HIV Prevention Update - August 2009
In Focus
Circumcision in HIV-infected Men and its Effect on HIV Transmission to Female Partners in Rakai, Uganda: A Randomised Controlled Trial
The Lancet (2009). Vol. 374, No. 9685, pp. 229–237
Wawer, M., Makumbi, F., Kigozi, G., et al.
Circumcision of HIV-infected men does not reduce HIV transmission to female partners over a 24-month period, especially if condoms are not used consistently and intercourse is resumed before complete healing of the surgical wound. These important results come from a randomized controlled trial based in Rakai, Uganda the first of its kind to measure circumcision in HIV-infected men and its effect on transmission to female partners. Nine hundred and twenty-two uncircumcised, HIV-infected, asymptomatic men aged 15–49 years with CD4-cell counts 350 cells per μL or more were enrolled and randomly assigned to receive immediate or delayed (24 months) circumcision. HIV-uninfected female partners of the randomized men were concurrently enrolled and followed up at 6, 12, and 24 months to assess HIV acquisition. Eighteen percent of women in the intervention group and twelve percent women in the control group acquired HIV during follow-up. Terminated early due to the futility of the results, longer-term effects of the trial could not be assessed. Nonetheless, the authors stress that the efficacy of male circumcision for prevention of HIV in uninfected men is clear and that male circumcision programs are likely to confer overall benefits to women.
Related HIV Prevention Knowledge Base Topic: Male Circumcision.
Alcohol Use, Intimate Partner Violence, Sexual Coercion and HIV among Women Aged 15–24 in Rakai, Uganda
AIDS Behavior (2009). Vol. 13, No. 2, pp. 225–233
Zablotska, I. B., Gray, R. H., Koenig, M. A., et al.
Disinhibition due to alcohol may spur intimate partner violence (IPV), sexual coercion, and increased risk of HIV infection. No matter who is drinking—the woman and/or her partner—the results are the same, as reported in this study of 3,422 women aged 15–24 in Rakai, Uganda. More than half of the women experiencing sexual coercion reported alcohol use before sex in their relationships. During the previous year, 26 percent experienced physical violence and 13 percent experienced sexual coercion. HIV prevalence was significantly higher with alcohol consumption before sex, particularly when women reported both prior sexual coercion and alcohol use. As in other studies, clustering of behaviors was apparent: 96 percent of women who reported lifetime experience of sexual coercion also experienced physical violence; physical violence and sexual coercion were significantly associated with having more than one sexual partner; and power imbalance in sexual interactions and non-consensual sex increased a woman’s vulnerability to HIV. The authors advocate for increased preventive interventions focusing on factors instigating IPV and interventions focused on changing male behaviors, alcohol use, and IPV.
Related HIV Prevention Knowledge Base Topic: Prevention of alcohol-related risk behavior.
Men Who Have Sex with Men and HIV/AIDS in Sub-Saharan Africa
The Lancet (2009). Vol. 374, No. 9687, pp. 416–422
Smith, A., Tapsoba, P., Peshu, N., et al.
Globally, men who have sex with men (MSM) have high rates of HIV infection. In some African countries, notes a recent study, HIV rates among MSM are ten times higher than among the general male population. MSM in sub-Saharan Africa continue to face harassment and stigma driven by cultural, religious, and political unwillingness to accept them as equal members of society. These and other factors lead to isolation and potentially risky behaviors among an increasingly hard-to-reach population. Moreover, these risks are not limited to men who have sex with men, as many of the infected also have female sexual partners. Rapid and sustained national and international commitment to the development of appropriate regional and country-based interventions is called for, along with actions and financial resources to reduce structural and social barriers and HIV infection for MSM in these communities.
Recent Studies
Behavioral Approaches
Effectiveness of Peer Education Interventions for HIV Prevention in Developing Countries: A Systematic Review and Meta-Analysis
AIDS Education and Prevention (2009). Vol. 21, No. 3, pp. 181–206
Medley, A., Kennedy, C., O’Reilly, K., & Sweat, M.
Peer education programs in developing countries are moderately effective in improving behavioral outcomes but show no significant impact on biological outcomes. This systematic review and meta-analysis of 30 peer education interventions in developing countries, published between January 1990 and November 2006, is one of the few studies measuring the effectiveness of such interventions. Mostly cross-sectional in nature, these studies cover a broad range of countries and target populations. Peer education interventions were found to be significantly associated with increased HIV knowledge, reduced equipment sharing among injecting drug users (IDUs), and increased condom use. However, they have a non-significant effect on sexually transmitted infections. Peer education can also be an effective strategy for changing behavior among hard-to-reach, hidden populations, such as commercial sex workers (CSWs) and IDUs. Program managers are encouraged to provide more detailed descriptions of their programs to help identify good and promising practices and strategies.
Secondary Prevention of HIV Infection: The Current State of Prevention for Positives
Current Opinion in HIV and AIDS (2009). Vol. 4, No. 4, pp. 279–287
Fisher, J. D & Smith, L.
Future prevention for positives (PfP) interventions should include early identification of people living with HIV (PLWH) through broad-based HIV testing initiatives and outreach targeting individuals who practice high-risk behaviors, their social networks, those with diseases with pathways to infection similar to HIV, patients in sexually transmitted infection clinics, young women attending antenatal clinics, and others as well as ‘opt out’ testing incorporated into medical facilities offering routine and emergency care. Psychosocial needs of PLWH (e.g., substance abuse, mental health, and reproductive health needs) should be addressed through referral and vigorous follow-up. Although all of these interventions may not be applicable to resource-limited settings, the authors advocate that most can be adapted, possibly without affecting outcomes. In this state-of-the-science review of the literature on secondary prevention of HIV infection or PfP interventions, the authors conclude that much remains to be done to understand why, when, and under what conditions PLWH engage in risky behavior and how best to integrate specific PfP interventions targeting diverse populations into an array of medical, social, psychological services for PLWH. They also conclude that widespread dissemination of PfP will necessitate organizational-level interventions (e.g., to counteract negative attitudes toward PfP interventions or staff feelings of inefficacy to change behavior of PLWH).
Related HIV Prevention Knowledge Base Topic: HIV Post-exposure prophylaxis (PEP).
Lives to Save: PEPFAR, HIV, and Injecting Drug Use in Africa
The Lancet (2009). Vol. 373, No. 9680, pp. 2006–2007
Csete, J., Gathumbi, A., Wolfe, D., & Cohen, J.
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has failed to reach thousands of injecting drug users (IDUs) in PEPFAR countries in Africa, many of whom have HIV, according to a recent commentary published in The Lancet. Despite spending more than $US18 billion on the continent and providing antiretroviral therapy to more than 2.1 million people with HIV, as many as 3 million sub-Saharan IDUs have not been helped. In most of these countries, including those most affected by HIV, affordable drug-dependency treatment is out of reach, needle exchange does not exist, and legal services are unavailable or unaffordable. Drug users in East Africa face widespread isolation and police repression. HIV prevalence among Kenyan IDUs—estimated to be at least 200,000—is at 68 to 88 percent. PEPFAR is well-placed to save many lives in Africa, the authors argue, by encouraging and funding effective and long-proven strategies for HIV prevention and treatment for drug users, including needle exchange, antiretroviral therapy, treatment for drug dependency, and funding for methadone and opiad programs.
Related HIV Prevention Knowledge Base Topic: Harm reduction for injecting drug users.
Biomedical Approaches
Sexual Transmission of HIV According to Viral Load and Antiretroviral Therapy: Systematic Review and Meta-Analysis.
AIDS (2009). Vol. 23, No. 11, pp. 1397–1404
Attia, S., Egger, M., Müller, M., Zwahlen, M.,& Low, N.
Studies of heterosexual discordant couples observed no transmission in patients treated with antiretroviral therapy (ART) and with viral load below 400 copies/ml, but data were compatible with one transmission per 79 person-years of follow-up (or 7,900 acts of sexual intercourse, if the yearly average is 100 contacts.) Reporting from 11 cohorts of 5,021 heterosexual couples and 461 HIV-transmission events, Attia and colleagues aimed to synthesize the evidence of heterosexual discordant couples on the risk of HIV transmission through unprotected sexual intercourse according to viral load and treatment with combination antiretroviral therapy. The rate of transmission overall from antiretroviral therapy-treated patients was 0.46 (95% CI 0.19-1.09) per 100 person-years, based on five events. The transmission rate from a seropositive partner with viral load below 400 copies/ml on antiretroviral therapy, based on two studies, was zero with an upper 97.5% confidence limit of 1.27 per 100 person-years, and 0.16 (95% CI 0.02-1.13) per 100 person-years if not on antiretroviral therapy, based on five studies and one event. Data were insufficient to calculate rates according to the presence or absence of sexually transmitted infections, condom use, or vaginal or anal intercourse. Further studies are needed to better define the risk of transmission from patients on ART.
Counseling and Choosing between Infant-feeding Options: Overall Limits and Local Interpretations by Health Care Providers and Women Living with HIV in Resource-poor Countries (Burkina Faso, Cambodia and Cameroon)
Social Science Medicine (2009). In press
Desclaux, A., & Alfieri, C.
A woman’s ability to choose feeding options for her baby is related to local practices and the local authorities’ capacity to provide comprehensive counseling. As part of prevention of mother-to-child HIV transmission (PMTCT) strategies, HIV-positive women are asked to choose between two options regarding infant feeding: replacement feeding or exclusive breastfeeding with early weaning. This qualitative study of mothers’ perceptions of infant feeding options in Burkina Faso, Cambodia, and Cameroon found that while health workers focused on economic aspects, the mothers considered social aspects such as those related to the risk of being stigmatized as a ‘‘bad mother’’ or as HIV-positive. The results also showed a range of counseling practices and strategies, including prescriptive counseling proposing only one option to all women, options based on the mother’s economic level (assessed by health care providers), and a choice of options. Limits to the effectiveness of health care providers’ counseling were also noted, such as providing information that was too complex; limited ability to enable women to overcome primarily structural barriers; poor access to replacement food (including breast-milk substitutes); overcoming norms and acceptance of infant feeding in some local cultures; overcoming gender inequality and stigma related to HIV; and difficulties associated with adherence to feeding options. The authors emphasized the need for adaptive counseling techniques.
Related HIV Prevention Knowledge Base Topic: Infant feeding for HIV-positive mothers.
Structural Approaches
The Global Strategy to Eliminate HIV Infection in Infants and Young Children: A Seven-Country Assessment of Costs and Feasibility
AIDS (2009). Vol. 23, No. 8, pp. 987–995
Nakakeeto, O. N., & Umaranayake, L.
In response to a call from the UN General Assembly Special Session on AIDS to reduce mother-to-child transmission of HIV by 2010, cost and human resource needs were projected for 2007 to –2015 and compared with the AIDS budget and available workers in the seven African countries of Burkina Faso, Cameroon, Cote d'Ivoire, Malawi, Rwanda, United Republic of Tanzania, and Zambia. Interventions included family planning, HIV testing and counseling, antiretroviral treatment, and prophylaxis for mothers with advanced HIV and HIV-exposed children. Results showed sufficient funding for three of the countries, but an adequate workforce for only one, Zambia. The report recommends taking human resource capacity into account when considering increased funding for prevention of mother-to-child HIV transmission (PMTCT) efforts.
Sexual Violence and its Health Consequences for Female Children in Swaziland: A Cluster Survey Study
The Lancet (2009). Vol. 373, No. 9679, pp. 1966–72
Reza, A., Breiding, M. J., Gulaid, J., Mercy, J. A., Blanton, C., Mthethwa, A., Bamrah,S., Dahlberg, L. L., & Anderson, M.
One in three girls in Swaziland has experienced sexual violence by age 18, reports UNICEF and the Centers for Disease Control (CDC). Moreover, in the same study examining sexual violence against girls 18 years and younger in sub-Saharan Africa, 90 percent of those reporting sexual violence said that it first occurred between the ages of 13 and 17. Based on the nationally representative study of 1,242 respondent Swazi girls and women aged 13 to 24, sexual violence was found to be associated with lifetime experience of sexually transmitted diseases, pregnancy complications or miscarriages, unwanted pregnancy, and self-report of feeling depressed. Five percent of girls had experienced forced sex before age 18 and nine percent of girls reported coerced intercourse. The most common perpetrators were boyfriends, husbands, and men or boys from the respondent's neighborhood, with the incident most often taking place in the respondent's own home. Considering that 22 percent of Swazi women between ages 15 and 24 are HIV-positive, the authors note that sexual violence could be a common HIV transmission mode, and as such call for local and national interventions surrounding sexual violence to focus on prevention of perpetration by men.
Emerging Areas
Cultural Scripts for Multiple and Concurrent Partnerships in Southern Africa: Why HIV Prevention Needs Anthropology
Sexual Health (2009). Vol. 6, No. 2
Leclerc-Madlala, S.
The success of partner reduction programs as a method to prevent HIV infection in southern Africa depends on a thorough anthropological knowledge of local cultural norms. Based on ethnographic discussions held between October 2007 and November 2008 with members of 228 NGOs representing seven countries in southern Africa, this article argues that sensitivity to the meanings people attach to their sexual behavior is required if sustainable long-term protection of people and communities against HIV is to be achieved. The Southern Africa region cannot afford another two decades of targeting people with a biomedical model and mixed prevention messages, but rather must engage people to collectively explore and address the cultural ideologies that underpin vulnerability to HIV.
Related HIV Prevention Knowledge Base Topic: Multiple and concurrent sexual partnerships.
Reports, Guidelines and Tools
Behavioral Approaches
Eastern and Southern Africa "Knowing their Epidemics," UNAIDS Five African Countries’ HIV Prevention Efforts not Reaching At-risk Groups
If national HIV prevention strategies are to succeed, countries must understand the character and drivers of their epidemic and focus on proven need through sustained and effective interventions. Unfortunately, due to errors and denial surrounding the actual factors driving new infections, significant resources are often invested into a variety of biomedical and behavioral prevention interventions that are not systematically evaluated for their impact or quality. To address this situation in five African countries, National AIDS Authorities, UNAIDS, and the World Bank have produced a series of detailed reports conducted in 2007 and 2008 that aim to characterize the true nature of the respective epidemics and their drivers, the existing HIV prevention response, and the allocation of funding for HIV prevention efforts. For example, the report notes that Lesotho should revise its prevention messages to address multiple concurrent partnerships and integrate the subject into future initiatives. The ultimate aim of the reports is to build capacity within countries to “synthesize” this information, interpret it, and propose future recommendations and policy interventions.
See the full reports at: http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/20090512_UNAIDS_WB_epi.asp
Biomedical Approaches
Missing the Target #7: Failing Women, Failing Children: HIV, Vertical Transmission and Women’s Health
Although the drugs have been available for over a decade, two-thirds of HIV-positive pregnant women in the developing world do not receive any antiretroviral drugs (ARVs) to prevent HIV transmission to infants, and most who do receive drugs are treated with a therapy known to be just over 40 percent effective rather than the triple-dose combination therapy that successfully prevents almost 98 percent of newborn HIV infections in the developed world. Efforts to prevent vertical transmission are failing to reach the very group it was designed for—HIV-positive pregnant women. Global and national programs to prevent vertical (mother-to-child) transmission are in disarray, and governments are falling seriously short of their goals. The report is based on research conducted in six countries—Argentina, Cambodia, Moldova, Morocco, Uganda, and Zimbabwe, between November 2008 and January 2009.
See the full report at: www.aidstreatmentaccess.org and www.itpcglobal.org
Moving Beyond Gender as Usual
Recognizing that accounting for gender-specific vulnerabilities, capabilities, and constraints is crucial to the success of global HIV/AIDS programs, this report analyzes and compares gender-related policies, strategies, and interventions used in Mozambique, Uganda, and Zambia. The report focuses on implementation efforts related to HIV/AIDS and gender inequality in these three countries by three major donors: the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank’s Africa Multi-Country AIDS Program. Emphasizing that most donors have not yet been able to incorporate gender into systematic programming that addresses the needs of women and girls, the report urges donors to develop a systematic response to gender inequality in HIV/AIDS programs. A number of donor-specific recommendations are made, such as increased gender expertise within institutions, development of clear and measurable gender-related indicators and targets, explicit and detailed guidance on gender analysis, and encouragement of stronger national policies on gender and HIV/AIDS.
See the full report at: www.cgdev.org
News, Events and Forums
Biomedical Approaches
Pre-Exposure Prophylaxis PrEP: Intermittent Dosing Trial to Begin
Pending regulatory approval, within the next few months the International AIDS Vaccine Initiative (IAVI) is planning the launch of two small Phase I/II studies in Kenya and Uganda on the safety of and adherence to intermittent versus once-daily oral PrEP dosing. All of the current oral Pre-Exposure Prophylaxis (PrEP) efficacy trials are looking at whether daily use of ARVs by HIV-negative people may reduce their risk of HIV infection. To assess the safety of dosing strategies, this IAVI trial will address “intermittent dosing” (taking PrEP some days, but not others, or taking it only when a person feels he or she is at higher risk) for PrEP stakeholders, acknowledging that in the real world people might not take PrEP drugs every day. [A glossary of intermittent PrEP strategies can be downloaded at www.prepwatch.org.] In December 2008, the AIDS Vaccine Advocacy coalition (AVAC) held a think tank to help explore these issues. (Adapted from HIV PxWire)
Meeting summary is available at: www.prepwatch.org
Gates Grant to Study Nipple Shield for Inactivating HIV and Preventing Transmission
Family Health International (FHI) received a US$100,000 Grand Challenges Explorations grant from the Bill & Melinda Gates Foundation to study an approach to inactivate HIV with minimal interference during breastfeeding. The research project, “Just Milk,” is being led by FHI's David Sokal, MD, and will focus on modifying an existing nipple shield. A porous felt-like material will be inserted in the shield’s tip, and the material saturated with a commonly used compound that can inactivate HIV without harming the child. According to FHI, this is the beginning development of a low-cost, accessible, and easy-to-use device that could potentially prevent thousands of cases of mother-to-child transmission.
To learn more about the Just Milk project, visit http://www.fhi.org/en/AboutFHI/Media/Releases/res_BMFG_Grant_Press_Release_May2009.htm
