HIV Prevention Update - September 2009
In Focus
UNAIDS HIV Prevention Toolkit Is Now Available Online
http://hivpreventiontoolkit.unaids.org/
According to UNAIDS, HIV prevention efforts must be intensified in scale and scope to have a substantial impact on the course of the epidemic. Developed for national and sub-national managers implementing and intensifying their HIV prevention efforts, this online HIV Prevention Toolkit consists of interactive modules based on the program cycle of the UNAIDS Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access (2007). Interactive and user-friendly, this web-based interface is presented in a clear, logical structure, allowing users to identify and access tools/resources best suited to their capacity and programming needs.
Potent HIV Antibodies Bring Researchers a Step Closer to Finding a Vaccine
Two highly potent broadly neutralizing antibodies (bNAbs) have been identified by a large team of researchers led by Dennis Burton, an immunologist at the Scripps Research Institute in San Diego, California. The effort, funded primarily by the International AIDS Vaccine Initiative (IAVI) innovation fund, finds that the two new antibodies have unusual characteristics that may be of enormous benefit to AIDS vaccine designers. Broadly neutralizing antibodies are valuable as they help us understand vulnerable portions of HIV called epitopes. Focusing on one donor’s blood, researchers sifted through 30,000 antibody-producing B cells to isolate two monoclonal antibodies, PG19 and PG16, that can prevent infection in more than 70 percent of 162 viral strains tested in cell culture. Burton and his team hope that a better understanding of the unusual way that PG19 and PG16 arrest the virus will assist researchers to design vaccines targeted to the vulnerable portions of HIV and lead to the discovery of other bNAbs. A full text of the research study can be accessed online in the September 3, 2009, issue of Science (Adapted from Jon Cohen’s article in Science, Vol. 325, No. 4, September 2009)
Does Sex in the Early Period after Circumcision Increase HIV-Seroconversion Risk? Pooled Analysis of Adult Male Circumcision Clinical Trials
AIDS (2009). Vol. 23, pp. 1557–1564
Mehta, S. D., Gray, R. H., Auvert, B., et al.
Although early sex after circumcision is not associated with HIV risk, men should nevertheless delay intercourse until the wound has completely healed, according to an analysis of three recent African trials in Kisumu, Kenya, Rakai, Uganda, and Orange Farm, South Africa. Two associations were examined: early sex (intercourse within 42 days of circumcision) and HIV acquisition at three and six months; and incomplete wound healing at one month and seroconversion at three and six months. Men reporting early sex did not have a higher HIV infection risk at three or six months (early sex was reported by 3.9 percent of participants in Kisumu, 5.4 percent in Rakai, and 22.5 percent in Orange Farm). In Kisumu, 16 men (1.3 percent) had incomplete wound healing at the 30-day visit, and no association was observed between incomplete wound healing and seroconversion for Rakai participants. In order to limit the possible risk of HIV infection during the early postoperative period, however, the authors call for circumcision programs that ensure counseling with active involvement of female participants wherever possible, and that offer instruction for wound care, personal wound assessment, and sexual abstinence.
For a copy of the abstract, visit: http://journals.lww.com
Related HIV Prevention Knowledge Base Topic: Male Circumcision
Recent Studies
Behavioral Intervention
Patterns of Self-Reported Behaviour Change Associated with Receiving Voluntary Counseling and Testing in a Longitudinal Study from Manicaland, Zimbabwe
AIDS and Behavior (2009). In press
Cremin, I., Nyamukapa, C., Sherr, L., et al.
This recent study suggests that among women, particularly those infected with HIV, behavioral risk reduction does occur following voluntary counseling and testing (VCT). The relationship between receipt of VCT and subsequent reported behavior among this population-based, open cohort in Manicaland, Zimbabwe was analyzed using generalized linear models with random effects. At the third survey, 8.6 percent of participants (1,079/12,533) had previously received VCT. Women who received VCT, both those positive and negative, reported a decreased number of new partners. Among those testing positive, the risk reduction was enhanced with time since testing. Among men, no behavioral risk reduction associated with VCT was observed. Significant increases in consistent condom use following VCT, with regular or non-regular partners, were not observed.
For a copy of the abstract and full text, visit: http://www.springerlink.com/content/w862806874572p83/
HIV in Adolescents in Sub-Saharan Africa
Current Opinion in HIV AIDS (2009). Vol. 4, No. 4, pp. 288–293
Cowan F., Pettifor, A.
Focusing on studies either from or relevant to sub-Saharan Africa, this report highlights the importance of adolescents as a target population for intervention approaches to HIV prevention. While numerous adolescent behavioral HIV prevention interventions have been evaluated, few have assessed their impact on HIV endpoints or been undertaken in Africa. In the three trials from Africa with HIV endpoints, none of the interventions had an impact on HIV, although all affected some knowledge, attitudes, and reported behaviors. In one of these trials, there was a borderline effect on herpes simplex virus-2 incidence. Adolescents have typically been excluded from trials of biological interventions, even though they are likely to benefit from these interventions if found to be effective. A brief review of other issues relevant to HIV prevention research in adolescents is also included in the report.
For a copy of the abstract, visit: http://www.ncbi.nlm.nih.gov
Perceptions of Couple HIV Counseling and Testing in Botswana: A Stakeholder Analysis
Patient Education and Counseling (2009). In press
Kebaabetswe, P., Ndase, P., Mujugira, A., et al.
This 2004 study of serodiscordant couples in Botswana found a preference for couples HIV counseling and testing (CHCT) in HIV prevention, as well as the need for a client-centered approach in couples HIV testing services. Key informant interviews and focus group discussions were conducted as formative research for a phase III clinical trial of herpes (HSV-2) suppression to prevent HIV transmission among HIV discordant couples. Key Informants were identified from the general public, health, religious, corporate, and HIV/AIDS service organizations and programs, and focus group discussion participants randomly selected through a two-stage process from different workplaces and attendees at a public health facility. Although calling for the integration of CHCT into existing HIV testing programs, the study acknowledges the difficulty of this task. Increasing CHCT uptake will require improving access, training providers, and addressing social, cultural, political, and logistical barriers. The study also demonstrates the challenges of HIV status disclosure and discordance among sexual partners who test as individuals.
For a copy of the abstract and to purchase the full text article, visit: http://www.sciencedirect.com/
Related HIV Prevention Knowledge Base Topic: HIV Prevention for Serodiscordant Couples
Biomedical Intervention
Male Circumcision and Male-to-Female HIV-1 Transmission Risk: A Multinational Prospective Study
The 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, South Africa (2009)
Baeten, J., Donnell, D., Inambao, M., et al.
Female partners experience some potential benefit and no increased risk from an HIV-1-infected male partner’s circumcision, suggests a multinational study presented at the 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. In this study of the effect of circumcision on male-to-female HIV-1 transmission risk among 1,097 HIV-1 serodiscordant couples in Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, and Zambia, 34 percent of male partners in serodiscordant couples were circumcised with a median follow-up of 18 months. Sixty-four female partners seroconverted to HIV-1 (incidence 3.8 per 100 person-years), and circumcision of the HIV-1 infected male partner associated with a 47 percent decrease in the risk of HIV-1 acquisition by the female partner. The magnitude of this effect was similar when adjusting for male partner plasma HIV-1 concentrations and unprotected sexual activity, and when restricted to the subset of HIV-1 transmission, events that were confirmed by viral sequencing to have occurred within the partnership. Randomization to acyclovir did not significantly alter the effect of male-to-female HIV-1 transmission risk. For longer-term potential benefits of male circumcision, short-term interventions to protect against transmission risk during wound healing after circumcision of HIV-1 infected men should be considered.
To download the e-Poster, visit: http://www.ias2009.org/pag/PDF/3771.pdf
Related HIV Prevention Knowledge Base Topic: Male Circumcision
Structural Intervention
HIV Vulnerabilities of Sex-Trafficked Indian Women and Girls
International Journal of Gynecology and Obstetrics (2009). In press
Gupta, J., Raj, A., Decker, M. R., et al.
A recent study of sex-trafficked women and girls in Mysore, India, 45.8 percent of whom tested HIV-positive, explores potential reasons for the heightened risk of HIV infection. Based on the narratives of 48 women ranging in age from 14 to 30 and receiving services at a local nongovernmental organization, researchers found that very low levels of autonomy, with control exacted by brothel managers and traffickers, led to increased risk of HIV infection. Lack of control heightened trafficked women’s and girls' vulnerability in the following ways: use of violent rape as a means of coercing initiation into sex work, inability to refuse sex, inability to use condoms or negotiate use, substance use as a coping strategy, and inadequate access to health care. The study finds it imperative that HIV prevention strategies be designed to help sex-trafficked women and girls negotiate this lack of autonomy.
For a copy of the abstract and to purchase a copy of the article, visit: http://www.sciencedirect.com/
Emerging Areas
A Systematic Review of Factors Influencing Fertility Desires and Intentions among People Living with HIV/AIDS: Implications for Policy and Service Delivery
AIDS and Behavior (2009). In press
Nattabi, B., Li, J., Thompson, S. C., et al.
Factors that positively influence reproductive decisions made by people living with HIV/AIDS (PLWHA) are young age, having few or no previous children, and having access to antiretroviral treatment (ART). The desire to have children is driven by a myriad of conflicting factors—personal, interpersonal, health-related, stigma-associated, socioeconomic, cultural, psychological, and gendered—and yet having children is an imperative for both male and female identities in many cultures. These results are part of a systematic review of the current literature published between 1990 and 2008 on factors influencing fertility desires and reproductive intentions among PLWHA. The authors urge policy makers and service providers to tailor programs for those more likely to consider having (more) children despite their HIV status, such as younger women and men under familial and socio-cultural pressure (e.g., early marriage, bride wealth, lineage continuity, preference for male children, reliance on human capacity for agricultural production, etc.); those from particular cultural or ethnic backgrounds; those with few numbers of children or no children at all; those on ART and feeling healthier; and those who have lost children to HIV.
For a copy of the abstract and full text, visit: http://www.springerlink.com/content/x47231802750688t/
Related HIV Prevention Knowledge Base Topic: Approaches to Address Policy and Political Factors
Unseen and Unheard: Predictors of Sexual Risk Behavior and HIV Infection among Men who Have Sex with Men in Chennai, India
AIDS Education and Prevention (2009). Vol. 21 No. 4, pp. 372–383
Thomas, B., Mimiaga, M. J., Menon, S., et al.
Given the prevalence of HIV among men who have sex with men (MSM) in India, efforts are still needed to reach hidden subpopulations of these men, in particular those already infected with HIV and those at high risk for HIV acquisition who are likely to engage in transmission risk behaviors. If ongoing sexual risk taking place among MSM is occurring in the context of psychosocial problems, such as depression and alcohol use, targeting both the HIV risk taking and the concurrent psychosocial problems may yield the highest potential for intervention success. These results are based on a cross-sectional study of 210 MSM in Chennai who completed an interviewer-administered psychosocial assessment, and then underwent HIV testing and counseling. More than one-fifth (46/210) reported unprotected anal intercourse in the previous three months, eight percent tested positive for HIV, and twenty-six percent had previously participated in an HIV prevention intervention. Within this MSM subpopulation (kothi, panthi, or double-decker), significant predictors of any unprotected anal intercourse included being less educated, not having previously participated in an HIV prevention program, having clinically significant depression symptoms, and having feelings of lower self-efficacy. Being less educated and not currently living with parent(s) were significant predictors of testing positive for HIV infection.
For a copy of the abstract and to purchase the article, visit: http://www.atypon-link.com/doi/abs/10.1521/aeap.2009.21.4.372
Knowledge, Use, and Concerns about Contraceptive Methods among Sero-Discordant Couples in Rwanda and Zambia
Journal of Women’s Health (2009). Vol. 18 No. 9
Grabbe, K., Stephenson, R., Vwalika, B., et al.
To provide information for the development of family planning services tailored to the unique needs of serodiscordant couples, this study examines serodiscordant couples in urban Rwanda and Zambia. When family planning knowledge, use, and concerns about contraception in both cohorts are compared, the study reveals that in both places, despite high levels of knowledge of contraception, use of contraceptive methods remains relatively low. There is a clear gender difference in both the reporting of knowledge and use of contraceptive methods, and there is evidence of clandestine contraceptive use by women. The study calls for the inclusion of information on family planning in voluntary counseling and testing services, in addition to tailoring the delivery of family planning information to meet to the needs and concerns of HIV-positive women or those with HIV-positive partners, as an essential step in the delivery of services and prevention efforts to reduce the transmission of HIV. Family planning and HIV prevention programs should integrate counseling on "dual method use," combining condoms for HIV/sexually transmitted infection prevention with a long-acting contraceptive for added protection against unplanned pregnancy.
For a copy of the abstract and to purchase the article, visit: http://www.liebertonline.com/doi/abs/10.1089/jwh.2008.1160
Related HIV Prevention Knowledge Base Topic: HIV Prevention for Serodiscordant Couples
Reports, Guidelines and Tools
Structural Intervention
Ensuring Universal Access to Comprehensive HIV Services for MSM in Asia and the Pacific
If HIV prevention efforts do not improve, men who have sex with men (MSM) will soon account for the largest proportion of people living with HIV in Asia. In China, it is estimated that MSM are up to 45 times more likely to be HIV-positive than the general population, according to a recently released amfAR report. The report also states that such statistics account for only a fraction of MSM at risk for HIV. As in other places in the world, Asia is home to men who have sex with both men and women, but do not identify as gay or do not associate any particular identity with their sexual behavior. Due to stigma, discrimination, and a lack of data on HIV among MSM, only two percent of MSM receive prevention services in 11 South and Southeast Asian nations. To improve the quality and reach of HIV prevention, treatment, care, and support services/programs for MSM and transgendered people in Asia and the Pacific, this report outlines examples of successful programs and offers key recommendations for operations research.
To download a copy of the report, visit: www.amfar.org/world/msm/article.aspx?id=7827
Sex Trafficking and STI/HIV in Southeast Asia: Connections between Sexual Exploitation, Violence and Sexual Risk
Trafficked female sex workers (FSWs) in Southeast Asia, a majority of them under the age of 17, are at substantial risk of sexually transmitted infections including HIV, according to a new independent regional research study by the Harvard School of Public Health and the United Nations Development Programme (UNDP). The study, covering Thailand, Cambodia, and Indonesia, describes trafficked FSWs reporting significantly greater numbers of male clients and greater difficulties demanding condom use, and yet finds them less likely to be knowledgeable about HIV or reached by HIV prevention programs. The study found trafficked FSWs three times as likely to experience physical, sexual, and psychological violence at initiation to sex work compared to non-trafficked FSWs. The trafficking of women and girls for sexual exploitation was also found to be associated with the denial of the most basic elements of human dignity, health, and wellbeing. In light of these results, Jeff O’Malley, Director, HIV/AIDS Practice, UNDP, New York, calls for a rights-based, not law enforcement-based, approach.
To download a copy of the report, visit: http://www2.undprcc.lk/resource_centre/pub_pdfs/P1113.pdf
News, Events and Forums
Biomedical Intervention
Five Major Studies at the South African IAS Conference Evaluate Making Breastfeeding Safe for HIV-Infected Mothers and Their Infants
The Breastfeeding, Antiretrovirals and Nutrition study (BAN), presented by the lead researcher Dr. Charles Chasela of the University of North Carolina Project in Lilongwe, Malawi, found that maternal antiretroviral therapy (ART) or infant prophylaxis during the time of breastfeeding is equally safe and effective in reducing postnatal mother-to-child transmission of HIV. The policy implications were clear according to Dr. Chasela, who remarked, “The BAN results give global and national policy makers the choice of which interventions to implement: either maternal ART or infant NVP, based on the appropriateness of their particular setting.” A retrospective analysis of the Drug Resource Enhancement against AIDS and Malnutrition cohort in Malawi and Mozambique found that giving ART during pregnancy and breastfeeding reduces the risk of a woman transmitting HIV to her infant to just two percent. In the Mma Bana randomized controlled study in Botswana, there was about a half a percent risk of transmission during breastfeeding, while the Post-Exposure Prophylaxis of Infant-Malawi study showed that extended antiretroviral prophylaxis of breastfeeding HIV-exposed infants for 14 weeks reduced postnatal transmission by 67 percent at age 14 weeks and 50 percent at age 9 months, with the caveat that infant prophylaxis must continue during the entire time of breastfeeding. Another randomized controlled trial, the Kesho Bora study, commenced treatment between weeks 28 and 36 of pregnancy and showed approximately a two percent risk of transmission during breastfeeding. (Adapted from Theo Smart Article for HATiP, No. 143, August 13, 2009)
For the full text of the article, visit: http://www.aidsmap.com/en/news/4207ACDE-402E-4BBC-AB34-41152F8B2D00.asp
Related HIV Prevention Knowledge Base Topic: Infant Feeding for HIV-positive Mothers
High-Risk HPV Infection Raises HIV Risk of Young Men at Least Fourfold
Infection with one or more of the cancer-causing subtypes of the human papilloma virus (HPV) multiplies the risk of acquiring HIV among young men by 4.5-fold. Presented by principle investigator Bertran Auvert, at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, these data were part of a randomized controlled study of 1,683 circumcised young men in South Africa who participated in the HPV sub-study testing for the presence of 13 high-risk cancer causing subtypes of HPV, and 24 low-risk wart-forming ones. Observed HPV prevalence was related to the risk of seroconversion during the study, and researchers also related it for the purposes of multivariate analysis to the participants’ age, education level, number of sexual partners, condom use, and whether they had tuberculosis or other sexually transmitted infections including herpes, gonorrhea, and chlamydia. Participants with at least one strain of HPV, respectively 17.5 percent and 14.3 percent of trial participants, were 4.5 times more likely to acquire HIV than participants without high-risk HPV when adjusted for other factors influencing HIV infection. This was associated exclusively with high-risk HPV infection, and the likelihood of acquiring HIV increased dramatically in men with multiple subtypes of HPV. Auvert calculated that each infection with an additional high-risk type of HPV increased the likelihood of HIV acquisition by two-thirds. Auvert also presented another study showing a 3.4-fold higher risk of HIV infection in female sex workers with high-risk HPV infection. (Adapted from NAM article by Gus Cairnes)
For full text of the article, visit: http://www.aidsmap.com/en/news/3F69099F-4825-49F8-863B-A6272D61D9A7.asp
