HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Traditional Male Circumcision for Reducing the Risk of HIV Infection: Perspectives of Young People in South Africa
Greely, P., Maharaj, P., Letsoalo, T., et al. Culture, Health & Sexuality (February 2013), Vol. 15 No. 2, pp. 148-159.
In this qualitative study of 15 focus group discussions of six to nine participants each, the authors examined young men's and women's perspectives on the role of traditional male circumcision in three provinces in South Africa, where traditional circumcision is widely practiced. They also explored the perceived impact of traditional circumcision as a strategy to reduce HIV risk. Most participants supported traditional male circumcision and viewed circumcised men more positively than uncircumcised men. Traditional male circumcision was viewed as a "rite of passage" into adulthood and a cultural expectation. However, some respondents suggested that traditional circumcision may lead to negative or risky sexual behaviors, e.g., alcohol abuse, engaging in early sexual intercourse, or violence against women. While traditional circumcision was more commonly practiced, participants were divided about its significance. Uncircumcised men and men not circumcised through traditional practice may experience discrimination. Uncircumcised men said that potentially unsafe practices could lead to long-term medical complications and HIV risk. Women discussed the benefits of condoms, especially with multiple partners, for HIV prevention. The authors acknowledged that their findings are not generalizable, but recommended strengthened training and supervision for providers of traditional circumcision. They also recommended that HIV prevention programs that promote male circumcision incorporate gender norms, safe sex practices, and prevention of gender-based violence.
- Modelling the Impact of HIV Prevention and Treatment for Men Who Have Sex with Men on HIV Epidemic Trajectories in Low- and Middle-Income Countries
Wirtz, A.L., Walker, D.G., Bollinger, L., et al. International Journal of STD & AIDS (March 2013), e-publication ahead of print.
The authors estimated the population-level impact of expanding coverage of HIV prevention interventions for men who have sex with men (MSM) and antiretroviral therapy (ART) in four countries from 2012 to 2016. The projections showed that expanding access to ART and increasing coverage of MSM interventions would collectively benefit MSM, and the strategies would be synergistic. Increased access to ART, combined with the targeted interventions, led to a 14, 15, 20, and 25 percent reduction in new infections among MSM in Ukraine, Peru, Thailand, and Kenya, respectively. Each county represented a scenario of MSM transmission within wider epidemics through anal sex or injecting drug use. Modeling scenarios included varying MSM intervention coverage levels, which were first analyzed with 2011 ART coverage, and then with expanded ART coverage. The greatest population-level impacts of the combination of expanded ART and MSM interventions were in Kenya and Thailand. The impact of MSM interventions alone was greatest in Peru and Thailand, where same-sex transmission is a key driver of the epidemic. Targeted MSM interventions can identify "hidden" risk groups occurring in generalized epidemics and link them to HIV services. The authors concluded that it is critical to respond to HIV transmission among MSM across HIV epidemics as part of countries' HIV responses.
- High PMTCT Program Uptake and Coverage of Mothers, Their Partners, and Babies in Northern Uganda: Achievements and Lessons Learned Over 10 Years of Implementation (2002-2011)
Bannink-Mbazzi, F., Lowicki-Zucca, M., Ojom, L., et al. Journal of Acquired Immune Deficiency Syndromes (April 2013), Vol. 62 No. 5, pp. e138-e145.
The authors presented data from prevention of mother-to-child transmission (PMTCT) programs supported through the Association of Volunteers in International Service Foundation and the Ministry of Health in 24 facilities in four rural districts in northern Uganda from 2002 to 2011. Analysis showed that the comprehensive PMTCT program, including community engagement, attained continuous improvements over 10 years. Of the nearly 140,700 women in all attended antenatal care services, 94 percent were tested for HIV, with overall prevalence of 6 percent. Overall, 79 percent of HIV-positive women started antiretroviral therapy or antiretroviral prophylaxis for PMTCT by 2011--above national proportions. Overall, 49 percent (n=68,928) of clients delivered in a health facility; approximately 7 percent were HIV-positive. HIV prevalence among children decreased from 10 percent in 2004 to 5 percent by 2011. Men's uptake of HIV testing considerably increased (from 6 percent in 2002 to 76 percent in 2011). The authors believed that implementation of interventions such as family support groups, couples testing, and male-friendly clinic spaces contributed to men's engagement, and that collaboration with various stakeholders, linkages among services, and training (including on supply chain management) are essential for successful programs. The authors concluded that comprehensive PMTCT is an effective strategy for reducing HIV transmission.
- Estimating HIV Prevalence and HIV-Related Risk Behaviors among Heterosexual Women Who Have Multiple Sex Partners Using Respondent-Driven Sampling in a High-Risk Community in South Africa
Townsend, L., Zembe, Y., Mathews, C., et al. Journal of Acquired Immune Deficiency Syndromes (April 2013), Vol. 62 No. 4, pp.457-464.
The authors utilized respondent-driven sampling (RDS) from March to July 2011 to recruit women who have multiple concurrent partners (MCP) near Cape Town for an HIV biological and behavioral surveillance survey to determine RDS effectiveness, HIV prevalence and characteristics, and risk differences between women who had and had not attended public health clinics. Women who had MCP also had high prevalence of HIV risk behaviors. In total, 845 women (ages 16-44) participated, and nearly 40 percent accepted rapid HIV testing, revealing a high prevalence rate (29 percent). Younger women (ages 20-24) had the highest prevalence (32 percent). Fifty percent reported sexually transmitted infection (STI) symptoms, and the majority (86 percent) reported MCP within the previous three months. Approximately 78 percent of women suspected partner infidelity, but their condom use was the same as women who did not suspect infidelity; overall use with main partners was low. Ten percent of participants had not previously attended health clinics and were younger, had early sexual debut, and reported STI symptoms and drug use. Strategies are needed to increase their engagement in sexual and reproductive health care. RDS recruitment was effective, and the authors concluded that HIV prevention programs should address HIV risk behaviors within this population.
- Social Network-Based Recruitment Successfully Reveals HIV-1 Transmission Networks among High-Risk Individuals in El Salvador
Dennis, A.M., Murillo, W., de Maria Hernandez, F., et al. Journal of Acquired Immune Deficiency Syndromes (May 2013), Vol. 63 No. 1, pp. 135-141.
Through cross-sectional analysis, the authors compared social recruitment chains and HIV phylogenetic clusters-individuals who share HIV strains-among men who have sex with men (MSM) and female sex workers (FSWs) to understand contributing factors of HIV transmission in three cities in El Salvador. Individuals were recruited through respondent-driven sampling (RDS). Many HIV-positive individuals were identified through RDS, and by subsequently applying phylogenetic analysis. The results showed that 14 percent of MSM recruited were HIV-positive and many were recently infected. Of nearly 700 MSM and 760 FSWs who consented to HIV testing, 141 were diagnosed HIV-positive, with 84 percent (n=119) providing a specimen for genotypic sequencing. The majority (67 percent) who tested positive were MSM, and tended to be younger and recently infected, compared to FSWs. Both groups had some prevalence of antiviral drug resistance. Among MSM, 43 percent were members of phylogenetic clusters, demonstrating that RDS successfully identified transmission networks. However, few HIV transmissions linked directly to social recruitment. The results emphasize the need to diagnose and link HIV-positive individuals to care earlier, especially young MSM. The authors concluded that utilizing a combination of social and molecular biomedical data could benefit HIV prevention by reaching high-risk groups early.
- Microbicides for the Prevention of Sexually Transmitted HIV Infection
Abdool Karim, Q., & Baxter, C. Expert Review of Anti-infective Therapy (January 2013), Vol. 11 No. 1, pp. 13-23.
The authors reviewed microbicides that have undergone testing, clinical developments in antiretroviral (ARV) microbicides, and challenges in and the future of microbicide development, focusing on vaginal microbicides. ARV agents dominate clinical microbicide development, with over 70 candidates in preclinical development. Clinically-tested microbicides have used various mechanisms: buffers, surfactants, cell entry blockers, and ARV agents. Tenofovir gel (CAPRISA 004 trial) was the first topical ARV drug to demonstrate moderate HIV and HSV-2 prevention in women. The Follow-on African Consortium for Tenofovir Studies (FACTS) 001 study is re-testing the CAPRISA 004 trial findings to support licensing of tenofovir gel; testing of new ARV agents, formulas, and delivery mechanisms is in progress. Challenges to microbicide development include adherence, research funding, suitability of the animal model used in preclinical tests, absence of established precedents, adherence to high ethical standards, acceptability of microbicide formulations, and concerns about resistance and user discontinuation of effective prevention methods such as condoms in favor of a new technology. Future microbicide research will include combination and multipurpose technologies to reduce HIV risk and prevent conception. Trials of dapivirine through vaginal rings are underway, and potential long-acting, slow-release ARV drugs to address adherence challenges are in development. According to the authors, a woman-initiated method to prevent HIV is needed, and adolescent women should be a priority population for an effective microbicide.
- How Informed are Clients Who Consent? A Mixed-Method Evaluation of Comprehension Among Clients of Male Circumcision Services in Zambia and Swaziland
Friedland, B.A., Apicella, L., Schenk, K.D., et al. AIDS and Behavior (February 2013), e-publication ahead of print.
The study evaluated the informed consent process of voluntary medical male circumcision (VMMC) programs in Swaziland and Zambia, focusing on clients' comprehension of the risks and benefits of male circumcision (MC), post-procedure instructions, and HIV risk reduction strategies. Most participants passed the comprehension test - 89 and 93 percent in Zambia and Swaziland, respectively. Incorrect responses were mostly on the risks of MC. Significantly fewer adolescents (both Swazi and Zambian) passed the test compared with adults. In semi-structured interviews, nearly all participants noted risks associated with MC, but several different definitions of risk arose, .e.g., risks of the surgery versus the reduced risk of HIV following MC. The most common motivations for MC were prevention of HIV and of sexually transmitted infections (STIs). All interviewees understood that MC is not entirely effective in HIV prevention, with most correctly estimating 60 percent protection. There was confusion about the level of STI protection and lack of protection against HIV for female partners. The majority understood the need to continue HIV risk reduction behaviors after MC, but few said that not adhering could increase HIV risk. The authors concluded that while VMMC is an important HIV prevention strategy, a client's full understanding of the risks and benefits of MC is critical, particularly among adolescents.
- Community Viral Load as a Measure for Assessment of HIV Treatment as Prevention
Miller, W.C., Powers, K.A., Smith, M.K., et al. The Lancet Infectious Diseases (March 2013).
The authors presented the limitations of using community viral load as a measure for assessing HIV epidemics, saying that the strategy has two potential uses: as a routine measure of a community's uptake of antiretroviral therapy, and as an indicator of HIV transmission within a community. The authors recommended caution in interpreting aggregate measures of viral load. The measurement is centered on individuals linked to and retained in HIV care, which creates a biased estimate by excluding undiagnosed individuals or those who are HIV-positive, yet not in care. Most communities do not have sufficient numbers of individuals retained in care to provide accurate estimates. Further, viral load varies over time; thus, the timing of measurement could affect accuracy. Accounting for a population's HIV-infected and uninfected people is important for understanding HIV transmission; current measures do not address HIV prevalence effects. Moreover, viral load distributions are often multimodal, which complicates aggregate measures. Community viral load is an inadequate measure of the potential for ongoing HIV transmission, because it represents a combination of sexual behaviors, networks, and viral loads among HIV-positive individuals, and does not identify individual transmission routes. According to the authors, a combination of measures monitoring the different aspects of the care cascade--including HIV testing, diagnosis, engagement in care, retention in care, and viral suppression--will be critical to an accurate understanding of an HIV epidemic.
- Effectiveness of a Community-based Positive Prevention Intervention for People Living with HIV who are not Receiving Antiretroviral Treatment: A Prospective Cohort Study
Sarna, A., Luchters, S., Musenge, E., et al. Global Health: Science and Practice (March 2013), Vol. 1 No. 1, pp. 52-67.
In a controlled cohort study, the authors found that an HIV risk reduction intervention implemented by community health workers (CHW) for Kenyan people living with HIV (PLHIV) who knew their status, yet were not on HIV treatment, decreased reported risky sexual behaviors and increased antiretroviral therapy (ART) uptake. Of 325 participants in the intervention arm, 97 percent completed six months of follow-up, as did 94 percent of the 309 participants in the control arm. Among intervention participants, reported concurrent relationships in the past three months decreased from 42 percent at baseline to 18 percent at follow-up, and ART uptake increased significantly (from 0.3 percent to 35 percent) relative to the control group (0.3 percent to 12 percent). Intervention participants reported significantly less unprotected sex in the past month compared with the controls. Knowledge of HIV transmission and self-efficacy of condom use were higher among the intervention participants; however, they reported reduced concern about HIV transmission due to ART availability. More control participants had low internalized stigma scores at follow-up. The findings indicate that CHWs can deliver HIV interventions effectively in communities. The authors concluded that this intervention is suitable for scale-up and replication in similar resource-limited contexts to reach PLHIV who are not accessing HIV services.
- Intimate Partner Violence during Pregnancy in Zimbabwe: A Cross-Sectional Study of Prevalence, Predictors and Associations with HIV
Shamu, S., Abrahams, N., Zarowsky, C., et al. Tropical Medicine & International Health (February 2013), e-publication ahead of print.
This cross-sectional study of 2,042 post-natal women in six low-income clinics in Harare, Zimbabwe determined the prevalence of and factors associated with intimate partner violence (IPV) during pregnancy. Forty-six percent of participants reported physical and/or sexual violence; 63 percent reported physical, sexual, and/or emotional violence. Approximately 30 percent reported three or more severe sexual violence events, and 10 percent reported six or more events during pregnancy. More IPV was reported if partners were younger and more educated, had multiple wives, did not pay a bride price, and did not live with families. IPV was more frequently reported if a woman or partner made an independent decision about pregnancy, a partner prevented contraception use, or if a woman did not desire/refused to become pregnant. Greater violence was reported by women who had more sexual partners, were treated for a sexually transmitted infection (STI) during pregnancy, ever had transactional sex, were HIV-positive, or had a partner with an STI but unknown HIV status. The study did not find associations between IPV and HIV infection. Further research should address the relationships between violence and reproductive health decision-making among couples, and between IPV and HIV status disclosure. It is vital to include men in reproductive health programs and to conduct interventions addressing gender norms and IPV.
- Are Integrated HIV Services Less Stigmatizing Than Stand-alone Models of Care? A Comparative Case Study from Swaziland
Church, K., Wringe, A., Fakudze, P. et al. Journal of Acquired Immune Deficiency Syndromes (January 2013), 16:17981.
A mixed-methods comparative case study that explored HIV stigma experiences across four HIV care models in Swaziland found that the model of care influenced stigma associated with perceived HIV status exposure; however, the relationship was complex. Antiretroviral therapy (ART) was offered in the same room as sexual and reproductive health (SRH) (integrated), in the same building as SRH (partially-integrated), in an outpatient clinic on a hospital campus (partially stand-alone), in an HIV testing- and ART-only site (stand-alone). Integrated care increased confidentiality for some clients. Partially integrated/stand-alone models were associated with the greatest risk of exposure; yet most clients at stand-alone sites preferred ART to remain separate due to mutual support from other people living with HIV. The results indicated an overall perception that HIV status could be exposed at the clinics, yet most clients trusted staff to maintain confidentiality. Forty-four percent of participants had a high perceived risk of exposure. Interviews showed that clients who accepted their own HIV status were more comfortable in HIV clinics. HIV services should include strategies to ensure privacy and reduce stigma related to structural factors, e.g., room labeling or ART client cards. The authors recommended considering the benefits of stand-alone models, particularly in high-prevalence settings, while consideration of integrating HIV care into other health services continues.
- An Analysis of the Implementation of PEPFAR’s Anti-Prostitution Pledge and its Implications for Successful HIV Prevention among Organizations Working with Sex Workers
Ditmore, M.H., & Allman, D. Journal of the International AIDS Society (2013), 16:17354.
The authors discuss the U.S. President's Emergency Plan for AIDS Relief's (PEFPAR) anti-prostitution pledge and illustrate its implications for HIV prevention through a case-study approach that uses cases from over 25 organizations and projects in 14 countries. Guidance on the implementation of the anti-prostitution pledge has been unclear and unpredictable, and many organizations interpret the restrictions subjectively, with varying outcomes. Analysis shows that some organizations have refused to work with sex workers out of fear of losing contracts with the U.S. Agency for International Development; others recognize that this refusal would discriminate against sex workers and deny them HIV prevention and health care. No clear guidance exists for HIV programs with sex workers, although there are guidelines for other high-risk populations. This guidance should be established so that no one, including sex workers, is denied services. The current U.S. Global AIDS Coordinator has said that "turning away anyone who should receive services would not be tolerated." Some programs and access to services for these populations have been eliminated as a result of the funding restrictions, and reporting and information about successful HIV prevention programs for sex workers is lacking, which impedes future development and implementation. The authors suggest re-evaluating funding restrictions and implementing evidence-based HIV programs for these populations.
- Prevalence of HIV among those 15 and Older in Rural South Africa
Gómez-Olivé, F.X., Angotti, N., Houle, B., et al. AIDS Care (January 2013)
To address gaps in understanding the HIV epidemic in South Africa, the authors conducted a cross-sectional biomarker survey of randomly selected rural adults aged 15 and older, and estimated HIV prevalence and associated socio-demographic factors. They compared their results with two previous studies in different contexts. Findings showed high HIV prevalences, similar to the country's highest in KwaZulu-Natal and nearby Swaziland. Prevalence among those aged 35-39 peaked at 45.3 percent among men and 46.1 percent among women. Of 7,193 eligible participants recruited from August 2010 to May 2011, 70 percent were located, with 4,362 participants (87 percent) consenting to both the interview and HIV testing. Overall, HIV prevalence was 19 percent, with prevalence for adults aged 50 or older at nearly 17 percent, suggesting that HIV infection occurs at an older age. Individuals in the high socioeconomic quintile were less likely to be HIV-positive than those in the low quintile. Younger men (ages 15-19, 20-24, and 25-29) were less likely to be HIV-positive than women in the same age groups, while older men (aged 55-59, 60-64, and 65-69) had greater chances of being HIV-positive compared to women. Two follow-up studies are being considered to estimate HIV incidence and entry into HIV care and treatment services. The authors recommended increasing HIV prevention activities for older adults and including them in health care treatment plans.
- Unexpectedly High HIV Prevalence among Female Sex Workers in Bangkok, Thailand in a Respondent-Driven Sampling Survey
Manopaiboon, C., Prybylski, D., Subhachaturas, W., et al. International Journal of STD & AIDS (March 2013), pp. 1-5.
Using respondent-driven sampling (RDS) from August to November 2007, the authors aimed to reach venue- and non-venue-based female sex workers (FSWs) in Bangkok, Thailand for a survey to estimate HIV risk behaviors and prevalence. Non-venue-based FSWs had higher HIV prevalence, and overall FSW HIV prevalence was considerably higher than in previous survey estimates (20 percent in the RDS survey versus 2.5 percent in the 2007 sentinel surveillance survey). The RDS method effectively recruited FSWs, and findings suggest that subpopulations of FSWs may not be reached by routine sampling. A total of 707 FSWs were recruited using the cascade model; 98 percent agreed to HIV testing and 97 percent agreed to testing for other sexually transmitted infections (STIs). Twenty-seven percent (n=190) returned for test results. Overall STI prevalence was low. Most FSWs were non-venue-based and 93 percent reported condom use with their last client. Younger age was associated with lower HIV prevalence. In multivariate analysis, a lower price and a current STI remained independently associated with HIV after adjusting for other factors. The Thai Ministry of Public Health adopted the RDS method to supplement routine surveillance activities in areas with many FSWs. The authors concluded that HIV prevention programs in Thailand should be customized to subpopulations of FSWs.
- The 20th Conference on Retroviruses and Opportunistic Infections
NAM Publications. NAM/aidsmap conference news: CROI 2013.
The NAM/aidsmap website features the 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013), which occurred on March 3-6, 2013 in Atlanta, Georgia. The website includes conference highlights, presentations, and several abstracts that were presented at the conference. The site includes an array of topics, such as "functional" HIV cure in a child, HIV risk among men who have sex with men in the United States, treatments for tuberculosis and hepatitis C, condom use, pre-exposure prophylaxis (in the Vaginal and Oral Interventions to Control the Epidemic, or VOICE, trial); and the cenicriviroc phase IIB study. Editor's choices from other related sources are also included.
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