed. Unmet needs for supportive services were low overall. Significant differences by region in needed and unmet need services were identified. Discussion: The majority of MMP respondents reported standard of care CD4 and viral load monitoring, high treatment use, undetectable HIV viral loads and CD4 counts indicative of good immune function and treatment efficacy. Information from MMP can be used by planning councils, policymakers, and HIV care providers to improve access to care and prevention. Identifying regional differences can facilitate sharing of best practices among health jurisdictions.

ABSTRACT Introduction Since its detection in the early 1980s, HIV and AIDS have claimed 32.7 million lives. The HIV epidemic continues to plague the world with its most devastating effects felt in Eastern and Southern Africa. The exposure, vulnerability, and impact of HIV have been prominent among military personnel due to environmental, demographic, and socioeconomic characteristics. Policies have been developed to mitigate its exposure, vulnerability, and impact on the military. However, there are disparities across these policies, especially on recruitment, enlistment, and deployment. These contentions inspired this evaluation, which was designed to provide vital information and insights for militaries developing new HIV policies, for example, the Ghana Armed Forces (GAF). Materials and Methods Content analyses of key documents and secondary resources from South Africa (SA), the USA, and the United Nations and International Labour Organizations were undertaken. The key documents evaluated included HIV and AIDS policies of the SA National Defence Force (SANDF), the U.S. DoD, UN Department of Peacekeeping Operations, and International Labour Organization (ILO); national HIV and AIDS policies; and legislations of SA and the USA. Results The SANDF policy permits the recruitment of HIV-positive applicants while the U.S. DoD policy does not. Mandatory pre-employment health assessments including HIV testing is conducted for prospective applicants. Again, discrimination against persons living with HIV (PLHIV) is discouraged by national policies and legislations of both countries and the ILO policy. At the same time, the SA national policy permits discrimination based on requirement of the job.On deployment, the SANDF policy explicitly permits deployment of HIV-positive service members, while the U.S. DoD policy cautiously does so. Both policies support mandatory pre-deployment health assessments in line with the UN peacekeeping policy and medical standards even though voluntary confidential HIV counseling and testing is recommended by the UN. All HIV-positive service members are retained and offered treatment and care services; however, the U.S. DoD policy retires unfit service members after 12 months of consecutive non-deployment. Further, the UN policy repatriates service members with pre-existing medical conditions and pays no compensation for death, injury, or illness, which is due to pre-existing medical conditions or not mission-related. Conclusions First, the contents of the military policies are not very diverse since most militaries do not enlist or deploy PLHIV except few countries including SA. Implementation and interpretation is however inconsistent. Some militaries continue to exclude PLHIV despite the existence of policies that permit their inclusion. Second, discrepancies exist among the military policies, national legislations, and international policies. The UN policy is not coherent and empowers the military to exclude PLHIV. Also, potential costs to be incurred, in the form of compensation and repatriation, seem to be a major factor in the decision to deploy HIV-positive service members. Harmonization of military HIV policies to ensure uniform standards, interpretation, and implementation and the coherence of the UN policy are essential to guide countries developing new policies, for example, GAF.

Abstract Background Since 2014, the Thailand National Guidelines have recommended pre-exposure prophylaxis (PrEP) to prevent HIV among persons at risk. In March 2016, Silom Community Clinic (SCC) began PrEP provision to men who have sex with men (MSM) and transgender women (TGW) in Bangkok, Thailand. Methods SCC staff routinely counseled MSM and TGW attending HIV voluntary counseling and testing about PrEP. If clients believed that they were at substantial risk of HIV and were interested in PrEP, they could receive PrEP after screening that included HIV and renal function testing. Eligible clients received a 30-day supply of daily oral tenofovir-emtricitabine costing 800 Baht (30 USD), and completed a baseline computer-assisted self-interview (CASI) on knowledge and behaviors. At every 3-month follow-up, PrEP clients had a CASI on adherence; if they were interested in discontinuation of PrEP, they completed a CASI that included reasons for discontinuation. We conducted a descriptive analysis of baseline and follow-up CASI results. Results From March 2016 to February 2018, 192 clients were prescribed PrEP, and 80 (42%) continued PrEP for at least 6 months. The median age of clients starting PrEP was 31 years (range, 17–67 years), and 98% were MSM. Overall, most (77%) reported at least 1 of four risk behaviors in the last 3 months; among the 148, 120 (81%) had a sex partner with unknown or positive HIV status, 99 (67%) had anal sex without a condom, 22 (15%) reported an STI, and 16 (11%) received money or goods in exchange for sex. Among the 166 clients who returned for at least one follow-up visit, 135 (81%) completed the CASI at the last follow-up visit; of those, 106 (78%) reported 100% adherence to daily PrEP in the last 7 days, and 126 (93%) reported ≥80% adherence in the last 30 days. Of the 36 clients who discontinued PrEP and completed CASI, 33% reported the reason for discontinuation was no current HIV risk (33%); most (69%) reported that they would consider PrEP in the future. Conclusion Most PrEP users reported adherence to daily PrEP, and almost one half of those starting PrEP continued through month six. PrEP use at SCC is dynamic, and commonly started and stopped based on self-assessed risk. Regular review of PrEP implementation, with a focus on client needs, will optimize use of this prevention approach. Disclosures All authors: No reported disclosures.

Background Video is a versatile and popular medium for digital health interventions. As mobile device and app technology advances, it is likely that video-based interventions will become increasingly common. Although clinic waiting rooms are complex and busy environments, they offer the opportunity to facilitate engagement with video-based digital interventions as patients wait to see their providers. However, to increase efficiency in public health, leverage the scalability and low cost of implementing digital interventions, and keep up with rapidly advancing technology and user needs, more design and development guidance is needed for video-based tailored interventions. Objective We provide a tutorial for digital intervention researchers and developers to efficiently design and develop video-based tailored digital health interventions. We describe the challenges and solutions encountered with Positive Health Check (PHC), a hybrid app used to deliver a brief, interactive, individually tailored video-based HIV behavioral counseling intervention. PHC uses video clips and multimedia digital assets to deliver intervention content, including interactive tailored messages and graphics, a repurposed animated video, and patient and provider handouts generated in real time by PHC. Methods We chronicle multiple challenges and solutions for the following: (1) using video as a medium to enhance user engagement, (2) navigating the complexity of linking a database of video clips with other digital assets, and (3) identifying the main steps involved in building an app that will seamlessly deliver to users individually tailored messages, graphics, and handouts. Results We leveraged video to enhance user engagement by featuring “video doctors,” full-screen video, storyboards, and streamlined scripts. We developed an approach to link the database of video clips with other digital assets through script coding and flow diagrams of algorithms to deliver a tailored user experience. We identified the steps to app development by using keyframes to design the integration of video and digital assets, using agile development methods to gather iterative feedback from multidisciplinary teams, and creating an intelligent data-driven back-end solution to tailor message delivery to individual users. Conclusions Video-based digital health interventions will continue to play an important role in the future of HIV prevention and treatment, as well as other clinical health practices. However, facilitating the adoption of an HIV video intervention in HIV clinical settings is a work in progress. Our experience in designing and developing PHC presented unique challenges due to the extensive use of a large database of videos tailored individually to each user. Although PHC focuses on promoting the health and well-being of persons with HIV, the challenges and solutions presented in this tutorial are transferable to the design and development of video-based digital health interventions focused on other areas of health.

Objective: To determine HIV presence and risk behaviors of persons of low socio-economic status in the city of Popayan, Colombia. Methods: Cross-sectional study; between 2008 and 2009, 363 participants of Popayan signed informed consent and received pre and post HIV test counseling. Socio-demographic characteristics and history of STDs, risk behaviors and previous HIV testing were assessed. Descriptive statistics, correlations and multivariate logistic regression were calculated. Results: Mean age 33.5±10.2; 66.0% women. Frequency of HIV positive patients was 3.86% (95% CI: 1.87-5.85), greater in men (7.38%; p= 0.013). Greater frequency of HIV-positive patients was observed in people age 29-37, those without a stable partner, and those with history of risky alcohol consumption (more than five drinks in 2 hrs). Conclusions: HIV-positive patients frequency in this population was greater than national estimate for general population, aged 15-49 in Colombia, with even greater frequency in men. This study suggests that characteristics associated with low socioeconomic status, in economically active population, without a stable partner and with risky alcohol use, can potentially increase risk of HIV infection

Background: Hospital admission for any reason provides the situation for voluntary HIV testing and consultation. Identifying the predictors of positivity may lead to a cost-effective method while enhancing professionalism. Objectives: To find the predictors of HIV-positive test result in a general hospital in Shiraz compared to a control group. Methods: In this case-control study, the records of all patients who received HIV testing upon their hospitalization in a general hospital in Shiraz, south of Iran, from January 2017 to the end of December 2017 were reviewed. For each HIV-positive case, at least one control from the same ward in the hospital with negative HIV test result was randomly selected. Based on the best-fitted model of logistic regression, the probability of positive HIV test results was estimated for each participant according to the risk factors, and a receiver operating characteristic (ROC) curve was drawn. Results: Out of 7333 persons who accepted to be tested, 77 patients tested positive for HIV, of whom 55 (71.4%) were male with the mean age of 41.5 ± 9.5 years. None of the HIV-positive patients were intravenous drug users, nor had they a history of imprisonment. The odds ratio (OR) was 21 for hepatitis-positive patients (hepatitis B and/or C) compared to negative ones, which was seven times higher in opium addicts than non-opium addicts. We developed a model using age, sex, opium addiction, and HBV and HCV status to predict the probability of being positive for HIV with an AUC of 0.853 (95% confidence interval 0.797 to 0.909). Conclusions: Hospital admission could be an appropriate momentum for providing voluntary counseling and testing. Infection with HBV and HCV are important risk factors for HIV infection, and additional testing should be offered, especially to these patients.

Background: Early detection and effective treatment with antiretroviral drugs would help preserve/improve the immune system, ameliorate quality of life of persons with HIV/AIDS and prevent unintentional spread of the virus. To that end provider initiated HIV counseling and testing (PIHCT) is recommended as standard of care for all patients attending health facilities in HIV endemic countries. This study aimed at determining the prevalence and factors associated with unknown HIV infection among medical admissions at Muhimbili National Hospital (MNH) as an indicator of PIHTC practice in Dares salaam, Tanzania. Methods: Patients newly hospitalized into MNH medical wards with unknown HIV sero-status were recruited in this hospital based cross sectional study. Patients were interviewed, examined, counseled and tested for HIV. CD4+ T lymphocytes count was determined for HIV positive and patients were followed up to determine in hospital outcome and duration of stay. Results: Of the 505 patients with unknown HIV status, 30 (5.9%) tested positive for HIV and all of them had visited another health facility before being referred to MNH compared to 78.5% among those who tested negative (p=0.004). More than two thirds (66.7%) of the newly diagnosed HIV patients had advanced disease. But, history of chronic diarrhea and/or severe weight loss, severe wasting (Slim disease) common features of AIDS in the 1980s were not apparent despite the late clinical presentation. Patients presenting with fever, oral ulcers, oral candidiasis, altered mental status, generalized lymphadenopathy were more likely to be diagnosed with HIV infection. Age of ≥50 years had a negative correlation towards a new diagnosis of HIV infection. Conclusion: Over 85% of medical patients referred to MNH did not know their HIV status. Newly diagnosed HIV sero-positive patients did not present with AIDS defining illnesses although over two thirds of them had advanced disease and in hospital mortality was high.

Photo by Filip Mroz on Unsplash INTRODUCTION The first live births via uterine transplant using deceased donors (UTx) occurred in Brazil in 2017[1] and in the United States in 2019.[2] Prior to that, living donors were the source of uteruses for transplant, with the first successful birth in Sweden in 2014, and the first successful birth in the US in 2017. This achievement in reproductive technology gives women with absolute uterine factor infertility (AUFI) the option to become a biological parent. In the US, 120,000 women of childbearing age are affected by AUFI.[3] Without UTx, their only option for having genetically related children is through gestational surrogacy. Since some religions and cultures prohibit the use of surrogates to achieve motherhood and surrogacy is illegal in many countries, some women would not otherwise have the chance to have biological children. For instance, China, Finland, Germany, Iceland, and other countries prohibit any form of commercial or altruistic surrogacy making adoption the only option for becoming a mother. However, in many cultures, biological ties are central to the understanding of the family. For example, in the Middle East, adoption is uncommon because biological connections are crucial.[4] Therefore, the only option these women would choose to become a mother is UTx. The exclusive value of UTx to these women is being able to experience pregnancy. Thus, UTx gives unique benefits to these women that adoption or surrogacy would not. The procedure entails surgery on a living or deceased donor to acquire the uterus. Then, the recipient undergoes transplantation followed by a course of immunosuppressive medication. After in vitro fertilization (IVF), the embryo is implanted into the transplanted uterus. If the pregnancy progresses, the child is delivered by C-section and the uterus is removed either simultaneously or later. This paper argues that both deceased and living donors should be permitted, while increased-risk donors should not be eligible. ANALYSIS l. Permitting Living Donors or Limiting all UTx to Deceased Donors The ethics of using a uterus from a deceased donor differs from using one from a living donor. The biggest concern for living donation is that it exposes the donor to unacceptable risks, especially considering that the procedure is elective and not life-saving. In other types of transplants, the sacrifice is warranted because the organ is needed to save the recipient's life. For instance, living kidney donations protect against kidney failure.[5] The uterine donor undergoes a four to eight-hour surgery to acquire the uterus for no potential health benefit to themselves or arguably, to the recipient.[6] UTx is not a life-saving procedure. Some argue that because there is no imminent threat to the health of patients with AUFI, it is unnecessary to expose live donors to risks of UTx. While treating AUFI is not technically medically necessary, many women find infertility debilitating to their physical and mental health. As a result, women want their infertility treated. Now that UTx with deceased donors has been successful, the ethical justification for continuing to allow living donation could be questioned. UTx from deceased donors cannot harm the donor and thus has a different overall risk-benefit calculation. It is reasonable to believe that opponents of living donation may view UTx from deceased donors as ethically permissible. From the public health and ethical perspective, retrieving uteruses from deceased donors is a preferable option for the following reasons: First, there is no medical risk to the donor; thus, public resources do not need to be allocated to resolving the potential complications from the procedure. Additionally, acquiring a uterus from a deceased donor takes less time than from a living donor.[7] Using deceased donors also decreases operating room visits compared to living-donor uterus acquisition, and allocates more time for the operating room to perform other procedures. However, without living donors, the pool of available uteruses for transplantation narrows. In 2017, there were 2,200 deceased female donors aged 18-47 in the US, defined as those willing to donate, not those with a procurable and usable uterus, or even a uterus at all.[8] 2,200 is an extremely low number of potential uterus donors considering that there are more than 120,000 women with AUFI in the US. Not every available uterus is suitable for donation; each must pass quality control. These donors could have had a hysterectomy, no pregnancies (having had a pregnancy makes the uterus more suitable for transplant), papillomavirus infection, or other conditions that would prevent them from being uterus donors.[9] Therefore, the number of potentially suitable uteruses from deceased donors is probably lower than 2,200. There is significant uterus scarcity. To expand the donor pool, living-donor transplants should be allowed to continue. Using living donors respects individual autonomy. The uterus does not serve a vital purpose and women who have had successful pregnancies and do not want to become pregnant again can donate without a concern for their own fertility. Because most living donors are related to the recipients, they will also benefit from this procedure since it would enable them to have family relationships, perhaps becoming an aunt or grandparent. By decreasing wait time, allowing living donors also would provide the option of UTx while women are younger and more likely to achieve pregnancy since the IVF would be more likely to succeed increasing the chances that UTx would result in a child. ll. Increased-Risk Donors To further expand the pool of donors, some favor making organs from “increased-risk” donors available to recipients. Increased-risk donors range from those with a history of IV drug use or certain sexual or behavioral histories.[10] The main risk associated with transplantation from increased-risk donors is the possibility of transmission of infections like HIV, hepatitis B, or hepatitis C. Whether the scarcity of transplantable uteruses makes it ethical to include increased-risk donors in the UTx donor pool, assuming there is still a scarcity once other qualified living donors are permitted depends on the risks and benefits. The organs of increased-risk donors are offered to patients for life-saving procedures such as a liver transplant.[11] For example, since the donor pool in South Africa is small, in one case, the best option was for a child to receive a partial liver transplant from his HIV-positive mother. The donation was approved to save the life. The risk of HIV infection, and the need for lifetime antiretroviral therapy paled in comparison to death due to the unavailability of a deceased or low-risk liver donor.[12] Yet, UTx is not a life-saving procedure. Because infertility treatment is not lifesaving, the risks do not outweigh the benefits. Increased-risk donations use the organs that otherwise may have been disposed of (or rejected by potential recipients) categorically even if a donor did not actually have the underlying disease like HIV, hepatitis B, or hepatitis C.[13] Yet increased-risk donations pose ethically unacceptable risks to the recipient and their fetus in the case of UTx. If the patient remained on the waitlist for a uterus transplant, she and the resulting fetus would forgo the risks associated with using an increased-risk donor. It is possible that being on a waitlist could be psychologically traumatizing for a patient. This does not justify the potential to expose the woman and possibly a fetus to HIV, or hepatitis B or hepatitis C if an increased-risk donor provided a uterus and had an undetected condition While infertility may be devastating to the women wanting UTx, UTx should not be treated as a life-saving procedure. Therefore, it is unethical to expand the donor pool to include increased-risk donors. lll. Potential Downsides of the Availability of Uterine Transplant The availability of UTx to the public may impose additional pressure on women affected by infertility to try an additional burdensome procedure before giving up genetic motherhood. In cultures where family ties are important, the spouse or family members may pressure women to undergo UTx for the benefit of having biological children. Moreover, it may add overall pressure on the women to become mothers and exacerbate the deficiency stigma on infertile women. Moreover, the availability of UTx may compromise the future of many children who are waiting for adoption. Adoption may start to be seen by others only as a last resort after attempting to have biological children. This is problematic because there are many already existing children who need parental love. These downsides can be addressed by assurances that women freely enter UTx. Counseling and assurances that women are acting of their own accord and not under duress or societal pressure can mitigate the downsides. The autonomy and the choice to engage in new assisted reproduction should not be dismissed out of a fear that women are choosing UTx for the wrong reasons. CONCLUSION UTx offers women with AUFI unique benefits like the experience of pregnancy and having children genetically related to them. A woman deciding whether to receive a uterus from a living or deceased donor, or not to undergo UTx at all should understand the risks and benefits, including the risk of the UTx not resulting in a viable pregnancy. Doctors or hospitals should decide whether to perform UTx on a case-by-case basis. Increased-risk donation that could expose the recipient and fetus to transmissible disease should be prohibited because the risks associated with increased-risk donation are not morally justified by UTx. Remaining on the transplant list would be safer. While increased-risk UTx should be prohibited, other living-donor procedures should be continued to widen the donor pool. Living-donor UTx will empower the donor since she will voluntarily make the decision to donate, helping another person. Women with infertility whose only chance to have a biological child should not be limited to uteruses supplied by deceased donors. [1] France 24, “First Baby Born after Uterus Transplant in France,” France 24 (France 24, February 17, 2021), https://www.france24.com/en/live-news/20210217-first-baby-born-after-uterus-transplant-in-france. [2] “For the First Time in North America, a Woman Gives Birth After Uterus Transplant From a Deceased Donor,” Health Essentials from Cleveland Clinic (Health Essentials from Cleveland Clinic, July 9, 2019), https://health.clevelandclinic.org/for-the-first-time-in-north-america-woman-gives-birth-after-uterus-transplant-from-deceased-donor/. [3] Max M. Maurer et al., “First Healthy Baby After Deceased Donor Uterus Transplantation: Birth to a New Era?” Transplantation 103, no. 4 (2019): pp. 652-653, https://doi.org/10.1097/tp.0000000000002627. [4] Yassari, N. “Adding by Choice: Adoption and Functional Equivalents in Islamic and Middle Eastern Law.” The American Journal of Comparative Law, 63(4), 927-962. Retrieved April 22, 2021, from https://www.jstor.org/stable/26425445 (Acknowledges that traditional Islamic law prohibits adoption but arguing jurisdictions have worked around the prohibition to create avenues toward adoption.) [5] Though some people might argue that dialysis would be an option, generally kidney transplants are justified by medical necessity and a transplant both saves the life and significantly improves quality of life compared to dialysis. [6] “Uterus Transplants: A New Door Opens,” Penn Medicine, April 29, 2019, https://www.pennmedicine.org/news/internal-newsletters/system-news/2019/may19/uterus-transplants-a-new-door-opens. [7] Niclas Kvarnström et al., “Live versus Deceased Donor in Uterus Transplantation,” Fertility and Sterility 112, no. 1 (2019): pp. 24-27, https://doi.org/10.1016/j.fertnstert.2019.05.029, 25. [8] Max M. Maurer et al., “First Healthy Baby After Deceased Donor Uterus Transplantation: Birth to a New Era?” Transplantation 103, no. 4 (2019): pp. 652-653, https://doi.org/10.1097/tp.0000000000002627, 653. [9] Max M. Maurer et al., “First Healthy Baby After Deceased Donor Uterus Transplantation: Birth to a New Era?” Transplantation 103, no. 4 (2019): pp. 652-653, https://doi.org/10.1097/tp.0000000000002627, 653. [10] Shelly Bansal et al., “Risky Business: Taking the Stigma Out of High-Risk Donation in Lung Transplantation,” The Annals of Thoracic Surgery 100, no. 5 (2015): pp. 1787-1794, https://doi.org/10.1016/j.athoracsur.2015.05.065, 1787. The Centers for Disease Control (CDC) define the high-risk donor if a person meets one or more of the following criteria: “1) men who have had sex with other men in the last 5 years, 2) a history of intravenous drug abuse, 3) persons who have hemophilia, 4) persons who have engaged in sex for money or drugs in the past 5 years, 5) persons who have engaged in sex with individuals who have high-risk behaviors or those that are suspected to have HIV, 6) anyone who has been exposed to HIV in the last 12 months, 7) inmates, and 8) children born to mothers who had HIV or mothers who met the criteria for high risk. [11] Jean Botha et al., “HIV and Solid Organ Transplantation: Where Are We Now,” Current HIV/AIDS Reports 16, no. 5 (April 2019): pp. 404-413, https://doi.org/10.1007/s11904-019-00460-7, 404. Harriet Rosanne Etheredge et al., “Needs Must: Living Donor Liver Transplantation from an HIV-Positive Mother to Her HIV-Negative Child in Johannesburg, South Africa,” Journal of Medical Ethics 45, no. 5 (2019): pp. 287-290, https://doi.org/10.1136/medethics-2018-105216. (A partial liver transplant was done from an HIV-positive mother to an HIV-negative child in South Africa in 2017). [12] Botha, et al. [13] David S. Goldberg and Josh Levitsky, “Transplanting Livers from HCV ‐Infected Donors into HCV ‐Negative Recipients: Promise but Mind the Pitfalls,” American Journal of Transplantation 19, no. 5 (December 2018): pp. 1264-1265, https://doi.org/10.1111/ajt.15193, 1264.

I hate being misunderstood. I guess we all do, but it goes with the territory. I use the word coloured, and he seems offended: 'We Brits don't say 'coloured'. It's regarded as patronising. We say black, if we say anything. And if we do it's for reasons of simple practicality. It doesn't matter. ' Of course, what he seems to be missing, is that the word coloured in South Africa now refers less to skin colour, and more to a distinct cultural group, with it's own language (a dialect of Afrikaans), food (of Malay origin), and music. To say black in this context would be inaccurate, and cause confusion. Danya and Kyla attend the Yeoville Community School, situated in a vibrant and culturally diverse suburb of Johannesburg. On returning from school one day Danya announces: 'We have to do something at school about our culture. What is our culture Daddy?'To which her father replies, 'Go and ask your mother.' 'Well…we're sort of New Age, sort of holistic…', Toni fumbles. A few days later… 'So what did you do in the end?' Soli asks. 'Oh, us and all the other coloured kids sang, Daar Kom die Alabama'1 says Kyla. It would seem that children want to know where they come from. 'I want you to divide yourself up into your different race groups', the facilitator says. We are in a Managing Diversity workshop, and he means the old South African race classification system, but of course he wants to see what we do with it. We end up with a group of Blacks (including three 'Asians'); an African group (including two 'Whites'); a White group (two); and the Human Race (two).'Why didn't you join the white group?' Thloki asks the Human Race.'I don't define myself by my race', I reply.'Ha! Wait till there's a war over resources' he laughs, 'then you'll quickly pick a side!' The postmodernist argument ensues: 'There is no such thing as race…all these arbitrary classifications…it's nothing but a social construct!''Well you never lived as a black person under apartheid. It was very real to me!'The facilitator aims to mediate/translate for the rest of us: 'Well yes, it is just a social construct. But one which had very real consequences for people.' 'Nobody goes into town anymore' a woman says. To which Har Bhajan replies, 'When I was last in town, there were lots of people there.' Of course, what she means is, hardly any white people go into town anymore. (And she's right about that.) But what is that, the way certain people become invisible, depending on who's looking? My friend Karima and I attend an Al Jarreau concert. Fairly expensive tickets, and almost the entire audience is black. I'm not sure why I'm quite so surprised. But this is Sandton, the richest formerly white suburb of Johannesburg. Perhaps working in the NGO sector I've missed how much things are actually changing… I wonder how many people in the audience have been into town lately. With the shift in power, and the -- albeit slow -- levelling of the playing field, now it is possible for white South Africans to be at the receiving end of racial discrimination too… I am visiting my cousin. He is 60, and a musician. But times are tough for him now. His brother was shot dead in his driveway while someone stole his car. And it's hard for him to find work. 'I am too white, now', he says. He is not bitter, just saddened. In his day he had probably the most famous jazz club in Johannesburg. Rumours it was called. 'The best little bootlegger in Bellevue' he called himself. He was known for breaking the law then. His club was racially integrated long before it was allowed. Controversial South African artist, Beezy Bailey, has an alter ego: 'The creation of Joyce was born of the frustration of 'increasingly prevalent affirmative action'. Bailey submitted two artworks for a triennial exhibition. One was with the traditional 'Beezy Bailey' signature (rejected) the other signed 'Joyce Ntobe'! The latter now enjoys an honoured place in the SA National Gallery as part of its permanent collection. When the curator of the SA National Gallery wanted to work on a paper about three black women artists, Joyce Ntobe being one, Bailey let the cat out the bag which caused a huge media 'scandale'.' (Carmel Art) I spent three months in London, and I realised how easy it is to be white there. Or rather, how easy it is to not be white. Of course, it 'doesn't matter' there, because it doesn't matter. It's easy to donate a monthly cheque to Worldvision, and read about the latest chaos in Zimbabwe in the free rag on the tube, and never have to look overwhelming poverty and disease in the face. But when you live on the African continent, you are very aware of being white. At the diversity workshop, I realise how white South Africans seem to get to take the rap here for the actions of white people on the planet. It's not just the effects of apartheid that black South Africans are angry about it seems, it's also the effects of the global economy, that cause the rich to become richer, and the poor to become poorer. Oh sure, that's not just an issue of race, but the poorest on our planet remain 'people of colour', and wealth remains concentrated in the West/North. I realise also that the Black and African groups at the workshop have one thing that they agree on quite strongly - the importance of making the African continent one's focus. Though the two of us in the Human Race group have both read Naomi Klein's No Logo -- and care about the effects on the poor of economic globalisation -- our sense of 'internationalism' is not viewed in a positive light, but seen rather as 'elitist'. * * * 'The thing about the Dutch' says Gary, 'is that they're pragmatic. They're not politically correct -- call the prostitutes prostitutes, not sex workers, but tax them, and give them health care. They have a strong human rights culture.' The Afrikaners are descendents of these transparent, curtainless Dutch. Sometimes I can see it. 'It is not words that make for bigotry, but attitudes', says columnist Ira Pilgrim. 'Some of the most bigoted people I have known always used the 'correct' words.'2 I am not politically correct. There are certain words I'd never use, and couldn't bring myself to, not out of political correctness, but because they're invested with hate. But words like 'whitey', darkie' and 'honky', where I sit, are terms of endearment. I'd never use them on strangers, but amongst friends, they're terms of affection and irony, because we're laughing at ourselves, and each other. 'It's hard to explain to anyone' Gary continues, 'what it's like living in a place where -- from the time you wake up in the morning, till you close your eyes at night -- every breath that you take is politicised.' Gary left the country because he didn't want to be conscripted to fight a war he didn't believe in. He's done well for himself in Europe. But he had to give up his homeland. I catch a 'Zola', the mini-bus taxi named after South Africa's barefoot runner Zola Budd, probably most famous for inadvertently tripping Mary Decker at the 1984 Olympics (Finnegan). Zola was little and fast, like the taxi's that 'zip, zip, zip' -- often to the infuriation of other motorists -- hence the affectionate nickname. They're the peril of the road, but the saviour of the immobile masses, with their unique language and hand signals. I overhear bits of Zulu conversation, including 'Brooke…Ridge…Thorne.' Our soaps, too, are politicised. It would seem that even black South Africans watch The Bold and the Beautiful for light relief. Usually I am the only whitey here, but accepted as just another carless commuter moving from A to B. Despite the safety risks of bad driving, I enjoy it. I did a Zulu course a few years ago. I didn't learn much Zulu -- discovered I don't have the tongue or an ear for African languages -- but I learnt a lot from the course nevertheless. 'Tell us about an experience that you've had, that was a result of cultural misunderstandings' says the facilitator. 'I spent much of my first year at University hungry' says Nhlanhla. 'My white friends would offer me food when I was visiting, but I would refuse, because in our culture, if you ask you don't really want to give. We just hand you a plate.' Nombulelo tells of the time she went on a yoga retreat. She was confused when she started to undress openly in the dormitory, and got disapproving looks from the other women. 'Why?' she wondered, 'we are all women together?' But these were Hindu women, whose sense of modesty was different from the openness of African women. For the whiteys, the major confusion seems to come from the issue of timekeeping. 'African time' is often referred to. Though in London, I did hear talk of 'Caribbean time'. Perhaps the concept of being on time is a particularly Western one (Makhale-Mahlangu). We are visiting friends of friends. There's an unlikely combination at the dinner table. She is tall and dark. I am short and fair. 'So where do you two know each other from?' Cairo asks. 'I'm Andie's sister', Kim replies. She reads the dumbfoundedness in Cairo's face. 'What can I say…my line got a bit deviated!' she laughs. She has my father's sense of humour. So have I. I ask my father, when he first became aware of racial prejudice. 'I was about six years old', he says. 'I threw my ball out of the school grounds, and called to the black man outside: 'Boy, please would you throw my ball back to me?' And the man replied: 'I am not a boy. I am old enough to be your grandfather.'' I am thinking about the time in our lives before we become aware of race… A friend tells me a story about how her six-year-old daughter came home from school and asked, 'Mommy, what's a [racist-term-not-to-be-repeated]?' She'd been called that. The late Lenny Bruce, controversial American comedian and social critic in the sixties, argued that it is 'the word that gives it the power of violence'3, and if we used 'the words' colloquially often enough, and began to invest them with new meanings, they would lose their power to hurt us. I am about to board a bus…'Woza (come) Mama', says the driver. 'Uyaphi?' (Where are you going?) '…green green, I'm going away to where the grass is greener still', come the Reggae sounds from his radio. We are discussing whether we should be focusing on our sameness or our differences. 'Of course we all want the same things…a home, a job, an education for our children', says Karima, but it's our differences that make us interesting.' I agree. Notes 1 Daar Kom die Alabama (Here Comes the Alabama) is a traditional 'Cape Coloured' song, originally sung in tribute to the Alabama, a confederate ship that docked in Cape Town in 1863. On board were Al Jolson-esque (Burlesque) performers, whom the slaves admired, and they imitated their style of performance. This tradition continues still today with the 'Coon Carnival' held on New Years Day and 'Tweede Nuwe Jaar' (Second New Year). It is said that the custom of Tweede Nuwe Jaar originated as a holiday for the slaves, who were too busy attending to their masters' needs on the first. For more information on the Coon Carnival, see http://www.iias.nl/host/ccrss/cp/cp3/cp3-__171___.html. 2 While the author makes some important general points about the drawbacks of political correctness, his reference to South Africa (including the correction) are in fact incorrect. The apartheid government had four major 'population groups' in it's classification system: African (black), Coloured, Asian and White. (The term black was used then only informally.) These were then sub-divided into other categories. See http://www.csvr.org.za/race.htm for further details. 3 The relevant extract from Julian Barry's 1971 play Lenny, can be found at http://www.abc.net.au/rn/talks/8.30/relrpt/stories/s271585.htm. References Barry, Julian. Lenny. Random House, 1971. http://www.freenetpages.co.uk/hp/lennybruce/ Downloaded 14 April 2002. Carmel Art Galleries. Beezy Bailey Curriculum Vitae, at http://www.carmelart.co.za/site/cvbb.htm Downloaded 14 April 2002. Finnegan, Mark. 'The 10 worst mishaps in the history of sport.' Observer Sport Monthly 5 November (2000). http://www.observer.co.uk/osm/story/0,69... Downloaded 14 April 2002. Klein, Naomi. No Logo: Taking Aim at the Brand Bullies. USA: Picador, 2000. http://www.nologo.org/ Downloaded 14 April 2002. Makhale-Mahlangu, Palesa. 'Reflections on Trauma Counselling Methods.' Seminar presented at the Centre for the Study of Violence and Reconciliation, Johannesburg, 31 July 1996. http://www.csvr.org.za/articles/artpales.htm Downloaded 14 April 2002. Martin, Denis-Constant. 'The Famous Invincible Darkies Cape Town's Coon Carnival: Aesthetic Transformation, Collective Representations and Social Meanings', 1998. http://www.iias.nl/host/ccrss/cp/cp3/cp3-__171___.html Downloaded 14 April 2002. Pilgrim, Ira. 'Kikes, Niggers, Queers, Scotchmen and Chinamen', Mendocino County Observer, 22 March (1990). http://www.mcn.org/c/irapilgrim/race02.html Downloaded 14 April 2002. Transfer of African Language Knowledge (TALK). http://www.icon.co.za/~sadiverse/about.htm Downloaded 14 April 2002. Andie Miller was born, and spent the first 23 years of her life at the Southern-most tip of the African continent, in Cape Town. She currently works as webmaster for the Centre for the Study of Violence and Reconciliation, and the National Development Agency in Johannesburg, South Africa. Links http://www.observer.co.uk/osm/story/0 http://www.iias.nl/host/ccrss/cp/cp3/cp3-__171___.html http://www.carmelart.co.za/site/cvbb.htm http://www.csvr.org.za/ http://www.abc.net.au/rn/talks/8.30/relrpt/stories/s271585.htm http://www.csvr.org.za/articles/artpales.htm http://www.nologo.org/ http://www.mcn.org/c/irapilgrim/race02.html http://www.freenetpages.co.uk/hp/lennybruce/ http://www.icon.co.za/~sadiverse/about.htm http://www.csvr.org.za/race.htm http://www.nda.org.za/ Citation reference for this article MLA Style Miller, Andie. "Multiculturalism and Shades of Meaning in the New South Africa" M/C: A Journal of Media and Culture 5.3 (2002). [your date of access] < http://www.media-culture.org.au/0207/shadesofmeaning.php>. Chicago Style Miller, Andie, "Multiculturalism and Shades of Meaning in the New South Africa" M/C: A Journal of Media and Culture 5, no. 3 (2002), < http://www.media-culture.org.au/0207/shadesofmeaning.php> ([your date of access]). APA Style Miller, Andie. (2002) Multiculturalism and Shades of Meaning in the New South Africa. M/C: A Journal of Media and Culture 5(3). < http://www.media-culture.org.au/0207/shadesofmeaning.php> ([your date of access]).