HIV Prevention Update - November 2009
In Focus
Multiple Sex Partners and Perceived Risk of HIV Infection in Zambia: Attitudinal Determinants and Gender Differences
AIDS Care (2009). Volume 21, No. 10, pp. 1211-1221
Do, M., & Meekers, D.
Having had multiple sex partners in the past year is the most important predictor of one’s perceived risk, independent of other HIV-related factors, according to a study of 2,610 men and women and 445 community leaders from 36 districts in Zambia. The observed differences in risky behavior and HIV-risk perceptions noted in this 2005 Zambia Health Communication Survey (conducted for the Health Communication Partnership) suggest that distinct intervention approaches are needed for men and women. HIV-prevention programs should approach men through their peers and communities, and focus their messages on risk perceptions. Although couples communication needs to be enhanced for both men and women, community-based interventions that approach men specifically are particularly important. Men were also more likely than women to have multiple sex partners and to be influenced by their peers and community members, but less likely than women to consider themselves at risk of HIV. Women were more likely than men to report some risk of HIV if they were aware of their partner's serostatus and had more interpersonal communication on HIV. Married women were less likely to consider themselves at risk than unmarried women.
For a copy of the abstract, visit: http://www.informaworld.com/smpp/content~content=a915627475~db=all~jumptype=rss
Related HIV Prevention Knowledge Base Topic: Multiple and Concurrent Sexual Partnerships
Male Circumcision and Risk of HIV Infection in Women: A Systematic Review and Meta-Analysis
Lancet Infectious Diseases (2009). Volume 9, pp. 669-677
Weiss, H. A., Hankins, C. A., Dickson, K.
There is compelling evidence that male circumcision reduces the risk of heterosexual men becoming infected with HIV and provides long-term indirect protection to women by reducing their risk of exposure to HIV. There is, however, insufficient data that circumcision directly reduces HIV risk for women. In this review, the authors identified 19 epidemiological analyses from 11 study populations of the association of male circumcision and direct HIV risk in women. A random-effects meta-analysis of data from one randomized control trial and six longitudinal analyses found no firm evidence for such a direct effect. The authors do attribute lower rates of HIV prevalence among women in some sub-Saharan African countries to reduced exposure to HIV in settings where male circumcision is widespread. And yet, a definitive answer to this question is logistically unfeasible, the authors claim, as it would require a randomized controlled trial of circumcision among 10,000 heterosexual men infected with HIV in serodiscordant relationships. The authors conclude that rapid scale-up of circumcision services must be integrated with existing prevention options to maximize benefits to both men and women.
For a copy of the abstract, visit: http://www.ncbi.nlm.nih.gov/pubmed/19850225?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1
Related HIV Prevention Knowledge Base Topic: Male Circumcision
Experience of Sexual Violence among Women in HIV Discordant Unions after Voluntary HIV Counseling and Testing: A Qualitative Critical Incident Study in Uganda
AIDS Care (2009). Volume 21, No. 11, pp. 1363-1370
Emusu, D., Ivankova, N., Jolly, P., Kirby, R., et al.
In Uganda, where 22 percent of adult women experience sexual violence, sexual violence can be heightened by the revelation of a couple’s discordant HIV serostatus irrespective of which partner is HIV positive. The most common form of sexual violence reported by women in HIV discordant unions was use of physical force, followed by verbal threats. This study investigated the experiences of 26 Ugandan women in HIV discordant unions who attended HIV post-test club services. Using a qualitative critical incident technique, four overall themes emerged characterizing their experience of sexual violence: knowledge of HIV test results, prevalence of sexual violence, vulnerability and proprietary views, and reactions to sexual violence. Economic dependence on male partners, as well as being younger and often physically weaker, hindered a women’s ability to resist sexual advances of those partners perceived to be at high risk of transmitting or getting infected with HIV. Alcohol abuse by male partners and suspicion of infidelity also contributed to sexual violence. The women’s reactions included concern over having children, fear of infection, desire to separate from their spouses/partners, helplessness, anger, and suicidal tendencies. These findings reinforce the need for couple counseling and testing activities that include issues pertaining to sexual violence.
For a copy of the abstract, visit: http://www.informaworld.com/smpp/content~content=a916267222~db=all~jumptype=rss
Related HIV Prevention Knowledge Base Topic: HIV Prevention for Serodiscordant Couples
Recent Studies
Behavioral Intervention
The Social Conditions for Successful Peer Education: A Comparison of Two HIV Prevention Programs Run by Sex Workers in India and South Africa
American Journal of Community Psychology (2009). Vol. 44, pp. 123-135
Cornish, F., & Campbell, C.
Scaling up peer education is not a simple process of replication and at times has been inconsistent with little consensus on areas for success. In each new setting, an assessment of the social context should be undertaken to anticipate the factors that might help or hinder peer education. This comparative case study of two peer education programs led by sex workers in India (The Songashi Project) and South Africa (The Summertown Project) aimed to develop an understanding of the social conditions which promote success or failure of community-led HIV prevention interventions. The two programs targeted similar groups (defined from a health intervention point of view), female commercial sex workers living in conditions of poverty and gender inequality and at high risk of poor sexual health, and used a similar intervention approach—peer education as a means of empowering sex workers to insist on condom use. By comparing these two projects, the authors identified certain key factors in the projects’ successes or failures that may inform future peer education efforts: peer education projects must be community and locally driven, and must include a wide range of stakeholders with long-term commitments of time and resources from donors.
For a copy of the full text article, visit: http://www.springerlink.com/content/42715412137476p6/
I Am Not "Umqwyito": A Qualitative Study of Peer Pressure and Sexual Risk Behaviour among Young Adolescents in CapeTown, South Africa
Scandinavian Journal of Public Health (2009). Vol. 37, No. 2, pp.107-112
Selikow, T., Ahmed, N., Flisher, A. J., Mathews, C., Mukoma, W.
Successful HIV prevention interventions need to engage the disconnect between educational messages and social messages, and to exploit the gaps between awareness, decision making, norms, intentions, and actions as spaces for positive interventions. This qualitative research study, based on eight focus groups of young people between the ages of 13 and 14 years in Cape Town, South Africa, revealed a number of unhealthy norms promoted by intense peer pressure which undermined the ABCD messages of HIV prevention initiatives. The authors identified two key factors enabling peer pressure: the centrality of adolescents’ sexual identities and their need to belong to a group, and the fact that despite adolescents’ desire to talk to adults about sexual issues adults are not available for such discussions. Peer education and increased communication with adults about sex were identified as ways to decrease the impact of negative peer pressure. Given that adolescents are influenced by peers from their own group and not necessarily by selected peers, models such as the Diffusion of Opinion Leaders, whereby positive norms are filtered through a peer educator who is a popular member of a given group, may be more effective.
For a copy of the abstract, visit: http://www.ncbi.nlm.nih.gov/pubmed/19493988?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&log$=citationsensor
Biomedical Intervention
Prevention of Breast Milk Transmission of HIV: The Time is Now (Editorial)
Journal of Acquired Immune Deficiency Syndrome (2009). Vol. 52, No. 3, pp. 305-308
Mofenson, L.
Interventions to prevent perinatal and breast milk HIV transmission have been proven effective in resource-limited countries—we now need to implement them—urges Mofenson in a recent editorial. Examining a range of observational studies and randomized clinical trials, Mofenson finds exciting new results that provide potential solutions to the difficult choice many mothers face: breastfeed but risk transmitting HIV to their infant, or not breastfeed and risk having their infant die of other infectious diseases or malnutrition. The recent observational studies confirmed by randomized clinical trials have now identified two interventions that can significantly reduce postnatal HIV infection: antiretroviral drugs provided for treatment (in which case HAART should be provided), or solely for prevention of mother-to-child transmission (in which case shorter, less intensive regimens may be equally as effective). Mofenson acknowledges, however, that implementation of existing interventions which have proven effective has been slow in resource-limited countries due to lack of availability and access to antenatal care and prevention of mother-to-child transmission services, and difficulties integrating perinatal prevention interventions within existing antiretroviral treatment and maternal and child health services, compounded by human resource constraints.
For a copy of the full text article, visit: http://journals.lww.com/jaids/Citation/2009/11010/Prevention_of_Breast_Milk_Transmission_of_HIV__The.1.aspx
Related HIV Prevention Knowledge Base Topic: Infant Feeding for HIV-positive Mothers
Postnatal HIV-1 Transmission after Cessation of Infant Extended Antiretroviral Prophylaxis and Effect of Maternal Highly Active Antiretroviral Therapy
Journal of Infectious Diseases (2009). Vol. 200, pp. 1490-1497
Taha, T. E., Kumwenda, J., Cole, S. R., et al.
Postnatal HIV transmission continues after cessation of infant prophylaxis and HAART-eligible women should start treatment early for their own health and to reduce postnatal HIV transmission to their infants, concludes this follow-up study conducted for the Post-Exposure Prophylaxis of Infants trial in Blantyre, Malawi (PEPI-Malawi). In the randomized clinical trial, the authors demonstrated that antiretroviral prophylaxis extended to age 14 weeks in infants was highly effective for reducing the risk of human immunodeficiency virus type 1 (HIV-1) infection associated with breast-feeding. The protective efficacy of the extended regimens of nevirapine alone or nevirapine plus zidovudine was 67 percent at both 6 and 14 weeks of prophylaxis. In the current analysis, the authors examined PEPI-Malawi data from 2,318 infants from the period after cessation of infant prophylaxis to estimate rates of infant HIV infection and determine the effect that maternal HAART use has on postnatal HIV transmission. The results show that transmission of HIV through breast milk continues after cessation of extended antiretroviral prophylaxis in infants. The increase in HIV transmission was similar whether the infant received control or extended regimens. These findings suggest that no “viral burst” or “catch-up” transmission occurs on discontinuation of antiretroviral prophylaxis, as has been hypothesized.
For a copy of the full text article, visit: http://www.journals.uchicago.edu/doi/abs/10.1086/644598?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov
Vaccination with ALVAC and AIDSVAX to Prevent HIV-1 Infection in Thailand
New England Journal of Medicine (2009). In press
Rerks-Ngarm, S., Pitisuttithum, P., Nitayaphanet, S. et al.
A combination of two genetically engineered HIV vaccines, neither of which had worked before in humans, made headlines in October for producing a moderate effect on reducing the risk of HIV infection. In a community-based, randomized, multicenter, double blind, placebo-controlled efficacy trial, the authors evaluated four priming injections of a recombinant canarypox vector vaccine (ALVAC-HIV [vCP1521]), plus two booster injections of a recombinant glycoprotein 120 subunit vaccine (AIDSVAX B/E). The vaccine and placebo injections were administered to 16,402 healthy men and women between the ages of 18 and 30 years in Rayong and Chon Buri provinces in Thailand. The volunteers were monitored for the coprimary end points, HIV-1 infection and early HIV-1 viraemia, at the end of the 6-month vaccination series and every six months thereafter for three years. In the intention-to-treat analysis involving 16,402 subjects, there was a trend toward the prevention of HIV-1 infection among the vaccine recipients, with a vaccine efficacy of 26.4 percent. In the modified intention-to-treat analysis involving 16,395 subjects (with the exclusion of seven subjects who were found to have had HIV-1 infection at baseline), the vaccine efficacy was 31.2 percent. Although the results show only a modest benefit, they offer insight for future research.
For more information, visit: http://www.hivvaccineenterprise.org/conference/2009/webcasting.html
For a copy of the full text article, visit: http://content.nejm.org/cgi/content/abstract/NEJMoa0908492v4
Structural Intervention
High HIV Prevalence among Men Who Have Sex with Men in Soweto, South Africa: Results from the Soweto Men’s Study
Journal of AIDS Behavior (2009). In press
Lane, T., Raymond, H. F., Dladla, S., et al.
HIV prevention and treatment for men who have sex with men (MSM) is urgently needed. Using respondent driven sampling (RDS) recruitment methods, the Soweto Men’s Study assessed HIV prevalence and associated risk factors among 378 MSM in Soweto, South Africa over 30 weeks in 2008.This first study of MSM in Africa assessing both HIV prevalence and risk factors confirmed that MSM are at high risk for HIV infection, with gay men at highest risk. Overall HIV prevalence was estimated at 13.2 percent, with 33.9 percent among gay-identified men, 6.4 percent among bisexual-identified men, and 10.1 percent among straight-identified MSM. Insertive anal intercourse was reported more commonly than receptive anal intercourse (85.2 percent versus 20.6 percent), while the multivariate analysis revealed that the strongest adjusted odds ratio for associations with decreased risk of HIV infection was for being circumcised. The authors advocate that given the potential for circumcision to decrease HIV transmission at the population level, and that many MSM who are insertive partners also have sex with women, this association should continue to be explored in further observational research with MSM throughout the region.
For a copy of the full text article, visit: http://www.springerlink.com/content/j28347774tm76217/
Correlates of Intention to Use Condoms among Sub-Saharan African Youth: The Applicability of the Theory of Planned Behaviour
Scandinavian Journal of Public Health (2009). Vol. 37, No. 2, pp. 87-91
Schaalma, H., Aaro, L. E., Flisher, A. J., et al.
Social cognition models such as the theory of planned behavior (TPB) are applicable in understanding the correlates of condom use intentions in African contexts. To test this theory, 15,782 secondary school students participated in a randomized controlled trial of school-based HIV/AIDS prevention programs in the regions of Cape Town, Polokwane, and Dar es Salaam. The study revealed that condom use intentions are primarily driven by perceptions of control, perceived social norms, and attitudes. Seven variables accounted for 77 percent of the variance in intentions to use condoms: attitudes, injunctive norms, self-efficacy, gender (lower condom use intentions among females), being a student at the Dar es Salaam site (lower scores than students in Cape Town and Polokwane), socioeconomic status (higher intentions with higher status), and access to condoms (higher intentions with higher access). Based on the results, the authors suggests that the TPB, and perhaps also similar social cognition models, is just as useful in African contexts as in American and European contexts. The authors do caution that although theoretical constructs are applicable across contexts, the content of the constructs may be different. Identification of the relevant and salient beliefs and social actors must be conducted when applying social cognition models.
For a copy of the abstract, visit: http://www.ncbi.nlm.nih.gov/sites/entrez
Reports, Guidelines and Tools
Structural Intervention
The Costs and Benefits of HIV Workplace Programs in Zambia
A 2007 ground-breaking study conducted by the Comprehensive HIV/AIDS Management Program (CHAMP) in Zambia among companies from the mining and agriculture sectors has contributed to discussion of the costs and benefits of HIV workplace programs. The study, focusing on seven companies ranging in size from 350 to 10,000 employees, found that the overall financial benefits of running an HIV workplace program outweighed program costs by three times on average, costing the companies $9,000 to replace a worker lost to HIV-related illness, but just US $1 over a year to sensitize a worker on HIV prevention. The research team estimated that a typical company would have saved US $200,000 over that year by preventing new infections. This paper presents the findings of the study, explores its immediate practical repercussions and its potential, and draws lessons for policy makers and program implementers.
To download a copy of the report, visit: http://www.hlspinstitute.org/projects/?mode=type&id=232487
Related HIV Prevention Knowledge Base Topic: Workplace Activities
Towards Universal Access Scaling up Priority HIV/AIDS Interventions in the Health Sector
September 2009 Progress Report, WHO
More than four million people in low- and middle-income countries were receiving antiretroviral therapy at the close of 2008, representing a 36 percent increase in one year and a tenfold increase over five years, according to a new report by the World Health Organization (WHO), the United Nations Children's Fund, and the Joint United Nations Programme on HIV/AIDS (UNAIDS). "This report shows tremendous progress in the global HIV/AIDS response," said WHO Director-General Margaret Chan. "But we need to do more. At least five million people living with HIV still do not have access to life-prolonging treatment and care. Prevention services fail to reach many in need.” While HIV interventions are expanding in some settings, people at high risk of getting HIV infection, such as sex workers, men who have sex with men, and injecting drug users, continue to face legal and socio-cultural barriers in obtaining healthcare services. According to Michel Sidibe, executive director of UNAIDS, “ensuring equitable access will be one of our primary concerns and UNAIDS will continue to act as a voice for the voiceless, ensuring that marginalized groups and people most vulnerable to HIV infection have access to the services that are so vital to their wellbeing and to that of their families and communities.”
For a copy of the full report, visit http://www.who.int/hiv/pub/2009progressreport/en/index.html
Strategic Considerations for Strengthening the Linkages between Family Planning and HIV/AIDS Policies, Programs, and Services
In response to calls from public health decision makers for guidance on Family Planning (FP)/HIV integration, the World Health Organization, the U.S. Agency for International Development, and Family Health International developed Strategic Considerations for Strengthening the Linkages between Family Planning and HIV/AIDS Policies, Programs, and Services. The partners drew from publications, the recommendations of more than 100 experts in FP and HIV/AIDS, and lessons learned from field experience. The document is designed to help program planners, implementers, and managers, including government officials and other country-level stakeholders, make appropriate decisions about whether to pursue the integration of FP and HIV services. It also explains how to approach integration in a strategic and systematic manner in order to achieve maximum public health benefit. Through a guided approach, the document aims to provide readers with an in-country perspective on whether and to what extent any integration is needed, action steps to creative high-quality integrated services, and instructions on how to monitor and scale-up these services. It also provides links to resources that will support the implementation of those action steps, such as facility assessment tools, training curricula, and job aids.
For a copy of the full report, visit http://www.fhi.org/en/RH/Pubs/booksReports/FP-HIV_Strategic_Considerations.htm
News, Events and Forums
Uganda Laws Troubling to Human Rights and AIDS Activists
A draft bill is currently before the Ugandan parliament seeking to impose stricter criminal sanctions on same-sex practices between consenting adults, including authorizing the death penalty in certain circumstances such as same-sex behavior by “serial offenders” and people living with HIV. According to AIDS activists, this bill will drive men who have sex with men further underground, making it even more difficult for them to access HIV services. Under the draft bill, “promotion of homosexuality,” including publishing information, or providing funds or premises for activities or other resources, is punishable by a seven-year sentence or a fine of US $50,000. Anyone found guilty of the offence of homosexuality would be forced to take an HIV test. According to The International AIDS Society, this runs counter to proven international evidence on HIV prevention and will prohibit frank discussions of sexuality and the provision of condoms to men engaging in same-sex behaviors. Human Rights Watch has also released a report on another proposed Ugandan law on HIV/AIDS soon to be taken up by Uganda’s parliament. This report criticizes repressive provisions in the legislation, such as mandatory testing for HIV, forced disclosure of HIV status, and criminalization of willful transmission of HIV.
For more information, visit: http://www.iasociety.org/Web/WebContent/File/IAS%20Statement%20-%20Uganda%20Anti-Homosexuality%20Legislation_22%20Oct%2009.pdf
http://www.hrw.org/en/news/2009/11/06/uganda-bill-threatens-progress-hivaids
Campaign to End Pediatric HIV/AIDS Launched in Africa
The Campaign to End Pediatric HIV/AIDS (CEPA) was launched in Johannesburg, South Africa in late October. CEPA is a
three-year campaign that will initially focus on six countries: Uganda, Kenya, Tanzania, Mozambique, Zambia, and Nigeria. According to CEPA, the campaign will mobilize the political will and financial resources needed to overcome bottlenecks to scaling up pediatric HIV diagnosis, treatment, and care programs. According to Mrs. Machel, who will chair the campaign’s pan‐African Leadership Council, “We must hold our governments accountable to the promises they made to children; they must put systems in place to implement these promises; they must create good public policies and do all in their power to end pediatric HIV and AIDS on our continent.” The campaign’s ultimate goal is to overcome implementation and policy bottlenecks to increasing coverage rates for prevention of mother‐to‐child transmission and pediatric treatment services from the current average of 30 to 40 percent to the globally agreed upon target of 80 percent. Implementation bottlenecks include inadequate health care worker training and insufficient transportation systems for health care commodities. Policy bottlenecks include lack of long‐term predictable financing and the lack of clear national policies and targets for scaling up access to pediatric HIV/AIDS services.
For more information, visit: www.endpediatricaids.net
