Track D Social Science, Human Rights and Political Science

We evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW‐IDUs) in Tijuana (TJ) and Ciudad Juarez (CJ) Mexico during 2008‐2010, when harm reduction was expanding in TJ, but not CJ.

In CJ, women receiving active vs. didactic injection risk interventions decreased receptive needle-sharing by 84% vs. 71%, respectively (p 00.05); in TJ, receptive needle-sharing declined by 95%, but was similar in active vs. didactic groups (p 00.54). TJ women reported significant increases in access to syringes and condoms, but CJ women did not-see figure.
Conclusion: In both cities, a 30-minute intervention promoting safersex in the context of drug use significantly reduced HIV/STI incidence with sustained effects at 12 months. Expanding free access to sterile syringes coupled with brief, didactic education on safer injection was both necessary and sufficient in achieving dramatic, sustained injection risk reductions in TJ. In the absence of expanding syringe access in CJ, the injection risk intervention still achieved significant, albeit more modest reductions, suggesting that community-level interventions incorporating harm reduction are more powerful than individual-level interventions for reducing injection risks. Background: The results of the HPTN 052 study, which showed antiretroviral treatment (ART) is highly effective in reducing HIV transmission, have been hailed as a ''game-changer'' in the fight against HIV, leading to calls for significant scaling up of treatmentas-prevention (TasP). But it is unclear how TasP could be financed, given flat-lining support for global HIV programs. We assess if TasP is indeed a game-changer against HIV, or if comparable benefits can be obtained at a lower cost by scaling up existing interventions such medical male circumcision (MMC). We also assess the impact of TasP in combination with MMC. Since MMC is currently being scaled up in many countries in sub-Saharan Africa, the effectiveness of TasP in conjunction with MMC is a highly policy-relevant question. Methods: We formulate a new mathematical model to overcome challenges in predicting the effectiveness of untried mass interventions (lack of a historical epidemic trajectory) and in predicting the combined effectiveness of different prevention interventions. Our model uses simple behavioral assumptions to estimate new HIV infections instead of estimating parameters by fitting a curve to a disease history. Results: For South Africa, a combination of high ART coverage at CD4B 350/ml and circumcision coverage provides approximately the same HIV incidence reduction as TasP (defined as universal ART for all HIV-infected persons) at a cost Â $5 billion less over 2009Á 2020. Circumcision outperforms high ART coverage at CD4 B350/ml (and TasP) significantly in cost per infection averted*$1096 compared to $6790 per infection averted. Further, circumcision increases in cost-effectiveness over time and becomes cost saving after 2040. Conclusion: The preventive benefits of ART are largely reaped with high ART coverage at CD4B350/ml. Expanding circumcision coverage first is most cost effective, and then scaling up ART under current guidelines is more cost-effective for preventing HIV infections than scaling up TasP. Background: The Total Control of Epidemic (TCE) Program of Humana People to People aims to reduce spread of HIV and its impact by systematically engaging individuals and communities to take control of their own risk factors, while increasing access to prevention, treatment and support services. Implemented in close partnership with respective Ministries of Health and National AIDS Councils across Sub-Saharan Africa and Asia, TCE has made major impact in HIV control. Methods: The TCE model works through two primary strategies: a) Individual HIV Counselling to Prevent New Infections: Every person in target areas was provided with counselling for behaviour change and was assisted to develop individual risk reduction plans. Homebased testing consistent with country guidelines was conducted as an integrated part of the process. b) Community Mobilization to Change Social Norms: To change social norms across the full range of HIV related issues (stigma, discrimination etc.), community-wide mobilization was carried out with local leaders, activists, PLHIV to project them as role models for others along with intensified promotion of existing services. Results: Since the first TCE pilot in Zimbabwe in 2000, 11 million people were covered in 11 countries. 28 million individual HIV counselling sessions were delivered. As a result, 2 million people were tested for HIV and received their results. Over 500,000 women attended PMTCT services. More than 600,000 community activists were trained and engaged in community mobilization activities. In Blantyre District of Malawi, 4 times increase of PMTCT utilization within 3 years and in Ehlanzeni District of South Africa, 6 times increase of PMTCT utilization within 4 years after TCE implementation were observed. Conclusion: With an average cost of U$ 2/person/year, the TCE model represents a cost effective community-based intervention for HIV control and care with proven results, that should be replicated across the most HIV affected countries.

WEAD0303
Phenomenal woman: the development of a program with the dual goals of HIV and substance abuse relapse prevention In response, Greenhope Services for Women, Inc developed ''Phenomenal Woman'', an HIV prevention program for women recently released from prison and/or mandated to receive residential substance abuse treatment. Methods: The target population for ''Phenomenal Woman'' is African-American and Latina women demonstrating relatively high HIV risk behaviors receiving residential substance abuse treatment at Greenhope. The development of ''Phenomenal Women'' involved incorporating key components from ''SISTA'', other HIV prevention programs, the ''Helping Women Recover'' curriculum, and newly created components. Formative research including: three focus groups, one key informant interview and two pilot cohorts were conducted to identify and pretest curriculum components and participant retention strategies. Results: ''Phenomenal Woman'' is comprised of 5 group sessions and a booster session held 45 days after program completion. Its primary aims include: enhancing women's sense of self, increasing HIV/STI knowledge, as well as attitudes, self-efficacy, and behaviors related to sexuality, safe and sober sex practices, and spirituality. Utilizing the formative feedback received (n 042 participants), the program creatively uses tangible objects (music, affirmation sheets, and meditation rocks) to reinforce the key messages of strength, resilience, and making healthy decisions regarding safe and sober sex behaviors. The program was implemented with 76 participants with retention rate of 100% across the five initial sessions and 72% at the booster session. Conclusion: Greenhope's ''Phenomenal Woman'' is an example of effectively developing and delivering curricula through the adaptation of evidence-based curricula and the creation of new components to address a target population's needs for HIV prevention and substance abuse relapse prevention. Through high levels of administrative support, participant retention rates were maximized. Accordingly, ''Phenomenal Woman'' holds considerable promise for dissemination to other agencies with similar target populations.

D2 -Behaviourial and social research on risk reduction interventions TUAD0302
HIV prevention needs of transgender sex workers in Serbia D. Ilic Association against AIDS -JAZAS, Belgrade, Serbia Presenting author email: drilic@sezampro.rs Background: Research among transgender persons is rare in Serbia. The emergence of HIV infection led to an increase in stigma and discrimination, but not to an increase in professional interest. Sex work in Serbia is illegal and sex workers are highly discriminated against, especially those of 'different sexual orientation'. This paper presents research of HIV prevention needs of transgender sex workers in Serbia. The research study is meant to be a baseline study for designing special prevention strategies for this population group. Methods: By snowball sampling methodology, 250 sex workers were incorporated into the research study, of those 40 were transgender, 55 male and 155 female. Results: A high level of multiple stigmatization and marginalization is the result of a combination of the following characteristics: gender, ethnicity (mainly Roma), very low education levels and high levels of auto-stigma. Moreover there is a statistically significant difference between transgender sex workers and male/female sex workers in terms of being victims of violence much more frequently, perpetrated by their peers, clients, police and citizens. Transgender persons differ also in terms of low levels of prevention knowledge, the presence of misconcepotions about HIV and inadequte assessments of risk to themselves.
Clearly, the preventive needs of this group cannot fully be met through programs designed for sex workers in general (such as outreach work, drop-in centers, mobile medical units, etc). Conclusion: It is necessary to develop additional preventive strategies, such as: -Behavior Change commmunication interventions, which are aimed at increasing self-efficacy, self-confidence which should result in an increase in visibility and affirmation of the transgender identity.
raising public awareness about human rights regardless of gender differences.
education of health care workers about the needs of this group.

WEAD0301
Behaviour change and associated factors among female sex workers in Kenya of years in sex work and one's level of HIV prevention knowledge. A re-orientation on the peer education programme to focus on HIV preventive measures beyond use of condoms is emphasized.

WEAD0304
Determinants of condom use in South Africa G. Matseke 1 , L. Simbayi 2 , N. Wabiri 1 and N. Ncitakalo 2 1 Human Sciences Research Council, Pretoria, South Africa. 2 Human Sciences Research Council, Cape Town, South Africa Presenting author email: gmatseke@hsrc.ac.za Background: Condom use as a means to prevent HIV infection has significantly increased over the past decade among all age groups in South Africa. However, little is known about what motivates the behaviour in South Africa. This study investigated the prevalence and demographic, psychosocial, and behavioural determinants of condom use among people aged 15 years and older in South Africa who were sexually active over the 12 months prior to the survey. Methods: Data from the 2008 national HIV population-based survey was used. This was a cross-sectional survey which was conducted using a multi-stage stratified sampling approach. Univariate analysis and multiple logistic regression were used to identify factors associated with condom use at last sexual intercourse. A total of 5072 respondents, 46.0% males and 54.0% females, who indicated having had sex in the last 12 months were involved in the study. Results: Overall, there was no gender difference found in condom use: males (64.6%) vs females (60.4%). The multiple logistic regression analyses indicated that youth aged 15Á24 years and students' learners were more likely to use condoms at last sex. (AOR02.2528, AOR02.4358, pB 0.05). Whites, Coloureds and Indians were less likely than Africans to use condoms (AOR 00.2125, AOR00.3000, AOR00.4511, pB 0.05). Likewise, married people and those whose current relationships exceeded a year were less likely to use condoms (AOR 00.2782, AOR00.3239, p00.00). Finally, having only one regular sexual partner significantly reduces the odds of condom use (AOR 00.2855, p 00.021). Conclusion: It is important to understand more about the nuances of condom use so that programmes can target those at greatest risk of infection such as African adults and people in stable relationships, especially those that might also be involved in other risky behaviours such as multiple concurrent sexual relationships.

THAD0301
Framing HIV testing messages for urban and rural audiences: evidence from field experiment in northwest Ethiopia M.A. Bekalu 1,2 and S. Eggermont 1 1 Katholieke Universiteit Leuven, Belgium, School for Mass Communication Research, Leuven, Belgium. 2 Bahir Dar University, Bahir Dar, Ethiopia Presenting author email: mesfiab@yahoo.com Background: Given their epidemiological and socio-ecological differences, urban and rural contexts may require differently designed prevention messages. Utilizing messages framed in terms of the benefits (gains) or costs (losses) associated with a particular HIV/ AIDS-related behavior could be one viable strategy to address urban-rural differences. Methods: Based on relevant literature, urbanity vs. rurality, experience with HIV testing and concern about and information needs on HIV/AIDS were tested as moderators of framed HIV testing messages' effectiveness. Gain-vs. loss-framed brochures were distributed to 394 participants (199 Urban: 46.2% male, 53.8% female; 195 Rural: 79% male, 21% female). Through pretest-posttest measures of intention to test for HIV, the relative persuasiveness of gain-and loss-framed messages was determined. Results: Urbanity vs. rurality, experience with HIV testing and concern about and information needs on HIV/AIDS significantly moderated the effects of gain-vs. loss-framing on Intention to Test for HIV, F(1, 385)09.28, pB0.01, n20.02; F(1, 385)017.20, pB0.001, n20.04; and F(1, 385) 018.97, p B0.001, n20.05, respectively. While urbanites, participants with more experience with HIV testing and those with higher concern about and information needs on HIV/AIDS were motivated by gain-framing, ruralites and those with lower concern about and information needs on HIV/AIDS were motivated by lossframing. Both gain-framing and loss-framing led to similar outcomes among individuals with low levels of experience with HIV testing, with a slight advantage for the loss-framed message. Conclusion: Urbanites and ruralites are motivated by differently framed prevention messages. It was also noted that to the extent recipients are concerned about HIV/AIDS and are familiar with HIV testing, gain-framing is more advantageous, suggesting a possible construal of HIV testing as more of a prevention than a detection behavior in such situations.  Tertiary Education Council, recognizing that HIV interventions for College/University (tertiary) students were few/fragmented, conducted a study to understand student behaviours, needs and gaps in services. Born in the 1990s, this generation of youth is the first of its kind-a generation who has grown up with HIV-infected, heavily affected and message-fatigued. Methods: Between 2009Á2010, TEC conducted a study of 10% of tertiary students using self-administered surveys (N 04312). Classes were randomly selected from 32 institutions and surveys were augmented by 28 post-survey FGDs. Participation was voluntary, anonymous and counselling was offered. Survey questions were qualitative and quantitative. Results: 57.0% of participants were female and 63.0% were aged 20Á24. HIV knowledge was high (over 90% responded correctly to 9/11 knowledge questions) but satisfaction with current HIV interventions was low (44.9%) and 38.5% said condoms are never available on campus. 82.5% were sexually active and 45.0% had already engaged in unprotected sex. 53.9% knew their HIV status and 49.4% knew their partner?s status. 33.7% reported that they were engaging in MCP. Key findings from the FGDs include: a) campuses are sexualized spaces b) students are involved in transactional relationships c) students do not perceive themselves to be at risk for HIV and d) campus interventions are few and irrelevant. Conclusion: Irrespective of increased knowledge and impact from AIDS deaths within their families while they were young children, the sexual practices that gave rise to the current HIV epidemic in Botswana persist among tertiary youth. The study raises serious reservations about the assumption that youth are making behaviour changes. It also exposes gaps in service provision and questions the strength and relevance of current interventions to youth in a country with a staggering incidence rate.

FRLBD01 Effect of a national social cash transfer program on HIV risk behavior in Kenya
Background: Cash transfer programs may reduce the risk of HIV transmission among young people from poor households by providing economic security. The Cash Transfer for Orphans and Vulnerable Children (CT-OVC) is the Government of Kenya's flagship social protection program, reaching 150,000 poor families with OVC age 17 or below. Households are provided a flat unconditional cash transfer of US$25 per month. The objective of this study is to assess whether the CT-OVC reduces HIV related behavioral risk among adolescents.
Methods: We use data from the third wave of the impact evaluation of the CT-OVC collected in 2011. The design is a clusterrandomized trial. 1912 households in seven districts across Kenya were part of wave three; two-thirds were in the program and the remaining third were randomized out at baseline in 2007. Data on sexual behavior and other risk related behaviors were collected in wave 3 only for residents age 15-25. We analyze data for residents age 21 and below who had not had sexual intercourse at baseline (N 01516, Females041%). We use multivariate analysis with controls for age, sex, Nairobi residence, and relationship to household head.
Results: Main study findings indicate that the CT-OVC has reduced the probability of sexual debut by 6.73 percentage points off a proportion of 0.37 who had ever had sex after the program began in 2007. This result appears to be driven by males. The program has also reduced the proportion of adolescents with 2 or more partners in the last 12 months, by 7.2 percentage points , and reduced the probability of 2 or more unprotected sex acts in the last 3 months for females (p00.10). Conclusion: A large scale, national cash transfer program may prevent HIV among adolescents by postponing sexual debut, reducing the number of partners and reducing the number of unprotected sex acts.

MOPDD0101
A pilot South African worksite-based parenting program: preliminary effects on parent-child communication about sex and HIV Background: There is a general consensus that people with severe mental illness(SMI) are more likely to have a history of childhood sexual abuse and are at increased risk for HIV. For this study, we hypothesized that our homeless, mentally ill participants reporting CSA would be more likely to report current engagement in HIV-risky behaviors, history of STI's, and associated psychopathology than their non-CSA counterparts. Furthermore, we hypothesized that those who had experienced CSA in early to middle childhood (EMCSA) would be more likely to report these challenges than those who had experienced CSA in adolescence (ACSA). Methods: As part of a NIH-funded RCT(1R01MH084696-01A2 PI Brady) primary and secondary prevention trial for adults with SMI at-risk for HIV transmission, ninety participants were administered an assessment battery which included the Structured Clinical Interview for DSM-IV, Demographic Inventory, and Timeline Followback. Chi-square analyses were used to test our hypotheses and analyze the relation between our variables of interest.
Results: There were no significant differences in current HIV-risky behaviors between CSA/non-CSA participants nor for EMCSA/ACSA participants. However, CSA participants were more likely to present with PTSD{x2(1, 90)012.95, p B.001}, ASPD{x2(1,90) 013.78, pB .001}, and prior Chlamydia diagnosis{x2(1,90) 08.46, p B.01} than non-CSA participants. Also, a trend showed that EMCSA participants were more likely to report current PTSD symptoms{x2(1,90) 02.73, p B.10} than ACSA participants. Interestingly, EMCSA participants were more likely to report being HIV positive{x2(1,45) 04.82, p B.05} than ACSA participants. Conclusion: CSA was associated with an increased likelihood of presenting with associated psychological sequelae and STI's, namely Chlamydia. Further, EMCSA participants were more likely to present with HIV disease than AMCA participants. Our research contributes to literature outlining the pernicious impact CSA has on physical and mental health in the severely mentally ill homeless population. Future studies should identify potential moderators of the CSAhealth risk relationship (e.g., gender).

WEPDD0303
Street-based adolescents: actual emphasis on HIV prevention Background: The numbers of street children vary from 30,000 to 100,000 in Ukraine. Their vulnerability to health-related risks, including HIV/AIDS, substance and drug abuse, was a subject of the baseline study in 2008. Based on its findings, UNICEF implemented a comprehensive approach to HIV-service delivery in four pilot cities and repeated the survey to assess the effectiveness of interventions in 2011.
Methods: Behavioral survey among street-based adolescents (N 0805, age 10Á19, 565 boys, 240 girls) was conducted using location-based network and convenience sampling. Data were disaggregated by age and gender. Comparative data analysis was applied to learn the behavioral and knowledge changes. The client satisfaction questionnaire was used to define the service access barriers.
Results: Street adolescents are highly vulnerable to HIV-infection: 22% injected drugs, 65% of girls provided commercial sex services; 7% of boys had sex with men; only 13% always used condom with casual sexual partners. Social vulnerability factors hinder access to medical and social services: two-thirds of respondents didn't have a permanent place of residence and were not covered by medical services. 46% didn't have an ID, 54% didn't have an education certificate. The piloted interventions caused the positive behavioral change and knowledge increase: a share of those, who correctly identified the ways of HIV transmission, has increased for 10%; a share of those, who were tested for HIV during the last year and received the result, has almost doubled. The biggest increase in HIVtesting is among girls: every sixth tested in 2008, every third in 2011. Conclusion: Study confirmed effectiveness and sustainability of implemented interventions and suggested a roll-out-strategy to the country. This is of critical importance as a significant number of street children remains uncovered by services and has a low level of knowledge about HIV/AIDS, HIV-service organizations and places, where support is provided and testing is available. While boys seemed vocal, uncontrolled and eager to discuss sex and condoms, girls preferred discussing love and care of people living with HIV/AIDS. Refugee boys produced culturally and linguistically diverse resource materials that were easily understood across the cultural groups while portraying males as innocent victims and females as potentially responsible for the spread of HIV. Notably, pupils received different and conflicting messages on similar topics depending on the teacher's religious background. While older teachers were perceived as 'parents', young male teachers were seen as having a hidden 'sex agenda'. Conclusion: In conclusion, gender, culture and religion, influence the learning of HIV/AIDS education in refugee schools in a complex manner, which if not understood and controlled could have negative implications. The study recommends pre-service multicultural teacher education and training on how to make HIV/AIDS education gender-responsive. Methods: Being highly sexualized sites, high schools act as a channel for sexual initiation and exploration. Thus, teachers can be catalysts to providing valuable and life altering information around HIV/AIDS to their students. Through a qualitative case study, teacher narratives were collected to identify their classroom structure; strategies; awareness of HIV/AIDS; and the challenges encountered when discussing the subject in their classroom. Overall, implicating communication processes were an essential factor in uncovering the subtle, yet, uncomfortable silences found in this study. Results: The surface-level understanding around HIV/AIDS and a lack of consistent training and access to accurate resources identified how teachers understood and valued HIV/AIDS information. Ultimately, such familiarity corresponded to how their students comprehended the virus and viewed the marginalized communities most affected. Conclusion: Theoretical frameworks connected to Paulo Freire's Engaged Pedagogy and Nel Noddings's Pedagogy of Care, were considered as tools for empowering teachers when imparting knowledge on HIV/AIDS.

THAD0306
Rethinking the 'teacher' in school-based, teacher-led sexuality education programmes in rural and urban Tanzania These are homosexuality, masturbation as an alternative to sexual intercourse, condom use, sexual pleasure and enjoyment, sexual behavours other than intercourse and appropriate and inappropriate touching. Three major reasons were given to why they rejected these topics. First, they explained that if students are taught about these topics, they may practice them and that would fuel sexual activity among them. Second, since they have to teach practically, teachers explained that demonstrating these topics would be an embarrassment to them and to the students. Third, they reported that these topics are against sexual norms of the communities where they (teachers) and students come from. Conclusion: With these findings, it is important to rethink the position of teachers in the delivery of CSE. Being ''teachers'' does not exclude individuals from abiding by sexual norms of their community. The rejection of these topics indicates that teachers still adhere to sexual norms of their communities. In order to strengthen CSE programmes, programmes need to work on sexual norms that may hinder the delivery and success of CSE in schools. Eight months after training, manyakanga had initiated 450 wali (about two girls per manyakanga per month). Parents, elders and non-program manyakanga who were initially suspicious of the modified unyago reported a preference for it. Pregnancy, MCP and school withdrawals are less common among wali who have been in the program. All-night celebrations for wali (associated with alcohol, drug use and sex) have been discontinued in the program areas. Conclusion: Harmful aspects of a traditional practice can be modified to promote positive behavior. Training and advocacy that involves community leaders (such as manyakanga) can produce a sustainable system of effective change agents. The modification of socio-cultural norms should be locally appropriate, incorporate the purpose and beneficial aspects of a practice, demonstrate added value, and be led by custodians of that practice.

TUPDE0105
Social capital and AIDS competent communities: evidence from eastern Zimbabwe Methods: We used Nhamo's (2010) conceptualisation of the 'HIV competent community' to frame thematic analysis of the Manicaland Project's qualitative dataset. 481 people participated in 30 children's draw-and-write, 100 interviews and 55 focus groups exploring local responses to HIV/AIDS. These included people on ART; healthcare workers; workers; community group members; sex workers and clients; and participants in cash transfers, home-based care, support groups and peer education. Results: Community group memberships are often associated with lower HIV incidence amongst women, and higher incidence amongst men. Group memberships impact directly through facilitating or hindering healthy behaviours, and indirectly through impacting service access, and the effects of peer education, home-based care and cash transfers. Gendered group communication styles often make women more likely to engage in positive health-related dialogue, and to entrench macho stereotypes and health-damaging behaviours in men, although this is not always the case. Conclusion: Growing evidence suggests indigenous community groups could become a useful focus for enhanced HIV/AIDS prevention, care, treatment and impact mitigation. Efforts might focus on enhancing the beneficial effects of groups (mostly on women) and limiting their damaging effects on men. Parallel efforts should facilitate contexts that are supportive of beneficial group effects, including a wider comprehensive response with empowering support from funders and community partnerships with supportive service providers.

WEPDD0301
Reducing children's vulnerability in a regions with HIV prevalence with an integrated livelihoods, protection and psychosocial support (PSS) package Background: In Western Uganda, high HIV prevalence, poverty, and abuse/exploitation threaten children's wellbeing and can contribute to high HIV transmission risk for vulnerable children. A comprehensive approach is needed to address the key drivers of vulnerability and improve child welfare for highly vulnerable children. World Education (WEI)'s Western Uganda Bantwana Program (WUBP) builds the capacity of nine community-based organizations (CBOs) to provide comprehensive services and referrals strengthening to 3,100 vulnerable children and their families to improve child welfare. Methods: Using the following methods, Bantwana and local partners gathered evidence suggesting that an integrated package of psychosocial support (PSS), livelihoods, and child protection (CP) interventions can effectively contribute to reducing child vulnerability and improve children's overall wellbeing: Child profiling baseline and follow-on survey: of 132 children, measuring child wellbeing across a range of internationally accepted vulnerability indicators; CP case study: focus group discussions with districts, children, schools, and other protection stakeholders to assess school and community child protection interventions; PSS assessment: interviews/focus group discussions with volunteers, caregivers, CBO partners and children, exploring effects of a household approach to PSS on child wellbeing; and Qualitative evaluation study (with Columbia University): of 247 households, to determine benefits of livelihoods/ protection interventions on child wellbeing.
Results: Preliminary results from the Columbia study suggest that an integrated protection/livelihood intervention can improve outcomes in child wellbeing. The CP case study and PSS assessments reveal that strengthening linkages among CP stakeholders (school, community, government and household)*improves child protection outcomes, while the child profiling survey reinforces the importance of a household approach. Conclusion: Preliminary evidence suggests that an integrated package of PSS, livelihoods, and CP intervention may reduce vulnerability and improve child wellbeing which could have implications for HIV prevention approaches for vulnerable children in regions with high HIV prevalence.

THPDC0206
Increasing transgender community capacity to impact HIV prevention and health care services: Coalitions in Action for Transgender Community Health (CATCH) Background: The Center of Excellence for Transgender Health (CoE) has been mobilizing transgender (trans) community throughout the United States utilizing a coalition building approach since 2007. The CoE along with its National Advisory Board (NAB) has identified and supported community leaders, health departments and key stakeholders in engaging the transgender community, identifying gaps and developing strategies for addressing identified unmet needs in the U.S. The CoE supports local community efforts in organizing conferences, symposiums, and summits that are focused on transgender specific health and well being. Methods: In the CATCH model, with support from staff of the CoE, local coalitions guide the community mobilization process and lead data collection and analysis efforts, prioritize HIV prevention and health care needs, develop a comprehensive plan to strengthen community access to and utilization of HIV prevention and health care services, and decide how to evaluate these efforts.

Results:
Community mobilization is a very empowering process that can provide participants with a sense of control, self esteem, self determination and increased capacity for changing systems to be transgender inclusive. Both providers and community members are able to create meaningful, sustainable linkages for capacity building and increasing access to services. Social networks created through CATCH are sustainable and increasingly multiplying. CATCH is a groundbreaking national network that ensures that community members have a voice in the transgender HIV and human rights movement through a coordinated effort.
Conclusion: CATCH increases transgender community capacity to access services by supporting advocacy efforts, creating networking opportunities, and increasing visibility of trans HIV prevention and health care needs. D7 -Child care, infant feeding, pre-chewing of food (premastication)

MOPDD0303
Determinants of infant feeding intent and appropriateness of choices for formula feeding in the Djoungolo Prevention of Mother-To-Child Transmission of HIV programme, Yaounde, Cameroon Background: The dilemma of infant feeding in HIV context of poor resource setting remains unresolved and the practice of replacement feeding may happen to be a curse by lowering child survival. Appropriate infant feeding counseling can reverse such risk as well as limiting spill-over (WHO, 2010.) Objective: to describe infant feeding intents of HIV positive women and determine the appropriateness of choice of those opting for formula-feeding after the counseling process. Methods: Routine infant feeding counseling of HIV positive mother offered by short-course trained counselors during the pregnancy or in the early-post partum. Intents were assessed using a generic acceptable, feasible, affordable sustainable, secure (AFASS) score composed of 7 variables grading from 0 to 2:type of energy, source of water, kind of latrines, disclosure to the partner, monthly income, ability to prepare bottle feeding and to give a reason for non breastfeeding. An AFASS score above 10/14 was considered as appropriate for formula feeding. Results: 950 women were included for cohort characteristic. Among 924 women counseled, 63% intended to formula feed their babies while 37% planned to breastfeed. The AFASS criteria !10 was met by 87% who intent to practice formula-feeding compared to 57% of those who intent to breastfeed. Women counseled during post-partum were more likely than others to opt for artificial feeding (p B 0.001). Formula-feeding choice was more appropriate in women counseled during pregnancy vs after delivery (p 00.02). The determinants of choosing replacement feeding were tertiary education (p B 0.001), no previous exclusive-breastfeeding, HIVstatus disclosure (p B 0.001) and AFASS score!10 (OR: 5; 95% CI: 3Á6). Conclusion: in Djoungolo, after infant feeding counseling, replacement feeding intent is mostly appropriate fitting mother's environment and livelihood. In addition, the desire to breastfeed remains real as more than 1/2 women who choose to breastfeed met the conditions to practice formula feeding. Background: Although evidence reveals that most heterosexual HIV transmission in sub-Saharan Africa takes place within marriage or cohabitation, approaches for people living with HIV (PLHIV) focus primarily on individuals. The Faithful House (TFH) is a couples-based, skills-building curriculum used with 45,000 couples in twelve countries, recently modified to address PLHIV issues. Research examined the effect of TFH on attitudes and behaviors to provide evidence for a couples-based approach for more holistic PLHIV programming. Methods: Participants, using convenience sampling, from HIV programs in four regions of Ethiopia were randomly distributed between intervention and control groups.The intervention group participated in TFH workshop for PLHIV. Both groups completed surveys at baseline and three months post-intervention which was analyzed using STATA. Results: The study surveyed 378 individuals with a mean age of 35.2. Most couples (88%) were either married or cohabitating. All participants had been tested for HIV with 90% testing positive. Intervention participants (193) reported significant changes (pB 0.01) in the quality of their relationship, including improved communication and joint decision-making about child care, finances and sexual negotiation. Intervention participants had statistically significant improvements in medication adherence (18% non-adherent at baseline versus 10% at three-months) and percentage diagnosed with sexually transmitted infections in the past three months (7.3% decreased to 4.7%). Of males with pregnant partners, 94% in the intervention group attended antenatal care visits compared with 36% in the control. Intervention participants also reported statistically significant decreases (p B0.05) in violent behaviors including insulting, shoving, and forcing sex. Conclusion: The modified TFH curriculum had a positive impact on attitudes and behaviors affecting the physical and relationship health of PLHIV couples. These preliminary results indicate potential for couples-based approaches for more holistic programming for PLHIV. Continued evaluations are critical in determining sustained impact on health status outcomes, attitudes and actual behavior change.
D9 -Counseling and testing (HIV counseling and testing (HCT) and voluntary counseling and testing (VCT)), social, psychological and behavioral aspects of HIV testing and counseling WEPDE0202 Mapping spatial barriers and facilitators to HIV testing by work environments among sex workers in Vancouver, Canada access to HIV prevention and care, including HIV testing, to vulnerable sub-populations in Vancouver, Canada. This study assessed the association between geographic factors measuring access to HIV testing sites and having a recent HIV test among hidden street-and off-street sex workers(SWs) in Vancouver. Methods: Baseline data were used, including an intervieweradministered questionnaire, HIV/STI testing and geographic location data, from an open prospective cohort of SWs recruited in 2010 in Metropolitan Vancouver (''An Evaluation of Sex Workers' Health Access''[AESHA]). Access was measured by density of testing sites within a catchment surrounding SWs' place of solicitation (radius0 distance travelled in 15 minutes of combined bus/walking) and time to travel to nearest testing site. Bivariate and multivariable logistic regression was used to identify if density and time were independently associated with recent HIV testing (in the last year). Adjusted odds ratios and 95% confidence intervals were reported (AOR: afternoons, discussed issues ''triggered'' by videos that were produced specifically for the intervention, learned stigma reducing mechanisms from each other, and practiced using these mechanisms in role plays. Participants completed a measure of internalized stigma before, immediately after, and 1-week after workshop participation. Results: The intervention demonstrated feasibility and the women enthusiastically accepted the intervention. The women reported decreased stigma from the start of the workshop to immediately after (p 00.05) and 1 week after workshop participation (p 00.07). Conclusion: Findings suggest that the Unity workshop holds promise for reducing internalized stigma for African-American women living with HIV.

MOPDD0105
Effectiveness of psycho-education in a family-to-family program on family relationships and emotional quotient of adolescents in HIV families in Thailand Background: This study examined the effectiveness of psychoeducation in Family-to-Family Project on family relationship and emotional quotient (EQ) of adolescents in HIV families in two representative provinces in Thailand, Chiangrai and Nakorn Ratchasima. The intervention included core elements identified by Thai Ministry of Public Health and University of California, Los Angles, USA for improving physical and mental health, family relationship, and social outcomes for HIV-affected families. Methods: The sample consisted of 194 adolescents (aged 12Á17 years) in 402 HIV-affected families. A randomized controlled trial with pre-test and post-test was performed during December 2006 -January 2009. Adolescents were randomly assigned into 2 groups: (a) adolescents whose parent and caregiver(s) attended psycho-education and (b) adolescents whose parent and caregiver(s) did not attend psycho-education. The instrument was a set of questionnaire including: family relationship and EQ. Data were collected prior to the beginning of the program, and at 24-month follow-up. They were analyzed using t-test and logistic regression statistics. Results: The study findings suggested, when controlled sex, age and education, family relationship and EQ of adolescents before and after the intervention in each group did not vary significantly. Study participants were surveyed at baseline, 5 and 9 months to assess psychiatric symptoms (using the Brief Symptom Inventory (BSI)), social support, coping, and medication adherence. Results: The CHAMP study participants were reflective of the HIV population in the region with respect to race (80% African-American) and gender (35% female).
Statistically significant decreases in the global BSI score and a number of BSI symptoms dimensions including anxiety, depression, obsessive compulsive, and hostility were detected. The sample means for anxiety, hostility, and phobia dropped below the BSI clinical significance level and the proportion of participants meeting the BSI case definition based on having a BSI Global Score of 63 or above decreased from 85% of participants to 54% of participants (p 0.018). Statistically significant improvement was also found for the SF-12 mental health scale, adaptive coping, overall social support and emotional support.
No statistically significant differences were noted in outcomes by gender or race/ethnicity. Conclusion: Findings from the CHAMP Study suggest that inhome mental health treatment may be beneficial in engaging and treating HIV-positive individuals with co-morbid mental health disorders.
D12 -Socio-economic vulnerability and stratification (e.g., inequality, poverty, wealth, social status) WEAD0102 Critical consciousness, perceived racial discrimination and perceived gender discrimination in relation to demographics and HIV status in African American women Track D Social Science, Human Rights and Political Science orphans in rural Africa cope with their loss remains scarce. We report on prevalence and predictors of complicated grief among a rural Zambian cohort. Methods: 376 rural Zambian orphans 10-18 years, (46.3%0female, 44.1% 0orphaned by AIDS) were interviewed five times. Respondents were included if they had lost their parent(s) at least two years prior to the final survey. Validated scales from Western settings were translated and culturally adapted. Complicated grief was defined as experiencing above average levels of grief symptoms in the last four weeks. Cross-sectional data assessed prevalence of complicated grief and tested multiple regression models. Bootstrapping supported robust regression coefficients estimates.
Results: Approximately one-third (30.3%; n 0114) of these orphans reported complicated grief symptoms. Independent predictors (pB 0.05) included peer bullying, daily stress (e.g. excessive household chores, looking after ill family) poor primary-caregiver relations, within household discrimination, number of primary caregiver losses, and time since loss. Together these explain a fifth of the grief found two or more years after parental death (R adj 2 00.21). Other theoretical predictors of complicated grief including age, sex, sudden or violent death, living with the deceased parent or experiencing their prolonged illness prior to death were not associated.
Expected comorbidities with depression, suicidal thoughts, PTSD, and functional impairment in everyday tasks were confirmed, underscoring construct validity. Conclusion: One-third of orphans exhibit debilitating grief two or more years after parent death. While these data highlight the centrality of community-based initiatives that sensitise caregivers of orphans to alleviate stigma and discrimination, additional research on children with complicated grief suggests benefits from more focussed interventions. Screening tools and effective counselling interventions adapted for this rural African population are urgently needed. Background: There is mixed evidence on the association between HIV prevalence and poverty, but an increasing number of studies have found a positive association between HIV prevalence and income inequality, especially among countries with generalized epidemics. Less is known about the association between income inequality and HIV prevalence in concentrated epidemics, such as among injection drug users in Vietnam, or whether this association holds at the community level. Methods: 1674 male IDUs, and 1349 community members (40% male) living in physical proximity, were recruited throughout Thai Nguyen. Both IDUs and community members completed crosssectional surveys. IDUs were tested for HIV. The GINI coefficient for income inequality was calculated for each commune from the selfreported incomes of non-IDU community members. Scatterplots of the communes were then constructed to compare community-level income inequality and HIV prevalence among IDU.

Results:
The HIV prevalence among IDU in 32 communes in Thai Nguyen is 31.2% (4.3%Á63.6%). There is a statistically significant positive correlation of 0.59 (pB0.001) between HIV prevalence among IDU and the income inequality level of communes, weighted by population.
A regression of HIV prevalence as a function of GINI coefficient shows that an increase in GINI coefficient of 0.10 is independently associated with an 8.8% increase in HIV prevalence (p 00.001), controlled for mean income of the commune. Conclusion: To our knowledge, this is the first analysis demonstrating the association between income inequality and HIV prevalence at a community level, where social and cultural factors are relatively homogenous. It is also the first to demonstrate the association between income inequality among the general population and the HIV prevalence of a high risk group in a concentrated epidemic. The results suggest that the distribution of local economic resources is related to HIV infection in high risk groups.

WEPDD0305
Does the 'inverse equity hypothesis' explain how both poverty and wealth can be associated with HIV prevalence in sub-Saharan Africa?

Track D Social Science, Human Rights and Political Science
Background: A controversial aspect of HIV/AIDS epidemiology has been whether it is relative wealth or relative poverty that is a key driver of the epidemic in sub-Saharan Africa. We hypothesised that the social epidemiology of HIV in Africa is changing from a situation where more new infections are acquired by those of relatively high socioeconomic position (SEP), to one where those of relatively low SEP are at greater risk. We suggested this pattern is compatible with the inverse equity hypothesis from child heath that suggests those of higher socioeconomic position benefit first from new health interventions. Methods: We analysed Demographic and Health Survey (DHS) data from sub-Saharan African countries with two surveys measuring HIV prevalence or with a second expected in the next two years. We inspected the pattern of HIV prevalence by SEP, indicated by education status. In the countries with two surveys we calculated the percentage risk difference for HIV prevalence stratified by education and sex.
Results: Data were available for eleven countries: four with two surveys and seven expecting a second survey within two years. In the first/only survey, higher SEP is broadly associated with higher HIV prevalence. In countries with two surveys, HIV prevalence has risen in the no education group in all cases except among women from Lesotho, and fallen among those with secondary education in all cases except women from Malawi. Conclusion: Available evidence strongly suggests that in the early phase of the epidemic HIV infections were concentrated among those of higher SEP. Our analysis supports the inverse equity hypothesis that new infections will increasingly concentrate in people of lower SEP because of lower access to public health interventions. Data that will be available within the next two years will further test this hypothesis. The inverse equity hypothesis has important implications for policy and resource allocation. Background: Swaziland has the highest HIV prevalence in the world. Many Swazis are chronically food insecure. Globally and within southern Africa, food insecurity has been linked to high-risk sexual behaviors, difficulty with antiretroviral (ARV) adherence, higher rates of mother-to-child transmission, and more rapid HIV progression. Methods: In-depth interviews were conducted with 20 HIV' female sex workers (SWs) in Swaziland. Interviews took place in four different regions of the country, and were designed to learn about context, experiences, and health service needs amongst Swazi sex workers. Interviews were coded in Atlas.ti. Results: Hunger was a consistent, major theme in our informants' lives. Women cited their own hunger or that of their children as the impetus to begin sex work, and as a primary force in continuing to sell sex. Nearly all informants requested food-related services (parcels, grants, or education) when asked about desired programming. Good nutrition and the ability to eat ''healthy'' or ''balanced'' foods was seen as an important means of controlling HIV disease progression. Informants discussed difficulty in adhering to ARVs when faced with taking pills on an empty stomach. Across interviews, discussions of CD4 counts and ARV adherence intertwined with discussions of poverty, hunger and healthy foods. Food security and food sharing were also seen as important expressions of social networks, which many SWs felt they had trouble accessing as a result of both their HIV status and profession.

WEPDD0104
Care and support by households and extended families in the era of HIV treatment: responses to HIV and AIDS in rural South Africa Background: The last century's economic and political upheavals are widely believed to have reduced African and particularly South African families' cohesion and ability to function collectively. AIDS has compounded this threat to the resilience of households and wider family networks. We explore the resilience of families to AIDS and demonstrate that theories of social capital, family obligation and reciprocity can help to explain access to familial support in rural KwaZulu-Natal, South Africa.
Methods: Data were collected over a 7-month period from a small sample of households dealing with AIDS illness or death using indepth interviews and participant observation. Retrospective and prospective data about households' experiences were analysed using framework analysis and the development of household case studies for comparisons. Results: Affected households and individuals drew on family relationships for financial and material support and physical care. Close family members, often sharing a common sense of home and family, were the most important source of care and support. Their greatest motivation was a strong moral obligation to family, associated with norms of familial assistance. Support from other family varied depending on whether levels of mutual trust, investment in social capital and physical proximity, enabled negotiated reciprocal exchange. Families suffering from conflicting obligations, conflict, severe poverty or extreme illness were more likely to be excluded from these networks and suffered because of their inability to secure familial support.

Conclusion:
Despite examples of exclusion, we demonstrate that social capital, reciprocity and a sense of family obligation persist in families responding to the impacts of AIDS, contributing to them maintaining cohesion, collective functioning and ultimately ensuring their resilience. Interventions to support the treatment, care and wellbeing of sick individuals need the flexibility to be able to both support families in their efforts to provide these services and address the needs of people without access to supportive family networks.

WEPDD0105
Family network proportion and HIV risk among black men who have sex with men Background: Black men who have sex with men (BMSM) have the highest rates of HIV in the United States. Despite increased attention to social and sexual networks as a framework for biomedical intervention, the role of family in these networks and their relationship to HIV prevention has received limited attention.
Methods: A network sample of BMSM and their family members (N 0380) was generated through respondent driven sampling of BMSM and elicitation of their personal networks. The proportion of personal networks that were family was calculated and weighted logistic regression was used to assess the relationship between this Methods: A total of 1,060 men (aged 15Á59) and 1,700 women (aged 15Á49) participated in a survey conducted in 4 provinces. Provinces and districts were purposively selected; households and individuals were randomly selected. The survey included questions related to gender-based violence, rape myths that blame women for rape (i.e., If a woman doesn't physically fight back, you can't really say it was rape), and attitudes towards gender norms (measured using the Gender Equitable Men scale) and contraception.
Results: 68% of females ever experienced either or both physical (35%) or sexual abuse (39%); only 15% sought help. 62% of all respondents endorsed at least 1 of 4 rape myths and 37% supported inequitable gender norms. Those with 2' partners (46%) in the last 12 months were more likely to support inequitable norms than those with 1 partner (39%) or no partners (26%) (p B 0.001). Nearly 20% of men think that contraception is women's business; 32% think women who use contraception are promiscuous. When women were asked about their last birth, 50% indicated they wanted to wait or did not want the pregnancy at all. Unintended pregnancies were highest among unmarried younger females (77Á85%) compared to married women aged 25' (50%). Conclusion: Inequitable gender norms are pervasive and may affect women's vulnerability to HIV and gender-based violence. ZPI is addressing power imbalances between men and women that contribute to HIV risk and focusing on male norms and behaviors that contribute to gender-based violence.

WEAD0104
Abuse and mortality in women with and at risk for HIV Conclusion: Mortality risk is significantly elevated for women exposed to GBV and appreciable even in the context of a high death rate due to HIV infection. Interventions to address GBV should remain a public health priority. Further research is needed to identify possible biologic pathways underlying abuse related sequelae.

WEAD0106
HIV risk behaviour among victims and perpetrators of male-on-male sexual violence in South Africa: results from a population-based survey

Track D Social Science, Human Rights and Political Science
Conclusion: Male-on-male sexual violence victimization and perpetration are common among men in the general population in South Africa and are associated with increased HIV risk behavior, as well as increased violence against women. Efforts to address the links between violence and HIV in South Africa must be extended to include prevention of male-on-male sexual violence, comprehensive support for male survivors of such violence, and efforts to address male-on-male perpetration.

MOPDD0205
Alarming rates of occupational violence and associated HIV risks among young female sex workers in post-conflict northern Uganda The study goal is to evaluate the effect of interventions on reducing community-level stigma. Methods: Randomly selected households and individuals were interviewed at baseline (N 0560) and endline (N 0560). We conducted t-tests on three stigma domains: fear of HIV infection through daily activity; shame associated with having HIV; and blame towards people with HIV. We developed three scales using confirmatory factor analysis and regressed each stigma scale on demographic characteristics, HIV knowledge, and exposure to intervention activities. Track D Social Science, Human Rights and Political Science  Track D Social Science, Human Rights and Political Science Respondents exposed to the monthly campaign, funfair and IEC materials were less likely to exhibit stigma along the dimensions of fear (4.2 points lower on average compared to respondents exposed to none or only one intervention; 95% CI: (7.4 to (0.6) and shame (4.7 points lower; 95% CI: (8.4 to (1.1), net of demographic controls and baseline levels of stigma. Personally knowing someone with HIV is associated with low fear and shame, and females are less likely to possess attitudes of shame compared to males. Analysis of the open-ended responses among HIV positives who did divorce, revealed that disclosure can create serious rifts with partners. Perceived community stigma was approximately reported at same levels across the four countries, but levels of self-stigma differed. Patients were more likely to report self-stigma in Burkina Faso, while they were the least likely to report self-stigma in Malawi. However, none of our stigma indicators was associated with disclosure. At individual level, those with a lower education and member of a support group disclose less than the rest. Conclusion: Seropositive patients tend to disclose to people in their support network. However, disclosure within the partnership is less common. We found no relationship between stigma and disclosure to partners. A tailored disclosure support and advice will be essential for programs looking at implementing treatment as prevention in serodiscordant couples.

WEAD0504
Internal stigma among HIV-positive adults in Ethiopia T. Bezabih World Food Programme, Programme/Nutrition and Education/HIV and AIDS, Addis Ababa, Ethiopia Presenting author email: tsegazeab.bezabih@gmail.com Background: Internal stigma or self-stigmatization is a critical problem among PLHIV as it usually leads to low self-esteem, a sense of worthlessness and depression, etc. The objective of this study is to assess the level of internal stigma among HIV-positive adults in Ethiopia Methods: This study utilized a nationally representative two-stage cluster sampling method to collect data from 3360 PLHIV (68% of them women) sample cases. Results: More than half of the PLHIV blamed themselves and reported to have low self-esteem. More than 40 percent of the PLHIV feel ashamed and guilty because of their HIV status. PLHIV residing in rural areas have higher likelihood of feeling guilty than PLHIV residing in urban areas. One out of five of the PLHIV felt suicidal, in connection with their HIV positive status. Abandoning aspirations/life goals, in connection to their HIV-positive status was reported by substantial proportion of PLHIV. For instance, the proportion of PLHIV who took the decision not to have (any more) children was 59 percent,), not to have sex was 40 percent and not to get married 37 percent. Significantly higher proportion of female PLHIV were noted to have taken all these decisions compared to males (P 00.000). Almost one-quarter of PLHIV revealed that they have isolated themselves from their family and/or friends as a result of their being HIV-positive. Nearly equal proportion of PLHIV have decided to withdraw from their education/training and stopped working (12 percent) because of their HIV-status. Conclusion: Internal stigma and its negative consequences are very common among PLHIV in Ethiopia. This may deter PLHIV from active participation in socio-economic activities of the community out of a fear of having their status revealed or being discriminated against. In order to address the problem, peer-to-peer support groups, skills building, network building, counselling, training, should be given attention. The final model demonstrated a dynamic interplay among future orientation, perceived social support and trusting relationships. Trusting relationships was the most proximate protective factor for depression. Perceived social support and future orientation were positively related to trusting relationships.

Conclusion:
We conclude that perceived social support, trusting relationships, and future orientation offer multiple levels of protection that can mitigate the effect of traumatic events and HIV-related stigma on depression. Trusting relationships with caregivers provides the most immediate source of psychological support. Future prevention interventions seeking to improve psychological wellbeing among children affected by HIV/AIDS should attend to these factors. Background: In the third decade of the HIV epidemic in the United States, the population of persons living with HIV/AIDS (PLHIV) has aged. While 50 and older was initially created as the ''older age'' category, that cut-point is no longer informative. Understanding the health status of different adult age-groups of PLHIV will assist in providing the types of healthcare services needed by an aging population.

D17 -
Methods: A convenience sample of 2,182 PLHIV was enrolled from HIV clinics and service organizations in the United States, Canada, Puerto Rico, Namibia, China, and Thailand from February 2010 to July, 2011. This subanalysis of U.S. participants (N 01293) assessed differences in PLHIV in three adult age groups: 40Á49 (n0687, 53%); 50Á59 (514, 40%); and 60 and older (n 092, 7% Conclusion: The oldest group of PLHIV has better mental health although they are living with multiple comorbidities, perhaps because they view themselves as survivors. Although fewer older persons have AIDS, 91% are taking HIV medications and their treatment self-efficacy is significantly higher than the younger age group (F 09.091, p 0.000). It might be time to reexamine the possibility of creating peer groups between middle and older aged PLHIV. Background: In 2010Á2011 we conducted a HIV and non-communicable disease (NCD) prevalence and risk behavior survey (''Ha Nakekela'' study) within the Agincourt Health and Demographic Surveillance System site (AHDSS) in Mpumalanga Province, South Africa (Menken P.I). We found surprisingly high levels of HIV prevalence at older ages, given in Table 1

Track D Social Science, Human Rights and Political Science
Older adults are either contracting HIV at earlier ages and surviving for a long period or they are contracting HIV at older ages. In this study we examine the sexual behavior and HIV risk for older adults in the two years previous to the study visit. Methods: The Ha Nakekela study was based on a probability sample of 7,428 individuals aged 15 years and above. We analyze the sexual behavior survey for the 2,051 adults over age 39 in the study to investigate the prevalence of sexual behavior risk factors for acquiring HIV. Results: We find evidence suggesting that older adults are at risk of acquiring HIV through unprotected sex and by having multiple partners. Fifteen percent of men over 39 report multiple partners, the majority of whom are significantly younger. Very few men (9.5%) and women (11.5%) reported condom use at last sex. We also find that older adults are not likely to know their or their partner's HIV status: only 5% of sexually active older adults said they knew the HIV status of their sexual partner. Of those that are HIV positive, 31% had never been tested and only 40% of those that had ever tested reported being on ART. Conclusion: The high HIV prevalence, lack of condom use, lack of testing, and low ART uptake of known positives suggests that older adults are an over-looked but critical population for both HIV prevention and treatment programs. Background: HIV/AIDS among adults 50 and older in Uganda is on the increase partly due to newly diagnosed infections in this age group as well as improved survival owing to antiretroviral therapy, for many HIV infected persons. Although national programmes are in place to ensure access to medical services, older people living with HIV have unique unmet healthcare needs. The objectives of this study were to identify the healthcare needs of older Ugandans living with HIV and to gather recommendations for improvements by health service providers. Methods: Data regarding healthcare needs were collected from HIV positive adults aged 50 years and older attending two large nongovernmental outpatient clinics in Kampala and Masaka districts, Uganda between March 2011 and June 2011. Individual in-depth open-ended qualitative interviews focus group discussions were conducted. Observations of clinic interactions were also recorded. Interview transcripts were analyzed using thematic content analysis. Results: The mean age of the respondents was 65 years, 50% were female, (n 040). Respondents expressed multiple age-related healthcare needs that may differ from their younger counterparts. Needs increased with higher age. Both men and women attributed double stigma from HIV and old age as a major factor affecting disclosure and seeking healthcare for HIV. 60% of the respondents expressed anxiety about their future access to healthcare, the lack of social services and end of life care. Lack of transport and food access issues compromised respondents' adherence to antiretroviral therapy. Conclusion: Older people living with HIV have unique healthcare needs which health promotion programmes should consider meeting through appropriate and innovative approaches such as preventing and managing age-related chronic illnesses, palliative care, developing age-friendly services and settings. Research to further explore the impact of these healthcare needs on the quality of life of older PLWHA is required.

WEAD0605
Prevalence of transmissible infections and socio-demographic and behavioral risk factors amongst prisoners in Mexico City: a cross-sectional study of 17,296 inmates S. Bautista-Arredondo National Institute of Public Health, Cuernavaca, Mexico Presenting author email: sbautista@insp.mx Background: The health of prisoners is an issue of global concern. Increased socio-demographic and behavioural risk factors prior to incarceration and poor prison living conditions contribute to increased prevalence of transmissible infections. Little is known about the health of prisoners in Mexico City. This study sought to establish prevalence data and risk factors to identify those currently needing healthcare and to inform future policy. Methods: This cross-sectional study was carried out in 4 Mexico City prisons, June to December 2010. Ethical approval was granted prior to starting; participation was voluntary, confidential and based on informed consent.
Participants were offered HIV, Hepatitis B, C and Syphilis testing. A representative sample completed a questionnaire on sociodemographic characteristics and risk behaviours. Positive results were delivered with counselling and treatment or referral with consent. Data was analysed using Stata. Results: 76.8% (15,517/20,196) men and 92.9% (1,779/1914) women participated. Complete data sets were available for 98.8%. Prevalence of HIV (0.7%), syphilis (Anti-TP Ab 4.1%; VDRL 2.0%), Hepatitis B (HBcAb 3.0%; HBsAg 0.2%) and Hepatitis C (3.2%) was higher in the study population compared with national data. The relative increase was greater for HIV and syphilis amongst women, Hepatitis C in men, and all infections in younger participants. Questionnaire data (1934 men, 520 women) demonstrated lower educational levels, increased smoking and substance use compared to national data. High levels of unsterile tattoing, physical abuse and a history of sexual violence were found. Conclusion: The study identified that health screening is acceptable to Mexico City prisoners and feasible on a large-scale. It demonstrated increased prevalence of HIV and other infections compared to national data, though low rates compared to international data. Individual participants benefited from earlier diagnosis, treatment and support. The data collected will also enable the formation of improved policy for this vulnerable group of individuals.

MOAD0103
The challenges of care and support for a generation of nosocomially infected young adults from Romania living with HIV Background: After two decades of living with HIV a generation of around 7,000 children from Romania nosocomially infected in communist era, turned into young adults. Hyper protection from the family, combined with discrimination in education services, developing social services, and a focus on medical aspects represented the environment these children grew. Between 2004 and 2010 the Global Fund financed social programs for their professional integration, increasing the percentage of those availing of cash benefits from 30% to 66%. In 2010 people living with HIV (PLHIV) and NGOs protested over ARV treatment interruptions and budgetary cuts due to economic crisis, although WHO estimated the treatment coverage at 83% in 2009. Methods: A nationally representative clinic-based research among PLHIV was carried out in 2011 (MarchÁJune) to determine their access to treatment, care and support (N 0618, 94%). Measures of treatment interruptions, adherence and access to services were included, as well as demographics variables. Sample was weighted according to subjects' surveillance center registration. Results: The vast majority of the sample (71.7%) is young (18Á24 years), with more than 6 years of known seropositivity (82.1%), receiving ARV for more than 6 years (78.7%), with more than 2 changes in their treatment plan (80.1%), and with their main source of income as cash benefits (80.5%). Unintended treatment interruptions were spread (65.2%, average interruption lasting 38 days), resulting in more visits to regional center (49.2% more than once a month), higher expenses and the need for new combinations of ARV. Discontinuous adherence was reported by 42.2%. Access to social services was high (over 80%). Conclusion: While Romania is a low prevalence country, and ensures high coverage of ARV treatment, authorities must pay attention at continuous treatment access for PLHIV, and support of treatment adherence to prevent deterioration of the health status and ensure universal access for PLHIV. Results: Birth-mothers reported more symptoms of depression (pB .001) and anxiety (p B .001) than non-birth caregivers. Non-birth caregivers were less likely (3%) to report substance use than HIV' (13%) or HIV( (12%) birth-mothers (p 0.006) ( Table 1). In multiple regression analyses, HIV'birth-mothers, but not HIV(birth mothers were significantly more depressed and anxious than nonbirth caregivers, after adjusting for age, race, number of children under 18-years, and having a partner in home (Table 2). Both birthmother groups (HIV' and HIV () had more substance use problems than non-birth caregivers even after adjusting for covariates. Among all caregivers in the study, those who reported either substance use or Latina ethnicity had significantly higher depression and anxiety scores (each p5.01; data not shown). Conclusion: Data support previous studies that HIV' birth-mothers have worse mental health outcomes than non-birth caregivers, warranting the development of efficacy-based interventions for this population. However, the data also indicate the vulnerability of inner-city HIV( birth-mothers, and the need for mental health Background: Women's low or unpaid role in providing care for people living with HIV in the form of home-based care while central to the response to HIV been has increasingly been recognised as entrenching unequal gender relationships. Frameworks to map out the pathways have suggested that this process occurs in three domains: financial costs, opportunity costs and physical and emotional costs. Yet such a framework has a tendency to ignore the broader conceptualisation of gender inequalities that include violence against women. Methods: We undertook 5 focus groups with 45 home-based carers in South Africa as part of a larger study focused on how to transform home-based care organisations from spaces of reproducing inequalities to transforming gender relationships. We conducted thematic analysis on the data exploring factors that could support or hinder gender equality. Results: As with other studies, our data showed home-based carers suffered economic costs related to their work, often spending their own money to provide for their patients. In addition, few received stipends or other financial support either from donors, government or NGOs. Many carers also related the extreme physical and emotional costs of the work they did; again reflecting what is already known about providing care. However, home-based carers also spoke about the central role of gender-based and sexual violence that they feared, risked and experienced both while working and sometimes within the organisations they worked in. Such relationships of violence undermined their ability to envision their work as spaces for women's empowerment and transformation. Conclusion: To move women's participation in home-based care from one of reinforcing gender inequalities to empowering women requires those supporting home-based carers to envision a wider conceptualisation of the gender inequalities home-based carers face, that includes the centrality of gender-and sexual-violence, and actively work to programme and tackle these.

FRLBD03
The impact of depression on retention in care and viral suppression in a large cohort of insured HIV-infected patients  The current study firstly aims to explore the impact of masculinity and femininity on ART experiences, in both a longitudinal and in-depth manner. In addition, the study investigates the complex interrelationships between gender constructs whereby males and females potentially influence-through intricate household dynamics-the ART experiences of the other gender. Methods: Based on a previous explorative quantitative study, we conducted a longitudinal qualitative study whereby 12 male and 12 female ART patients were repeatedly interviewed >over the course of 1 year in the Free State province of South Africa. Results: Despite several cases of lipodystrophy and other side-effects among women due to ART, they seem to adhere and lead healthy lifestyles, often in the absence of a male partner. Male patients reported a clear notion of masculinity that required males to be in control and act strong, highly sexual and economically productive, thus conflicting with the role of 'good patient' that is expected to accept being HIV-positive, take instructions, and engage in healthenabling behaviors. The majority of men interviewed overcame these barriers and internalized their treatment, albeit with fewer sideeffects and more support in terms of reminding and accompanying them to the clinic (mostly by females). Conclusion: The study findings have both theoretical and practical relevance. Theoretically, the longitudinal impact of gender and household dynamics on the ART career draws attention to the sociological processes influencing ART outcomes. Practically, the study demonstrates that policy interventions aimed at improving long-term ART outcomes should incorporate the (interactions between) gender-specific illness and treatment experiences. Background: Asian gay men make up the highest group in MSM/gay HIV notification after Anglo background, constituting a priority group for HIV health promotion in Australia (MHAHS, 2011). Multiple challenges exist as issues of stigma, migration, isolation, in addition to sexual stereotyping and homophobia within the gay and ethnic communities respectively, complicates this work.The immediacy of these issues renders HIV health promotion a second order issue. Underrepresentation in HIV health promotion work, research and general media also contributes to their invisibility.
Multicultural HIV & Hepatitis C Service (MHAHS). Trends in NSW HIV notifications 1999Á2010. (unpublished). Methods: The ''A-Men'' publication was developed with an aim to engage lived experiences and visibility of Asian gay identities as an entry point to promoting sexual health and wellbeing. The approach was two-pronged: a resource production engaging broader issues facing Asian gay men -the person-centric approach; and the developmental process that involves and builds community ownership -'for the community, by the community'. With $5000 community arts funding from Sydney city council, the resource was developed and distributed in-print and online. Results: A total of 70 volunteers from 9 different Asian ethnicities were involved in the production.1000 hard-copies were launched in March and distributed through community and service providers. 1600 users accessed the online version to date. Volunteer feedback (n 058) showed increased social-connectedness, self-esteem, pride, HIV awareness and knowledge of services. 2 community focus groups (n 062)reported similar trends: greater community engagement and dialogue around wellbeing and self-esteem. Conclusion: A broader exploration of lived realities was effective in enlivening HIV messaging with Asian gay men. Through engaging intersections of identity, art and community building, a 'biggest bang for your buck' can be achieved in a resource limited setting. Through cultural change, "A-Men" addressed the barriers to HIV awareness and wellbeing, in the process building a more resilient and empowered community.
D30 -Sexual minorities and HIV vulnerability and/or resilience (e.g., gay and other men who have sex with men (MSM), lesbians and other women who have sex with women (WSW), bisexuals, transgenders, transsexuals THAD0504 Relationship between comfort with and disclosure about sexual orientation on HIV-related risk behaviours and HIV testing among men who have sex with men in Beirut, Lebanon Background: Evidence suggests that men who have sex with men (MSM) account for most new HIV infections in Lebanon and act as a bridge to transmission in the general population. In a region where same-sex sexual activity is highly stigmatized, a better understanding of the psychosocial factors that influence sexual risk behavior and HIV testing in MSM is essential for HIV prevention initiatives to be effective. Methods: An exploratory, qualitative study was conducted with a sample of 31 MSM living in Beirut. Semi-structured interviews examined relationships with family and friends, comfort with and disclosure of sexual orientation, sexual behavior, and HIV testing. All interviews were recorded, transcribed, and coded in Atlas-ti to identify themes and extract counts. Results: All men self-identified as homosexual (77.4%) or bisexual (22.6%), although 32.3% also have sex with women, and a majority (64.5%) reported some discomfort with their sexual orientation. The men described a strong heterosexual social norm, causing some to feel guilty and lead a ''double life'' where they conceal their sexual orientation by publically feigning attraction or dating women, or dissociating from effeminate men. Comfort with and disclosure about sexual orientation appeared to be linked with sexual risk behaviors and HIV testing. As compared to the remaining sample (n 018), the 13 participants who were both uncomfortable with their sexual orientation and had not disclosed to either parent reported higher rates of unsafe sex (69.2% versus 33.3%), more annual sexual partners (mean036.7 versus 17.0), and lower rates of being HIV-tested (53.8% versus 88.9%) and discussing HIV risk with their sex partners (38.5% versus 88.9%).
Conclusion: These findings reveal the influence of sexual identity acceptance and disclosure on condom use and HIV testing in the context of high societal stigma, and suggest the need for HIV prevention interventions to facilitate progression through these psychosocial processes of sexual development. Background: Evidence indicates that MSM experience higher rates of intimate partner violence (IPV) than non-MSM; however, no study has examined what defines IPV among MSM, or the associations between MSM-specific IPV and sexual risk-taking Methods: Seven focus group discussions were held with 84 MSM, generating 30 types of IPV, including HIV-specific IPV. These were tested using a cross-sectional survey of 1,074 MSM. Factor analysis generated five domains of MSM-specific IPV, including a domain of HIV-related IPV. Six logistic regression models for unprotected anal intercourse (UAI) were created (n 0626). Models controlled for age, race, education, employment, HIV status, and gay identity, with the key covariate being receipt or perpetration of three different IPV measurements: MSM-specific, Conflict Tactics Scale (CTS), and World Health Organization (WHO). Results: The MSM-specific IPV definition included HIV-specific typologies of violence not currently included in any definition of IPV, e.g., not disclosing HIV-positivity to a partner, and captured significantly higher reporting of IPV compared to WHO (46.2% v. 13.5% receipt of IPV; 31.9% v. 8.5% perpetration of IPV). Reporting receipt of neither WHO-defined IPV nor CTS-defined IPV was significantly associated with UAI, but reporting receipt of MSMspecific IPV significantly increased odds of UAI Conclusion: This study provides for the first time a MSM-specific definition of IPV that captures HIV-related violence not represented in standard definitions. MSM who reported MSM-specific IPV had increased odds of UAI at last sex. These findings suggest that MSM experiencing IPV are at higher risk for HIV seroconversion, although this association may not be recognized by using non-MSM-specific definitions of IPV that do not include HIV-related violence. Background: HIV prevalence among MSM in India remains disproportionately high at 7.4% as compared with overall national prevalence of 0.3%. India HIV/AIDS Alliance in consortium with five other organizations implements the five-year Global Fund-supported Pehchān program in 17 Indian states to build the capacity of 200 CBOs to serve as effective HIV prevention partners with the National AIDS Control Program and reach 453,750 MSM, transgenders and hijras using a community-driven and rights-based approach. Nondisclosure of identity and low self-esteem due to internalized stigma are known to be associated with vulnerabilities that place these populations at greater risk of HIV infection. Methods: A cross-sectional baseline study sampled 2,762 MSM, transgenders and hijras (TG/H: 16%) in 55 districts across 10 states to understand demographics, behavior and needs of target populations. Time and Location Cluster Sampling (TLCS) was used to identify these often hard-to-reach and relatively mobile populations. Data were analyzed using SPSS. Results: Self-disclosure of sexual identity occurred least with parents (21%) for reasons ranging from fear of being rejected and rendered homeless to adverse legal consequences. Self-disclosure with siblings was also low (22%), for fear of being neglect, isolation, and verbal/ physical abuse. Disclosure was highest amongst community peers (67%). Feelings of shame (33%), self-blame (28%) and feelings of guilt (26%) were associated with sexual identity among study subjects. 30% of respondents have actively attempted to avoid disclosure of their sexual identity.

Track D Social Science, Human Rights and Political Science
Conclusion: Low self-esteem among MSM, transgenders and hijras and fear of rejection leads to non-disclosure of sexual identity. Based on the insights from the baseline, Pehchān developed a life skills training module that places greater emphasis on coping, communication and interpersonal skills to address sexual identity. The program plans messaging to change attitudes about homosexuality and gender identity within families and communities in India to strengthen support structures and manage conflicts more successfully. Among 5,066 survey participants, 1,488 were YMSM (age 30/younger). YMSM respondents were from: Asia (65%), Latin America (10%), Australasia (9%), North America (6%), Europe (4%), and Africa (3%). Chi-square and Wilcoxon rank-sum were used to evaluate differences between YMSM and other MSM. Multivariable regression was used to identify predictors of access to HIV prevention services. Background: In India, many MSM either are married or expect to marry. The present study aimed to identify strategies for the national HIV programme to promote the health of women partners of MSM both in terms of preventing HIV transmission and in promoting early HIV diagnosis and treatment. Methods: Qualitative field research used a collective case study design to collect data in 2010/11 from 11 sites in seven states among 401 MSM (HIV prevention outreach workers and beneficiaries) through 57 focus groups (n 0364; 46% married) and 37 key informant interviews. Women partners of MSM could not be recruited for the study. Potential interventions proposed are based on the inferences drawn by synthesising both the literature review and qualitative data (thematic analysis). Results: Both literature review and qualitative data showed that women partners of MSM can include wives, casual, regular, paid or paying partners, and they may be at higher risk of HIV due to their male partners' high-risk sexual behaviours, which include having a large number of male and/or female partners combined with inconsistent condom use. Field data revealed that self-identified MSM may enter into heterosexual marriage with willingness, under compulsion (e.g., family pressure) or with indifference. Importantly, qualitative data offer new insights into whether disclosure of sexuality and/or HIV status among MSM is significant in preventing HIV transmission to female partners. Conclusion: HIV prevention messages aimed at MSM ought to explicitly promote awareness of the risks/vulnerabilities faced by female partners. Such strategies ought to particularly include counselling and HIV testing approaches that address the complexities of safer sex practices with both male and female sexual partners. Developing interventions for single MSM that raises awareness of the HIV risks faced by their women partners and implementing interventions that explicitly target married MSM and their wives are key to effective, future HIV prevention programming. structure of male sex workers with HIV status in Houston, Texas. Methods: The study used network data from a cross-sectional network study derived from male sex workers in Houston, Texas. A convenience sampling plan was used wherein male sex workers were identified first and then were asked to refer their social, drug, or sex partners (both male and female) to the study. Netdraw, UCINET version 6, and Stata version 11 were used. Results: The analysis consisted of 395 participants; with a mean age 33.1 years old (SD 09.7); 84.3% male; 31.4% gay, 44.3% bisexual, and 24.3% straight. There were 81 (20.5%) HIV positive, 253 (64.1%) HIV negative, and 61 (15.4%) unknown HIV status. Two thirds of the participants traded sex for money or drugs in the last 30 days. The network had 17 components and 32 isolates. The largest component of the network consisted of 155 people (39.2%), and the second largest consisted of 16 people. The graph below indicates that HIV positive and HIV negative people tended to be clustered together. The mean sexual network size in the last 30 days was 35.1 (SD 064.4). There was no difference in the sexual network size among HIV positive, HIV negative, and unknown HIV status. Conclusion: Our network data showed that most network participants were connected with each other in 17 separate components, and more than a third were connected in the same network. HIV positive and HIV negative participants tended to be clustered together. These findings indicate high potential for network-level HIV interventions for HIV positive and HIV negative people. Background: Northern Uganda hosts one of the highest prevalences of HIV and teenage pregnancy in the country. The Gender Roles Equality and Transformations (GREAT) Project conducted ethnographic research to understand the processes through which social norms about gender, SRH, and violence, which underlie HIV vulnerability, are transmitted in this post-conflict setting.

D35 -
Methods: Forty life histories were collected from adolescents across the life course: very young adolescence, older adolescence, newly married, and pregnant with or parenting a first child. Forty in-depth interviews were also conducted with adults who significantly influence adolescents in study communities. Data were analyzed using AtlasTI software. Results: Data reveal efforts to destigmatize HIV have been largely successful as evidenced by widespread support for youth access to HIV services, including education, testing, condoms, and treatment, as well as by the ritualization of HIV testing among young unmarried couples. The need for young people to ''test their blood'' before beginning sexual activity appears to have become a cultural norm, viewed by adults and adolescents as a rite of passage into sexual relationships. These efforts, however, have not translated to other aspects of adolescent SRH, namely, pregnancy prevention.

Respondent Category
# of Males In-Depth Interviews (ages 20 years and above).

# of Females
Results show that most respondents do not acknowledge the link between HIV prevention and family planning (FP) and oppose adolescent use of FP products. Condoms are viewed as acceptable only in the context of HIV prevention but not for pregnancy prevention. Opposition to adolescent FP use is primarily due to fear of compromised future fertility or increased promiscuity. Conclusion: Severe social, economic, and medical consequences resulting from early pregnancy, particularly in low-resource settings, have been globally recognized. Efforts are needed to build on successes in HIV prevention efforts to address adolescent SRH in a more comprehensive manner. Methods: An exploratory qualitative study was conducted with female sex workers in India. Sixty FSWs participated in 5 focus groups and 25 semi-structured in-depth interviews in addition to completing a short questionnaire that captured basic socio-demographic information.

Social Network of Male Sex Workers in Houston.
Results: The majority (60%) of FSWs was based in rural areas and was Hindu (90.3%). Respondents' mean age was 30.2 years, with an average of 6.4 years of education. Only 28% reported being legally married or living with a partner and 82% had at least one child. Further, for 58%, sex work was the main income source. Findings implied a complex interplay of factors that determined FSWs' abilities and willingness to avoid unsafe sexual behaviors with paying clients, regular/trusted clients, and non-paying intimate partners. Often, this was dictated largely by economic hardships, emotional attachments, social norms, perceived lack of power as well as the threat of violence and to a less extent by the knowledge of HIV risk. Further, discrimination and exploitation by community members including police combined with the need to hide their sex worker identities often put FSWs in situations that compromised their efforts to avoid risky behaviors. Conclusion: A deeper understanding of the multifaceted exchanges between the various partner types that heighten FSWs' vulnerabilities is critical when planning HIV prevention interventions in addition to adopting a human-rights framework and recognizing women's agency in safeguarding health. Challenging popular notions of sex workers as undeserving of substantive support and individual rights would go a long way in ensuring the effectiveness of HIV prevention efforts.

TUAD0304
Emotional men and pragmatic women: relationship and gender dynamics between female sex workers and their regular partners in the Dominican Republic Background: Male partners of female sex workers (FSW) have traditionally been viewed as holding power and decision-making authority regarding condom use due to the transactional nature of their relationships. The aim of this study is to explore relationship and gender dynamics between FSW and their regular partners and consider how these dynamics influence HIV vulnerability. Methods: We conducted qualitative interviews with FSW (n 020) and regular partners (n 020). FSW were recruited from an ongoing cohort study and regular partners were referred by non-participating FSW in the cohort. Regular partners were defined as trusted and/or intimate partners with whom the referring FSW reported sex with at least 4 times in the last 3 months. We used narrative and thematic analysis to describe the relationship history and identify emergent themes. Results: Both FSW and regular partners described emotional, sexual, and economic attachments to each other. Regular partners, however, described greater emotional and sexual attachment. While most men provided some economic support to their FSW partner, they were aware that due to their limited economic resources, they were not able to provide for all of their partner's needs. In contrast, FSW displayed more pragmatic attitudes, emphasizing the importance of both the material and emotional support provided by regular partners. Some FSW clearly stated that while they had the strongest emotional attachment to their regular partner, they had to maintain other partnerships in order to survive. Conclusion: Findings challenge hegemonic norms of masculinity between FSW and their regular partners and highlight the intersection between socio-economic position and relationship power. HIV prevention efforts targeting FSW and regular partners must address both emotional and socio-economic dimensions of relationships and their influence on HIV protective behaviors.

TUAD0305
Older women and sex work: breaking the silence on the gendered structural drivers of HIV in Uganda Methods: 100 women were purposively selected from a cohort of 1027 high-risk women. Life history interviews and in-depth interviews on their life and work, including sexual practices, were conducted with each woman. Data were analyzed using thematic content analysis. Informed consent and ethical clearance were obtained. Results: Sixteenwomen were aged over 35, and had joined sex work as young adults usually because of financial need. They continued to take an active part in sex work. These women perceived sex work to be addictive, because of the quick access it could give to cash. Some women confided that they found their continued sex work humiliating and they really wanted to give up because they were too old and they feared that their children might find out what they did. However, faced with recurrent economic demands, paying children's school fees and buying food, these women had few alternatives.

Track D Social Science, Human Rights and Political Science
Most wished for a 'husband' who could help them. In the absence of such support or alternative livelihoods, giving up FSW was not an option. As they aged, they commanded lower rates from clients. Some augmented their living by selling alcohol and providing labour in the community, including child care to younger sex workers. All these women were at risk of HIV, STIs and sexual violence. Conclusion: Sex work remains a key structural driver of HIV among some vulnerable older women. Sexual violence and high risk behaviour characterized sexual relations. There is an urgent need for interventions to support such middle-aged and older women. Methods: We conducted a focus group study with 92 women in 4 U.S. cities between March and April 2012. Participants were recruited by local, woman-serving CBOs that also hosted the groups, which were led by trained facilitators. Participants completed a questionnaire with demographic and behavioral information. Focus group questions elicited basic understanding of PrEP, attitudes about its administration and uptake, barriers to use, and targeting and marketing. All sessions were digitally recorded and transcribed, and transcripts were analyzed to identify predominant themes and any demographic or site differences. Results: Across sites, almost no women had heard of PrEP prior to the study; but once informed about it, nearly all found it an important option. Key considerations in deciding to take PrEP were cost (including who would pay), efficacy (most wanted 85Á99%), and side effects (including interaction with contraceptives). PrEP was seen as "additional," not substitute, protection to condoms. Young women were the most commonly named target population, and schools the best venue for informing them. Mistrust of men was a main motivator for PrEP among women in Oakland and Washington; and churches were seen as a key barrier to PrEP in Memphis. Conclusion: Women at risk for HIV in the U.S. are likely to use PrEP if it is known to be highly effective, doesn?t cost too much, doesn?t have significant side effects, and is promoted by peers and CBOs. Track D Social Science, Human Rights and Political Science vessel they worked on (traditional vs. commercial) and gear used (hook/line vs. trawlers/purse seiners) to draw upon different social networks and spheres of influence. Data were coded thematically and analyzed to inform key research questions around drug use and aspects of social networks. Results: Economics, occupational culture, punitive policies and stigma shaped the social networks of drug-using fishermen. Social networks, in turn, shaped HIV risk perceptions and behavior through the following pathways: 1) social influence -through the introduction to drugs, male homosociality, and peer pressure; 2) social supportdrug users relied on other drug users for information and emotional needs; 3) social engagement -other drug users provided a sense of community and shared identity; and 4) access to resources and goods, like drugs. Conclusion: These results suggest that aspects of social networks both constrain and enable HIV risk behavior among Malaysian fishermen by mediating the relationships between social structures and individual behaviors. Understanding the role of network influence in drug use and HIV risk among fishermen is essential to developing HIV prevention interventions that are appropriate for the unique needs of this highly interconnected population. Background: Drug users often use multiple substances and are involved in sexual risk behaviors, and thus are at high risk of sexually acquiring or transmitting HIV. Studies on typologies of drug use are limited, especially those that examine the relationship between typologies of polydrug use and unsafe sex practices. Methods: Using respondent driven sampling, 248 rural drug users were recruited in rural areas of the Midwest. They participated in a longitudinal, natural history study of illicit drug use and health service utilization. Latent Class Analysis was used to identify a typology of poly-drug use and assess differences in sexual risk for HIV transmission between these classes. Results: All stimulant users consumed multiple drugs in the previous 30 days and many (63.7%) reported unsafe sex (condomless sex). Three latent classes were identified: Class 1 (N0107): all used powder cocaine, 90% used marijuana, 42.2% used crack-cocaine, 23.0% used heroin, and few used other stimulants and methamphetamine; Class 2 (N 067): all used crack-cocaine, 72.3% used marijuana, 20.8% used powder cocaine, 90.0% used heroin, few used other stimulants, and no methamphetamine; Class 3 (N 074): all used methamphetamine, 92.6% used marijuana, 74.2% used crackcocaine, 88.1% used power-cocaine, 17.7% used heroin, and 49.1% used other stimulants. Although the patterns of drug use practice among the classes vary, the prevalence (64.5%, 67.2% and 59.5%, for Classes 1, 2, and 3, respectively) of unsafe sex practices was not significantly different across the classes (p00.6213).

D42 -Sexual transmission and drug use
Conclusion: Rural stimulant users can be classified into three latent classes: primary cocaine users, primary crack users, and heavy multiple stimulant users. High prevalence of unsafe sex practices was reported across all classes. While much attention has been given to HIV risk reduction efforts among urban stimulant users, HIV prevention and intervention efforts for rural stimulant user are still greatly needed. Methods: We used Latent Class Trajectory Analysis (LCTA) to assess statistically reliable patterns of SDA use over time. Classifying each participant into a distinct trajectory, we used MLR and LCTA including potential covariates to determine pre-existing V&R factors predicting SDA trajectories. Results: The best fitting model yielded 5 distinct SDA use trajectories (Figure). While 10% of men were classified as high-sustained users of two SDA, the largest group (40%) never used SDAs. The next largest group (29%) used moderate (B1) SDA consistently; and 2 groups (11Á12% each) showed change in opposite directions (i.e., from low to moderate use or moderate to low use).
Only white race, higher education and income, high sexual sensation seeking (SSS), and adult internalized homophobia were consistently predictive of high-sustained and increasing SDA trajectories. Inclusion of a sexual risk measure (#UAS partners) in the LCTA modeling did not alter the trajectories or V&R modeling results. Conclusion: We identified two subgroups of MSM with problematic SDA use. Adding #UASP did not improve the LCTA results, indicating SDA use is still a powerful measure of HIV risk among a minority of MSM who resemble the club/circuit participants of the 1980s/90s. Their vulnerabilities, particularly high SSS and internalized homophobia, are potential intervention targets if instituted before SDA use and HIV infection are established. Background: Bangladesh is thus far regarded as a low HIV prevalence country with increased vulnerability due to several risk factors including high demand for commercial sex. Male clients of female sex workers (FSWs) are considered to be a potential bridge population to transmit HIV and other sexually transmitted infections (STIs) to the general population. The objectives of this paper are to describe the correlation between illicit substances (ISs), unsafe sexual behavior and self-reported symptoms suggesting STIs among male clients of FSWs in Bangladesh. Methods: A cross-sectional study was conducted among 1565 male clients of FSWs during November 2005 to July 2006 in three sex trade settings (streets, hotels, and brothels) in Bangladesh. No personal identification of the clients was recorded and only verbal consent was taken in the structured questionnaire administered by male interviewers. Bivariate and multivariate data analysis was performed. Results: Among the male clients of FSWs, 36.2% aged 524 years, nearly 30% never attended school, and above one-half (54.6%) of them were never-married. Nearly one-third (30%) used ISs. Cannabis (60.6%), alcohol (51.9%), heroin (6.8%), sleeping pills (5.7%), and injecting drugs (1.5%) were used by these clients. Consistent condom use with non-marital sexual partners in the last one month from the interview date was reported by only 13.2% of those who used ISs.
Almost one-half(45%) of the IS-users experienced the symptom of STIs in the last 12 months prior to the interview date. The IS-users were 1.7 times more likely to have symptom of STIs than the nonusers (adj. OR 01.70, 95% CI: 1.29Á2.20). Conclusion: Use of ISs was a significant risk factor for having symptom of STIs among the male clients of FSWs and they are less likely to use condoms consistently during non-marital sexual relationship. There is an urgent need to implement targeted intervention to promote safer sex behavior for male clients of FSWs in Bangladesh, especially those who use ISs. Methods: A cross sectional survey was conducted with PWID in three states. 181 respondents were selected through systematic random sampling using client information made available by partner NGOs at selected sites. Data were analyzed using SPSS software. Results: 60% of PWID interviewed have injected drugs for more than 5 years; 32% inject daily and 33% at least once a week in the last 30 days. 22% of PWID have injected using needles or syringes previously used by another person. In the last 12 months, 55% of respondents had sexual intercourse with regular partners; 22.9% with casual partners; and 26.6% with commercial sex partners. During last sexual contact, 70% used condoms with regular partners; 64% with casual partners; and 51.7% with commercial sex partners respectively. Of the 100 respondents who disclosed their HIV status, 21% reported being HIV-positive. Conclusion: Unsafe injection practices along with low condom usage are putting PWID at dual HIV risk. These findings support the development of focused prevention strategies that address both injection drug use and sexual behavior as part of Hridaya's harm reduction approach.

TUPDD0205
Substance use and high-risk sexual behavior: dose-response associations in episodic and high-frequency substance-using men who have sex with men (SUMSM) Background: Substance use is associated with high-risk sexual behaviors and HIV-seroconversion among MSM. Most MSM use substances episodically but research does not usually distinguish between episodic (less than weekly) and high-frequency (at least weekly) users when evaluating HIV risk. We sought to assess the relationship between engaging in serodiscordant unprotected anal intercourse with a partner of unknown or HIV-positive status (SDUA) and varying frequencies of use for different substances.

Methods:
We screened 640 substance-using HIV-negative individuals for a qualitative study to adapt the Personalized Cognitive Counseling HIV prevention intervention for SUMSM in San Francisco from March 2009-January 2010. Data on substance use and sexual risk behaviors were collected via structured telephone interviews. We examined the association between SDUA and different frequency (episodic or high-frequency) of use for methamphetamine, cocaine, and poppers, using multivariable logistic regression, adjusting for age and race. Results: Episodic use was more prevalent than high-frequency use for methamphetamine (13% vs. 6%), cocaine(26% vs. 5%) and poppers (25% vs. 9%). We observed significant dose-response relationships (i.e., greater risk with more frequent use) between episodic use and high-frequency use of methamphetamine, cocaine, and poppers; and having SDUA. Compared to non-users, the adjusted odds ratios (AOR) for SDUA among episodic and high-frequency methamphetamine users were 6.6 and 7.2, respectively. AORs for episodic and high-frequency cocaine users were 2.0 and 4.4, respectively. For poppers, AORs for episodic and high-frequency users was 1.7 and 2.8, respectively (all AORs pB 0.01; see Table 1). Conclusion: Infrequent and episodic substance use may be a driver of HIV transmission. In our sample of SUMSM, even infrequent use such as less than weekly use of methamphetamine, cocaine, and poppers was associated with greater odds of having unprotected sex with a serodiscordant partner. HIV prevention interventions should integrate efforts specifically addressing the range of substance use patterns, to minimize the harms associated with high-frequency, as well as episodic use.
D43 -Criminalization of drug use and people who use drugs and its impact on HIV

MOAD0204
The impact of police violence on HIV risks among people who inject drugs in Thailand Background: According to the latest update on the global state of harm reduction published in 2010, OST is available in 70 countries and territories around the world. The global coverage is estimated at the level of between 6 and 12 OST clients per 100 PWID. However, in most countries of Central and Eastern Europe and Central Asia coverage is limited due to long-term pilots and lack of systematic scale-up. The purpose of this study is to provide an up-to-date overview of the state of OST service provision in Eurasia, with a particular focus on access and quality issues. Methods: Data were collected in 28 countries between August and November 2011 in order to capture some of the most recent developments related to OST service provision in Eurasia. We conducted an on-line survey using a semi-structured questionnaire in Russian and English, reviewed available literature and interviewed key stakeholders. Results: Essential OST-related data including year of OST introduction, OST medications, number of clients, number of sites in prison and community settings, geographic coverage, and availability of take-home doses were analysed for all 28 countries. Based on this analysis, countries were divided into three groups: i) countries with sustained availability of OST programmes; ii) countries with limited availability and sustainability of OST programmes; and iii) countries with no OST programmes. Within each of the three groups, we identified challenges and opportunities for scaling up OST services, improving their quality and/or strategies for overcoming existing opposition.
Conclusion: While some progress has been made and more countries introduced OST over the past three years, numerous challenges still exist. The opportunities for increasing access to and improving quality of OST programmes are related to six areas, ranging from national ownership of OST service provision to protection from police harassment and violation of human rights of OST clients and service providers. Methods: A qualitative study was conducted in 2011 to determine reasons behind current dosing practices. Key informant interviews were conducted in 10 MMT clinics in 3 provinces (Guangdong, Guangxi, and Guizhou) among current and former MMT clients, their family members, and service providers. All interviews were conducted using a field guide and each interview lasted around 45 minutes. Interviews were recorded and transcripts were analyzed using a coding scheme and thematic sorting. Results: Interviews with clients and their family members revealed that they did not view drug users as patients with a chronic disease in need of long-term treatment; they expected MMT to end drug use in a short time. They also thought that methadone was more addictive than heroin and that methadone withdrawal was more severe and long-lasting. This contributed to their preference for lower and tapering methadone dosing. Interviews with MMT providers revealed that many doctors did not have previous experience in drug use treatment. Lack of experience and insufficient training led to client-dominated, lower methadone dosing and the common misperception ''the lower dose, the safer and better for patients.'' Conclusion: Factors contributing to lower methadone dosing include clients and their families' misperceptions as well as providers' limited experience and training in MMT. To improve the performance of MMT in China, it is recommended that capacity building for providers be improved and education and counseling of clients and their family members be strengthened. Results: Qualitative data were analyzed first separately, and then collaboratively, by two teams of analysts in Kenya and U.S.A. using a phenomenological framework. Seven primary thematic areas of active coping strategies were reported: 1) accepting a new HIV' identity; 2) disclosing HIV' status to supportive others; 3) engaging in holistic self care; 4) participating in formal support and health promotion programs; 5) advocating for other HIV' individuals; 6) finding HIV' role models; and 7) re-engaging with friends for social activities. Seven primary sources of social support were also revealed: 1) romantic partners; 2) friends; 3) healthcare workers/ counselors; 4) people living with HIV; 5) co-workers/employers; 6) religious colleagues; and 7) affirming HIV' media figures.

D45 -
Conclusion: These data demonstrate that Kenyan youth who are newly diagnosed with HIV demonstrate resilience across multiple dimensions. In addition to intrapersonal-level resilience related to individual cognitions and behaviors, they also reported interpersonal-level resilience related to both seeking support and providing advocacy/support for others. Future interventions for Kenyan youth newly diagnosed with HIV should work to enhance the coping and social support of these young people through the use of creative strategies focused on developing and maintaining varying types of resilience.

MOAD0302
Living with HIV increases risk for poor mental health among adults caring for orphaned children in South Africa Background: There is a dearth of literature on the challenges and coping mechanisms of school-age HIV infected children. The purpose of this study was to investigate challenges faced by HIV infected children in Botswana and to assess the coping mechanisms they employ to cope and survive. Methods: The study was conducted among HIV-infected children and adolescents aged 6Á18 years, using a cross-sectional design, in 12 antiretroviral therapy sites accounting for over 90% of all HIVinfected children receiving Highly-Active Antiretroviral Therapy in Botswana. Data were gathered using a structured pretested interviewer administered questionnaire and focus group discussions. Focus group discussions were held until saturation was achieved. Quantitative data were analyzed using descriptive statistics and cross-tabulations. Qualitative data were grouped into mutually exclusive categories according to themes emerging from the data. . Gender specific experiences from rural and urban settings were explored in each country. Data was collected using in-depth interviews with adolescents (n0150) and guardian/ parents (n046), focus group discussions (n 068), participant observation (3 months) and a knowledge, attitude and practice survey (n 01498). Data was analysed through a triangulation approach.
Results: Preliminary analyses reveal that key challenges for adolescents living with HIV include accessing information on SRH; disclosing their status to peers; talking about sex and HIV in the context of a relationship, within families and with health service providers; planning to have children; and emotional well-being. HIV represents a complex challenge for adolescents who lack safe and nonjudgemental environments to talk about safer-sex options and pregnancy, whilst it is assumed by families and health providers that sexual activities should not start before adulthood. Few health services provide support tailored to adolescents; health providers give out inappropriate information and frequently breach confidentiality, resulting in further marginalising adolescents living with HIV. Conclusion: Despite variations between the four countries and in rural vs. urban settings, the attitude of health care providers and the lack of family-centred approach result in inadequate support for adolescents when they first experience sexual and love relationships.
The study provides evidence that new policies and funding for HIV in low income settings must include safer-sex advice and SRH interventions, training for health-workers and families in order to provide adolescents with skills to make choices about relationships, safer-sex and HIV disclosure. . Are less likely to be homeowners, more likely to live in social or rented accommodation Many, particularly gay men, report social isolation due to age or HIV stigma, death of peers or concerns about disclosure. They also report difficulties getting primary healthcare, particularly from dentists and GPs, which are more heavily used by older people. Full results can be obtained from www.tht.org.uk/50Plus.
Conclusion: HIV appears to systematically disadvantage people in health, social and financial terms over a lifetime. Attention must be paid to healthcare and financial and social inclusion of older PLHIV, but also to informing long term condition management for younger and future generations of PLHIV about the greater importance of healthy lifestyle and financial planning. Work must be done to inform geriatric and generic healtcare providers about the needs of older PLHIV.

THPDD0206
Same old problem? Differing characteristics between heterosexual older adults with HIV who are white (HW) or from BME community (HBME) . HBME à have more other long-term health conditions (HBMEß have the least), but only 50% are taking medication for these (70% HW ß are). HBME higher levels of depression (28.8/21.6%), particularly HBME à (34.2%), but HW three times as likely to rate emotional/ psychological health as poor.
Financial/Social Exclusion: HBME all of those with no income and 3x not enough income for basic needs (45.3/15.7%).
HW more likely to own their own home (47.1/18.2%). HBME more likely to be homeless, living in asylum support housing or renting council flat/house. Socially, HW more likely to disclose to Partner (16.4/4.5%), family members (16.4/12.7%) or friends (16.4/12.7%). HBME more likely to seek support from non-family. Conclusion: There are major health, financial and social differences between HW and HBME. These factors need to be considered when targeting support for these groups.

MOAD0304
Who really provides care and support? The roles of young people in skipped-generation households D. Reijer 1,2 1 AIDS Healthcare Foundation, Amsterdam, Netherlands. 2 University of Amsterdam, Amsterdam, Netherlands Presenting author email: daniel.reijer@aidshealth.org Background: In communities severely affected by HIV many children are growing-up without their parents in skipped-generation households. Often these are headed by their grandparents. This research aims to critically examine what it means for children to grow-up in these households and which roles and responsibilities they assume. Methods: The data for this qualitative and quantitative study were collected in Misangwa, a small community in the rural part of the Copperbelt Province in Zambia. Data collection was conducted by means of household surveys, in-depth interviews, Focus Group Discussions, and observational techniques. Respondents were members of the younger and the older generation found in 65 skippedgeneration households. Their lives were followed over the course of thirteen months. Results: Between 2001 and 2009 the number of skipped-generation households in Misangwa has increased. The proportion of children living in these households also increased significantly. The experiences and roles these children have are complex. It was found that especially older children actively impact the situation in their homes and are often wholly responsible for many aspects of daily life in the households. They work on the fields and are engaged in income-generation. Given the social isolation of many skipped-generation households a focus on households, rather than families, can be justified. Conclusion: Literature often characterizes fostering as one-directional. This research examined skipped-generation households using ecological theories of child development. It found that that it is often children, and not guardians, who care for others in the households. Depending on age, personal characteristics and granted freedoms the older Background: There is a high demand from donors to predict which NGOs are able to improve the health outcomes of their populations and ensure an adequate return on social investment. The principal drivers of capacity development for NGOs are often those of the donor, and promote the development of organizations contrary to achieving sustainability. This stems from insufficient knowledge of the predictors of organizational sustainability, and how to measure and prioritize capacity building efforts.These gaps must be filled since local NGOs are the backbone for services in HIV care, support, and treatment. Methods: We studied three NGOs providing community based/ residential care to OVC. An instrument was developed, consisting of 14 organizational domains, to enable a quantifiable and replicable assessment of an organization's level of development. Data was collected from key informants, staff surveys, record review and abstraction of routine program data. Domains were weighted in order to ascertain their relative importance in a ''healthy'' organization, and individual NGO performance was measured against this standard. Results: The profiles generated were those of well-managed but unsustainable organizations. Financial and pharmaceutical management scored highly, while governance structures and strategic and business planning were weak. When graphed, the output revealed that only one organization's capacity was balanced while the other two curves were asymmetrical, indicating uneven capacities and ability to deliver services (Figure 1). Conclusion: The quantitative instrument is the first tool enabling consistent, repeated assessments on the organizational capacities of NGOs providing HIV services. It guides donors on which NGOs to invest in and which capacities to build. It also enables donors to rigorously evaluate capacity building efforts of international organizations and hold them accountable. This is vital as resources for HIV/AIDS are in jeopardy and as PEPFAR increasingly emphasizes the delivery of HIV services through local organizations, investment in organizational development and country-owned capacity building. Background: HIV-related stigma and discrimination is widespread in health care settings and poses a barrier for HIV prevention and control. The objective of the intervention was to reduce service providers' stigmatizing attitudes and behaviors toward people living with HIV (PLH). Methods: The study was conducted in 2008-2011 in 40 county-level hospitals in two provinces of China. The hospitals were matched into pairs, with one hospital in each pair randomly assigned to the intervention condition after the baseline assessment. For intervention hospitals, we identified and trained about 20% of the popular opinion leasers (POL) among service providers to disseminate stigma reduction messages within their hospital. At the same time, universal precaution supplies were provided to all participating hospitals. A total of 1,760 participants, 44 from each hospital, were assessed at baseline, 6, and 12 months. Main outcomes of the intervention included general prejudicial attitude towards PLH, avoidance Track D Social Science, Human Rights and Political Science intent to treat PLH, and perceived institutional support in the hospitals. Results: Significant improvements for the intervention group were observed in reducing prejudicial attitude (Estimate 2.401, SE00.220; P B.0001), reducing avoidance intent (Estimate 01.098, SE00.174; P B.0001), and increasing institutional support (Estimate00.390, SE 00.131; P 0.0029) at 6 months after controlling for age, gender, occupation, prior contacts with PLH, and province. The intervention effects were sustained and strengthened at 12 months. Conclusion: Reduction in stigmatizing attitudes and behaviors among service providers can be achieved by an intervention implemented in health care settings.The intervention has the potential to be integrated into the health care systems in China and other countries. Background: AIDS stigma inflicts hardship and suffering on People-Living-with-HIV (PLHIV), reducing the likelihood of HIV testing, treatment and disclosure. Stigma can be particularly harmful in health care settings. This study was designed to examine and reduce AIDS stigma among nurses and nursing students in India. Methods: We interviewed 369 nurses in Mumbai and Bangalore, assessing stigma, endorsement of coercive measures and discrimination toward PLHIV. Based on these results, we developed, implemented and evaluated a 2-session stigma reduction intervention, co-facilitated by PLHIV, for 50 intervention and 50 control nursing students. Results: Casual transmission misconceptions were common, with 28% of nurses believing HIV could be transmitted by sharing a glass and 26% HIV by sharing toilets with PLHIV. 70% agreed that people who were infected via sex/drugs deserved their infections. Almost all (96Á99%) endorsed mandatory testing for sex workers and surgery patients and most stated that HIV-infected men (77%) and women (73%) should not be allowed to get married and that HIV-infected women should not be allowed to have children (76%). 88% said they would treat PLHIV differently from other patients, taking unnecessary precautions when drawing blood. significantly more participants worried about acquiring HIV at work (41%) than in their personal lives (14%, pB0.001). Multiple regression analyses showed that worries about occupational transmission, negative feelings toward PLHA and transmission misconceptions were significantly associated with AIDS stigma.

D71 -Stigma and discrimination in health
Nursing students showed similar misconceptions and stigma levels as the nurses. Following the intervention, students showed significant pre-post decrease in all stigma scores, including blame, endorsement of coercive measures, and intent to discriminate (all pB0.01). In contrast, pre-post scores among control students remained the same. Conclusion: These findings demonstrate high levels of AIDS stigma in these health-care settings, that may be reduced by a brief intervention using a human rights framework, focusing on underlying variables and involving PLHIV. Background: Stigma is a hindrance to care for people living with HIV (PLHA) in Egypt. To understand how gender affects stigma among healthcare workers (HCWs), a study was conducted to identify the differences in HIV related misconceptions and attitudes of male (M) and female (F) doctors. Methods: A cross-sectional study was conducted in two tertiary care hospitals in Cairo from OctoberÁDecember 2010. All doctors working in surgical departments were invited to participate; three hundred thirty two accepted (210 males, 122 females). Data was collected on socio-demographic information and HIV related misconceptions and attitudes. A chi square test was used to examine the differences between male and female doctors. Differences were also significant in terms of blame and refusal to deliver care: 40% of females would not treat a PLHA (vs. 20% males), 50% would refuse to treat an injecting drug user with HIV (vs 36.8% males), and 57.4% would not treat a sex worker (vs. 40.7% males).  Background: Studies indicate that stigma and discrimination among health workers is higher than in other sectors. This subsequently affects service delivery and access to care and treatment for health workers living with HIV. This study aimed to determine the impact of HIV, including stigma and discrimination, on demand and supply of service delivery in order to develop health sector specific mitigation policies. Methods: Data was collected from key informant interviews with 35 health facility managers and 6 focus group discussions with various cadres of facility and community based health workers in both public and faith based health facilities drawn from eight provinces in Kenya over the period June-August 2011. Content analysis of the key informant interviews and focus group discussions was done to determine health worker perceptions on the impact of stigma and discrimination on demand and supply of HIV services.
Results: Although stigma in the general community was reported to be reducing, the majority of the key informants felt that stigma amongst health workers was of significant concern. Stigma contributed to a high tendency of health workers to self test for HIV, avoid uptake of post exposure prophylaxis, and seek counselling and antiretroviral therapy in distant facilities. Disclosure of HIV status among health workers remained low particularly in lower level facilities. Despite high level of knowledge on HIV, it emerged from the FGDs that health workers living with HIV are discriminated against by other health workers. This manifested as a refusal to shake hands, share utensils and bias in the allocation of duties. Conclusion: Policy and programmatic interventions, to support health workers living with HIV and to eliminate stigma and discrimination, are required within a comprehensive HIV workplace programme for all health workers in the country. 67 government and 30 NGO service providers were trained on case management, HIV basics, psychosocial counseling, reproductive health counseling and other topics. Data were collected on the uptake of services for at-risk women delivered by the trained providers using case management records. Results: A cross-sectoral referral network between government healthcare, social services and non-government agencies was established. An interagency referral guide was published, and an interagency protocol is being developed. A government-NGO risk screening, home visiting and case management service was institutionalized in five government social service centers, with 249 women screened and 159 (63.9%) enrolled as high risk. These women, their children and other family members received 1,201 services over 1,126 service encounters. The rate of child abandonment by HIVpositive mothers in Yekaterinburg decreased from 6.3% in 2009 to 1.9% in 2011.  Methods: 10 trainings with HIV affected children were conducted. It was aimed at extension of the emotional and volitional spheres. 10 children 8Á13 years old were selected (8 parents were HIV', 2 HIV-). The age group was selected as the middle childhood years are significant in reviewing children-parents relationship. Children in middle childhood years are emotionally less active than teenagers. Design of meetings was planned (fables-discussions, games, art-therapeutic exercises).They were aimed at decreasing emotional tension, empathy development, value system identification, emotional harmony. Parenting works were also carried out. Results: During 10 group meetings it was possible to establish psychological intimacy. Group thinking was strengthened through art-therapeutic techniques ''the group tree''. Subsequent works have focused on skill development. Through discussion of Fables and arttherapy childrens vision was enlarged and turned versatile, developing the moral values.
Children learned to understand their emotions properly, see themselves on the underside for understanding others' reactions through. Parents noted the positive change in children-parents relations with and in school environment. Conclusion: The values and skills obtained during the meetings will help the children for further disclosure and acceptance of parents' status, to manage their emotions and feelings not allowing the parents illness to cause pshycological problems in themselves. Currently individual work with parents and children is still ongoing. More similar and parent-children mixed group meetings are planned for the future. Methods: The CBTS model is composed of adherence counselor, case managers, community nurses and community volunteers (CVs) with distinct responsibilities. This team, established at the facility level, was trained to assist establishment of community level support for HIV patients.
At the facility, the team leads patients through structured treatment preparation prior to ART initiation; conduct home visits; sets up appointment system and same day follow-up for patients who miss clinic appointments; and provides supportive counseling to assist status disclosure and stigma reduction. CVs focus on providing home visits, LTFU tracing, awareness raising, early identification and counseling for OIs, and referring pregnant mothers for prevention-ofmother-to-child-transmission (PMTCT) programs. Results: Following CBTS start-up in St. Luke hospital, the LTFU rate declined rapidly from 53.1 LTFU/1,000 patient months of followup (PMFU) in December 2010 to 47.3 LTFU/ 1,000 PMFU in March 2011. The retention rate has also shown statistically significant increase from 74.8% in March 2009 to 79.6% in March 2011.In addition, the overall patient crude retention rate has increased from 34.4% to 47.5%. Moreover, cross-directional linkages to other community-based programs supporting PLHIV have improved and community-wide disclosure among pregnant women has been promoted. Conclusion: This experience proves that higher adherence rates can be attained through the CBTS model structured care programs. Such innovative community programs could to be scaled up and replicated for substantial country wide results.

TUAD0203
Community support systems: from horizontal initiative to vertical institution A. Wagner University of Hildesheim, Hildesheim, Germany Presenting author email: andreas.wagner@uni-hildesheim.de Background: Community support systems are effective structures to provide care and support to most vulnerable children and PLWHA. However, sustainability of such initiatives can be weak. The purpose of this study was to get insight into sustainability issues of World Vision's community based care and support programming in Eastern and Southern Africa.
Methods: A qualitative review has recently been conducted, including 13 key informant interviews and 54 focus group discussions with community initiative members, non-governmental organization staff and government representatives in Ethiopia, Kenya, Mozambique, Uganda and Zambia. Results: The study results indicate that the sustainability of community based organizations depends on several issues, one of the key factors being vertical linking to government structures. These links can take different shapes, ranging from loose cooperation between government officers and community organizations to government representatives becoming members of community organizations' executive or coordinating boards. Such cooperation can even lead to a full adoption and institutionalization of community care and support initiatives into regional or national government structures, including further roll-out of such systems. The findings further indicate that any form of government structure cooperation with community based care and support systems can improve the community organizations' sustainability and increase the service delivery of both sides. Conclusion: As it seems, the stronger the link to government structures, the higher the community groups' sustainability. However, sustainability also depends on the quality and availability of resources within such cooperation, as well as on the individual commitment of the partners. And finally there is also need to consider the possible pitfalls in government structure co-option, like the loss of access to external NGO funding and a politicization or restructuring of community groups, which can change their initial focus or even undermine and end volunteers' efforts in providing care and support to vulnerable children and PLWHA. Methods: 24 communities were selected from high TB-prone areas, high density areas and hardly-reached communities. A consensus meeting involving various community stakeholders was held during which 50 CVs were selected to facilitate active referral of TB suspects to DOTS centres and linkage with HIV testing services in ART clinics and other healthcare facilities in the areas.
The CVs were trained on the basics of TB, suspects' identification, defaulter tracing, adherence support and TB/HIV relationships. They were involved in providing support and follow-up services for smear-positive cases, linkage with HIV testing and treatment for dually-infected persons; and organizing community mobilization.
Monthly CVs review meetings were held while PLAN Foundation staff provided supportive supervision to the CVs in communities. Results: There were steady and significant increases in number of TB suspects referred by CVs between project onset in June 2011 and October 2011. TB clients referred to DOTS centres for screening were: June-47; July-56; August-118; September-274; October-238 totaling 733 for the period. Of these, 78 of the suspects were smear positive cases while 25 were dual infected with TB and HIV. Conclusion: Engaging CVs is effective in identifying, referring, supporting and following up TB suspects and persons infected with TB and HIV. There is the need for linkage of TB and HIV services as a strategy for detecting HIV infection among people with TB. Community mobilization through CVs helps to increase awareness about TB and HIV in communities.
There should be improved support and motivation for CVs as vital linkages to communities TB/HIV interventions. Background: Effectively reaching PLHIV in rural, hard-to-reach areas is considered critical to improving access to health services and enrolment in care and treatment, which are needed to improve PLHIV's quality of life. Health facilities are located at least 20 kilometers from a farming population in Lamu District, Kenya. Infrastructure is poor and transport is unavailable; therefore, access to information and health services is an uphill battle. PLHIV there have had no option but to default treatment or share drugs. Methods: Through Ministry of Health (MOH) structures, community sensitization was undertaken and trained clinical staff made available. Technical and financial support to conduct monthly mobile clinics was provided through AIDS, Population, and Health Integrated Assistance (APHIAplus). Comprehensive services for PLHIV were provided, including education on secondary prevention, HIV counseling and testing, provision of Septrin and HAART, adherence and support counseling, prevention with positives package, and treatment of opportunistic infections during monthly clinic days. Service delivery data was collected and summarized using standard MOH tools. Results: From June 2010 to December 2011, 304 people were tested for HIV and 6% were found positive. Cumulatively 52 (48 active) patients have received HIV care (18 new) and 37 of them are actively on HAART (20 new). Patient retention is 92% and 87% have disclosed their serostatus to their sexual partners. All patients have had a CD4 test and 6-month monitoring is regularly conducted. The patients have formed a vibrant support group for psychosocial support and economic empowerment. Conclusion: With structured links to health systems and community involvement, sustainable models of outreach clinics for remote and hard-to-reach areas can be developed to achieve universal access to HIV prevention, care, and treatment. The approach has the potential to promote ART adherence, patient retention on care and treatment, and stigma reduction in the community.
Background: There is a sense of urgency to identify instruments that can promote the health and development of children in poor resource and high HIV prevalence areas of sub-Saharan Africa. This has led to a surge in technical programmes, such as cash transfers, whose new ideas and resources may not necessarily resonate with local support structures. This paper describes the effects of a community-led cash transfer programme in Manicaland Province, Zimbabwe, and explores how community members appropriated 'techno-fixes' in ways that benefits them and achieve buy-in. Methods: We report on data from 35 individual interviews and three focus group discussions, involving 24 key informants, 24 cash transfer beneficiaries, of which four are children, and 14 non-beneficiaries. Results: A thematic network analysis found the cash transfer programme to have had a substantial effect on children's schooling and education, mainly through improved access, concentration and ultimately performance, but also on their health and well-being, primarily through improved food intake, access to healthcare and reduced levels of stress and worry at a household-level. The programme was also said to provide the beneficiaries with an important platform to reduce levels of poverty, primarily through investment opportunities arising from having greater disposable income. Encouraged by local participation in the programme, conditionalities and witnessing its positive effects, both benefiting and non-benefiting community members spoke enthusiastically about the programme and highlighted their preference for conditional cash transfers-indicating community-wide buy-in and involvement. Conclusion: We conclude that despite their invasiveness, cash transfer programmes can, if implemented through local community structures, be appropriated at a community-level in ways that facilitate health-enabling and supportive social environments for vulnerable children and youth in sub-Saharan Africa.
D75 -Impact of service delivery on providers, coping strategies, burn-out and motivation Background: The advent of UNAIDS ''Treatment as Prevention'' policy of global antiretroviral (ARV) scale-up is not only life-saving for HIV-positive health care users, but may also hold significant potential to improve health care worker clinical practices, professionalism, and workplace morale. This research investigates the impact of ARV service delivery programming on health care workers? clinical practices and personal and workplace morale in a rural western Ugandan setting. Methods: As part of a larger community study (N 0142, 48% female), individual qualitative interviews were conducted with health care workers (n 015, 47% female) from Rwimi clinic in Kabarole District, during a four-month period. Clinic practices were also assessed through 40 hours of participant observation. Findings were coded and analyzed using Attride-Stirling?s Thematic Network Analysis, and further mapped for discussion using the Social World Triad, a conceptual model developed for this study. Results: ARVs are seen as being a positive, helpful force which allows health care workers to re-frame their clinical practice and professional identity to one of mastery over the illness. Their representations of HIV/AIDS are correspondingly beginning to change, to that of an illness which is manageable and controllable with drugs, thereby providing health care workers with renewed hope and a sense of clinical competence not felt since before the HIV/AIDS era. Professional practice is improving through more positive clinical interactions between health care workers and clients, which could lead to improved health service programming uptake by the community. Conclusion: The clinical use of ARVs has also improved the personal coping strategies, workplace morale, and professionalism of health care workers at this clinic. Such findings encourage increased advocacy and community outreach efforts regarding ARV service provsion, and suggest that ARVs could be utilized in concert with broader social and biomedical interventions and programming, as a social change agent to reduce stigma and improve health service uptake. Background: As the efforts to tackle the HIV/AIDS pandemic have become increasingly more refined, the dialogue about the ways in which the local understandings of gender and sexualities and dynamics of stigma shape the success or failure of treatment and prevention efforts has come to the fore. This presentation examines one such example in which the complex social, political, and health entanglements affect*in differing and often unexpected ways*the efforts to provide HIV-related prevention and treatment services. Specifically, it provides a qualitative socio-political analysis of the debates around the emergence of an HIV-focused clinic in Mexico City, where after the approval of a local law more comprehensive health care services for trans individuals were also to be delivered. Methods: It is based on fourteen months of ethnographic research in Mexico City conducted in two phases spanning 2009Á2011. It draws on qualitative interviews, observations and analysis of relevant textual documents, and provides a qualitative ''bottom-up'' analytical approach to the gathered data. Results: The results show that the emergence of a transgender health program delivered in what is known as the HIV clinic sparked a heated controversy between supporters and detractors. Due to the intersections between structural vulnerabilities and existing dynamics of stigma around HIV, many trans women*and particularly sex workers*prevented themselves from accessing HIV-related and other health care services available to them in this hospital. Many of them did not want to be seen as potentially HIV positive individuals, as this may have brought both negative social and labour consequences into their lives. Conclusion: The predicament between accessing or not health services in a clinic tainted with stigma had direct implications for the successful prevention and treatment of HIV and other illnesses. This study supports the view that local sociocultural and political dimensions need to be fully considered when envisioning HIVspecific programs. Track D Social Science, Human Rights and Political Science for cross-country comparisons where countries share a regional identity and where policy diffusion across state/national lines may be expected.

THAD0402
Effective representation of PLHIV in decision making processes still an uphill journey in Malawi; why? In order to contribute to the national response has developed an initiative to visualize this situation and promote the active participation of women with HIV in the national response to the increased incidence departments to advocate for the promotion and defense of human rights, including reducing the stigma and discrimination, and develop preventive actions to prevent other women from acquiring HIV. Methods: Qualitative evaluation. Results: 6 departments have women?s organizations and local references with HIV prevention and support for the capture and defense of human rights including access to treatment, care and support. Women with HIV at 3 CONISIDA integrated departmental and national CONISIDA, 5 Commissions to Fight AIDS, from civil society (CNLCSSC) and 6 Multidisciplinary Care Teams departmental hospitals. Coordination with various stakeholders and mobilizing key social sectors, around HIV prevention in women and the promotion and defense and guarantee of the rights of women with HIV enhancing hardly a social response is obtained as quickly and effectively with other actors.

Conclusion:
The initiative developed has been proposed as a successful model to be incorporated in the national response to HIV. Their strategies: i) Strengthening the organization of women with HIV in their communities, ii) development of their capacities in advocacy, communication and addressing HIV with other women affected by the epidemic; iii) public advocacy decision makers to influence the reduction of stigma and discrimination and vi) the exchange of experience can be replicated and adapted to different contexts to be feasible to develop successfully.

THAD0403
Mainstreaming gender into the national Global Fund strategy in China: a case study from a grassroots women's NGO network W. Yuan Henan Women's Action Group, Zhengzhou, China Presenting author email: yuanwenli2010@gmail.com Background: Despite the growing number of women infected with HIV/AIDS in China, insufficient attention to women living with HIV/ AIDS in the Global Fund's strategy and structure continue to increase the vulnerability and participation of women. No expenses in the budget are designated for projects focused on women, and all 11 NGO representatives in the Country Coordinating Mechanism (CCM) are men. Methods: The Henan Women's Network works to mainstream gender-based approaches into China's national AIDS strategy in order to help women gain improved access to HIV/AIDS prevention, treatment and care services. The Network used three major strategies to advocate within the national Global Fund mechanism as entry point for broader national advocacy: working with female PLWHA to conduct needs assessment, and strengthen collaboration between women's health organizations; submit recommendations and mobilize international organizations including UNWOMEN and UNAIDS to incorporate gender concepts into the revision of CCM regulations; and cooperate with the All China Women's Federation on gender rights awareness trainings for health departments, the Federation and female PLWHA. Results: After incorporation of a gender strategy into the CCM regulations and a targeted call for applications from women, 40% of 2011 CCM NGO consultants are women. Their increased participation in decision-making process will further the development of genderbased approaches in budget and strategy. Conclusion: Actual needs of women living with HIV/AIDS have been successfully passed on through a local grassroots network. Integrated support from international organizations, the government, scholars, experts and community organizations was instrumental in achieving consensus in a gender-based strategy. Moving forward, capacitybuilding for women living with HIV/AIDS need to enable greater participation, and needs assessments will need to clarify suitable targets for women. Budgets promulgated by the CCM need to define specific expenses to implement gender-based strategies. Results: Participatory processes (workshops, focus groups, and indepth interviews) involving women, including WLHIV, were used to identify key priorities, activities, and HIV strategies for the National Accelerated Plan (2010) and eMTCT Strategy (2012). The EC-UN Women project fostered HIV-positive women's leadership through training, technical assistance, advocacy planning sessions, and the development of formal mechanisms within national AIDS coordinating bodies that include women.
These case studies demonstrate that WLHIV's active participation in national HIV policies and strategies development increases their visibility and ensures that their needs and rights are prioritized (e.g. requirement of future participation of women and girls in national HIV decision-making). Such practices enable WLHIV to be directly involved in implementation, monitoring, and evaluation of strategies they helped to develop (e.g. by aligning their own programs and budgets to the National Accelerated Plan). Conclusion: These Rwandan cases highlight MIWA's positive impact and the need for concentrated commitment to actively involve WLHIV in decision-making. Deliberate programming is needed to ensure that women and girls are empowered and equipped to transform national agendas to protect and promote their needs and rights in the HIV context in all countries.

TUPDD0104
Ending discrimination in recruitment processes: an effective campaign to prohibit pre-employment questionnaires L. Dunkeyson and E. Briggs NAT (National AIDS Trust), London, United Kingdom Presenting author email: laura.dunkeyson@nat.org.uk Background: The UK is currently reforming its benefits system to encourage people with health conditions to return to work. However, research indicates that unscrupulous employers were using preemployment health questionnaires to discriminate against people with health conditions in the recruitment process. Research from 2006 found that when a non-disabled person and a disabled person who disclosed their disability applied for the same job, non-disabled applicants were invited to twice as many interviews. Research also shows that fewer than 50% of people diagnosed with HIV in the UK are in employment. Methods: NAT brought together a coalition of organisations including mental health and HIV charities, to campaign to prohibit the use of health questionnaires before a job offer.The Equality Bill was identified as an appropriate piece of legislation to outlaw the use of these questionnaires. Media coverage of the impact of discrimination on people living with HIV and mental health conditions raised the profile of the campaign. The coalition submitted evidence to Parliamentary Select Committees including international examples and secured cross party support for the campaign in the House of Commons. After initially rejecting the idea, the Government met with the coalition and representatives living with HIV to listen to our concerns. Results: The Government accepted the evidence presented by the coalition and tabled an amendment to the Equality Bill prohibiting the use of pre-employment health questionnaires. The Equality Act came into force in October 2010 and it is now unlawful for employers to ask health related questionnaires before a job offer. This is a significant step forward in ending discrimination in recruitment for people living with HIV. Conclusion: There are significant gains to be made in building coalitions with organisations supporting people with other health conditions that face similar stigma and discrimination to campaign to reform legislation.

TUPDD0105
AIDS and human rights activists fighting for maternal health justice in Uganda: the value of real synergies midwives contributes to reluctance of health professionals to attend to HIV positive mothers, particularly in remote areas. Methods: Civil society networks in Uganda formed a diverse coalition to implement a legal and advocacy strategy to challenge the epidemic of preventable maternal death in Uganda. Combining a Constitutional Court challenge with a challenge in the court of public opinion, the coalition used grassroots mobilization, media work, budget monitoring and advocacy in Parliament to create a common platform for health justice advocacy, prioritizing issues ranging from HIV treatment access to the shortage of nurses. The multiple factors that contribute to preventable maternal death, including HIV, created multiple opportunities for high impact civil society advocacy. Results: This new civil society coalition has been able to break down walls between disease-and condition-specific advocacy and implement bold campaigns to scale up access to essential health services in Uganda. In one year, the coalition has supported an historic legal challenge on the right to health and preventable maternal death; has successfully advocated for increased investments in increased professional health worker recruitment, remuneration and equitable deployment; and has generated national and international press attention to the human right to health in Uganda. Conclusion: We have developed an approach to advocacy in Uganda that joins civil society focusing on a wide range of diseases and conditions in synergy. Uniting around key policy opportunities has resulted in important progress in the struggle for health for all. Background: The purpose of the study was to identify barriers to and opportunities for evidence-based policy on illicit drugs in four sub-Saharan African countries-Tanzania, South Africa, Nigeria and Ghana. Small-scale studies indicate that HIV transmission is linked to injection and non-injection drug use in all of these countries.

D80 -Evidence-informed policy development
Methods: A policy case study for each country was developed through in-person semi-structured interviews with key informants, including policy-makers, academic experts, NGO representatives and representatives of international organizations. Results: The lack of population-based data and trend data on the extent of drug use and drug injection is an impediment to policymaking, leading to denial at policy levels. In all four countries, the law allows the police wide latitude in search, seizure and arrest of people accused or suspected of committing minor drug crimes, who can receive long prison sentences. Except in Tanzania, there are very limited affordable options for evidence-based drug treatment, especially of opioid dependence. Pressure from the US and other external actors to demonstrate interdiction successes may contribute to the domination of the policing-based drug policy. South Africa's drug policy-making has been walled off from HIV policy-making bodies. Ghana is seeking to generate population-based data on the extent of drug injection as health authorities bemoan the weakness of mental health and drug treatment services.
Conclusion: Criminalization and policing dominate drug policy in most of these countries, impeding evidence-based responses to HIV. There is an urgent need to build capacity among policy-makers and civil society to rethink entrenched policing-based approaches to drug use and to raise awareness of affordable evidence-based services for people who use drugs. The advances made in Tanzania's methadone program, including new awareness by the police of the importance of public health approaches, should be an occasion for learning across the continent.

WEAD0604
Bottlenecks analysis: a critical step to evidence-based planning for eMTCT, Cameroon experience  1 and 2). Strategies and interventions to address these bottlenecks include: 1) capacity building of community actors for the promotion of integrated PMTCT/SMNI, 2) strengthening procurement and supply management system, 3) quality assurance of PMTCT service delivery, 4) strengthening monitoring and evaluation. Conclusion: The bottleneck analysis has proven to be a powerful method for identifying and analyzing disparities and factors impeding the performance of MNCH and PMTCT programmes. To generate accurate information and draw relevant conclusions quality data are a prerequisite. This was one of the major challenges which were addressed by actively collecting data by field actors. Choices and decisions on key bottlenecks should be based on their potential impact on programme performance, relevance and feasibility of corrective strategies, and availability of resources for action. Participation of all level-stakeholders from the onset of the process increases ownership, and recognition of findings. Results from the analysis were precious inputs for the development of the national mother to child transmission elimination Plan. The plan provides a framework for strategic vision and coordination for all actors and is therefore a structured road map to achieving the set targets for PMTCT by 2015. Background: The demand for effectiveness swept through the international community raising expectations about results and their impact. None has been more affected than CSOs. Despite being at the front-lines of the international response to HIV/AIDS, these efforts were not always evaluated. This evaluation of the community response asked: Do communities with a strong community engagement show: (i) better knowledge, attitudes, perceptions and behavior, (ii) greater access to and utilization of HIV/AIDS services, and (iii) social transformation? Methods: Given the complexity/variety of community responses, the approach selected involved several countries, studies and methods. Experimental and quasi-experimental methods measure community results looking for changes in knowledge, behaviors, utilization of services and health outcomes with indicators related to prevention, treatment, care, support and mitigation. Quantitative and qualitative data from CBO/NGOs/households were collected and analyzed to better understand social transformation and the findings.
Results: Eleven studies were conducted in 8 countries (2009Á2011) (Burkina Faso, Kenya, India, Lesotho, Nigeria, Senegal, South Africa, Zimbabwe). Strong casual evidence shows that specific community interventions can affect the course of the HIV epidemic through increased HIV knowledge and reduced stigma, and increased condom use, testing uptake, treatment adherence and use of services. Example: (i) community empowerment increased services utilization among FSWs in India (p B0.001); (ii) peer mentoring nearly doubled the number of individuals attending pre-test HCT and by 120% the number of individuals receiving their test results (pB0.1) in Senegal. Strong evidence shows that community-based actions play a complementary role to national programs by providing services to less favored communities (i.e. rural communities; high risk groups).
Conclusion: This evidence can support decision-making by CSOs and resource allocations at national level to ensure that civil society components are integrated in the national response to decrease dependency on international funding for a more effective and efficient achievement of the 3-Zeros.   Track D Social Science, Human Rights and Political Science blood donation guidelines is necessary to maximize blood donations and improve blood safety protocols. Methods: Advocates, including public health and blood bank communities, blood product recipients, and NGOs, have pushed for a more equitable policy. In May 2010, GMHC joined with leading hemophilia advocates, who also represent a population disproportionately impacted by HIV, to raise awareness of blood donation guidelines in agreement that: the current deferral of all MSM results in a large number of potentially eligible blood donations; and that there are some high-risk activities permissible from heterosexual donors under the current policy. Both perspectives were presented to the Advisory Committee on Blood Safety and Availability (ACBSA) in June 2010. Results: The ACBSA recommended that sufficient data were not present at that time to change the policy banning MSM, that current blood donation guidelines are ''suboptimal'', and that a robust research agenda be pursued in order to carefully examine alternative policies. Government agencies are now implementing the ACBSA's recommendations to identify a subset of low-risk MSM blood donors. In tandem with U.S. momentum for reform, a number of other countries, including the United Kingdom, have made reforms to their policies to allow MSM to become blood donors. Conclusion: International momentum to revise blood donation guidelines for MSM advances efforts to maximize blood safety, increases blood donation, and decreases stigma of MSM. Background: Political leadership is known to affect HIV prevention and treatment. In this presentation, we aim to show the dimensions of political governance that are associated with ART coverage using country-level data. Methods: Percentage of ART coverage from 2004 to 2009 as estimated by UNAIDS is analysed as the outcome measure. Highincome countries as defined by the World Bank in 2009 are excluded from the analyses. Measures of political governance and GDP per capita (log-transformed) from the World Bank, adult literacy rate (UNESCO, reflected and log-transformed), gender inequality index from World Development Report 2011, skilled birth attendance at delivery compiled by World Bank (reflected and log-transformed) and disability adjusted life years (DALY) due to non-HIV causes and international (HIV and non-HIV) health funding per capita from the Institute of Health Metrics and Evaluation were fitted separately as predictors in multi-level linear models, in which year of reporting or estimation and HIV prevalence from UNAIDS are included. Missing data were imputed for fitting a final model that includes year, HIV prevalence and variables that remained statistically significant. Results: Higher levels of ART coverage are significantly associated with higher GDP per capita (p B 0.001), lower gender inequality (p 00.003), higher literacy rate (p 00.011), higher percentage of births attended by skilled attendants (p 00.002) and less DALY due to non-HIV causes (p 00.033). It is also highly significantly associated with better political governance in all six dimensions( political stability, voice and accountability, control of corruption, rule of law, government effectiveness and regulatory quality) (p B 0.001). In the final model, only political stability and voice and accountability remained as statistically significantly associated with higher levels of ART coverage. Conclusion: The analyses indicate that better political governance are crucial determinants of ART coverage in a country.

WEPDD0205
Three I's for HIV/TB and early ART to prevent HIV and TB: policy review of HIV and TB guidelines for high HIV/TBburden African countries Background: Gender inequalities are a key driver of the epidemic, yet despite this being recognised for many years, global policies to change these often have had little effect. Using the UNAIDS' Agenda for Country Level Accelerated Action on Women, Girls, Gender Equality and HIV which is its flagship gender and HIV policy as a case study, we explore the barriers and facilitators of the Agenda's development and implementation, to understand the strengths and limitations of gender policy better. Methods: We conducted semi-structured interviews with 16 southern African and global gender and HIV/AIDS policy makers, researchers and activists who had been involved in the development or implementation of the Agenda. We analyse their responses using thematic analysis. Results: Barriers to the development and implementation of the Agenda included the lack of resources and tools to development and implement the policy; the lack of participation of women in grassroots organisations, despite this being a pillar of HIV and gender policy; and a lack of political will to see the policy translate into meaningful programmes and change on the ground, despite significant visible support from key actors in UNAIDS. Yet positively, the Agenda also provided a collaborative platform for women's organisations to develop and common language to prioritise women and girls and ensured consistent and strong language around this emerged. Conclusion: Our study suggests that despite the Agenda being the 'flagship' policy on women and girls in the context of HIV championed by UNAIDS, there remain significant weaknesses in how the Agenda was developed and is being implemented. These challenges are reflective of the wider field of gender and HIV and reflect the limited real commitment that is often placed around challenging gender inequalities in the response to HIV.

D86 -Policies addressing HIV and AIDS in the workplace and educational institutions TUPDD0102
License denied: professional and vocational licensing restrictions affecting people living with HIV in the United States A. Yager HIV Law Project, New York, United States Presenting author email: ayager@hivlawproject.org Background: We reviewed the laws of the 50 states and compiled those vocational and professional licensing laws (e.g. for licensure to be an acupuncturist, barber, massage therapist, midwife, cosmetologist, nurse practitioner, doctor, dentist, etc.) that discriminate against people living with HIV/AIDS and/or those with a communicable, contagious, or infectious disease. Methods: The statutes, regulations, and cases were identified in Westlaw using the following search terms: ''HIV,'' ''Human immunodeficiency virus,'' ''communicable,'' ''contagious,'' ''infectious,'' and ''disease.'' The volume includes laws that explicitly discriminate against people living with HIV/AIDS (PLWHA) as well as laws that do so implicitly through restrictions concerning communicable, contagious, or infectious diseases. While we did attempt to include all relevant state law, this does not promise to be an exhaustive list. Results: The results of this survey reveal a deeply rooted HIV stigma that has been embraced by policy makers in a majority of the states. Thirty-five of the fifty states have licensing requirements that explicitly discriminate against people living with HIV/AIDS for one or more of the fifteen vocations considered here, and forty-four states have requirements that either discriminate against PLWHA or discriminate against people living with infectious, communicable, or contagious diseases. These laws lack any basis in the science of HIV transmission, and maintaining them only validates the ignorance and bias that spawned them. Conclusion: Licensing criteria that discriminate against people living with HIV/AIDS violate federal law. States that allow these discriminatory laws to remain on the books are ignoring scientific consensus and promoting HIV stigma. If PLWHA in the United States are to enjoy the same employment opportunities that other individuals enjoy, then states must examine their licensing procedures and alter or remove any discriminatory requirements until all licensing practices are in compliance with the Americans with Disabilities Act and guidance from the Department of Justice. Background: The southern United States has the highest numbers of adults and adolescents living with HIV and the highest death rates from AIDS. Numerous southern cities are in the top ten for HIV infection rates. Yet state laws and policies fuel the epidemic and exacerbate pervasive stigma and discrimination. Methods: This long-term, multi-method investigation is based on hundreds of interviews with people living with HIV and AIDS, their advocates, public health officials, legislators, judges and medical providers, as well as extensive legal and policy analysis. Results: Multiple state laws and policies create an "environment of risk" that has made the South the nation?s leading region for both HIV infection and deaths from AIDS. In the South, where poverty levels are the highest in the nation and fewer people have access to health insurance state policies are contributing to the disproportionate impact of HIV on minority communities. The failure to invest in public health, Medicaid and HIV-specific programs, particularly housing and transportation for a rural population; insistence on failed abstinence-based education; criminalization of HIV exposure; homophobic laws that drive MSM and transgender people underground and away from essential health services and the highest incarceration rates in the nation are some of the human rights violations that undermine public health efforts and fuel the epidemic in southern states. Conclusion: Laws and policies in the southern U.S. are undermining human rights and conflict with the goals and objectives of the National HIV/AIDS Strategy. This interactive session will identify strategies for challenging these policies at the federal, state and local level.  Background: This study examines how HIV/AIDS funds, including vertical Global Public Goods for Health (GPGH), might be leveraged to contribute to production of horizontal GPGH through health system strengthening. Specifically, it addresses the following questions: 1)How can vertical (disease-specific funds) be used to decrease the impact of funding asymmetries between vertical and horizontal GPGH and support the production of horizontal GPGH? 2)How would complementary activities be evaluated with regard to their contribution to health system strengthening? Methods: Global Fund grant information was used to examine the extent to which HIV/AIDS grants are currently contributing to system strengthening and capacity building at the national level beyond their disease-specific areas and if the inclusion of health system strengthening components influences grant performance. In addition, a framework is developed to evaluate the contribution of HIV/ AIDS programs to the production of GPGH through the horizontal strengthening of national health systems. Results: In the bivariate analysis, the number of health system strengthening components was significantly related to performance. However, as more variables were added the significant disappears. The grant characteristics significant across the models were grant duration and region. While the results regarding the positive association between health system strengthening components and grant performance are inconclusive, the inclusion of health system strengthening components doesn?t appear to interfere with a grants ability to meet its disease specific performance targets. Conclusion: The results from this analysis indicate the need for additional research to examine the relationship between health systems, health system strengthening, and HIV/AIDS program performance. The critical step would be to examine how the national subsystems are contributing to the international level through governance, financing or provision of goods and services related to GPGH. Track D Social Science, Human Rights and Political Science those who have: a) health systems with mainly public financing, or b) large Global Fund grants. In both cases, most of the funding goes to medical interventions, people living with AIDS and general population. Spending on key populations at higher risk for HIV exposure is minimal, although the epidemics are concentrated, with high prevalence among gay men, sex workers and Trans. Antiretroviral spending is about U.S. $ 26 million, with few countries monitoring length of survival and quality of life since treatment initiation. Conclusion: There are sharp contrasts in financial position of the response to HIV in Central America. NASA 2010 showed evidence that will put these issues on the political agenda of countries and define an updated and more effective financial strategy.

WEAD0602
Using geographic information systems mapping as a decision support tool for PEPFAR South Africa Background: PEPFAR South Africa saw a 2008 government policy shift in HIV opening doors to more formal collaborative planning and greater transparency in implementation of donor-supported programs. In 2010, PEPFAR commissioned a national survey to catalog i) geographic location of partners and sites and ii) human and financial resources used for implementation. This dynamic online reporting, graphing and mapping tool is called the PEPFAR Inventory and is accessible freely on the Internet. Its purpose is to provide strategic information to monitor implementation of the PEPFAR Partnership Framework between the United States and South African Governments.
Methods: Data were captured into a single database and 6,600 sites were geocoded using open source tools. Sites were then assigned to sub-districts, municipalities and provinces using additional open source proprietary software. A combination of open source software was used to create searchable maps. Results: The Inventory is integrated with results and budget data which will be linked to targets. This will make it possible for the PEPFAR Inventory to monitor achievement and US Government investment across the country. Cluster maps enable program managers to view program coverage. MapGuide software provides an interface to display various data sets comparatively, such as population and HIV prevalence, pin-maps per agency, prime partner, site type, site ownership and program area. Viewing which partners are working in the same geographical and programme area helps to avoid duplication of effort. Conclusion: The Inventory, developed by the USAID-funded Enhancing Strategic Information Project implemented by John Snow Inc., is a critical tool for monitoring the Partnership Framework. Aggregated provincial data can be integrated with other datasets at similar geographical levels to determine if PEPFAR resources are distributed to respond to the needs of the epidemic. It is envisaged that HIV/AIDS activities of other donors will eventually be linked to allow better coordination and more effective targetting. Convincing evidences are needed to concert policies from public security and health departments.

Methods:
The research was carried out jointly by the Kunming CDC, FSW peer workers and university volunteers, in four populated urban districts in Kunming China. In the initial phase, an estimation of FSWs was conducted. The second phase included literature review of policies, laws, regulations and practices related to Sao Huang, with special attentions drawn to Women's Education Center, a facility created under the public security system to detain FSWs arrested in Sao Huang. The third phase was a study on the lives of FSW and impact from Sao Huang particularly related to health service accessibility. Face-to-face interviews, focus group discussions and questionnaires were carried out to cover 561 FSWs. Results: Extensive discrimination already hampers FSWs' rights to health information and services. Sao Huang efforts have furthered such obstacles. Sao Huang is also a main driving factor for FSWs to move to 'safer' locations, increasing FSWs' invisibility thus weakening service accessibility. Sao Huang promotes distrustful relationship and tension between FSWs and public service departments, including that of health provision, which makes it even more difficult for health department to access FSWs. Conclusion: Sao Huang is a wide-spread national policy which needs to be restructured in order to adapt to the growing needs for HIV response in China. The research group is organizing evidences from the research to draft a paper advocating for changes in this particular policy. Methods: A study on HIV and legal empowerment was commissioned to place the program in a broader access to justice paradigm. In each country, a comprehensive needs analysis or an environmental scan was undertaken to determine the needs, available services and gaps in HIV-related legal services. A local organization already providing legal services was given technical and financial support to improve quality and scale up, including documentation of their work. Regional and international consultations were held to promote sharing on management challenges, and substantive issues such as criminal law, needs of women and girls, and access to treatments for HIV. An independent end of program evaluation was undertaken in early 2012. Results: A review of results in program countries and other contexts revealed success factors such as: engagement of outreach workers to create demand for services; women friendly and child friendly services can increase uptake; opportunities exist to mainstream HIVrelated legal services into existing government services; service (such as child care) can increase access and assist sustainability, particularly for female clients; technical assistance can improve case documentation and hence advocacy for science-based policy and law reform. Conclusion: Legal empowerment and access to justice approaches are essential elements of the enabling legal and policy environment for the response to HIV. They are needed to help take prevention, care, treatment and support to scale. Background: Existing prostitution policies directly affect an individual's ability to protect oneself from risk of HIV/AIDS in terms of access of services and ability to negotiate safety. We examine the policies as they are written, but also from the perspectives of those they are directed toward. This panel offers an explicit analysis of policy related to sex work, prostitution, and trafficking through the perspectives of sex workers, including the criminalization of prostitution in general as well as specific policies and practices (i.e., Condoms as Evidence (DC), Prostitution Free Zones (DC), and End Demand (Chicago). Methods: Our goal is to analyze policy through direct communication (in-depth interviews, surveys and case studies) related to criminalization of prostitution in general with a focus on specific policies including Condoms as Evidence, Prostitution Free Zones, and End Demand Campaigns. Our research includes 34 in-depth interviews, 50 surveys, and 6 case studies and is representative of Washington, DC, the southwest and northeast areas of the country. Results: Trafficking and prostitution policies undermine HIV programs and the health of those individuals toward whom they are targeted because Stigma and fear discourage sex workers from seeking out health services, which can further endanger the worker as well as his/her clients and partners. Quick and risky negotiations with clients because of criminalization leads a worker to operate from a less empowered place from which to negotiate specific sexual activities safely New anti-trafficking legislation criminalizes organizations if they provide certain services to a person they believe is trafficked but don't take the person to the police.

Conclusion:
Existing policies must be analyzed with these questions in mind and revised/reframed to place individuals' safety and health at the forefront Sex worker and sex worker rights activists must be at the forefront and integral to these discussions and reworking of policies.

MOPDD0204
Criminalizing condoms: how policing practices put sex workers and HIV services at risk Background: In many countries police practices are dramatically out of sync with declared government policies to prevent HIV by promoting access to condoms. Police confiscation and destruction of condoms held by sex workers and outreach workers impair sex workers' access to condoms. Police treatment of condoms as evidence of criminal activity and as tools for extortion threatens sex workers' ability to safely carry condoms and negotiate their use with clients. Methods: In a joint research effort, community groups in Kenya, Namibia, Russia, South Africa, the United States, and Zimbabwe administered detailed questionnaires to 139 sex workers and 40 outreach workers. Results: Research revealed that police routinely stop and search sex workers and confiscate their condoms. In some locations, police destroy sex workers' condoms by burning them, cutting them up, driving on them, or throwing them in the garbage. Police confiscation and destruction of sex workers' condoms increases their vulnerability to HIV. Sex workers reported having unprotected sex with clients after police took their condoms. In some cases, police use condom possession as justification to detain or arrest a person on charges of engaging in sex work, or as leverage to extort bribes or sexual favors. Sex workers sometimes do not carry condoms or refuse condoms from health care providers because they fear condoms will get them in trouble with police. Police further impede sex workers' access to condoms by surveilling and harassing outreach workers and taking or destroying condoms meant for distribution. Conclusion: Policing practices are undermining messages of condom accessibility and acceptability crucial for disease prevention and the promotion of individual and public health. Policing tactics and guidelines must be brought into alignment with international best practices to prevent HIV. As a first step, governments should eliminate laws that criminalize sex work and other structural obstacles to police reform.

MOPDD0206
The legal framework of sex work and its interface with HIV: barriers for a sustainable response to HIV programming in Bangladesh Background: Due to the current legal frame work of sex work in Bangladesh sustainable HIV prevention interventions among Female Sex workers (FSWs) is a major challenge. It is clear from experience gained so far that social marginalization & disempowerment that characterize FSWs community are the key vulnerabilities that need to be addressed before any interventions related to HIV can be successfully adopted by them with ownership. Methods: The first ever national congress of FSWs in Bangladesh organized by Save the Children was participated in by 1000 FSW around the country from 29 FSWs networks. They discussed legal and policy issues related to sex work and its consequences. This allowed an opportunity for shared experience from leading national, international organizations working with FSWs for last 20 years to have an analysis of the legal framework of sex work among Bangladesh.

Track D Social Science, Human Rights and Political Science
Results: Hotel or Street, in any settings FSWs are not in a legal position to say no and or insist client for negotiating safe sex. According to anti-prostitution law two or more FSWs cannot work together which interferes with the ability to form collective resistance to violence, abuse & unsafe sex. On the other hand Police and Municipality law creates fear of Arrest hinders community outreach and FSW is hidden: this means it is difficult to identify, contact & build trust and avoiding arrest prevails over safer sex. Also Police powers harasses peer educators, carrying condoms seen as 'promoting', 'soliciting' & 'carrying on' sex work. Due to criminalization of Brothels prevention program cannot ensure 100% condom use, frequent raids disrupt HIV services. Conclusion: The legal and policy framework requires radical restructuring to reduce legal sanctions and social marginalization and allow capacity building will work for sex workers community to build a sustainable HIV AIDS program in partnership with other stakeholders including government in Bangladesh. Results: Although there are some variations in the intellectual property provisions demanded in FTAs by the EU and US their primary aim is to decrease the space for generic production of medicines including ARVs. Provisions like data exclusivity (a new monopoly on off-patent medicines), extention of patent terms beyond 20 years, enforcement measures that will have a chilling effect on generic production, interfere with judicial independence and put shipments of medicines at risk of being seized feature in these FTAs. In addition the investment chapter puts government actions to ensure access to medicines or provision of healthcare at risk of MNC's legal cases filed in private, international arbitration. Conclusion: In 2001 the price of ARVs crashed from $10,000 per person per year to $350. In 2001, governments around the world signed the Doha Declaration stating that international trade rules on intellectual property should not come in the way of providing access to medicines for all. FTAs go well beyond these international trade rules that are already resulting in higher prices of newer ARVs and medicines for Hepatitis C. Understanding the nitty gritty of the demands made in these FTAs is crucial to effective advocacy on the FTAs and for the proper involvement and consultation of PLHIV and health groups by their governments.

WEAD0402
ARV patents on the rise? An analysis of ARV patent status in 69 low-and middle-income countries Background: There has been widespread concern about the impact of patents on access to low-cost generic antiretroviral (ARV) drugs in low-and middle-income countries (LMIC). Patents can hinder competition, which has provided sustainable price reductions for the older generation, less-widely-patented ARVs. However, until recently, limited data on patent status in developing countries hampered a full understanding of the implications of pharmaceutical patenting in these countries. Methods: We compared patenting trends for 12 molecules invented pre-1995 and 12 invented post-1995, the year the WTO TRIPS Agreement came into force. We used data from the Medicines Patent Pool ARV Patent Database, the most comprehensive and regularly updated source of such information, providing information on 69 countries accounting for 84% of PLHIV in LMICs. We analyzed trends regarding: the number of molecules for which patents were applied for in a given territory, the number of LMICs with ARV patents, the expected date of patent expiration, and the implications for the development of and access to fixed-dose combinations (FDCs). Results: Since 1995, pharmaceutical companies are filing for patents in a greater number of LMICs and for a greater number of molecules, such that newer ARVs are more widely-patented than older drugs. A patent on just one drug in a 2-or 3-drug FDC can pose barriers for accessing the entire FDC, and such patents can pose problems in up to 80% of territories for which data was available. Conclusion: Since 1995, pharmaceutical companies are filing for patents in a greater number of LMICs and for a greater number of molecules, such that newer ARVs are more widely-patented than older drugs. A patent on just one drug in a 2-or 3-drug FDC can pose barriers for accessing the entire FDC, and such patents can pose problems in up to 80% of territories for which data was available.

WEAD0403
Intellectual property rights and access to HIV/AIDS medicines in french speaking African countries: issues, problems and prospects

E. Kameni University of Pretoria, Faculty of Law, Pretoria, South Africa
Background: The french speaking countries of African 'have been struck the hard by the pandemic. In recent years, however, the governments have made concerted efforts in combating the disease. With the support of international organisations programs on treatment, care and education have increased. However, a recurrent problem has been the difficulties of making HIV/AIDS medicines accessible. Stringent intellectual property laws act as a stumbling block to access to HIV/AIDS medicines. Methods: Presentation of a panoramic view of the problems created by stringent intellectual property laws and how they affect access to HIV/AIDS medicines. Analysis of various approaches to facilitate access to HIV/AIDS medicines. Proffering recommendations for reforms.

Track D Social Science, Human Rights and Political Science
Results: Demonstrating that the patent regime of the Bangui Agreement to which most Francophone African countries have signed is hampering access to HIV/IADS medicines and that there is an urgent need for reform. Conclusion: Though the coming into force of the WTO and the TRIPS Agreement ushered in a new dynamic on when and how countries had to use certain measures to provide, promote and protect access to HIV/AIDS medicines, french speaking African countries still have certain limited policy spaces for which to manoeuver and improve access to medicines. Most of them are signatories to international and regional treaties which creates rights to health obligations. Subsequent developments after coming into force of TRIPS have tended to tilt towards supporting access to medicines. The sad problem though is regional policy incoherence and countries' entering into treaties with TRIPS plus provisions. Fortunately, international law provides enough justification for enacting access to medicines pieces of legislation. Making maximum use of TRIPS flexibilities, incorporating human rights perspectives in intellectual property treaties, forging a strong alliance with civil society are just some of the measures needed by french African countries in increasing access to HIV/AIDS medicines.

WEAD0404
Impact of anti-counterfeiting measures on access to generic ARVs in developing countries N. Metheny Thai AIDS Treatment Action Group, Treatment Access Legal Advocate, Bangkok, Thailand Presenting author email: nmetheny@hsph.harvard.edu Background: Over the past decade, the issue of counterfeit medicines has been seen as a burgeoning public health concern, requiring immediate action. Some decisionmakers have advocated for addressing the counterfeit issue through legislative measures targeting intellectual property enforcement. During this process, the term ''counterfeit medicine'' has been defined in ambiguous and confusing ways that have numerous legal interpretations, and thus intended and unintended consequences. One particular issue is the conflating of counterfeit medicine with generic drugs, which has and will continue to impede access to generic ARVs in developing countries. Methods: My study consists of a political and legal analysis of three anti-counterfeiting efforts and their impacts on access to generic ARVs in developing countries, with a particular focus on East Africa. Results: My analysis begins with a brief discussion and overview of some definitions of counterfeit medicine used by WHO and under the TRIPS agreement. The analysis will then explore anti-counterfeiting efforts in Kenya, in the East African Community, and in Anticounterfeiting Trade Agreement (ACTA). I then explore an example in each context of how these measures have or will impede access to generic ARVs in developing countries. Conclusion: Based on this analysis, the anti-counterfeiting measures examined pose a real and dangerous threat to accessing generic ARVs in developing countries. The counterfeit definitions used conflate generics with counterfeit medicines. Thus, a clearer and more concise definition of counterfeit is needed to avoid negative implications for generic ARVs. Finally, the real public health concern at issue here is addressing the safety quality and efficacy of medicines, and anti-counterfeiting measures do not adequately address these concerns. Therefore, rather than trying to deal with substandard medicines through intellectual property rights enforcement, other policies need to be developed that not only address the real issue, but also do not pose a threat to accessing generic ARVs. Background: Morocco is facing a rising HIV epidemic among people using drugs (PUD). HIV prevalence among PUD ranks from 7% to 38% according to recent studies as HIV prevalence in general population is estimated to be 0.1%. This major change in epidemic pattern led Moroccan stakeholders to pay more attention to PUD. A first national harm reduction (HR) strategic plan (2008Á2011) has allowed some needles and syringes programs as well as methadone for 80 people out of other HR services.

WEAE0102
But PUD are facing legal and social barriers acting as potential barriers for access to HIV prevention, care and treatment. Country is in need to assess those barriers in order to design a more comprehensive approach to mitigate and reverse HIV among PUD. Methods: National HIV/AIDS community based organization ALCS has managed a cross sectional study in 3 North cities. 300 PUD recruited through outreach programs were asked to answer a questionnaire including 9 questions designed to assess human right violation from police officers, health professional and closed environment. Human right violation was defined as a break in national endorsed civil rights or break in national health good practices. Results: 99.8% of PUD have been victims of at least one of those 9 violations with following sub scores: 87% from police officers (eg. non legal custody) and 49% from health professional (eg. non access to emergency hospital units). 60% has faced situation closed to human exploitation with drug smugglers or other PUD (including sexual intercourse against drug). Famility is also a major cause of human right violations. Conclusion: Human Right should be considered as a central component of HR interventions in Morocco. At a time the country is designing HR scaling up it could improve PUD access to health services and alleviate family burden.

TUAD0104
Model of human rights protection of sex workers exposed to forced HIV/STI testing through combination of court litigation and psycho-social support Background: In Macedonia, sex workers are among the most discriminated communities. Due to self stigma and no trust in the system, our experience shows that SWs almost never report perpetrators or demand protection via litigation. This made us aware about the complexity of raising awareness to litigate cases of human rights breaches.
In November 2008 a systematic human rights violation by state happened when 23 SWs were unlawfully arrested and forcibly tested for HIV/HepC. Seven SWs were found HCV positive and criminally charged. Encouraging sex workers to demand justice, HOPS developed a complex model of legal, psycho-social and media support. Methods: After the incident, HOPS created intervention team of lawyer, outreach worker, social worker and psychologist for free information and support for emotional trauma and possible lawsuits. For the first time 13 SWs raised 2 court cases against institutions and media, and defended themselves in the criminal case. 3 years after, 2 cases finished, 1 is ongoing, but the SWs successfully resisted fears and remained motivated to follow through. Consequently, 7 criminally charged SWs were sentenced on parole, and the civil suit against state institutions was won. Results: SW in Macedonia are at risk for rights violation. Strategic litigation is a powerful protection tool, and while free legal aid is crucial, effective support should address emotional and other aspects of marginalization and resisting the state without fearing victimization. Trusted outreach and social workers, skilled psychologists and peer support must be part of the supportive model, involving the media and allies to create supportive environment. Conclusion: Promoting the success of this model nationally and regionally, in order for organizations working with marginalized groups to adopt it in motivating them to report violence and use disposable mechanisms, including litigation. These positive outcomes will empower SWs in our country to seek justice.

WEAD0203
When sex is a crime: ending the criminalization of HIVpositive women's sexuality in the United States by using grass roots advocacy and leadership development to eliminate criminal HIV exposure and transmission laws Result: Since October 2011, 125 people have been reached through PJP forums; thousands more through PJP and partner websites. PJP forums increased community knowledge of the impact of HIV criminalization laws on women, and provided general and womenspecific advocacy tools to build an infrastructure at the state level to monitor and challenge existing laws. With technical assistance from PJP, HIV-positive women founded local advocacy groups in the four forum states to eliminate state criminalization laws; began monitoring criminal prosecutions and discriminatory practices; and put a woman's face to the consequences of HIV criminal laws. Conclusion: HIV-positive women's engagement in turning the tide of the epidemic by personally advocating for elimination of criminal HIV exposure and transmission laws has increased awareness of the breadth of the laws' harms. Further policy research and political will is needed to support advocates to fight discriminatory criminal laws.

WEAD0205
Advocating against the criminalization of HIV nondisclosure: an analysis of community-led, science-based criminal law reform in Ontario, Canada (2) a campaign to establish prosecutorial guidelines has been an effective community mobilization tool, but has stalled at implementation due to lack of provincial buy-in; (3) a proactive media campaign has, for the first time in Canada, generated widespread favourable mainstream media coverage of opposition to criminalization; (4) political lobbying has helped prevent harmful interventions in 2 cases recently heard by the Supreme Court of Canada. Conclusion: Science-based criminal law reform led by a community organization can enhance legal defense, mobilize allies and impact media coverage, but faces challenges of engagement with provincial criminal justice authorities.

THAD0203
A handbook on HIV, law and human rights for the judiciary: a critical tool in a human rights-based HIV response A. Symington, R. Elliott, C. Kazatchkine, S. Ka Hon Chu and M. Golichenko Canadian HIV/AIDS Legal Network, Toronto, Canada Presenting author email: asymington@aidslaw.ca Background: The HIV epidemic has raised new and complex legal challenges, leading to a wide range of judgements on HIV-related matters. Given the diversity of issues and the quickly evolving science, judges need more opportunities to take stock of developments relevant to the cases before them. If properly informed and supported, the judiciary can help create the legal and social environment necessary to roll back the HIV epidemic. Methods: An advisory committee of sitting and retired judges, judicial trainers, and legal experts from around the world was constituted to inform the scope, format and content of the handbook. Issue experts prepared chapter outlines and draft texts which were shared with the advisory committee for detailed feedback. The final text includes case summaries, key principles, plain language explanations of the science and treatment of HIV, statistics, and factors to consider when adjudicating cases. Results: The result is a comprehensive and user-friendly handbook for the judiciary, suitable for use as a reference manual and in judicial training sessions throughout the world. Issues addressed include: discrimination, criminalization of HIV exposure, sexual assault and domestic violence, drug policy and the rights of people who use drugs, women's rights in family and property law, HIV-related treatment and healthcare, key populations at higher risk of HIV exposure, and judging during the HIV epidemic. Conclusion: The handbook for judges is a unique resource with significant potential to provide judges with a contextualized understanding of key HIV-related issues, and thus improve rights protections for people living with and affected by HIV. This potential will be maximized through judicial training sessions and commitment by governments to include the judicial sector in strategies to attain universal access. The tools and training needed by judges are distinct from existing HIV-related resources therefore targeted, sensitive approaches are needed.

THAD0204
Using courts to eliminate discrimination in women's property and inheritance laws in southern Africa P. Patel Southern Africa Litigation Centre, HIV Programme, Johannesburg, South Africa Presenting author email: pritip@salc.org.za Background: It is well-documented that discrimination in women's access to property and inheritance hinders an effective response to HIV. However, in southern Africa, where HIV prevalence still remains high, numerous laws on property and inheritance rights explicitly discriminate against women. Law reform efforts are slow and in many cases have been ineffective resulting in discriminatory laws remaining in place. Approaching courts through litigation as a means of striking down such laws is underutilized in southern Africa. Methods: In an attempt to accelerate the revision and/or striking down of laws discriminating against women in property and inheritance rights, we are using litigation before domestic courts to effectively strike down laws that discriminate against women with respect to property and inheritance in southern Africa. Results: A number of cases have been filed. A case challenging a customary law rule denying women the opportunity to inherit from their father's estate is in the Botswana High Court; the Lesotho Constitutional Court will hear a challenge to a law denying women the right to succeed to chieftainship; and the Malawi Constitutional Court is expected to issue a decision on whether courts are permitted to only take monetary contribution to property into account when determining property distribution at the time of divorce. In each of these cases, the relief sought is a change in the discriminatory law. In all cases, the countries have constitutional provisions protecting women from discrimination. Decisions in the cases are expected by June 2012. Conclusion: Law reform measures are critical to revise laws that facially discriminate against women with respect to property and inheritance rights. However, for relatively fast and effective reform, more advocates should approach courts asking them to strike down discriminatory laws. Track D Social Science, Human Rights and Political Science AIDS).Subjects with a current/previous AIDS defining illness were excluded.WHO Stage 3 subjects were eligible; baseline viral load was not an exclusion criterion. Results were released, based on data collection to February 21, 2011 with 90% of couples enrolled a median 1.7 years. The study was designed and occurred while ARV initiation guidelines were evolving giving rise to 2 questions: researchers? duty to offer subjects treatment at trial onset or midtrial according to current guidelines and use of the word ''early'' to describe the study results. Methods: The dates and recommendations of country /international guidelines for ARV initiation were cross checked against the study period, inclusion /exclusion criteria and triggers for ''delayed-therapy group'' treatment. The 052 study protocol was assessed against recognized international research guidelines. Results: Tables 1 and 2 show that during the 052 study period, contemporaneous country/international guidelines for ARV initiation recommended substantially earlier triggers for treatment than those used in the 052 ''delayed-therapy group''. The use of the 052 word ''Early'' relative to recommended treatment triggers is not reflective of those contemporaneous guidelines. Table 3 shows that the 052 study protocol may be inconsistent with international research ethics guidelines. Conclusion: The 052 ''delayed-therapy group'' did not receive ARVs in accordance with national/international guidelines. The 052 descriptor ''Early'' is inaccurate relative to standard ARV initiation guidelines. According to contemporary research ethics standards the wellbeing of subjects should be paramount, requiring provision of the current standard of treatment to clinical trial subjects-in this case to the ''delayed-therapy group''. Background: HIV testing is a major part of HIV prevention efforts across the globe. In US and World Health Organization (WHO) HIV testing guidelines, opt-out testing has replaced voluntary confidential testing as a means of combating low rates of HIV testing. The success of opt-out testing is not assured, particularly due to financial, legal, operational, and cultural barriers, such as limited reimbursements for testing, obstructive laws that require written consent, limited access to healthcare, and poor compliance by care providers in testing patients perceived to be low-risk for HIV infection. Alternative methods of promoting HIV testing warrant analysis in comparison to opt-out testing. Methods: HIV testing policies were hypothesized empirically and identified in the scientific and popular press. Each method was analyzed for consistency with WHO policy on HIV testing, which emphasizes the '3 Cs' of proper human rights-centered HIV testing. These conditions require that HIV testing must be: confidential, complemented by counseling, and informed, voluntary consent. Results: We identified incentivized testing, anonymous mandatory testing, and names-based mandatory testing as alternatives to voluntary confidential and opt-out testing. Incentivized testing, in which a person's ''willingness'' to be tested is rewarded, e.g., with money, is voluntary but potentially coercive to those of lower socioeconomic status. Incentivized testing is in limited use but largescale implementation would need to be names-based in order to avoid significant fraud. Anonymous mandatory testing using de-identified codes that allow verification that a person has undergone HIV testing preserves confidentiality but is involuntary. Names-based mandatory testing violates confidentiality and volition. Conclusion: Though each HIV testing policy provides counseling, optout testing remains the only ethical approach for the promotion of HIV testing as it avoids coercion and loss of privacy. Financial, legal, operational, and cultural barriers to greater uptake of opt-out testing must be removed so that ethically unacceptable HIV testing policies are avoided.

MOPDD0403
Cost effectiveness of two transport strategies for retention of young mothers and infants enrolled in a phase IIb, TB vaccine clinical trial in Siaya, Kenya Background: Study participants are reimbursed for transport costs incurred when travelling for clinic visits. Reimbursement also compensates for time spent in the clinic and is important for participant motivation and retention. In impoverished communities, determining adequate reimbursement is challenging. Undercompensation leads to low recruitment/retention rates, high mortality and missed trial endpoints. Ethical Committees cap reimbursements as overcompensation leads to undue influence. We sought to examine reimbursement practices, their impacts on costs and study participation in an ongoing tuberculosis vaccine trial. Methods: Mothers in rural Western Kenya were approached to recruit their infants. Once enrolled, they come for seven scheduled visits and an average of two unscheduled/sick visits in a span of two months. Reimbursement was set at a rate of $4 per visit regardless of distance and cost incurred. Distances to clinic were measured by study staff. Furthest distance covered is 30km costing $6. Where the reimbursement rate was unacceptable to the mother given cost or critical study visits would be missed, mothers were ferried to clinic by designated vehicles at a cost of $18 per subject. Results: Of 144 participants enrolled after 7 months, 57(40%) were under-compensated when compared to the costs incurred in attending study visits and expressed dissatisfaction with amounts reimbursed. Of these, retention rate was 99%.118 of sick participants attended clinic and 30(20%) sought care elsewhere due to cost. Participant satisfaction was not measured. Conclusion: High retention rates were achieved despite undercompensation but at a cost three times higher compared to cost of directly reimbursing the mothers. Given the challenges of conducting trials in areas with limited infrastructure, there's need for continuing dialogue between investigators and Ethical Committees regarding amounts given to participants which may be based on a gradient of reimbursement according to distances travelled. There's room for educating mothers/participants on research ethics and non monetary research participation benefits.

MOPDD0404
Exploring research participants' perceptions and comprehension of the informed consent process in a preexposure HIV prevention study in Zimbabwe: a case study

Track D Social Science, Human Rights and Political Science
Background: Ensuring informed consent is a complicated component of research, particularly with HIV prevention research conducted in poor settings. An inherent challenge characteristic of the informed consent process for HIV prevention studies is making sure that subjects understand that participation does not increase exposure to HIV and does not necessarily protect them from HIV. It is important to continuously monitor the informed consent process. Methods: In June-September, 2011, gender-specific in-depth interviews (n020) were held with interviewees who had been purposively selected from participants who had exited a vaginal HIV prevention study in Harare, Zimbabwe. An interview guide was used to elicit views around the informed consent process. Discussions were conducted in mother tongue and audio-recorded. Audio-recorded data were transcribed, translated verbatim into English, coded using NVivo 8 and analysed using grounded theory principles.
Results: Key information about study was given, as subjects articulated study aims well. However, it appeared that the informed consent process had been rushed and some participants had not had enough time to decide. Moreover, some participants reported that due to both excitement and anxiety, they had felt pressured to sign consent forms before comprehending some aspects of the study. Some mentioned that they had found it difficult to ask questions about the study. Both the study procedure and duration had not been fully explained. There were mixed feelings on importance of male partner involvement in decision-making around study participation, with some feeling that spouses should have been involved and others stating that partner consultation did not matter. Conclusion: This study elicited some of the issues that characterise the informed consent process for clinical trials conducted in poor settings. It also highlighted the need for researchers' ingenuity in order to come up with strategies that tailor the informed process to suit the specific needs and circumstances of individual participants.

MOPDD0405
'It doesn't work that way around here': lessons learned from an HIV community-based research study conducted in a hospital setting Background: Conducting community-based research with people living with HIV requires maintaining both individual and collective ethical standards. Research teams need to be cognisant of individual and community conceptions of informed consent, risks and benefits, and confidentiality. Although much has been written about challenges to obtaining ethics approval for HIV CBR, there have been fewer opportunities to describe ethical issues which emerge over the 'life' of these projects. This presentation addresses this gap by describing the ethical tensions which emerged during an HIV CBR study conducted in a hospital setting. Methods: Using a case study analysis, this presentation draws on field notes, minutes from team meetings, and reflexive memos to offer a critical chronology of decisions made to improve ethical practice in one HIV CBR study. Various disciplinary (nursing, social work, public health) and stakeholder (clinician, coordinator, researcher, participant) perspectives are highlighted and contrasted to show how 'ethics' was understood and negotiated. Results: We discuss the range of issues that emerged at the intersections of HIV, drug use, negotiating clinical space, and piloting innovative arts-based methods. Issues of cognition and HIV required the use of a multi-step informed consent process. Research team members balanced the need to support participants with reminders while being conscious of not creating undue pressure to participate. Maintaining confidentiality proved challenging because of the way space and time are managed in a clinical setting. The sensitive nature of the study and proposed group data collection necessitated changing the study design from group to individual data collection techniques to protect confidentiality. Interestingly, this happened despite having undertaken preliminary community consultations to determine the best approach. Background: The implementation of this model comes from the minimum interventions of the Peruvian health system towards HIV/ AIDS positive children and adolescents. The objective is to establish a program that provides children and adolescents with a caring, quality and confidential service. The model would contribute to reduce stigma and discrimination towards this specific HIV/AIDS positive population in South Lima. Methods: The implementation of the model required training sessions to HIV positive children and adolescents of poor families, family members of low educational level, some quechua speakers and teachers from local schools. The topics of the trainings were the following: 1) human rights, stigma and discrimination, 2) self-care for children and adolescents, 3) diagnosis management, 4) psychotherapeutic issues with family members. Teachers and community leaders participate on a specific training on sensitization and advocacy. Results: 31 HIV positive children and adolescents were trained on self-care and human rights. 28 families of HIV positive children received psychosocial support and their capacities and knowledge have been strengthened. 45 community leaders are more knowledgeable and sensitive on topics related to HIV/AIDS stigma and discrimination and can reproduce the training. 73 teachers are trained on topics related to HIV and children, stigma and discrimination and reproduced training to students, family members, in order to reduce rejection of HIV positive children and adolescents within their communities. Background: In the 2000s, France's policy on illegal drug users has become increasingly stringent. The National AIDS Council wanted to assess the impact of this punitive policy on risk reduction policy targeting drug users, notably injection drug users. Methods: Around thirty hearings were held with representatives of the relevant authorities (Ministries of Home Affairs, Justice, and Health), HIV/AIDS control associations, associations specialized in addiction and related issues, and drug user self-help groups. A review of the literature was also undertaken. Results: Policies on illegal drugs have focused on strengthening sanctions against drug users. From 2001 to 2007 the number of arrests for drug offences increased by 106%. Accusations relating to drug use represented 85% of all offences during the period in question. Consequently, the cost of this punitive policy, estimated at 590 million Euros in 1995, is now much higher. In comparison risk reduction policy seems to be underfunded. Risk reduction centers have a budget of 30 million Euros and are only present in threequarters of French counties (départements). Furthermore, this punitive framework means risk reduction tools, notably those targeting women, young people, people in detention, vulnerable users, and injection drug users have not been sufficiently diversified. Conclusion: The punitive policy on drug users has been made a top policy and budget priority, with risk reduction policy relegated to second place. This policy has hindered the development of pragmatic risk reduction measures, such as medically supervised injection centres, or prison-based needle exchange programs, adapted across the country to support the most vulnerable populations. Background: In 2003, France adopted a law against procuring and soliciting in order to discourage the practice of prostitution. The National AIDS Council wanted to assess its impact on sex workers in terms of prevention. Methods: Around thirty hearings were held with representatives of the relevant authorities (Ministries of Home Affairs, Social Affairs, and Health), specialist police units and associations involved in the subject: associations campaigning and working on health and community health, social reintegration, abolition of prostitution, and sex workers' unions. A field investigation was also carried out within a community health association. Finally, all gray literature was analyzed. Results: The 2003 law has undermined sex workers, the majority of whom are foreigners, without directly protecting the victims of procuring. Accusations against sex workers multiplied twenty-fold in the first half of the 2000s, before dropping slightly. There has been no increase in accusations for procuring. The activity has shifted to more isolated locations, under clandestine conditions with greater exposure to violence. The prevention work carried out by community health associations has become increasingly difficult, partly due to uncertainties regarding the availability of subsidies. The police and health authorities have not managed to cooperate effectively. Conclusion: The introduction of a punitive law has complicated prevention work targeting sex workers. In a hostile legislative context, it seems important to support and reinforce community health actions by means of a comprehensive approach combining prevention, access to health care, social and human rights. Background: HIV infection is higher among sex workers than in the general population, yet sex workers often lack access to HIV prevention services. A police practice that interferes with HIV prevention is using condoms as evidence of prostitution. Methods: A multi-method investigation of the practice of using condoms as evidence of prostitution was conducted in New York City, Washington, D.C., Los Angeles and San Francisco between October 2011 and April 2012. In-depth interviews with hundreds of sex workers, their advocates, outreach workers, police, prosecutors, judges, and public health officials were conducted, combined with legal and policy analysis. Results: Police engage in the routine and widespread practice of using the presence of condoms on individuals to profile them as prostitutes, to threaten arrest and as a basis for arrest on charges related to prostitution. In San Francisco, police and city regulators use condoms as a basis for arrest in clubs frequented by transgendered persons, in massage parlors and other businesses. In New York City, prosecutors introduce condoms into evidence to support prostitution charges. In Washington D.C. police confiscate condoms found on persons they identify as sex workers. In Los Angeles, sex workers follow what they believe to be the ''three-condom rule'', fearing arrest for exceeding a routinely enforced limit. In each city these practices take place in a wider context of police harassment and abuse of sex workers and those perceived to be engaging in sex work, including verbal and physical degradation and other misconduct. Transgendered women and LGBT youth are particularly targeted. Conclusion: Human rights abuses make some sex workers less likely to carry condoms, particularly those most vulnerable to arrest, such as undocumented immigrants. The criminalization of condoms interferes with the right to health and undermines public health objectives of universal access to disease prevention. In Africa, the continent with the most HIV-specific criminal laws but with few known prosecutions, Guinea, Togo and Senegal have revised their existing HIV-related legislation or adopted new legislation in line with UNAIDS guidance. Conclusion: Given the lack or inadequacy of systems to track HIVrelated prosecutions in most places, it is not possible to determine the actual number of prosecutions for every country in the world. These data should be considered illustrative of a more widespread, but generally undocumented, use of criminal law against people with HIV. Improved monitoring of laws, law enforcement, and access to justice is still required to fully understand impact on HIV response and PLHIV.

WEAD0202
The impact of HIV/AIDS criminalization on awareness, prevention and stigma in the: a qualitative analysis of stakeholders' perspectives in Ontario, Canada THAD0201 Knowledge and experience of HIV and the law amongst global key populations: global focus group feedback and recommendations for policy change S. Simon ICASO, UNAIDS PCB NGO Delegation CF, Brussels, Belgium Presenting author email: saraesimon@gmail.com Background: Laws criminalizing certain behaviors, and HIV nondisclosure, exposure and transmission are resurgent in developed and developing countries around the world. This study set out to understand how laws impact health seeking behavior and what coping mechanisms result amongst different key populations and to recommend policy changes. Methods: A qualitative four-part questionnaire was developed and used in 27 focus groups carried out by community members during August and September 2011 in all regions of the world. More than 240 participants (51% PLHIV) from 32 countries, selected by their affiliation with a key population, took part in the study. Participants were asked non-identifying information such as HIV status, associated population group, gender, and housing situation. The hundreds of pages of feedback were analyzed for common themes across geographic region and population grouping. Common trends were then verified to develop key findings. Results: Results show that individuals are being deterred from seeking health services when their behavior is criminalized. Evidence revealed that laws criminalizing HIV and certain behaviors promote the persecution of people living with HIV. HIV-specific criminal laws are reinforcing or increasing the stigma and discrimination that inhibit access to health services and undermine treatment. Evidence also demonstrated that legal protections for people living with HIV and key affected populations are insufficient or unenforced. Conclusion: The current goals of accessing HIV prevention, treatment and care services are being undermined where the legal environment is unable to enforce laws protective of individuals at high risk of or living with HIV. Measures to be taken include: supporting antistigma and HIV education campaigns, specifically within the judicial system and amongst law enforcement; opposing and repealing HIV criminal laws; and promoting access to legal aid. Quantitative prevention research on HIV criminal laws and rates of HIV testing would be useful in statistically proving what was discussed in this study.

THAD0205
Making multi-collaborative partnerships work and worth it: experience in working with Philippine National Police and Quezon City Police Department to address the use of condoms as evidence of prostitution among sex workers J. Acaba Action for Health Initiatives (ACHIEVE), Inc., Quezon City, Philippines Presenting author email: jpacaba@gmail.com Background: In 2010, Action for Health Initiatives (ACHIEVE), Inc. conducted a research wherein evidence was found that the broad language of national anti-prostitution and anti-trafficking laws hinder effective HIV prevention initiatives among sex workers in the city. Considered as ''victims'', sex workers are ''rescued'' while establishments are raided by police authorities using condoms as evidence of prostitution or trafficking. These hamper condom distribution and outreach activities of HIV prevention workers.
Methods: To address this issue, ACHIEVE, in partnership with the Quezon City Health Department (QCHD), held a series of consultative workshops, individual meetings and interfacing meetings with the Philippine National Police (PNP) officers, Quezon City Police Department (QCPD) officials and the local entertainment establishment organization in January 2011. The consultations sought to build partnership by forming memorandum of agreement (MOA) between QCPD and QCHD to end the conflicting law enforcement practice of using condom as evidence of prostitution. Results: Bureaucracy, strict hierarchy within the Police Department and the very fast turnover of officials were identified as constraints in partnership-building with the police. However, the support given by the Quezon City Health Department and the sex work establishment owners association and the community help in convincing police officers and sensitizing them during the process despite their strong moral positions against sex work. After seven months, a MOA was drafted subject for adoption by PNP Chief of Police. Conclusion: While the MOA was refused to be signed by the PNP Chief of Police, the process opened many doors for partnerships and for alternative next steps. These include increased support from the Quezon City STI/AIDS Council and garnered support from police officials of various QCPD and PNP offices who were not previously partnered with. The Quezon City Committee on Health also committed to provide support in implementing rights-based and issue-based HIV education among frontline police officers.

MOPDD0202
Condoms as evidence: police, sex workers and condom confiscation in Zimbabwe S. Maseko and S. Ndlovu Sexual Rights Centre, Bulawayo, Zimbabwe Presenting author email: director_cad@yahoo.com Background: The moralisation and criminalisation of sex work in Zimbabwe creates serious barriers to sex workers realising their rights. This research sought to examine the specific role played by the police in violating the rights of sex workers. The lack of rule of law means police have extensive powers and often act with impunity. This research sought to highlight the impact of the behaviour of law enforcement on the health and human rights of sex workers, particularly around the issue of condoms used as evidence of sex work. Methods: Twenty-one sex workers and six outreach workers were interviewed in Bulawayo, Zimbabwe. The research considered the relationship between police and sex workers, specifically the confiscation of condoms.

Results:
All 21 sex workers interviewed characterised their relationship with the police as bad, as 17 of the 21 sex workers cited harassment and intimidation from the police. 17 of 21 sex workers said they had been arrested on charges related to sex work. Sex workers said that the police practice of confiscating and destroying condoms or harassing and arresting sex workers with condoms had affected their ability to negotiate condom use in a variety of ways. 5 of 21 sex workers said police had confiscated their condoms. Those who had condoms taken from them, reported between 2 and 9 such encounters with police during the previous 12 months. Abstracts  The Ministry of Justice should encourage interaction and dialogue between sex workers and organisations working with sex workers and law enforcement agents. The results also reflect the importance of ensuring that sex workers and organisations working with sex workers participate in the development of Zimbabwe's national HIV/ AIDS Strategy. A government working group should be created to explore the decriminalisation of sex work.

MOPDD0203
The impact of laws criminalizing commercial sex clients and third parties on the health and safety of sex workers based on the street and in drug venues: a Canadian case study Background: A significant body of work has examined the impacts of laws criminalizing commercial sex on sex workers' health and safety. However, the impacts of laws criminalizing clients and third parties (i.e. managers, receptionists, cleaning staff . . .) on sex workers have hardly been documented. In Canada, sex work is criminalized through provisions against being found in a bawdy-house, running a bawdy-house, living on the avails of prostitution and communication for the purposes of prostitution. These are used to arrest sex workers, clients and third parties. Methods: Stella is an organization by and for sex workers. The analysis of the impact of the different legal provisions criminalizing commercial sex on the health and safety of female and transgender sex workers specifically based on the street and in drug venues (i.e. crack houses, shooting galleries...) arises from available documentary data, reports on violent incidents through our aggressors' list and also from our observations and personal experience. Results: The criminalization of clients under the 'communicating' law places sex workers based on the street and in drug venues at greater health and safety risks by limiting their choice of clients and ability to negotiate safer sex, and causing displacement to dangerous and isolated areas far from HIV prevention and outreach services. The provisions against bawdy-houses create a greater risk of homelessness as it is grounds for eviction, including from social housing. Conclusion: Often justified as ''protecting'' sex workers, the laws against clients and third parties actually place sex workers at greater risk, especially as they preclude the opening of safe indoor spaces. Take note that drug use legislations also increase these risks when discriminating sex workers. Background: Food insecurity and HIV are part of a vicious and selfperpetuating cycle. In 2009, the World Health Assembly mandated the World Health Organization to report on global nutrition and HIV activities. However, the literature lacks definitional consensus for food insecurity in the context of HIV. Methods: Using a standard literature review methodology, the aim was to describe and evaluate current definitions of food insecurity and measurement tools in the context of HIV. This study critically reviewed:

D105 -
i. operational definitions of food insecurity and its subtypes; ii. clinical and survey measurement tools to assess food insecurity; iii. program monitoring and evaluation tools to assess performance of food security interventions at the population-level.
Results: Epidemiologically validated tools have been used to measure food insecurity, hunger, and dietary diversity at the individual, household, and community levels. Some of these have been developed and validated in HIV-endemic countries. Examples of tools used with HIV-positive populations include household food insecurity scales and nutritional assessment measures such as dietary intake. Food safety, however, is seldom addressed in the HIV literature. Increasingly, there is a global movement towards integrating food security and HIV indicators across multiple organizations to strengthen program performance. With HAART expansion, profiles of food insecure people living with HIV/AIDS are shifting and measurements must reflect individual, social, and cultural factors such as over/under nutrition, resource constraints, food supplementation, literacy, and addiction. Conclusion: Further research is needed to harmonize definitions of food security and its indicators in order to facilitate comparisons. Measurement tools need to be validated in both low and high resource settings, with different ethnic populations and genders and with HIV-positive populations to build a more comprehensive knowledge base.

MOPDD0302
Severe household food insecurity is highly prevalent and associated with suboptimal breastfeeding practices among HIV-positive women in rural Uganda Background: For HIV-positive persons, optimal adherence ( ]95% of tablets taken as prescribed) to highly active antiretroviral therapy (HAART) is required to prevent development of drug resistance and treatment failure. Forcibly displaced populations such as refugees and internally-displaced persons may face unique challenges with respect to adherence and succeeding on HAART. To this end, we performed a systematic review of the literature on adherence to HAART and treatment outcomes in conflict-affected and forcibly displaced populations, assessed the quality of the evidence, and make suggestions for future research. Methods: MEDLINE, EMBASE, and Global Health databases for 1995Á 2011 were searched using the OVID platform. A backwards citation review of subsequent work that had cited the OVID results was performed using the Web of Science database. ReliefWeb and MSF websites were searched for additional grey literature. Results: We screened 297 records and identified 17 reports covering 15 quantitative and two qualitative studies. Three-quarters (11/15) of the quantitative studies were retrospective studies based on chart review; five included B100 clients. The geographic distribution was limited, and studies in North America and Africa were disproportionately represented. The range of optimal adherence prevalence was 87-99.5% and good treatment outcomes were also reported. The qualitative studies suggested that food security, community-based volunteers, health workers and social networks were important for maintaining adherence. Conclusion: Results to date have been encouraging, though most studies had relatively weak designs. Given the diversity of settings where forcibly displaced persons are diagnosed with HIV and treated with HAART, further studies on adherence and treatment outcomes are needed to support HAART scale-up and justifications for inclusion of these vulnerable groups in national treatment plans. There is also a need for systematic and replicable measurement of adherence in future studies among these groups. Background: HIV has multidimensional effects that pose unique challenges to development in Cambodia. One effect is a large number of orphans and vulnerable children (OVC). Many OVC are less likely to access regular schooling and have low levels of social, financial and psychological support as well as wider community support. KHANA provides a program of community based care and support including social welfare, nutrition and schooling support for these children.
Methods: KHANA collected data among OVC reached by community based care and support to assess changes in nutrition and schooling as well as care and community support between 2009 and 2011. The sample size was 194 in 2009 and 316 in 2011. Both surveys used cluster sampling with a take-all approach, using health center catchment areas as clusters and the same data collection tools. Chi-square test was used to detect changes in schooling, nutrition and community support.
Results: There was a significant increase in OVC regular access to schooling (83.1% vs 96.2%, p-valueB0.001). The level of change was larger for girls (77.8% vs. 95.9%, p value B 0.001) than boys (87.5% vs. 96.6%, p-valueB0.006) reaching similar outcomes. Reports of daily meal reduction due to not enough food decreased from 53.1% to 39.2% (p-value 00.002). Reports of periods of inadequate food supply during the year dropped from 36.1% to 16.5%. There were increases in community support to OVC, with psychological and schooling supports both increasing significantly by 32% and 45% respectively. Conclusion: The findings highlight positive changes in some aspects of social support among OVC. The children reached with community based care and support demonstrated increased psychological support and access to regular schooling. Socio economic status as measured by secure access to food also improved significantly. These improvements are likely due to contributions from KHANA program as well as increased community and family support. Background: The question of the potential role of income support in an ARV treatment programme is of particular relevance in South Africa, where individuals too ill to work qualify for a specific form of income transfer, or, as it is called in South Africa, a social welfare grant, namely the disability grant (DG). ARV patients face the dilemma of trading off a stable source of income against their current and/or future health and adhering sub-optimally to ARV treatment so as to not lose the grant. Methods: This paper employs a pooled longitudinal, panel dataset from two Free State cohort studies of public sector ARV clients to determine how disability grant terminations may impact on virologic and immunologic treatment outcomes. Linear and logistic multivariate random-effects (RE) regression models are employed to assess the impact of grant terminations on CD4 counts, viral load (RNA) and viral suppression. Results: The findings suggest that the termination of access to a disability grant does in fact translate into poorer treatment outcomes, particularly in the first year of ARV treatment. Disability grants impact negatively on viral suppression regardless of treatment duration [OR 0.253, 95% CI 0.087Á0.733]. Disability grant terminations at the outset of ARV treatment initiation impacts negatively on CD4 counts [(103.8, 95% CI (164.6 (43.0], log of viral load [ 4.07, 95% CI 2.58Á5.56] and viral suppression [OR 0.019, 95% CI 0.002Á 0.181] at 3Á12 months on ARV treatment. Conclusion: Social welfare officers and health care teams, in particular physicians considering applications for the renewal of a disability grant, should take particular care when deciding to refuse applications for the renewal of a short-term grant in the early phases of the ARV treatment career. In the longer term, healthy ARV clients should be referred to welfare-to-work programmes to eliminate dependency on social welfare grants.