HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- HIV-1 Prevention for HIV-1 Serodiscordant Couples
Curran, K., Baeten, J.M., Coates, T.J., et al. Current HIV/AIDS Reports (March 2012), e-publication ahead of print.
A high percentage of HIV-positive individuals in sub-Saharan Africa are in stable relationships, according to this review focusing on HIV prevention for HIV-serodiscordant couples (where one partner is HIV-positive and the other is HIV-negative). To address the needs of serodiscordant couples, the authors recommend a diverse set of interventions—such as HIV testing and counseling, couples counseling, condom promotion, antiretroviral therapy (ART) for the HIV-positive partner, male circumcision for the HIV-negative male partner, and pre-exposure prophylaxis (PrEP) for the HIV-negative partner—depending on the couple’s needs and fertility intentions. According to the authors, couples HIV testing and counseling is a core intervention that should be scaled up in high-prevalence settings. They call for increased counselor and clinician training for community HIV testing and counseling focusing on risk assessment, facilitated disclosure, and risk reduction strategies to improve the quality of counseling services. They also stress that couples counseling must include referrals and linkages to ART and prevention of mother-to-child transmission programs for the HIV-positive partner, and referrals to effective prevention programs for the HIV-negative partner. The authors also recommend that public health impact modeling, cost-effectiveness analysis, data from implementation science, and the forthcoming World Health Organization recommendations inform policies and programs on ART for HIV-positive partners and pre-exposure prophylaxis (PrEP) for HIV-negative partners.
- Pattern and Levels of Spending Allocated to HIV Prevention Programs in Low- and Middle-Income Countries
Amico, P., Gobet, B., Avila-Figueroa, C., et al. BioMed Central Public Health (March 2012), Vol. 12 No. 221.
This analysis, which examines how 69 low- and middle-income countries spent their limited prevention funding in 2008, finds that in 53 countries, 60 percent of prevention resources were spent in five areas: behavior change communication (16 percent), counseling and testing (14 percent), prevention of mother-to-child transmission (13 percent), blood safety (10 percent), and condoms (7 percent). The authors tracked data from national domestic spending reports and conducted analyses based on National AIDS Spending Assessment methods and classifications. Overall prevention funding amounted to U.S.$1.1 million (21 percent) of HIV resources, compared to 53 percent spent on treatment and care. According to the authors, prevention spending did not reflect the epidemiological context in each country, and only 7 percent of prevention funding was spent on most-at-risk populations and less than 1 percent on male circumcision. They stress that the mapping of resource flows will help local policymakers monitor effectiveness of national programs and transfer funds to where they are most needed. Countries with low-level epidemics spent 45 percent on prevention, while countries with concentrated and generalized epidemics spent 20 and 21 percent, respectively. International donors provided 90 percent of funding for prevention in sub-Saharan Africa, compared to 62 percent in South and Southeast Asia and 15 percent in Latin America and the Caribbean.
- HIV Prevention and Cure Insights Come From Failure and Success
Cohen, J. Science (March 2012), Vol. 335 No. 6074, p. 1291.
According to the author, the 19th Conference on Retroviruses and Opportunistic Infections (CROI) held in March 2012 provided insights into why some trials of pre-exposure prophylaxis (PrEP) have demonstrated effectiveness while others have not. During the conference—attended by over 4,200 individuals from 83 countries—participants discussed an assessment of the FEM-PrEP trial, which closed early due to futility. The trial involved more than 2,000 women in South Africa, Kenya, and Tanzania who took either a combination of tenofovir and emtricitabine or a placebo every day for nearly two years. According to the data presented at the conference, poor adherence, as indicated by drug concentrations in the women’s blood (less than 26 percent had a high enough drug concentration to stop HIV), was a major factor in the results that ended the trial early. According to researchers, these results demonstrate that if taken as prescribed, PrEP use in women will likely reduce the risk of acquiring HIV. To increase adherence rates, researchers are now developing long-lasting formulations that require once-a-week rather than daily dosing. Other sessions at the conference focused on finding a cure for HIV by awakening the “resting cells” that hide HIV in someone with undetectable viral loads or by boosting the immune response against HIV. The use of antiretroviral therapy (ART) as prevention, expanding early diagnosis of HIV, linkages to care, retention, microbicides, and male circumcision were also discussed as important prevention strategies.
- HIV and STI Prevalence Among Female Sex Workers in Côte d’Ivoire: Why Targeted Prevention Programs Should Be Continued and Strengthened
Vuylsteke, B., Semdé, G., Sika, L., et al. PLoS One (March 2012), Vol. 7 No. 3, p. e32627.
This study assessing condom use and prevalence of sexually transmitted infections (STIs) and HIV among 1,110 female sex workers (FSWs) in Côte d’Ivoire finds high rates of STIs and HIV among this population. The authors argue that targeted HIV prevention efforts focusing on high-risk populations, such as sex workers, are still necessary and must be brought to scale to reduce HIV prevalence. Overall HIV prevalence among the FSWs in the study was 26.6 percent. According to the authors, women who attended FSW-dedicated HIV and STI clinics for the first time were less likely to have used a condom during the previous working day than were repeat clinic visitors (66.9 percent vs. 77.5 percent). Only 26.4 percent of FSWs—both first-time and routine clinic visitors—reported always using a condom with their regular non-paying partners, such as boyfriends and husbands. The authors note that the low level of condom use with regular partners and the high STI and HIV prevalence levels among FSWs suggest that the regular partners may be serving as a bridge of HIV transmission to the general population. The authors support increased HIV prevention programming targeting FSWs.
- Condom Use Errors and Problems: A Global View
Sanders, S.A., Yarber, W.L., Kaufman, E.L, et al. Sexual Health (February 2012), Vol. 9 No. 1, pp. 81-95.
Condom use errors are widespread globally and continue to lessen the efficacy of condoms. These results are from a systematic literature review of 50 articles on condom use representing 14 countries and a diverse set of populations (e.g., sex workers, clients at clinics for sexually transmitted infections [STIs], monogamous married couples, etc.) from 1995 to 2011. According to the authors, common errors involve incomplete use (e.g., putting on a condom after intercourse has begun or early removal of a condom followed by unprotected intercourse), not leaving space at the tip, not squeezing air from the tip prior to use, putting the condom on inside out and having to remove and replace it, not using water-based lubricants, and incorrect withdrawal. Some common problems include breakage, slippage, leakage, erection problems during condom application, erection problems during condom use, and problems with the fit or feel of a condom. The authors found that the majority of articles discussed breakage and slippage, yet argue that other problems, such as early removal of condoms and incomplete use, may be just as serious, particularly when they expose a partner to STIs. Some under-researched areas include duration of condom use during intercourse and condom-associated erection difficulties. The authors offer some guidelines on correct condom use before, at the time of, and after intercourse, and offer a Condom Use Experience model to guide future research.
- Acceptability of Early Infant Male Circumcision as an HIV Prevention Intervention in Zimbabwe: A Qualitative Perspective
Mavhu, W., Hatzold, K., Laver, S.M., et al. PLoS One (February 2012), Vol. 7 No. 2, p. e32475.
According to the authors, early infant male circumcision (EIMC) is a safer and more cost-effective method than adult circumcision. They find that barriers related to perceptions of safety and low levels of knowledge about male circumcision— rather than individual beliefs— are more likely to impede the uptake of EIMC. In a 2009 survey, 60 percent of Zimbabwean women and 58 percent of men reported a willingness to have their sons circumcised. This qualitative study found similar acceptability rates as well as low levels of knowledge about the actual procedure. The authors encourage the use of community awareness and mobilization campaigns aimed at both women and men to spread information about male circumcision beyond the clinic setting. They underscore the importance of understanding cultural and religious beliefs attached to male circumcision among certain groups and involving religious and traditional leaders in EIMC campaigns. They also stress that, although fathers often learn about EIMC from the mother (who themselves learn about the procedure at health centers), it’s important to provide information directly to fathers in workplaces and beer halls. Safety issues, such as the belief that a newborn’s penis is “too fragile” to undergo circumcision, must also be addressed. They encourage the use of quality assurance methods to ensure an acceptable cosmetic result and to prevent adverse effects. They also encourage increased education for nurses and midwives to improve their ability to safely perform EIMC.
- Children Who Acquire HIV Infection Perinatally Are at Higher Risk of Early Death Than Those Acquiring Infection Through Breastmilk: A Meta-Analysis
Becquet, R., Marston, M., Dabis, F., et al. PLoS One (February 2012), Vol. 7 No. 2, p. e28510.
According to the authors of this study, children who acquire HIV postnatally are more likely to survive (36 percent mortality rate at 18 months) than those who acquire HIV during the time of delivery (60 percent mortality rate). These results are from a pooled analysis of all available clinical trial data in sub-Saharan Africa on mother-to-child HIV transmission prevention during the past 15 years. The authors suggest that these findings can be attributed to the immunological immaturity of the fetus and newborn and consequent difficulty in controlling the virus, versus the more mature immune system of infants who acquire HIV postnatally from infected breast milk. The authors also find that maternal health affects infant survival: the rate of infant mortality at two years was one-third higher among women with a CD4 count lower than 350 cells/ml than mothers with a higher CD4 count. Children of mothers who died during the first two years postpartum were also two times more likely to succumb to infant mortality. Based on these results, the authors stress the urgency of providing comprehensive care, including antiretroviral treatment, to all women with an antepartum CD4 count lower than 350 cells/ml, to improve not only the survival of mothers but also of their infected and uninfected children. They also recommend programming for prevention of mother-to-child HIV transmission due to breastfeeding as well as early assessment of HIV infection in HIV-exposed children.
- Safety of Task-Shifting for Male Medical Circumcision: A Systematic Review and Meta-Analysis
Ford, N., Chu, K., & Mills, E.J. AIDS (March 2012), Vol. 26 No. 5, pp. 559-66.
This systematic review assessed the safety of medical male circumcision (MC) by non-physician providers (nurses, midwives, surgical aides, and clinical officers). The authors found task-shifting of MC to trained non-physician providers in a supportive environment does not increase the frequency of adverse effects and is thus very different from MC performed by untrained or minimally trained lay providers with little or no supervision or supportive equipment. The authors, who reviewed 25,000 procedures carried out by trained non-physicians, found rates of adverse events similar to MC conducted by doctors or specialists, including urologists and surgeons. According to the authors, the quality of training and supervision and the availability of safe equipment are more likely to affect the safety of MC than the cadre of health professional that conducts the procedure. Another safety factor is the number of circumcisions performed; one study found that adverse events averaged 3.8 percent for the first 100 procedures by trained personnel, but fell to 0.7 percent after 400 procedures. They also found that practitioners with more MC experience take less time to perform the procedure. The authors encourage further research into the cost-effectiveness of task-shifting for male circumcision, particularly since some men seeking MC turn to informal providers to avoid charges, often resulting in adverse effects. More research is also needed to understand other factors that may contribute to safety, including length and duration of training, supportive medical materials, experience and skillset of providers, and reporting of adverse events.
- Elimination of Paediatric HIV in KwaZulu-Natal, South Africa: Large-Scale Assessment of Interventions for the Prevention of Mother-to-Child Transmission
Horwood, C., Vermaak, K., Butler, L., et al. Bulletin of World Health Organization (March 2012), Vol. 90 No. 3, pp. 168-75.
Large-scale elimination of pediatric HIV appears feasible in KwaZulu-Natal, South Africa, which has some of the highest HIV prevalence in the world. This study was designed to determine the rates of mother-to-child transmission (MTCT) in KwaZulu-Natal, using all infants receiving their first immunizations as a population proxy. According to the authors, a major decrease in MTCT (66 percent) was achieved within a short time period through better prevention of mother-to-child transmission (PMTCT) programming; 90 percent of mothers reported that they had been tested for HIV during their most recent pregnancy, and 9 percent knew they were infected before their most recent pregnancy. They also cite the rapid transition of the province’s health facilities to providing dual antiretroviral prophylaxis, which offers more protection than nevirapine alone, and to providing HIV-positive mothers with lifelong antiretroviral treatment. According to the authors, lifelong treatment will contribute significantly to reducing HIV infections in children as well as to lowering mortality in mothers and infants (currently, 14 percent of HIV-positive mothers in KwaZulu-Natal are enrolled in a lifelong treatment program). The authors detected challenges in the current MTCT programming, including ongoing high rates of maternal HIV prevalence and HIV diagnosis late in pregnancy. According to the authors, early HIV testing and ART regimens through the period of breastfeeding for at least 90 percent of HIV-positive women will be essential to reach the overall mother-to-child transmission target of 5 percent or less by 2015.
- Evaluating AVAHAN’s Design Implementation and Impact: Lessons Learned for the HIV Prevention Community
Laga, M., & Vuylsteke, B. BMC Public Health (December 2012), Vol. 11 No. 6, pp. 1-4.
This article discusses lessons learned from AVAHAN, the world’s largest HIV prevention program, implemented in India since 2003. According to the authors, the program was timely and strategic in focusing solely on prevention efforts with those at highest risk in the highest prevalence states. The evidence-based programming—including peer-led outreach and behavior change communication, services for sexually transmitted infection (STI) testing and care, condom promotion and distribution, harm reduction for people who inject drugs, and community mobilization empowerment methods—reached its planned coverage targets. According to the authors, AVAHAN demonstrated impact by averting an estimated 100,178 new HIV infections between 2003 and 2008. AVAHAN’s successes, the authors write, were due in large part to specific practices of AVAHAN management, including paying close attention to management details, employing mostly senior managers from the private sector, carefully selecting lead partners and nongovernmental organizations to participate, and implementing a results-based program with an extensive monitoring and evaluation system. Condom uptake and declines in STI and HIV rates in key populations, such as sex workers, have been observed consistently across the program. The authors defend AVAHAN’s decision not to implement the program based solely on the findings of a probability evaluation design conducted before the program was launched. They do acknowledge that more real-life evaluation at the program and clinic sites could have increased the amount of baseline data on such key points as condom use among first-time clinic users.
- Comparative Costs and Cost-Effectiveness of Behavioural Interventions as Part of HIV Prevention Strategies
Hsu, J., Zinsou, C., & Parkhurst, J. Health Policy Plan (March 2012), e-publication ahead of print.
Individual interventions continue to be a valued prevention tool, but according to the authors may not translate into a cost-effective impact on behavior change. This analysis measuring the cost-effectiveness of five behavior change communication interventions in Benin finds that cost-per-person-reached varies according to method of communication, with rates per person ranging from U.S.$2.29 for public outreach events to U.S.$25.07 for billboards. According to the authors, the five interventions had a limited effect on behavior change, with only magazine ads, radio broadcasts, and public outreach events demonstrating a significant correlation with reported condom use. Among these three, magazine ads and radio broadcasts were more cost-effective than public outreach events. The authors point out that the process measure of “person reached” does not necessarily translate into cost-effectiveness in terms of reported behavioral outcomes. Unlike other studies, this analysis did not find a strong correlation between reported systematic condom use and peer education. The authors found that personnel costs make up the majority of the total costs (63.9 percent) and that service contracts with nongovernmental organizations (NGOs) make up 8.2 percent of costs. They encourage program implementers to explore whether contracting out to local NGOs is preferable to having the implementing agency provide services. The authors encourage further studies evaluating cost-effectiveness using a quasi-experimental design measuring specific target groups in combination with other interventions.
- HIV Epidemic Appraisals for Assisting in the Design of Effective Prevention Programmes: Shifting the Paradigm Back to Basics
Mishra, S., Sgaier, S.K., Thompson, L.H., et al. PLoS One (March 2012), Vol. 7 No. 3, pp. 1-10.
Using India as a platform, this study measured the effectiveness of two traditional methods of measuring HIV epidemics: the numerical proxy method and the Modes of Transmission (MOT) model. While the numerical proxy method focuses on current HIV prevalence thresholds, the MOT assesses HIV incidence over one year among high-risk groups. According to the authors, the two approaches often provide differing assessments, and neither focuses on the epidemiologic drivers that enable HIV to persist in a geographical area. According to the authors, the numerical proxy method, which relies primarily on prevalence thresholds, has the tendency to misclassify concentrated and mixed epidemics as “generalized” (e.g., Thailand and the majority of districts in India). This misclassification causes policymakers to unwittingly focus on the general population as opposed to key populations. The MOT model, developed to address the shortcomings of the numerical proxy methodology, also has challenges because the short time period may miss the underlying medium- and long-term transmission dynamics. To address these limitations, the authors propose an alternative appraisal approach that aims to identify drivers of the epidemic through the lens of transmission pathways. The authors encourage program implementers to understand structural factors leading to HIV vulnerability and implement a setting-based approach to HIV prevention.
- The Fiscal Dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda
World Bank (March 2012).
African governments and foreign aid donors need to increase their focus on preventing HIV, according to this new World Bank report. The authors write that without an overall reduction in HIV infections, the growth of existing treatment programs for people living with HIV will outpace the ability of governments and donors, particularly in Southern Africa, to finance them. According to the authors, in countries such as Uganda that rely heavily on donor funding (up to 85 percent of programming costs), treatment costs will outpace donor financing rapidly, particularly since treatment of new infections is spread out over decades. They caution that investments to date are based on past infections, and that the actual costs of treating future new infections will dwarf current spending (the costs of HIV and AIDS in Botswana are expected to rise to over 12 percent of government revenues by 2021). The authors point out that South Africa will save up to U.S.$2,500 per infection by scaling up prevention programming, and argue that low-income countries will benefit most by better assessing the financial sustainability of their HIV programming. They recommend that countries improve strategic investments in prevention programming by collecting data on the drivers of the epidemic in each country context.
- Injection Drug Use in Ukraine—The Challenges of Providing HIV Prevention and Care
Nieburg, P., & Carty, L. Center for Strategic International Studies (March 2012).
According to this new report, 60 percent of all people living with HIV and AIDS (PLHIV) in the Ukraine are people who inject drugs (PWID). Although nearly 50 percent of new HIV infections are among PWID, only 8 percent of all Ukrainian HIV-positive individuals receiving antiretroviral treatment (ART) in 2010 were PWID. The authors report that despite efforts to provide access for PWID to uncontaminated needles and syringes and to offer methadone through medication-assisted treatment programs, there are still a number of technical, administrative, financial, and structural obstacles that prevent PWID from accessing comprehensive HIV and drug use treatment and care programs. The authors outline some recommendations on how to improve programming for PWID and their sexual contacts, including:
• Addressing gaps in the Ukrainian national plan for comprehensive programming for PWID
• Making optimal use of Global Fund financing from 2012 to 2016 and addressing a number of administrative and structural obstacles to ensure successful implementation
• Leveraging the U.S.-Ukrainian Partnership Framework to effect long-term policy change.
The authors recommend a close monitoring of some of the country’s overall government health reforms that could inadvertently cause problems in providing comprehensive treatment and care to PWID. They stress that the U.S. Government, through the implementation of the bilateral Partnership Framework agreement, can help implement successful programming for PWID in Ukraine.
- Updated WHO Guidance on TB and HIV and WHO Guidance on Couples HIV Testing & Counselling
World Health Organization (March and April 2012).
In March 2012, the World Health Organization (WHO) released an updated global policy for joint prevention, diagnosis and treatment of tuberculosis (TB) and HIV. This updated guidance, based on the 2004 WHO guidance on TB and HIV, is designed to coordinate public health interventions to manage the 12-fold increase in the number of people living with HIV screened for TB (from 200,000 in 2005 to over 2.3 million in 2010). According to the guidance, comprehensive services for HIV must include the “Three I’s” for an HIV/TB strategy: isoniazid preventive therapy, intensified TB screening, and infection control for TB. The main elements of the new policy include:
• Routine HIV testing for TB patients, people with symptoms of TB, and their partners or family members • Provision of cotrimoxazole, a cost-effective medicine that prevents lung or other infections for all TB patients who are infected with HIV • Antiretroviral therapy (ART) for all TB patients with HIV as early as possible (ideally within the first two weeks of starting anti-TB treatment), regardless of immune system measurements.
In April 2012, WHO also released new guidance on couples HIV testing and counseling. This document recommends that couples HIV testing and counseling be offered in all facilities where counseling and testing is available and that partners disclose their status to each other and access prevention, care, and treatment services. According to the guidance, if only one partner is HIV-positive, ART should be offered to that partner, regardless of his or her immune status (CD4 count). The guidance offers a number of recommendations and a rating of the importance of implementing each recommendation.