BackgroundA high burden of HIV in many sub-Saharan African countries has triggered renewed interest in volunteer-based community health programmes as a way to support treatment roll-out and to deliver services to children orphaned due to HIV. This study was undertaken as an evaluation of a USAID project implemented by a consortium of 7 NGOs operating in 52 Zambian districts. We aimed to examine motivations for becoming volunteer caregivers, experiences in service and commitment to continue volunteering in the future.MethodsA mixed-method survey approach was adopted incorporating close- and open-ended questions. District selection (3 of 52) was purposive, based on representation of urban, peri-urban and rural volunteers from a mix of the consortium’s NGO affiliates. Individual volunteer recruitment was achieved via group information sessions and opportunistic sampling was used to reach a quota (~300) per study district. All participants provided written informed consent.ResultsA total of 758 eligible caregivers were surveyed. Through parallel analyses of different data types and cross-over mixed analyses, we found shifting patterns in motivations across question type, question topic and question timing. In relation to motivations for entering service, responses to both open- and close-ended questions highlighted the importance of value-oriented functions and higher order social aspirations such as “helping society” or “humanity”. However, 70% of participants also agreed to at least one close-ended economic motivation statement and nearly a quarter (23%) agreed to all four. Illustrating economic need, as well as economic motivation, over half (53%) the study respondents agreed that they had become a volunteer because they needed help from the project. Volunteers with lower and mid-level standard-of-living scores were significantly more likely to agree with economic motivation statements.ConclusionsReliance by national and international health programmes on volunteer workforces is rooted in the assumption that volunteers are less costly and thus more sustainable than maintaining a professional cadre of community health workers. Understanding individuals’ motivations for entering and remaining in volunteer service is therefore critical for programme planners and policy makers. This study demonstrated that volunteers had complex motivations for entering and continuing service, including “helping” and other pro-social values, but also manifest expectations of and need for material support. These findings contribute to evidence in support of various reforms needed to strengthen the viability and sustainability of volunteer-dependent services including the need to acknowledge and plan for the economic vulnerability of so-called volunteer recruits.

No abstract

Background We aimed to explore HIV RNA (ribonucleic acid) virologic levels greater than 1,000 copies/millilitre (ml), among HIV-positive adolescents aged 15–24 years, establish the spread of CD4 T- cell counts and inspect characteristics of adolescents presenting with new HIV infections, including co-infections with Hepatitis B virus and syphilis. Methods We analysed data from the Zambia Population-based HIV Impact Assessment 2016 survey. Two-stage stratified cluster probability sample design was used to select the target population. Our study truncated the population to focus on the age-group 15–24 whose biomarker tests and household information were complete. Our primary outcome measure was “New HIV-positive Infections among 15-24-year-olds” defined as HIV-positive biomarker samples presenting with HIV RNA ≥ 1,000 copies/ml without detectable ARVs. We tested associations between new HIV infections and clinical characteristics using negative binomial models adjusting for age, sex, education, marital-status, residence among several covariates. Results Overall, 2·3% ([166/7320], 95% CI: 1·9–2·6) adolescents aged 15–24 years were diagnosed with new HIV infections, with greater proportions among females (3·3% [139/4,165], 95% CI: 2·8–3·9) than males (0·86% [27/3,155], 95% CI: 0·6–1·2). Almost half (47·6%) of seroconversions had HIV RNA ≥ 50,000 copies/ml and an average CD4 + T-cell count of 479 cells/mm 3. HBV– positive adolescents (IRR 8·6, 95% CI: 2·9–24·9, P < 0·001, model 2) were at increased risk of new infections unlike those testing positive for syphilis antibodies (IRR 1·22, 95% CI: 0·2–8·3, P < 0·84). Adjusting for confounders revealed that being married or cohabiting, testing positive for HBV, being a rural resident and attaining higher than secondary education emerged as strongest correlates of new infections. Conclusion High baseline levels of viral load and low CD4 + T-cell count in recent HIV infections among adolescents indicate weak immune repertoire at first diagnosis, increasing the risk of contagion. As the epidemic continues to spread within the adolescent population, HIV-infection will become more complex and greater proportions of adolescents will likely be infected by regular partners. This suggests growing need for interventions targeted at stable partnerships and intensified public health campaigns specific for adolescents.

Although the theory and methods of legal epidemiology—the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population—have been well developed in the context of domestic law, the challenges posed by shifting the frame of analysis to the global legal space have not yet been fully explored. While legal epidemiology rests on the foundational principles that law acts as an intervention, that law can be an object of scientific study and that law has impacts that should be evaluated, its application to the global level requires the recognition that international laws, policies and norms can cause effects independently from their legal implementation within countries. The global legal space blurs distinctions between ‘hard’ and ‘soft’ law, often operating through pathways of global agenda setting, legal language, political pressures, social mobilisation and trade pressures to have direct impacts on people, places and products. Despite these complexities, international law has been overwhelmingly studied as operating solely through national policy change, with only one global quasi-experimental evaluation of an international law’s impact on health published to date. To promote greater adoption of global legal epidemiology, we expand on an existing typology of public health law studies with examples of policymaking, mapping, implementation, intervention and mechanism studies. Global legal epidemiology holds great promise as a way to produce rigorous and impactful research on the international laws, policies and norms that shape our collective health, equity and well-being.