The Brazilian National AIDS Program is widely recognized as the leading example of an integrated HIV/AIDS prevention, care, and treatment program in a developing country. We critically analyze the Brazilian experience, distinguishing those elements that are unique to Brazil from the programmatic and policy decisions that can aid the development of similar programs in other low-and middleincome and developing countries.Among the critical issues that are discussed are human rights and solidarity, the interface of politics and public health, sexuality and culture, the integration of prevention and treatment, the transition from an epidemic rooted among men who have sex with men to one that increasingly affects women, and special prevention and treatment programs for injection drug users. (Am J Public Health.

Structural barriers to antiretroviral treatment (ART) adherence are economic, institutional, political and cultural factors, that collectively influence the extent to which persons living with HIV follow their medication regimens. We identify three sets of structural barriers to ART adherence that are salient in Southern Africa: poverty-related, institutional, and political and cultural. Examples of poverty-related barriers are competing demands in the context of resource-constrained settings, the lack of transport infrastructure, food insecurity, the role of disability grants and poor social support. Examples of institutional factors are logistical barriers, overburdened health care facilities, limited access to mental health services and difficulties in ensuring adequate counseling. Examples of political and cultural barriers are controversies in the provision of treatment for AIDS, migration, traditional beliefs about HIV and AIDS, poor health literacy and gender inequalities. In forging a way forward, we identify ways in which individuals, communities and health care systems may overcome some of these structural barriers. Finally, we make recommendations for further research on structural barriers to ART adherence. In all likelihood, enhancing adherence to ART requires the efforts of a variety of disciplines, including public health, psychology, anthropology, sociology and medicine.

This intervention successfully reduced sexual risk behaviors of homeless men with mental illness. The effect diminished over 18 months but did not disappear. Similar approaches may be effective in other impaired high-risk groups.

We conducted a randomised clinical trial to test the efficacy of an enhanced version of an intervention previously shown to reduce HIV sexual risk behaviours among men with severe mental illness. One-hundred-and-forty-nine subjects aged 18-59 years were randomly assigned to the experimental or control conditions. Sexual risk behaviours were assessed every three months for 12-months. The primary analysis compared experimental and control groups with respect to sexual risk behaviours with casual partners as measured by the Vaginal Episodes Equivalent (VEE) score. Additional analyses included comparison of VEE scores of those men sexually active in the three months prior to baseline and the proportion of condom-protected sexual acts with casual partners. There were no significant differences in sexual risk behaviours with casual partners between experimental and control subjects. Additional analyses demonstrated a trend toward sexual risk reduction at six months post-intervention (p=0.06) but not at 12 months. These results may reflect a lack of efficacy or a true reduction in risk that the trial was underpowered to detect at the 0.05-level. If there was a true reduction in risk, it was not maintained after the initial six months.

Further study is required to determine the optimal balance between efficacy and feasibility of this intervention.

In settings with low

Adherence is integral to improving and maintaining the health and quality of life of people living with HIV. Two-hundred HIV-positive adults recruited from teaching hospitals and nongovernmental organizations (NGOs) in Rio de Janeiro City were assessed on socio-demographic factors, adherence to antiretroviral therapy (ART) and psychosocial factors hypothesized to be associated with ART. Predictors of non-adherence were analyzed using bivariate and multivariate analyses. Self-reported medication adherence was high (82% had adherence > 90%). Nonadherence was associated with personal factors (i.e. sexual orientation, self-efficacy), physical factors (i.e. loss of appetite) and interpersonal factors (i.e. doctor-patient relationship). Adherence in Brazil is as good, if not better, than that seen in the US and western Europe, which is noteworthy since the sample was derived predominantly from public healthcare settings. It is possible that the connection to NGOs in Rio de Janeiro City played a helpful role in achieving high levels of adherence in this sample of people living with HIV and AIDS. Recommendations, based on study findings, include enhancing and sustaining supportive services for NGOs, promoting patient self-efficacy and behavioral skills for adherence, increasing social network support and having healthcare providers directly address patients' medication beliefs, attitudes and experience with side effects.

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