Archive for the STDS Category

Understanding Lymphogranuloma Venereum

Saturday, October 15th, 2011 | Permalink

While there are many different types of sexually transmitted diseases in the world, only the more common diseases are usually

covered by awareness campaigns and media documentaries. However, the dynamic nature of the world means that new sexually transmitted diseases are discovered every day or become prominent off and on. One sexually transmitted disease that was considered very rare before the year of 2003 is Lymphogranuloma Venereum. As a result of this sexually transmitted disease becoming more prominent in recent years in even developed countries, it is critical that awareness about it is increased. The following are some basic facts pertaining to Lymphogranuloma Venereum.

Picture of a male with Lymphogranuloma Venereum

Lymphogranuloma Venereum

What is Lymphogranuloma Venereum?

Lymphogranuloma Venereum is a sexually transmitted disease that affects both men and women alike. It is a disease that is caused by the microorganism Chlamydia Trachomatis. Chlamydia Trachomatis is a bacterium that enters the body through some break in the skin or through mucous membranes. Other names of the disease include Climatic bubo, Durand Nicolas Favre disease, Poradenitis inguinale and Strumous bubo. As the name of the sexually transmitted disease suggests, it involves the infection of the lymph nodes. Once a person is infected, the

organism moves down the lymphatic tunnels and multiplies within the mononuclear phagocytes of the lymph nodes.

What are the different stages and clinical manifestations of the disease?

There are primarily three different clinical manifestations of Lymphogranuloma Venereum, namely the inguinal syndrome, the rectal syndrome and the pharyngeal syndrome. As the names suggest, the three manifestations show up in different places of the body with the inguinal syndrome seen in external sex organs i.e. vagina and penis, the rectal syndrome in the anus and the rectum and the pharyngeal syndrome seen in the pharynx and the neck.

The symptoms or the physical manifestations of the sexually transmitted disease vary on the basis of the stage at which the disease is. There are primarily two stages of the disease i.e. the primary and the secondary. The primary stage of the sexually transmitted disease is characterized by a single genital ulcer that is hard to spot for both men and women but more in women. The primary stage symptoms show up between three to twelve days of infection.

The second stage of the disease, although usually seen within 10 to 30 days after the primary stage, can be seen for up to six months. There is a range of clinical symptoms of this kind of infection with visible manifestations being abnormal discharges, pain, swelling and a range of other problems. It is worth noting that as the organism multiplies and the disease progresses, there is significant swelling in lymph nodes which are then called buboes.

How is Lymphogranuloma Venereum cured?

The treatment of this sexually transmitted disease is an amalgamation of different procedures such as antibiotic regime, drainage of buboes through needle aspiration or even incision, dilation of the rectal stricture, and many others. Commonly used antibiotics in the case of Lymphogranuloma Venereum are tetracycline, doxycycline and erythromycin. Untreated Lymphogranuloma Venereum can result in a variety of more complex problems like edema, arthritis, pneumonitis, hepatitis and perihepatitis.

But where are our moral heroes?

Sunday, August 14th, 2011 | Permalink

Introduction

When an article by journalist Emily Wax, first published in the Washington Post in August 2003 (Wax, 2003) was posted shortly afterwards onto the CABA (Children Affected by AIDS) forum list-serve, a flurry of electronic conversation ensued.

Wax’s article – a story of two sets of siblings orphaned by AIDS2 – is an evocative account of some of the potential implications of the death of parents for children in Africa (in this case, in rural Kenya). These children, Wax argues, “are part of the lost generation… A generation that is growing up without parental guidance”, a state she links to the likelihood of unfulfilled potential on the part of the children, and of worsening political instability for the State and continent. She describes, in dramatic terms, the children’s exploitation, abandonment and neglect by relatives; their dropping out of school, their hunger, their isolation – among other things.

Responses from those subscribed to the CABA list ranged from critiques of Wax’s presentation of the situation of AIDS in Africa as one of passivity and hopelessness (Giese, 2003; Monk, 2003; Williamson, 2003), to reiterations thereof (Samson, 2003).  More striking, however, was the string of well-intentioned responses that “pooled  resources”  (Feldman,  2003)  to  ensure  that  the  particular  children documented in Wax’s story would receive school uniforms, books, clothes and food, at least for “the coming semester/term” (Arum, Odhiambo, & Ondiek, 2003). One writer, delighted at the collaborative response, articulated her wish “for a nice little trust fund to be set up that would go directly to a boarding school for all 8 of these  children  to  grow  and  flourish.  To  safely  reach  adulthood  together” (‘Maureen’, 2003).

In one fell hyperspacial swoop, communications across the list-serve encapsulated the issues that had been of concern to us – and others – for some time, and neatly documented themselves in the intransience of type-face and the immediacy of the internet. The media is powerful, through (among other things) it’s spin on stories, it’s ability to communicate the unfamiliar or distant, it’s global reach.  The responses to Wax’s article in the Washington Post illustrate the way in which readers’ interpretation of messages in the print media can prompt well-intentioned but not necessarily appropriate action, in this case to assist children.  Eight orphaned children in Kenya may have their lifetimes altered – possibly with a trust fund that inserts them into entirely different circumstances to those they might even  have  experienced  were  their  parents  living.   However,  the  destitute circumstances of the eight children in the story are not unique. Targeted assistance, in particular of material goods, to these particular children in isolation of others does not take sufficient account of the context of their challenges. In addition, it could put their safety at risk by generating neighbourhood jealousies (Giese, Meintjes, Croke, & Chamberlain, 2003).

Appropriate responses to children in the face the epidemic are critical.  South Africa currently has resident the highest number of HIV-positive individuals of any country in Africa, with an estimated 5 million people living with HIV or AIDS in 2004, of whom roughly 245 000 are likely to be children under the age of 15 (Dorrington,  Bradshaw,  Johnson,  &  Budlender,  2004).  High  levels  of  adult morbidity and mortality do – and will continue to for many years – affect the country’s large child population (estimated at roughly 39% of the total), even with widespread antiretroviral treatment intervention (Authors’ analysis of ‘Community Profiles  2001  Population  Census’).  For  this  reason,  what  is  conveyed  both explicitly and implicitly within media text about the impact of HIV/AIDS on children deserves examination in terms of its impact on public knowledge, policy design and interventions.

Despite  an  extensive  multidisciplinary  literature  examining  discourses  of 3 Most studies analyse media reporting in the global North – in particular Britain, Europe, the United States and Australia – with only a few isolated studies examining reporting on AIDS in the South African/African media. Existing studies of AIDS in the African media generally employ quantitative content analysis methodologies that enable commentary on trends in type, frequency and extent of reporting, prominence given to particular themes, representation of children in media reporting on AIDS.  Existing references to media reporting on children and AIDS are isolated to brief comments as opposed to full analyses.  No researchers have undertaken any in-depth analysis of the particular ways that the media represents children affected by HIV/AIDS.  This paper thus sets out to analyse English-medium South African press reporting on children and HIV/AIDS, in an effort to closely consider the messages being communicated to the local public about the impact of AIDS on children. We examine what is emphasized, and what is omitted, with respect to the effect of HIV/AIDS on children’s lives, and explore some of the implications of patterns found in the reporting.

The relationship between media coverage and public opinion, and the role of media language  and  content  in  shaping  public  attitudes,  discussions,  responses  – including towards HIV/AIDS – has been repeatedly documented and discussed (Beamish, 2002; Hughes & Malila, 1999; Kitzinger, 1993, 1995; Lupton, 1994; Schindlamayr,  2001;  Williams,  1999,  among  others).  Lupton  (1994:9),  for example, concludes that “the way in which the phenomenon of AIDS has been represented in the entertainment and news mass media has played an important role in the development of shared cultural meanings about AIDS”4.

This said, social scientists vary in the degree of agency they accrue to the reader, and thus the extent to which media text is treated as constitutive of social relations and mainstream ideologies (Rapport & Overing, 2000).  As Askew and Wilk (2002) point out, readers are also engaged in producing meaning and hence have the potential to interpret a story in a variety of ways, perhaps resisting or challenging the perspectives of the news writer. Yet she clearly regards the media to have authority in this relationship: “media producers apply a host of strategies main subjects, etc rather than conducting discourse analysis (Finlay, 2003; Kasoma, 2000; Linda, 2000; Mchombu, 2000; Odhiambo, 2000).  Work by Page (2003) and Connelly and McCloud (2003) is an exception to this.  Like analyses of media elsewhere, none of these studies on African media pay more than cursory attention to reporting on children in the context of HIV. Where mention is made, it is with regards to ‘AIDS orphans’ rather than to children infected with HIV.

South African journalist Jo Stein (2002: 16) makes an important point however when she states that it is not media “in and of itself, but in relation to a complex set of social players and historical variables, which determines what issues gain currency as social priorities”. In other words, the nature of the relationship between media coverage and government or public policy is not straightforward. The historical, cultural, political and socio-economic context to the AIDS debate all play a part in shaping media coverage and (the individual andgroup) responses to such coverage.

Of primary concern to our study therefore is the possibility that the South African news  media  plays  an  influential  role  in  creating  or  maintaining  a  general understanding of the way in which AIDS affects children, which in turn may contribute to the nation’s responses in terms of social policy and resource distribution.

Considerable attention has been given by analysts to the nature of the constraints placed upon news-making bodies and their impact on reporting (see Bell, 1991; Lupton, 1994; Stein, 2002). In this respect, it is not our intention to go over ‘old ground’.  Rather,  we begin  by  acknowledging  the  differences  between  what journalists would like to produce and what they are able to, given limits to time, budget, access to (re)sources and literary freedom. The same can be said for editors whose decisions are influenced by the need to sell a product and maintain a particular political position (Stein, 2002). We thus recognise that the nature of the ‘news market’ is critical in allowing more or less space for certain topics, as well as determining the breadth of interpretation of issues raised.

Methods

The analysis that follows is drawn from articles published in the South African press.  A range of English-medium South African newspapers – some of them local, some of them regional and national, including both dailies and weeklies, were systematically monitored over two periods of three months each, from March to May 2002 and again over the same period during 2003.  In addition reporting during the week around World AIDS day in 2002 (1st December) was monitored.

Newspapers included the Business Day, Cape Argus, Cape Times, the Citizen, City Press, Daily News, EP Herald, Independent on Saturday, the Mail & Guardian, the Natal  Witness,  Saturday  Star,  Sowetan,  Sowetan  Sunday  World,  Sunday Independent, Sunday Times, Sunday Tribune, The Star, and the Weekend Argus. Nine of these papers are dailies, eight are produced weekly.

In the 2002 monitoring period, additional English-medium papers that were monitored were the daily papers Business Times, Daily Dispatch, and the Pretoria News. In the 2003 period, The Sunday Sun was monitored in addition to those listed.

The articles were sourced at the time of their publication by the Media Monitoring Project (MMP) and Perinatal HIV Research Unit (PHRU) at the University of Witwatersrand, as part of larger media analysis studies, on children in the case of the former, and HIV/AIDS in the latter. The choices made by the two agencies account for the slightly different – though largely overlapping – sample of papers.

A total of 150 articles were identified as relating to children and HIV/AIDS during the monitoring period. Of these however, 44 included only a tangential reference to children affected by HIV/AIDS. One hundred and fourteen articles have therefore been analysed in detail for the purposes of this paper.

Our analytical approach followed a form of discourse analysis conducted on all articles, columns and editorials touching on issues relating to HIV/AIDS and children that were published during these periods. Analysis focussed on the verbal and linguistic text of the articles rather than accompanying images. A central theme was identified for each article, as well as a series of sub-themes. Both explicit and implicit messaging was considered – via careful examination of metaphor, and other lexical choice, as well as through content included and excluded. We were thus concerned to identify particular and recurring discourses, shared ways of talking and thinking about children and HIV/AIDS.

In this regard, we follow Pennycook’s (1994:128) definition of ‘discourse’ to mean “ways of organising meaning that are often, though not exclusively, realised through language. Discourses are about the creation and limitation of possibilities, they are systems of power/knowledge (pouvoir/savoir) within which we take up subject positions”.

Communication through the print media is a primary means of social exchange around  issues  considered  to  be  of  national  or  local  importance  (such  as HIV/AIDS). In recognising that the production and consumption of text (for the print media) takes place in a specific socio-cultural, political and historical space, we can expect the content and tone of articles to be structured by particular norms and conventions. The anthropologist Dell Hymes (1972 in Rapport and Overing, 2000:118) uses the term ‘speech community’ to refer to those who share rules concerning the conduct and interpretation of speech, and who determine particular ways of proper speaking which its competent members will practise. Thinking about the journalists’ writing on health and social issues in South Africa, as well as their readership, as ‘speech communities’ poses questions related to the rules of ‘proper writing’ about HIV/AIDS and children, and the social processes and power relationships that maintain these rules.

Who features in the reporting?

During the periods monitored, reporting relating to HIV/AIDS and children focused overwhelmingly on orphaned children5, and on existing or ‘necessary’ responses to “the orphan problem”.  HIV-positive children also received some attention, though considerably more limited. Very few news articles during the monitoring periods considered the broader impacts of the epidemic on children. Only two of a total of 114 articles analysed made reference to children living with sick caregivers. An overwhelming majority of the reports focus their attention on the issues as they relate to South Africa: only four articles consider other countries, two Southern Africa in general, and two provide a global perspective.

Although there has been an important shift amongst experts to conceptualising the impact of AIDS on children as being more broad-based than orphaning, articles continued  to use  the outdated  (and  much  maligned)  terminology  of ‘AIDS orphans’. The majority also propagated the popular stereotype of the orphan as the archetypal vulnerable child of the AIDS pandemic (a stereotype that remains similarly widespread in much existing research and reporting by International Agencies and others) (Meintjes & Giese, 2004). References to ‘AIDS orphans’ as, for example, “the innocents who are perhaps the most vulnerable victims of AIDS” (Independent on Saturday, 30.11.2002) are prevalent in articles.

In instances where the issue being reported does not exclusively apply to children who have been orphaned, and is salient to other children, it is common for articles to focus attention on its relevance as a concern regarding orphans.  An article published in the Star, and subsequently in the Daily News (in an edited form) in April 2003 on the difficulties experienced by orphans in accessing the social grants to which they are entitled provides a good example of this trend. The article is an otherwise excellent piece of reporting that stands apart from most of the articles published during the monitoring period for its timely investigation of a critical issue, its provision of evidence, and its consultation with children.  However, the centreing of its argument on orphans – as opposed to poor children in general, to whom  the  majority  of  issues  it  reported  apply  equally  –  resulted  in misunderstandings that revealed themselves in a series of articles that appeared in response. Subsequent related articles called for interventions targeting ‘AIDS orphans’ that would in fact be more appropriately directed at poor children. This is in contrast to patterns noted by studies elsewhere, where references are made largely to HIV-positive children.  This comes as no surprise considering the majority of other studies examine media reporting in countries where ARV treatment is accessible and rates of AIDS-related parental death therefore much lower.

Research illustrates in particular how children’s vulnerabilities can be exacerbated during periods when they are living with sick caregivers or others who are terminally ill, as increased demands are made on the financial and social resources of the household.  While South Africa remains some years away from a peak in orphan numbers, the country is currently home to vast numbers of children whose care is potentially compromised by residence or relationships with sickly adults (Giese et al., 2003). Furthermore, HIV/AIDS does not only impact on those whom it ‘directly’ affects: the same research study illustrates the ways in which whole neighbourhoods face increased demands on ‘informal’ networks of support to provide for those who need help (Giese et al., 2003; Meintjes, Giese, Croke, & Chamberlain, 2003).

Thus, we would argue that while the issue of children orphaned by HIV/AIDS is a critical one, the emphasis placed on this issue by journalists risks obscuring the diversity of additional ways in which children are affected by HIV/AIDS, and stands to divert public knowledge and attention away from other critical points of intervention and support.

Morality, the media, and AIDS

The extent to which poor children in South Africa struggle to access the cash grants to which they are entitled because of administrative and legislative requirements are well documented. See for example, Case, Hosegood & Lund (2003), Clacherty (2001), Giese et al. (2003), Leatt (2004), Rosa, Leatt & Hall (2005) and Rosa & Mpokotho (2004).

Distinctions made through language and imaging are shown to set apart ‘innocent’ and ‘guilty’ victims of HIV, with blamelessness generally being situated within white, middleclass, heterosexual populations.  Researchers argue that through practices of ‘othering’, and the accompanying blame, discourses of AIDS reporting thus  produce  and  –  importantly  –  reproduce  hegemonic  stereotypes,  power relations and notions of deviance (Juhasz, 1990; McAllister & Kitron, 2003; Sacks, 1996;  Treichler,  1988;  Watney,  1989a,  1989b).

Pre-existing  ideologies  and narratives are drawn upon by the media in order to make sense of a (no longer so) new phenomenon (Lupton, 1994). Referring to representations of the epidemic in the USA, McAllister and Kitron (2003:58) note that “AIDS is the disease of the peripheral, the poor, the deviant, the morally ill (and is only newsworthy when it threatens ‘the mainstream’).  For the most part, news coverage [in the New York Times and other prominent US papers] has reinforced these meanings”.  These kinds of reporting practices contribute to binding HIV/AIDS up in moralism in a way that, according to Kistenberg (2003), discourses around other diseases have not.

Discourses of morality are no less present in the South African press reporting on children in the context of HIV/AIDS.  However, with South African reporting on the impact of HIV/AIDS on children centred predominantly on issues broadly relating to orphanhood and to children’s care, the notions of morality and moral deviance communicated by the press take on additional dimensions to those discussed elsewhere. It is to the analysis of these that we now turn.

Innocents discarded: the moral transgressions of ‘the African family’

The theme of children’s innocence lies at the centre of the South African print media’s reporting on children in the context of AIDS. Children, and particularly orphans, are portrayed as blameless victims of a situation beyond their control.

These children are “the innocents … with absolutely nothing to lose” (Independent on Saturday, 30.11.2002b), “helpless victims of a social and medical nightmare”, a “band  of  little  angels”  (Sowetan  Sunday  World, 24.3.2002)  who  “deserve” assistance (Daily News, 3.5.2003).

In all likelihood journalists have good intentions in presenting children this way. By publishing articles that highlight children’s needs, the press stands to provoke empathy, and perhaps action, towards improving children’s lives. Moreover, we know that the consequences of the epidemic for children are multi-faceted and very serious. It is therefore appropriate that the media draws attention to children’s vulnerability. The issue under debate is how this is done; what implicit messages are conveyed to the readership and what impact do these have on general understandings of how South African children and adults are responding to the epidemic.

The discourse of the ‘innocent victim’ is not new in media reporting on children in general (Moeller, 2002), and is briefly noted with respect to discourses regarding HIV-positive children in a number of the analyses of HIV/AIDS reporting around the world (Konick, 2003; Lupton, 1994, 1999, 2003; McAllister & Kitron, 2003; Page, 2003; Sacks, 1996). Along similar lines to others, Lupton notes of reporting in Australia, “the most innocent of all people with HIV/AIDS … are infants and young children, who are commonly positioned as devoid of any blame, shame or guilt for their infection” (Lupton, 1999:38). With ‘innocence’ presented as the foremost characteristic of children affected by AIDS, ‘guilt’ of others is implied, even in the absence of any explicit juxtaposition. And thus paradigms of morality in relation to HIV/AIDS, are reinforced.

In particular, moral judgement is (implicitly or explicitly) directed at caregivers – biological mothers as well as broader kinship and community networks – in press reports during the period monitored.  As noted similarly by Sacks in her study of reporting of women and HIV/AIDS in the press in the USA, pregnant HIV-positive women were commonly framed as irresponsible and uncaring, ‘bad’ mothers for becoming pregnant in the first place, and in the South African situation, even more morally aberrant for risking HIV transmission to their children as a result of subsequent choices.   We see reports such as that in the Cape Times (9.4.2003) which condemn women for being irresponsible towards their unborn – implicitly ‘innocent’ – children.

“Thousands of babies born in South Africa are being put at risk of ‘inheriting’ HIV at birth because of their mothers’ reluctance to have an HIV test … A Johannesburg obstetrician and gynaecologist said studies had shown that nearly half of the pregnant women who declined to be tested were HIV-positive. Concern now was for the babies of untested mothers who had ‘no voice’ and who were at risk”

The article employs emotive language and references an obstetrician’s study (providing it with scientific authority despite a questionable point being made) but fails to take into account women’s contexts in its implicit critique of their choices.

More prominent in the press reports however, was a discourse regarding the loss of morality – frequently framed as a loss of ‘traditional African values’ – specifically related to the provision of care for children.  Critique of absent parents or others identified as having a moral responsibility to take care of children is evident throughout much of the reporting, with their failure to do so a consistent theme.

The emphasis on ‘dumping’ babies depicts poor African mothers (in particular) as people who cannot or will not care for their children. They are described as “desperate” (Pretoria News, 15.4.2003) and “despairing” (Star,16.4.2002), and only cursory reference is made to the contexts of mothers’ decisions to leave their children in the hands of others. At no point in any of the press articles was there any discussion of the complex set of social, economic, health and emotional pressures acting on poor women, nor any reference to the large numbers of women in similar positions who are caring for their children despite the odds stacked against them.

The perceived loss of morality is also referred to directly in many of the articles produced during the monitoring period. It is common for articles to make reference to a time that they claim was different. For example, readers are told that “In the past orphaned children were cared for by uncles or aunts or grandparents” (Mail&Guardian, 17.04.2003) – now, it is implied, this is not the case. Or that “This country used to pride itself in the spirit of ubuntu. Somehow that, like some of the other post ’94 goodwill, has disappeared” (Star, 17.4.2002).  Articles describe a disintegration of ‘traditional African values’ – the notion of ubuntu being central, and in a number of instances join the president’s call for widespread moral regeneration.  Appeals are made for “a moral crusade” (Independent on Saturday, 11.5.2002b) or a “return to traditional Christian family values in our societies”  (Citizen, 20.5.2003)  to  “help  rebuild  a  caring  nation”  (Sowetan, 7.5.2002), and are peppered with references to the requirements of “African tradition and morality” (Sowetan Sunday World, 23.3.2003) and how “vukuzenzele [self reliance] should be rekindled among sections of our society” (Sowetan, 7.5.2002). An article in the Star newspaper (20.4.2002) reporting on the launch of South  Africa’s  Moral  Regeneration  Movement  focuses  its  attention  almost exclusively on the situation of children in the context of AIDS.  South Africans (read black South Africans) are urged to “go back to their roots”, and quoting deputy president Zuma, “revive our social support networks and ‘promote the notion that ‘every child is my child’ which formed a rock on which communities were built’”, in order to ensure that orphaned children are integrated into families. “Family is the key to renewal”, the article’s headline proclaims in bold text. “We need to strengthen the moral fibre of our society, as a matter of priority, by rebuilding the family unit”, the article continues.  Throughout this article and others, discourses of a loss of morality are focussed on the failure specifically of the African family.  In this way, in much of the reporting, morality – and specifically moral transgression – becomes racialised.

Thus, by using evocative language that presents children affected by HIV/AIDS as deserted by traditional structures of family/adult care and by focussing attention on children who are living without adult caregivers, the English-language South African press produces a moral dichotomy not recorded in analyses of media reporting elsewhere: that of the AIDS epidemic in South Africa constituting – and being constituted by – new crises of morality in the form of African families’ failure in their moral responsibility for children, resulting in the forsaking of a generation of ‘innocent’ children who deserve better.  Children are presented as victims of a situation within broader society. Innocent (morally pure) children are again juxtaposed with guilty (morally deviant) adults.  However, in this instance, the cumulative effect of South African press reporting is the implicit directing of blame not only at those who are HIV-positive, but also at those who fail in their perceived moral duties to those who are considered to be innocent victims of the pandemic.

Moral messaging does not end here. Representations of families and communities failing in their moral responsibilities towards children, and of helpless child victims of the pandemic, coalesce in places into apocalyptic conclusions of resultant terror and the demise of society as we know it.  A number of different discourses operate together to communicate a moral panic located in predictions of a South African society out of control.

These metaphors of natural disaster in addition emphasise people other than those referred to in the metaphors as victims of the circumstances, powerless in the face of the onslaught of others. We return to this notion shortly.

Another linguistic technique which achieves similar effect is the application of hyperbole in describing the epidemic.  Though more limited in association than metaphors of natural disaster, the descriptions such as “soaring AIDS deaths” (Independent  on  Saturday,  11.5.2002a),  “mushrooming  orphan  numbers” (Independent on Saturday, 30.11.2002a) and references to the likes of “AIDS orphan explosions” (Independent on Saturday, 11.5.2002a) that were similarly present in some press reports, point again to a situation that is worsening rapidly and exponentially, with negative implications.

Definitions of orphaning applying to estimates and projections generally relate to children who may have experienced the death of either one or both parents.  The majority of children thus enumerated in South Africa will have lost one parent, rather than both.  As has been pointed out elsewhere (Meintjes & Giese, 2004), a lack of clarity regarding the definition of orphaning to which estimates and projections pertain operates to feed incorrect notions of the nature of the tragedy – in this case, to inflate the number of children who are ‘double orphans’ in the popular imagination.

We see then how crises of morality are implicitly located in the predictions of the nature of horror that is anticipated to follow from increasing numbers of AIDS deaths, and concomitantly increasing numbers of orphans in South Africa.  As a result of an absence of care they deserve (the moral failure of ‘the African family’), it is suggested that orphaned children will grow up inadequately socialised. These children, ‘innocent victims’ of circumstances beyond their control at the start, are expected to become morally deviant as they mature in the absence of the care to which  they  are  entitled.  In  representations  in  the  press  reports,  one  moral transgression – the lack of provision of care for children – can be seen to feed another, in the form of the creation of a proportion of young people in society who are without good values and morals.

In these ways, it is repeatedly communicated to readers that the oft-labelled “AIDS orphan crisis” (City Press, 1.12.2002; Star, 30.5.2003, among others) is not simply a crisis for affected children, but perhaps of more concern, a looming crisis for readers themselves. Concomitantly, a dichotomy of belonging and ‘non-belonging’ that  is  again  infused  with  notions  of  morality,  is  communicated:  Moral righteousness is situated with those who ‘belong’, the ‘us’ to which articles refer, the HIV-negative, those not ‘contaminated’ by HIV, while a fate of moral degeneration is placed upon those affected, ‘orphans’ of the epidemic.

Public responses: the heroes of the pandemic

Amidst widespread (if by and large implicit) reference to failure on the part of African families, and to less extensive but nonetheless prevalent predictions of public terror, there are articles which denounce a perceived absence of support for children, and rebuke those identified as responsible. In pointing out that readers live in “a society which largely continues to close its collective eyes to [orphans’] plight” and posing the question “Is this how much we care about our children?” (Daily News, 3.5.2003), or arguing that “something should be done to show [orphans] there are people who care” (Business Day, 2.5.2003; Star, 2.5.2003), South Africans are admonished in the press for not taking sufficient moral responsibility in stepping in where families are failing children. “Where”, readers are asked, “are our moral heroes?” (Sunday Times, 16.3.2003). The contrast between press representations of the African family and representations of those who are documented to be responding to children affected by AIDS is striking. Representations of the first – of kin networks that have failed their children – are juxtaposed with representations of people who have gone way beyond the normal call of duty to assist children.

It is in the main the middle class (and largely the white middle class) who feature in press reports as responding to children affected by HIV/AIDS. Articles heroise these individuals for the self-sacrifice, compromise and risk-taking involved in caring  for  those  who  are  implicitly  not  considered  to  be  their  immediate responsibility.  Thus for example, readers learn of a “Cape Town-born banker … who gave up a successful financial career in London to help raise funds for AIDS orphans in South Africa” (Star, 30.5.2002); or an intrepid doctor who adventures beyond hospital walls and comfort to bring aid to children: “Dr Jana Oosthuizen climbs out of the bright red CitiGolf, … humps a heavy rucksack on her back full of medical paraphernalia and heads for the tin shack that is home to five children orphaned by AIDS’ (Financial Mail, 6.12.2002); an “American doctor” who moved across the world to South Africa to start a hospice for dying children (Argus, 22.3.2002); a South African businessman who reverses his decision to emigrate to Canada, “motivated [by] the spectre of millions of orphans left destitute in the wake of the HIV/AIDS devastation … to tackle what is rapidly evolving into a ‘lost generation’ scenario”  (Natal Witness, 3.5.2003); or an emergency/foster mother  who is described as “one of those amazing people who open their hearts to needy children irrespective of the fact that there isn’t enough room for them all in her 3-bedroomed council house”. In each case, their status as ‘outsiders’ to the specifics of the situation is made clear to readers through reference to where they are from in relation to the children they care for.

It is entirely appropriate that affirmation and praise be directed at those who intervene. For many, personal sacrifices and risks are indeed involved. In addition, far-reaching efforts on the part of South Africans are required in order to adequately address the scale of the epidemic, including its repercussions for children. Reporting on these efforts is fitting. However the cumulative effect of the press texts analysed is to locate the moral high ground in the hands of the (white) middle class – whose actions, it is implied, go far beyond the actions of those who should be responding. Distinctions about who is providing support to children affected by HIV/AIDS are made not only in terms of class but also in terms of race.  Commentary such as  “We commend the Topsy Foundation and gardening guru Keith Kirsten for caring about the HIV-infected or affected black children the government does not want to care for” (Sowetan Sunday World, 24.3.2002) provides an overt example of this trend.

The silence in the press reports with regard to the role that African communities are playing in supporting children affected by HIV/AIDS is striking. That more than 90% of children who are orphaned (as well as many others that are not) live with relatives (Budlender & Meintjes, 2004; Hosegood & Ford, 2003; Meintjes & Giese, 2004) and are not cast out to the streets or left to exist as so-called child- headed households is a fact made explicit in only one article (Sowetan, 8.3.2002) published during the monitoring periods. In a couple of articles, the presence of a grandmother or other relative caring for a child is noted but, as illustrated earlier, by far the most predominant image presented in the press articles is of children resident without adult caregivers, having been ‘discarded’ by those responsible for them.

The creation of binary oppositions is a common strategy in the news media (Askew & Wilk, 2002:5). What is important are the associations that are created by, or reinforced, by these oppositions. In this instance, the oppositional representations bolster an overriding racialisation of morality that runs – whether intentionally or unintentionally – through the reporting on children in the context of HIV/AIDS.

Moral ‘decay’ in African communities is offset by the heroism and self-sacrifice of those who take exceptional moral responsibility, responsibility explicitly presented as ‘beyond the call of duty’.  And while these people’s and organisations’ actions are indeed admirable in many respects, the absence of recognition of the role that poor African kin and communities are playing creates  a skewed picture of the challenges that children and South Africans more broadly face as a result of the AIDS  epidemic.  Indeed,  South  Africa’s  particular  political  history  makes reflections which locate moral virtue in the hands of the white middle-class somewhat alarming.

The co-existence  of  contradictory  images  of children

The language used in these articles presents a third powerful image of children, namely the rare and highly capable hero. Far fewer articles analysed portrayed this picture  of  AIDS-affected  children  as  compared  to  depictions  of  vulnerable, innocent victims or threatening delinquents discussed above. Yet this third image deserves attention because its assertion of (albeit unusual) positive agency on the part of the child appears to contradict the helplessness and negative agency (namely criminality) so prevalent in the majority of press reporting.

Here is a further example of a set of binary oppositions orientated around notions of morality. The difference is that they make implicit reference to what is considered appropriate in childhood rather than what a family ought to be and do for children (although the two are related).

We argue that cultural notions of the developing person are so deeply embedded that writers and readers are unaware of their presence in everyday discourse. For example, reporting like that cited above on Nkosi Johnson shows that children are assumed to be incompetent unless they prove otherwise. Research in modern industrialised  societies  finds  that  competence  is  associated  with  adulthood, meaning that the abilities of children and youth are often overlooked (Hutchby & Moran-Ellis, 1998).   Age specific associations start to matter in relation to children’s relationship with wider social forces. Early childhood is seen as a period of innocence and vulnerability, whereas youth is seen as a period of rebellion (Dimmock, 1997). Writers, probably unconsciously, make reference to one or other of these embedded cultural assumptions relating to age and behaviour, rather than any substantive evidence from children’s lives.

Our first concern is that the absence of critical debate in the articles analysed implies that neither writers nor readers question whether such images reflect reality. In what ways, for example, are children with sick parents acting to support themselves and their families? And what are the limitations placed on children in this position? No discussion around these, nor many other relevant questions, is evident in press reporting.  Secondly, the absence of debate suggests a lack of thinking about the possible implications for social policy and children’s lives of reporting that draws more heavily on culturally situated moral convention than on empirical evidence.

Children as sources

In all 114 articles examined for this study, five directly source the children or young people to whom they refer. The representations of children which transpire as a result are salient for the ways in which they diverge from those which prevail in much of the reporting (and which are described above).

Consider for example, an article in the Mail & Guardian (17.04.2003) which reported  on  children’s  school-based  peer  education  and  HIV/AIDS  support activities in an area of Kenya heavily affected by HIV/AIDS. The journalist observes young children providing nuanced information about HIV/AIDS in response to questions from peers, and performing insightful dramas “full of sly observation of adult behaviour, wit and humour”.  In observing and engaging the children directly, his conclusions about children’s experiences and responses to AIDS  contrast  with  the  dominant  imaging  of  children  as  victims  of  their circumstances.  “While all of these children will have had bitter experience of HIV/AIDS”, he notes, “there is no sense that they have submitted to its tyranny, or that they are helpless in the face of it”. Another article – this time in the Saturday Star (15.3.2003) – reported the situation of a young man and his sister (described in the headline as ‘AIDS orphans’) who face eviction from their house because of bureaucratic glitches accessing their mother’s pension funds after her death. Sidwell Blangwe, the ‘AIDS orphan’ at the centre of the article and its primary source, is presented as articulate, competent and active. “When faced with the threat of losing his home and an end to his younger sister Refiloe’s education, he didn’t become despondent but was spurred into taking action”. Similar imaging is present in a third article about a 13 year old girl who lives with her HIV-positive mother, and who has become a vocal AIDS activist (Daily News, 15.4.2003). “She has not let the tragedies tarnish her zest for life”, the article notes, quoting the young woman’s comment that “I love music, dancing and hanging out with my friends. I dream of becoming a professional model”.

In each of these instances, the positive agency of the children is highlighted alongside their qualities as resilient, capable, responsible human beings. That such contrasting images to those more common in the press – of children as pathetic, helpless victims or irresponsible thugs – are present in the few articles which source children provides good evidence, we would argue, of the value of finding ways to directly engage children in articles about children.

Conclusion

It could be argued that the public rarely examines, let alone deconstructs, the messages within press texts, and that communicating the key message – namely that ‘children are suffering as a result of the AIDS epidemic so we need to act’ – in whatever way possible, should be a priority for South African journalists. And that for this reason, the use of various well-rehearsed news writing strategies, including the use of sensationalism, stereotyping, essentialism, and binary oppositions, is justified. However, as Askew and Wilk (2002) have pointed out, these strategies predispose and guide audiences towards readings which favour existing power structures, and characteristically replicate existing hegemonic discourses.

We argue that these strategies are employed at a cost, both in the public’s knowledge and attitudes around the impact of AIDS, and more importantly, in the lives of children affected by the epidemic. For example, portraying orphans as children without adult or ‘family’ care, or as victims or delinquents, or withoutadequate recognition of the challenges they share with other children also growing up in a time of HIV/AIDS, can lead to inappropriate policy and programme responses. These can include inappropriately targeted responses, the foregrounding of institutional care for orphaned children, and decisions that prioritise protecting the public over meeting children’s needs. If such decisions are informed by images of large numbers of criminal children, we can only expect that interventions will aim to contain, reform and perhaps punish young people (Bray, 2003).

Layer upon layer of moral messaging is present in South African press reporting on children living in the context of AIDS. The cumulative effect of the reporting – at least during the periods monitored by this study – is the communication of a series of moral judgements about who is and who is not performing appropriate roles in relation to children. In this respect, representations in the South African press differ from those documented by studies of the media elsewhere. Discourses of existing moral transgression on the part of African parents and families (read kinship networks) for failing in their moral responsibility towards their children coalesce with discourses of anticipated moral decay amongst (previously innocent) children who lack their due care. The need for moral regeneration amongst South Africans generally (but implicitly black South Africans) is contrasted with an accolade of (usually white) middle class individuals who have gone beyond their moral duty to respond. In each instance, the particular moralism is highly questionable in the light of both empirical evidence and principles of human dignity underlying our constitution.

It is not our intention to suggest that South African journalists and other media workers are deliberately – with negative intent – promoting these kinds of messages. Rather, our aim is to illustrate the ways in which a pervasive discourse around children and family life, language choice by individual journalists, and particular silences in reporting children’s everyday experiences and their responses in the face of these, can operate in tandem to produce a very skewed picture.

Previous research has shown that elements of these discourses can be found in writing by academics and development organisations (Bray, 2003; Meintjes & Giese,  2004).  These  continuities  suggest  that  subtle  but  powerful  social conventions exist that restrict writing on children and family life in the context of AIDS, and that these are unintentionally reinforced by different institutions. In this regard, the media would seem to be missing an opportunity to do what they are best at, namely to be the critical voice against such conventions9. As we have suggested, reporting that consults children directly or research conducted with children would enable the press to better fulfil this role.

Sexual Networks and HIV Program Design

Friday, August 12th, 2011 | Permalink

By Martina Morris, PhD; Ruth O. Levine, MA; and Marcia Weaver, PhD

Introduction

Sexual Network Analysis: Changing the Face of HIV Program Design

Social network analysis is changing the way HIV prevention strategies are designed and, ultimately, how HIV transmission is viewed in epidemiological circles. What began as research on kinship structures in the field of anthropology and small group studies in social psychology has evolved into a powerful body of research on sexual networks that is particularly pertinent to HIV prevention efforts. This new knowledge broadens the focus from individuals to the web of relationships that encompass the individual. These romantic and sexual partnerships form the dynamic network along which disease travels. The implications of this conceptual shift are profound, reshaping how and for whom interventions are designed.

For the last three decades, the core group concept has guided intervention strategies for sexually transmitted infections (STIs) (Yorke, Hethcote, and Nold 1978). STI prevention and treatment strategies targeted the few active individuals who repeatedly became infected and were responsible for a disproportionate share of the caseload. This strategy became less useful within the context of HIV, an incurable infection and chronic disease.

The spread of HIV, particularly in settings with generalized epidemics, depends on the extent to which a network is connected. To evaluate this requires empirical research on sexual network structures, examining the patterns of sexual relationships in a locale and how they link together to make the pathways that shape the epidemic (see Figure 1). Some network structures facilitate spread, whereas other structures impede it. For example, HIV program planners are becoming increasingly interested in methods for mapping “bridge populations,” those people who have sex with both high- and low-risk partners, thereby creating a pathway for the virus to spread. Until recently,
the theory existed for looking at sexual network structures, but not the prerequisite statistical and mathematical models to identify and quantify transmission pathways and prevention targets. However, the pervasive spread of HIV in sub-Saharan African countries has galvanized researchers to narrow the gap between theory and methodology.

In the early 1990s, local researchers in Uganda had begun to suspect that concurrency (when an individual has multiple partnerships at the same time) was amplifying the local HIV epidemic. No models existed at that time for projecting the impact of concurrency on HIV transmission, nor were there data on how often or widely concurrency occurred. The work of Watts and May (1992) and Morris and Kretzschmar (1997) bridged that gap, providing both the theory and tools for understanding sexual network structures and a simple methodology for collecting sexual network data.

These approaches represent a movement away from the core group theory, revitalized recently by Liljeros et al. (2001), a group of physicists who argue that HIV prevention efforts should be directed at individuals who have the largest number of partners, as based on a theoretical model of the distribution of sexual contacts. Jones and Handcock (2003) challenged their statistical approach and the conclusion that HIV prevention efforts should target promiscuous individuals.

Network approaches provide a more solid methodology for mapping risk and projecting HIV transmission and for orienting behavioral prevention interventions. The fact that HIV risk behavior occurs in the context of a partnership means that individual knowledge, attitudes, and beliefs do not determine behavior and are mediated by the relationship between partners. All the attendant characteristics of relations―gender dynamics, age and power differentials, cultural mores, and socioeconomic inequalities—become the context in which behavior change must be negotiated. For example, a literature review by Luke and Kurz (2002) highlighted cross- generational sexual relationships between adolescent girls and older men in sub-Saharan Africa, specifically because these partnerships are so important to the context of HIV transmission but were not receiving nearly enough focus from HIV prevention programs.

In sum, network position determines both the level of exposure to HIV and the interactional context that constrains behavioral change. This is what makes network research so essential to HIV prevention research. In this article, we review recent research on two characteristics of sexual networks: concurrency and assortative mixing.

Current State of Research

Concurrency

Concurrency is of key interest to HIV/AIDS researchers who study sexual networks. Over a period of time, sexual partnerships link together to form larger sexual networks. These networks or roadways exist regardless of whether or not disease is present. In a network characterized by serial monogamy, with time gaps occurring between relationships, HIV becomes temporarily locked in partnerships. As a result, it travels much more slowly through the sexual network, and earlier partners are not indirectly exposed by later partners. In a sexual network characterized by concurrency, in which all current partners are potentially at risk, being among the first of these partners is no longer protective. Concurrency helps explain the rationale for shifting the focus of HIV prevention efforts from the individual to the individual and his or her sexual partners (Morris 2001).

Using simulation models, Morris and Kretzschmar (1997) found that concurrency exponentially increases the number of individuals infected as well as the rate of HIV spread within a population. The researchers established a mean number of partnerships and tracked the spread of HIV through ten hypothetical structures of sexual networks, beginning with serial monogamy, and moving toward increasing increments of concurrency. In a direct application of these methods, and using survey data from Uganda, Morris et al. (2004) identified high rates of concurrency. Based on these findings, the researchers concluded that concurrency may play a critical role in the generalized HIV spread in some sub-Saharan African countries and called for further modeling efforts and an HIV prevention message of one partner at one time. More recent empirical studies have verified that persons with concurrent partners are three times more likely to transmit an infection (Potterat et al. 1999; Koumans et al. 2001).

The diversity and richness of concurrency in sexual networks are described by Gorbach et al. (2002). Based on interviews with 140 STI patients and a non-representative sample of 120 individuals from high- and low-STI prevalence communities in an urban setting in the United States, six common types of concurrent partnership patterns were identified, each carrying its own level of social acceptability, STI risk, and condom use practices. Given the nuances of these varied patterns, a range of prevention interventions, rather than one standard approach, is most likely needed. Table 1 (below) describes these different types of concurrency.

Assortative mixing

Assortative mixing is another sexual network characteristic that influences epidemic spread. Assortative mixing simply means the extent to which individuals choose sexual partners who are similar in age, race, sexual orientation, marital status, socioeconomic status, religion, or locale. When these groups are distinct and stable, HIV may remain isolated in well-defined pockets of the general population (Morris 1991). Through mathematical modeling, Morris (1991) demonstrated that in a setting with strong assortative sexual networks, a small bridge population connecting the two groups may not be powerful enough to counter the effect of the assortative mixing patterns in terms of HIV transmission rates. Assortative mixing tends to create several, unlinked smaller epidemics within a population, as compared to patterns more indicative of concurrency, where ever-increasing numbers of people are linked together, thereby amplifying the rate of HIV transmission (Morris 1997).

In Thailand, Morris et al. (1996) used sexual network data to determine who was at highest risk for HIV transmission from a bridge population of men who had relations with both commercial sex partners (CSPs) and non-CSPs. The non-intuitive answer was that young, unmarried women in the general population were the group most likely to be exposed to potential transmission across this bridge. The analysis was based on a 1992 behavioral study that gathered information on sexual behavior from low-income men and long-haul truck drivers. Morris et al. (1996) were able to calculate that for every 100 sexually active men, 30 women in the general population were potentially exposed to HIV in the past year, based on condom use, the number of men with concurrent CSPs and non-CSPs, and the rate of partner acquisition. Sexual network analysis of age- and group- specific patterns indicated that younger men who engaged in commercial sex had a higher number of non-CSPs than older men, and that more of their non-CSPs were non-spousal female partners. Without such analysis, researchers might have assumed that spouses, rather than young unmarried women, were the primary group placed at risk. These types of findings inform program intervention design and ensure that all at-risk groups are identified.

Morris and Dean (1994) looked at the impact of age-mixing patterns on HIV transmission rates in homosexual men and found that assortative mixing initially amplified the spread of infection within the most active group (those aged 25–35 years). Therefore, the usual protective effect that assortative mixing provided to the other groups was overwhelmed by the higher levels of HIV prevalence. However, as contact rates declined and HIV mortality increased within the older age groups, the net protective effect of assortative mixing for all age groups grew, particularly for the youngest group of enrollees (aged 18–24 years). The network analysis was based on data from the decade-long Longitudinal AIDS Impact Project in New York City (LAIP), a seven-year behavior study of gay men in New York City.

The Turning Point: Data Collection and Analysis

Traditional methods of STI partner notification and contact tracing do not transfer easily to the behavioral survey setting, where issues of privacy, confidentiality, and limited access to HIV testing are paramount. These roadblocks have stimulated researchers to develop more “user friendly” ways to study sexual networks and broaden the way that network concepts can be used at many levels of STI programming. For example, in a review of partner notification studies from several countries, Rothenberg (2002) discovered that case finding in some instances went beyond simply identifying sexual partners to tracing a broader social network of at-risk friends and acquaintances.

In order to undertake sexual network analysis, researchers are developing new tools to support this crossover research between epidemiology and social network theory (see handbook on network epidemiology, Morris
2004). One of the greatest challenges is the collection and analysis of network data. In the ideal situation, researchers would collect data on all individuals within a given network. This “complete network data” would be used to definitively map an entire set of partnerships. The first wave of the National Longitudinal Survey of Adolescent Health (Udry and Bearman 1998; Bearman and Jones 1997), conducted in the United States in 1995, gathered one of the few existing examples of complete network data in a national survey setting. Researchers were able to construct a comprehensive map of the romantic and non-romantic sexual relationships in one high school, by gathering data from each student on a total of 535 romantic relationships (Moody 2002). Moody calculates the sequence and timing of relations to show all possible pathways a disease can travel through this romantic network.

However, as comprehensive network data are almost unheard of in the developing world, partial or “local” network data are often collected. Partial networks are typically surveyed through some kind of snowball sampling. An example is shown in Figure 1. This sexual network from Colorado Springs was sampled using a combination of multisite enrollment and contact tracing from 1990 to 1995. The figure, based on data reported in the first year of the study, shows all sexual partnerships that had occurred during the previous six months. In a “local network” study, a representative sample of a population is asked to report information on their immediate partners, but the partners are not traced or enrolled. These local network data are rich enough to examine for concurrency and assortative mixing patterns, although researchers question how much information is lost by using this less
comprehensive approach (Morris 1997).

The Future

Research on sexual networks benefits from a new synergy of improved tools, better data, and a clear need for this type of analysis on the part of HIV program planners in the field.

Researchers are actively investigating ways to improve the quality and breadth of information obtained from local network data. Morris (2003) is exploring sophisticated statistical approaches that will form the basis of a hybrid approach to local and complete network data. Sexual network theorists have traditionally used linear algebra tools to describe clustering and connectivity, and standard statistical methods for estimation and inference. Morris’ recent work, drawing on exponential random graph models, represents a leap forward, providing sexual network theorists with intermediate statistical tools for modeling dependent data and a methodology for extrapolating from local network information. For the first time, researchers will be able to plug in sexual network data directly from the field into simulation models.

Moody (2002) broaches an area of modeling that is still at the stage of theory. However, by comparing various sexual network structures from concurrency to monogamy, Moody is able to demonstrate that the timing of relationships is critical for determining the diffusion of disease. While sexual network theorists understand the practical implications, statistical methods do not yet exist that can map the spread of disease and simultaneously account for the sequence or timing of relationships.

Recommendations for Practice: Research Implications for HIV/AIDS Programming

Local network data can be collected with a simple module that probes for key information on current and previous partners of the respondents. This module is easily integrated into a standard questionnaire, and is extremely flexible in terms of length and content. The data are invaluable for designing HIV prevention interventions that hone in on the most vulnerable links of HIV transmission. The module may start with a question as simple as, “I’d like to ask you some questions about the person you had sex with most recently.” Essential information includes the dates of first and last sexual encounters, in order to establish partnership intervals, and partner attributes (e.g., age, race, geographic local, education, occupation), relationship attributes (e.g., nature of the partnership, if they have children, how they met), sexual behavior, and risk factors (Morris 1997). These same questions should be asked in regard to the respondent’s two previous partners, at a minimum.

Two local network studies from Thailand and Uganda conducted in the early 1990s demonstrate how to collect sexual network data in the field (Morris et al. 2004). The cross-sectional study in Thailand collected survey information from 678 brothel-based prostitutes, 330 long-distance truck drivers, and 1,075 low-income men from the general population. Respondents were asked 32 questions about each of their three most recent sexual partners, covering partner attributes and the nature of their relationships, sexual behavior, and condom use. In Uganda, a cross-sectional survey of individuals from 90 communities in the Rakai district included 77 questions about each of the respondent’s most recent three partners. The extensive number of questions, while not feasible in every situation, provided data rich in detail. In both cases, findings from the data helped identify sexual network characteristics that hastened the spread of HIV and therefore had implications for intervention design.

Conclusion

Sexual network analysis is changing the face of HIV prevention strategies by moving the focus of prevention efforts from isolated individuals to sexual partnerships. Network analysis can be used to identify those most at risk of HIV infection, the relational context of the risk behavior, and the means to tailor prevention strategies accordingly. Only within the past few years have specific sexual network characteristics been identified as critical to understanding HIV transmission patterns and spread of disease. Assortative mixing creates two effects: slowing disease spread between groups and increasing disease spread within groups. Concurrency amplifies the spread of HIV through multiple partnerships. In the future, other network characteristics may emerge that are just as important to track and understand. New modeling and statistical tools are advancing the field rapidly and will
soon allow researchers to accurately forecast the spread of disease through particular sexual networks and to predict the effects of interventions that alter the characteristics of networks.

References

Armendáriz de Aghion, B., and J. Moruch. 2000. Microfinance beyond group lending. The Economics of
Transition, 8(2):401–420.

Bearman, P.S. and J. Jones. 1997. The National Longitudinal Study of Adolescent Health: Research Design [www document]. Accessed at http://www.cpc.unc.edu/projects/addhealth/

Gorbach, P.M., B.P. Stoner, S.O. Aral, W.L.H. Whittington, and K.K. Holmes. 2002. “It Takes a Village”: Understanding concurrent sexual partnerships in Seattle, Washington. Sexually Transmitted Diseases, 29(8):453–
462.
Jones, J.H., and M.S. Handcock. 2003. Sexual contacts and epidemic thresholds. Nature, 423(6940):605–606. Koumans, E.H., T.A. Farley, and J.J. Gibson, C. Langley, M.W. Ross, M. McFarlane, and J. Braxton. 2001.
Characteristics of persons with syphilis in areas of persisting syphilis in the United States: Sustained transmission associated with concurrent partnerships. Sexually Transmitted Diseases, 28(9):497–503.

Liljeros, F., C.R. Edling, L.A. Nunes Amaral, H.E. Stanley, and Y. Ǻberg. 2001. The web of human sexual contacts: Promiscuous individuals are the vulnerable nodes to target in safe-sex campaigns. Nature,
411(6840):907–908.

Luke, N., and K.M. Kurz. 2002. Cross-generational and transactional sexual relations in sub-Saharan Africa: Prevalence of behavior and implications for negotiating safer sexual practices. International Center for Research on Women: Washington, D.C.

Moody, J. 2002. The importance of relationship timing for diffusion. Social Forces, 81(1):25–56. Moody, J., and M. Morris. 2000. Sexual network (personal communication). Colorado Springs, Colo.
Morris, M. (ed.). 2004. Network epidemiology: A handbook for survey design and data collection. International
Studies in Demography Series. Oxford: Oxford University Press.

Morris, M. 2003. “Local rules and global properties: Modeling the emergence of network structure” (National Academy of Sciences workshop), in Dynamic social network modeling and analysis. R. Breiger, K. Carley, and P. Pattison (eds.). Washington, D.C.: The National Academies Press. pp. 174–186.

Morris, M. 2001. Concurrent partnerships and syphilis persistence: New thoughts on an old puzzle. Sexually
Transmitted Diseases, 28(9):504–507.

Morris, M. 1997. Sexual networks and HIV. AIDS, 11(Suppl A): S209–S216.

Morris, M. 1991. A log-linear modeling framework for selective mixing. Mathematical Biosciences, 107(2):349–
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Morris, M., and L. Dean. 1994. Effect of sexual behavior change on long-term human immunodeficiency virus prevalence among homosexual men. American Journal of Epidemiology, 140(3):217–232.

Morris, M., and M. Kretzschmar. 1997. Concurrent partnerships and the spread of HIV. AIDS, 11(5):641–648.

8 Morris, Levine, and Weaver 2004

Morris, M., C. Podhisita, M.J. Wawer, and M.S. Handcock. 1996. Bridge populations in the spread of HIV/AIDS
in Thailand. AIDS, 10(11):1265–1271.

Morris, M., M.J. Wawer, C. Podhisita, T. Pramualratana, N. Sewankambo, and D. Serwadda. 2004. “The Thailand and Ugandan Sexual Network Studies,” in M. Morris (ed.), Network epidemiology: A handbook for survey design and data collection. Oxford: Oxford University Press. pp. 42–57.

Potterat, J.J., H. Zimmerman-Rogers, S.Q. Muth, R.B. Rothenberg, D.L. Green, J.E. Taylor, M.S. Bonney, and H.A. White. 1999. Chlamydia transmission: Concurrency, reproduction number, and the epidemic trajectory. American Journal of Epidemiology, 150(12):1331–1339.

Rothenberg, R. 2002. The transformation of partner notification. Clinical Infectious Diseases, 35(Suppl 2): S138– S145.

Udry, J.R., and P.S. Bearman. 1998. “New methods for new research on adolescent sexual behavior,” in R. Jessor
(ed.), New perspectives on adolescent risk behavior. Cambridge: Cambridge University Press. pp. 241–269.

Watts, C.H., and R.M. May. 1992. The influence of concurrent partnerships on the dynamics of HIV/AIDS.
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Transmitted Diseases, 5(2):51–56.

9 Morris, Levine, and Weaver 2004

The Advances Through HIV/AIDS Research Series

This series uses an innovative methodology to bridge the dynamic worlds of HIV/AIDS research and the practice of HIV/AIDS prevention, care, and support in developing countries. The 2002–2003 series includes nine papers on a range of topics. The goal of the series is to disseminate key research findings and expert analyses to busy practitioners and policy makers working in the field. Each paper places significant, new, or controversial research findings in a broader context and explores their practical and policy implications for those working on the frontlines. These are not “best practice” recommendations. Instead, the series aims to help decision makers recognize research breakthroughs and emerging technical challenges, and consider their implications for HIV/AIDS program planning, design, and applied research

The Methodology

In the development of each paper, an internationally recognized expert frames the paper, identifying key issues, recommending the most pertinent and recent publications, and describing significant ongoing research. The key issues and research findings are then modified into an accessible format for a broad audience. These papers are not lengthy or exhaustive literature reviews; rather, they provide a rapid, rich, and selective examination of key issues and findings on the topic from the perspective of one well-known expert in the field.

The Expert

Martina Morris, PhD, is the Blumstein-Jordan professor in the Department of Sociology and professor in the Department of Statistics at the University of Washington, and director of the Center for Studies in Demography and Ecology. She is principal investigator on four grants funded by the National Institute of Child Health and Human Development: “Quantifying HIV transmission risk in sex/drug networks,” “Modeling HIV and STD in drug user and social networks,” “HIV and STIs in young adults: A network approach,” and “Sexual networks and HIV: Data, models, and intervention.” Dr. Morris has published extensively on the issues of concurrent partnerships and sexual networks specific to HIV/AIDS. She is deputy editor of the journal Sociological Methodology.

The Staff

Faculty and professional staff at the Center for Health Education and Research (CHER), University of Washington (UW), Seattle, are responsible for producing this series as part of The Synergy Project, managed by Social & Scientific Systems, Inc. (SSS). At UW, Ruth Levine is primary author, Elaine Douglas is senior editor, and Marcia Weaver is project lead. The Synergy Project is funded by USAID. At SSS, Barbara de Zalduondo is technical reviewer, and Polly Gilbert is responsible for dissemination. The opinions expressed in this series are those of the experts and authors and do not necessarily reflect the views of UW, SSS, or USAID.

Vaginal Gel to Slow HIV Infection Rates?

Sunday, July 17th, 2011 | Permalink

With women being the largest group of HIV infected people in the world, a new treatment that could help them avoid transmitting the virus is causing excitement. A vaginal gel that can be self-applied may help reduce the numbers of infections.

With over 60 percent of new infections being women, and over 50 percent of the estimated 34 million people living with HIV or AIDS, women are the target of new efforts to curb the infection.

The Gel

The new treatment gel contains the anti-retroviral drug tenofovir. Infected women squirt the gel into themselves using a special applicator. This happens twice, 12 hours before sex, and 12 hours after.

The gel has also been found to reduce the incidences of herpes simplex 2, which is another virulent infection that causes problems on its own merits, but also makes it easier for HIV to gain a foothold in a person.

It works by lining the walls of the vagina, and penetrating the cells underneath, allowing the antiviral to get to work. This method is proving very effective in the trials so far.

The Trial

The Center for the AIDS Program of Research in South Africa (CAPRISA) has been running the trial in conjunction with the University of KwaZulu-Natal in Durban, South Africa. Funding was secured from the US Agency for International Development and the South African government for the trial.

There have been 11 such trials since 2004, with 6 other gels being tested. This latest one is the only one to have provided tangible improvements in infection rates.

Of almost 900 women in the test, 445 of them receiving the active gel, all were 39 percent less likely to become infected with HIV. The 444 using a placebo gel weren’t so lucky.Among women who used the gel exactly as instructed, the infection rate fell by 54 percent, suggesting that rates could be halved if women use it properly.

The use of antiviral drugs has been used to reduce the spread of HIV for a while now, in fact, it coincides with another study by the World Health Organization, in association with the United States National Institutes of Health. This study used antiviral drugs administered early to reduce the spread of the HIV virus.

Why it Works

This gel worked where others have failed thanks to the antiviral ingredient tenofovir. The other gels were simply being tested as a physical barrier to infection. Including the antiviral in the gel has helped produce the results we have today. The new gel penetrates and protects from within the cells that HIV normally infects.

With other treatments being researched, and some positive findings being fed into the media, it paints a picture of a gradual improvement in the treatment of HIV and AIDS. This gel is so exciting because it can be made available to the poorest countries, who usually have the highest rates of infection.

As long as the gel is used correctly, it can provide an effective barrier to many people. When used in conjunction with common sense, and other preventive measures, it could dent the spread of the disease across the world.

The Effect

If the gel works as the research suggests, it could reduce the number of infections significantly. By closing another door to the virus, we are gradually reducing its ability to transfer to another person. If used alongside other treatment methods, it could provide an impermeable barrier to entry.

With women being the most common carriers of HIV, it makes sense to develop a treatment that not only protects, them, but others too. Used in conjunction with condoms, this treatment could be very effective in reducing the spread of the virus.

If only one-third of South African women used the gel, it could prevent 1.3 million infections and 820,000 deaths over 20 years. Multiply that across the world, and we have a real sign of hope for the future.

The other significant effect is that of power. There is little a woman can do to protect herself from infection right now. Much is in the hands of the man. Giving a woman the tools to protect herself brings her destiny back into her own hands.

The Future

Another trial of the gel is planned for the near future, with the help of the United Nations Program on HIV/AIDS. The aim of the trial is to confirm the results of the first one, and to refine the gel to see if it can become even more effective.

Once confirmed, the process can begin to make the gel available across the world. Gilead, the California-based company which developed tenofovir, has granted the South African government permission to make the drug and to sell it in the gel without having to pay the company a royalty. That is a significant barrier removed, and the cost to produced reduced significantly.

Licensing for individual markets takes time, sometimes up to 2 years, so the gel won’t be available for a few years yet.

Alternatives

At the same time, Australian firm Starpharma are trialing a different vaginal gel called VivaGel, which uses a different antiviral, but is said to produce similar results.

This gel is based on dendrimers and has demonstrated effective inhibition of HIV and HSV-2 even 24 hours after application. If either of these gel treatments are successful, it provides a significant inroad to preventing the spread of HIV.

VivaGel is still undergoing clinical trials, but it promises to be a huge factor in the fight against the spread of HIV, and could cut the HIV infection rate even more than current treatments available on the open market.

Add a comprehensive education campaign to the release of either of these gels, and make them widely available and we have a possible reduction in infections across the board. It’s unlikely that these two gels are the only ones undergoing trials or development.

Once the formulas are made available, and companies like Gilead are generous enough to waive their royalties, we have a viable, effective treatment for the spread of HIV.

Understanding Genital Herpes and the Relevant Implications

Sunday, July 17th, 2011 | Permalink

Genital herpes is a disease that most educated people know about throughout the world. The reason for this is simply the widespread nature of the disease. However, apart from the fact that genital herpes is a sexually transmitted disease, most people do not know anything else about the disease. Unfortunately, most sexually transmitted diseases are so sly that knowing about them is the only way that they can be spotted. Hence, the following is some information relevant to genital herpes.

Defining genital herpes

As explained above, genital herpes is a sexually transmitted disease. It is caused by two types of viruses, namely the Herpes Simplex Virus Type 1 (HSV-1) and the Herpes Simplex Virus Type 2 (HSV-2). Of the two, the latter is much more widespread than the former. Genital herpes spreads through sexual contact, whether there is some visual mark on the infected person or not. This means that genital herpes does not need any kind of break from the skin like a sore or rash to spread from one person to another.

Symptoms of genital herpes (info 1 & 2)

Genital herpes, as a disease, is particularly hard to spot because of the way its symptoms show up. As a result of this difficulty, most people with the disease are not even aware of the fact that they have it. Typically, genital herpes shows itself in the form of outbreaks of blisters near the genitals or rectum. These blisters break leaving behind sensitive ulcers or sores which also heal after a period of two to four weeks. Following this outbreak, there may be more outbreaks at a later stage. However, the following outbreaks are usually less severe and do not last as long. The first outbreak, more often than not, shows up in less than two weeks of the person being infected. During this outbreak, some symptoms that can crop up include another set of sores, flu like symptoms like fever, and swelling. It is worth stating that these symptoms are mostly very mild and, hence, are ignored by the infected person. A typical characteristic of genital herpes is that it makes the infected person much more susceptible to the risks of contracting HIV.

Special considerations

Most people think that a person infected with genital herpes would show visible signs. Furthermore, many people also think that unless a person is in the middle of an outbreak, the virus cannot spread. On the contrary, genital herpes is infectious even if the infected person is not currently in the midst of a blister outbreak. In different words, irrespective of whether a person is going through an outbreak, he or she can spread the disease to another person.

Treatment of genital herpes

Unfortunately, there is no known cure for genital herpes. However, there are techniques and procedures that reduce the impact of the disease. For example, a person suffering from genital herpes can take antiviral medication which will result in the outbreaks either being eliminated completely or being shortened. However, the effect is not lasting which means that the person has to stay on medication.

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