HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Combination Implementation for HIV Prevention: Moving from Clinical Trial Evidence to Population-level Effects
Chang, L.W., Serwadda, D., Quinn, T.C., et al. Lancet Infectious Diseases (January 2013), Vol. 13, pp. 65-76.
The authors of this review identify strategies for combination implementation for HIV prevention to complement the growing number of large-scale combination HIV prevention programs in low- and middle-income countries. They define combination implementation for HIV prevention as practical, local implementation of evidence-based strategies to facilitate and maintain high uptake and high quality in HIV prevention interventions. The authors discuss various strategies, including HIV testing and counseling (e.g., facility-based, mobile, workplace, or home-based testing); linkage and retention in care (e.g., point-of-care CD4 testing, integration with tuberculosis or primary care services, innovative client tracking programs); treatment support (e.g., peer support programs and mobile technologies); individual- and community-level behavior change initiatives, particularly promotion of condom use; cross-cutting strategies including task shifting (not only for service scale-up, but for long-term activities); and structural interventions (e.g., financial incentives for both supply and demand). The authors described how the strategies could supplement HIV prevention programs such as medical male circumcision and treatment as prevention. Although many strategies were identified, there is still insufficient evidence on combining implementation strategies to better understand how to maximize benefits and minimize costs. Along with results of combination HIV prevention experience to date, combination implementation efforts may help facilitate population-level effects that have the potential to reverse the HIV epidemic; however, the authors warn that these strategies require rigorous implementation and assessment.
- Uptake of Home-Based Voluntary HIV Testing in Sub-Saharan Africa: A Systematic Review and Meta-Analysis
Sabapathy, K., Van den Bergh, R., Fidler, S., et al. PLOS Medicine (December 2012), Vol. 9 No. 12, pp. e1001351.
Home-based voluntary HIV testing (HBT) is highly acceptable to clients, according to the authors of a systematic review and meta-analysis of evidence on the uptake and acceptability of HBT published between January 1, 2000 and September 24, 2012. Of 114 articles reviewed, 19 articles (21 HBT studies in five countries: Kenya, Malawi, South Africa, Uganda and Zambia) were included in the meta-analysis. HBT acceptance ranged from 58.1 percent to 99.1 percent (n=432,835) with a pooled average of 83 percent of people accepting testing; and of those, 99 percent received test results. Forty to seventy-nine percent of persons who were diagnosed with HIV following HBT had not been previously diagnosed. In the meta-analysis, the proportion of men and women who accepted testing was nearly equal (78.5 and 81.5 percent accepted testing, respectively). Results indicated that HBT has the potential to substantially increase awareness of HIV status among previously undiagnosed men and women in sub-Saharan Africa, reaches wide audiences in various contexts, and may be used in addition to other HIV testing approaches. However, the studies did not address follow-up services such as access to treatment for persons who tested HIV positive. Sustainability and cost-effectiveness studies on HBT should also be facilitated.
- Worldwide Burden of HIV in Transgender Women: A Systematic Review and Meta-Analysis
Baral, S.D., Poteat, T., Strömdahl, S., et al. Lancet Infectious Diseases (December 2012), e-publication ahead of print.
The authors of this systematic review and meta-analysis of literature, conducted from January 1, 2001 to November 30, 2011 to assess the relative HIV burden in transgender women globally, find that transgender women are a highly burdened population for HIV. The meta-analysis documented the burden of HIV in transgender women compared with the burden in other adults of reproductive age. Data were available from 15 countries: the United States, six countries in the Asia-Pacific region, five countries in Latin America, and three countries in Europe; no data were available from Africa and the Pacific Islands. Within the 15 countries, the pooled HIV prevalence for transgender women was 19.1 percent (n=11,066); and 17.7 percent (n=7,197) in low- and middle-income countries and 21.6 percent (n=3,869) in high-income countries. Further, transgender women were 48.8 times more likely to be infected with HIV compared with all adults across the 15 countries. The authors conclude that improved HIV surveillance, prevention, treatment and care interventions are critical for transgender women.
- HIV Testing in Low- and Middle-Income Countries: An Urgent Need for Scaling Up
Laurent, C. Journal of Public Health Policy (December 2012), pp. 1-5, e-publication ahead of print.
The author provides commentary on the status of HIV testing in low- and middle-income countries, which remains critically low among countries where HIV prevalence is high. Only 20 percent of adults and 28 percent of infants born to an HIV-positive mother are tested promptly. HIV testing, combined with adequate counseling, is beneficial to persons who test positive (e.g., facilitating assessment of eligibility for antiretroviral therapy or ART, psychosocial support, and other services), persons who test negative (allowing for risk reduction counseling), and at the population level. HIV testing approaches include facility-based, community-based, couple- or partner-based, and self-testing. Earlier HIV diagnosis is critical for improved health outcomes and aligns with the World Health Organization's (WHO) recommendation for earlier initiation of ART. Expanding HIV testing supports the WHO's objective of universal access to HIV prevention, treatment, and care and support, as well as the United Nations' Millennium Development Goals related to HIV. However, various barriers to HIV testing remain at the individual (e.g., lack of awareness and fear of stigma) and structural levels (e.g., limited laboratory equipment and negative health care workers' attitudes). The author highlights a successful scale-up of early infant HIV testing in facilities in Rwanda. This was a comprehensive program, supported with national leadership, that can serve as a model for other countries.
- State of Condom Use in HIV Prevention Science and Practice
Crosby, R. Current HIV/AIDS Reports (March 2013), Vol. 10 No. 1, pp. 59-64.
The authors explored four areas of research on advances in condom use for HIV prevention. These included improved assessment of condom use (e.g., technology for data collection and use of event-specific and partner-specific assessments), condom efficacy research (e.g., establishment of essential research designs to evaluate effectiveness), innovative condom design to reduce errors in condom use-often related to the size and fit of condoms-and to improve correct and consistent use, and evidence-based interventions that use condoms as a key prevention activity. Moving forward, the authors conclude that condom innovation is critical, but also acknowledge that other biomedical interventions may lead to reduced condom use. Research should emphasize condom use among most-at-risk groups, particularly among men who have sex with men. According to the authors, condom promotion efforts should be scaled up as part of combination prevention, and condom use should be re-marketed as a practice that makes sex healthy and pleasurable.
- Prevention of HIV-1 Infection 2013: Glimmers of Hope
Cohen, M. Journal of the International AIDS Society (November 2012), Vol. 15 No. 4.
In this commentary, the author discusses the efficiency of HIV transmission, followed by current evidence about and potential strategies for HIV prevention. The efficiency of HIV transmission depends upon various factors, including infectiousness and susceptibility. According to the author, in terms of HIV prevention strategies, several coordinated behavioral and biological interventions appear to be associated with a decline in HIV incidence in some contexts. Initiating antiretroviral treatment earlier may be reducing HIV in some populations, according to ecological evidence. Achieving full benefits of "treatment as prevention" and pre-exposure prophylaxis may require universal "test and treat" approaches to identify, link, and retain greater numbers of HIV-positive persons in HIV care. The resource-intensive nature of the test and treat approach highlights the need for research to identify a cure for HIV so that people can eventually reduce or stop treatment-which raises the importance of HIV vaccine development. Current clinical trials provide hope for this possibility.
- The New Role of Antiretrovirals in Combination HIV Prevention: A Mathematical Modelling Analysis
Cremin, I., Alsallaq, R., Dybul, M., et al. AIDS (January 2013), Vol. 27, pp. 447-458
The authors developed and analyzed a mathematical model to examine the optimal application, impact, and cost-effectiveness of three HIV prevention interventions: 1) pre-exposure prophylaxis (PrEP), 2) earlier antiretroviral therapy (ART) initiation for HIV-positive persons, and 3) PrEP and earlier ART combined with medical male circumcision in a high HIV prevalence context (KwaZulu-Natal, South Africa). Potential impact was estimated with PrEP alone, in combination with earlier ART, and both interventions combined with medical male circumcision. The results indicated that using only PrEP in this context would have limited impact, unless the cost could be considerably reduced. Providing earlier ART would be more cost-effective in terms of infections averted and quality-adjusted life years gained. However, PrEP, in addition to earlier ART, would have a greater impact on reducing HIV incidence. A concentrated approach to ensure high adherence rates in a PrEP intervention could be more effective, according to the authors. Earlier ART and PrEP combined with medical male circumcision at high coverage levels could greatly reduce HIV incidence. The authors conclude that an evidence-based combination prevention approach provides the greatest potential for HIV prevention.
- Towards an AIDS-Free Generation with Option B+: Reconceptualizing and Integrating Prevention of Mother to Child Transmission (PMTCT) with Pediatric Antiretroviral Therapy Initiatives
Thyssen, A., Lange, J.H., Thyssen, E., et al. Journal of Acquired Immune Deficiency Syndromes (February 2013), Vol. 62 No. 2, pp. 127-128.
In this editorial, the authors discuss a study of mortality and loss to follow-up (LTFU) outcomes in HIV-positive children on antiretroviral therapy (ART) in Asia and East, South, and West Africa, and prevention of mother-to-child transmission (PMTCT) strategies. Cumulative mortality was nearly 6 percent, and LTFU was approximately 12 percent (although varying by country). Children younger than 12 months were at higher risk compared to those between the ages of 10 and 15. Further, because the majority of infections are transmitted during labor or breast feeding, strengthening PMTCT is a focus under the United States Government's goal to create an "AIDS-free generation." Improving outcomes among HIV-positive children may entail adopting PMTCT Option B+ (originally introduced in Malawi), which would place all HIV-positive pregnant women on ART for life-varying from the World Health Organization's two current options, which both recommend cessation of treatment either immediately postpartum or once the child has stopped breastfeeding. While further research and economic feasibility studies are necessary, the authors suggest that placing HIV-positive mothers on ART at the same treatment site with Option B+ may provide more treatment support for their children and ultimately result in improved health outcomes, including lower mortality and LTFU rates.
- The Promise of Pre-Exposure Prophylaxis with Antiretroviral Drugs to Prevent HIV Transmission: A Review
Hankins, C.A. & Dybul, M.R. Current Opinions in HIV/AIDS (January 2013), Vol. 8 No. 1, pp. 50-58.
In this review, the authors summarize clinical trial findings on oral and topical pre-exposure prophylaxis (PrEP), and how PrEP may be applied with combination HIV prevention strategies. Findings from the trials indicated mixed results regarding effectiveness. Oral PrEP taken daily was found effective in the Pre-Exposure Prophylaxis Initiative (iPrEx), Partners' PrEP, and TDF2 trials, but not in the Fem-PrEP or the Vaginal and Oral Interventions to Control the Epidemic (VOICE) trial tenofovir arm. Tenofovir vaginal gel was found effective for topical protection in the South African Centre for the AIDS Programme of Research in South Africa (CAPRISA) 004 trial when used peri-coitally, but not applied daily (in the VOICE trial). These findings show that adherence is critical to ensure adequate drug levels for protection, and as important as efficacy in determining program success. In the clinical trials, no cases of drug resistance were identified, reported risky sexual behaviors declined, and adverse events among participants were limited. Although overall results varied, PrEP is estimated to be generally cost-effective, particularly when persons at highest HIV risk are targeted. The future of PrEP is expanding with local prophylaxis, systematic prophylaxis, and multiuse technologies such as vaginal rings that can be used both contraception and STI prevention. The authors conclude that antiretroviral-based prevention strategies should include quality counseling to support adherence.
- Oral and Injectable Contraception Use and Risk of HIV Acquisition among Women in the Methods for Improving Reproductive Health in Africa (MIRA) Study
McCoy, S.I., Zheng, W., Montgomery, E., et al. AIDS (January 2013), Vol. 27
This study summarizes the findings of a secondary data analysis conducted on 4,913 sexually active women in South Africa and Zimbabwe to evaluate the effect of oral and injectable hormonal contraception on the risk of acquiring HIV. During the study period, 283 women seroconverted for HIV. In the unweighted site-adjusted Cox model, overall oral contraceptive use was not associated with an increased HIV risk; however, the injectable method was associated with an increased risk. After adjustment for baseline and time-dependent confounders, there was no effect of oral contraceptives on HIV risk. A small increased risk among injectable contraception users resulted; however, this finding is uncertain due to large confidence intervals. The authors report that, overall, oral contraceptives were not associated with increased HIV acquisition. However, they note that, because of the uncertainty of findings regarding injectable contraception, dual protection with condoms should be emphasized for women at risk of HIV in generalized epidemics.
- Developing Effective Health Interventions for Women Who Inject Drugs: Key Areas and Recommendations for Program Development and Policy
Pinkham, S., Stoicescu, C., & Myers, B. Advances in Preventive Medicine (September 2012), Vol. 2012.
The authors use existing evidence to review the experiences of females who inject drugs (FWID) compared with men who inject drugs, and to suggest strategies for HIV prevention interventions. Findings showed that FWID are at an elevated risk for HIV, and face barriers accessing health care. Overlap between sexual and drug social networks was common in FWID. Intimate partner violence was more commonly reported among FWID than among women in the general population. Evidence suggested an overlap between FWID and sex work. Women's motivations for seeking treatment for drug use varied from that of men; pregnancy, or a partner initiating treatment, were common. Females who injected drugs had limited access to prenatal care, and the authors warn that harm reduction programs may not address all their sexual and reproductive health needs. Further, an increasing number of women were being incarcerated for injection drug use and in need of healthcare; in some contexts, the HIV rate was higher among incarcerated women than men. While harm reduction programs have been successful in reducing drug-related risk, there has been less improvement with unsafe sexual behaviors. However, many interventions for FWID have been successful. The authors conclude that comprehensive, multidisciplinary interventions specific to the needs of FWID, accompanied by policies that empower women to seek health care, are necessary.
- Is Early Sexual Debut a Risk Factor for HIV Infection Among Women in Sub-Saharan Africa? A Systematic Review
Stöckl, H., Kalra, N., Jacobi, J., et al. American Journal of Reproductive Immunology (February 2013), Vol. 69 Suppl. 1, pp. 27-40
The authors conducted a systematic review to summarize evidence on the association between early sexual debut and women's risk of HIV in sub-Saharan Africa. The review found mixed results in all published evidence. Twenty-five studies met the inclusion criteria; the majority were cross-sectional studies. Among high-quality studies with large sample sizes, there was a consistent finding of bivariate association between early sex and HIV risk, which remained after controlling for socio-demographic factors and other confounders. Yet there were mixed results regarding the association, controlling for later high risk behavior. Half of the studies suggested that increased HIV risk was related to later engagement in sexual risk behaviors, as opposed to the age of sexual debut. Risk may also be related to biological factors. Because of methodological limitations, the review findings need to be interpreted with caution. The authors state that the findings highlight the need for additional research to improve understanding of the determining factors and implications of women's early sexual debut, associations with HIV risk, and areas for intervention.
- Pregnancy Decisions of Women Living with HIV: The Need for Multidisciplinary Perspectives
Gruskin, S. Reproductive Health Matters (December 2012), Editorial, Vol. 20 No. 39S, pp. 1-4
The author of this editorial presents an overview of articles that offer multidisciplinary perspectives on aspects of pregnancy decisions for HIV-positive women. There are concerns about the direction of policy of the global response to HIV and pregnancy. Recently, limited evidence regarding whether injectable hormonal contraception increases HIV risk has made policy decisions challenging. Postnatal services, in addition to abortion services and policies, are lacking, and reproductive health services are generally inadequate for HIV-serodiscordant couples. Yet, while more programs are available for HIV-positive women, health services need to offer quality support and respond to all reproductive health needs in a stigma and discrimination-free setting, because stigma limits women's access to care and may influence reproductive health decisions. Essential health services are associated not only with prevention of mother-to-child transmission, but also improved maternal health. The collection of articles also included a proposed framework for designing and implementing integrated services that identifies influences on reproductive decision making by serodiscordant couples. A study from the Asia-Pacific region was included that identified issues women encounter when accessing reproductive health services. The author urges researchers and program planners to use the evidence presented to drive multidisciplinary research studies, policies, and program design and implementation for reproductive health.
- Developments in the Field of HIV Estimates: Methods, Parameters and Trends
Stanecki, K., Garnett, G.P., & Ghys, P.D. Sexually Transmitted Infections (December 2012), Vol. 88 No. S2.
Continuously updating and improving data quality and explaining data and analytic methods are essential to improving the estimation and understanding of HIV worldwide. The authors of this editorial introduce a collection of 15 articles that provide an update on improvements in HIV estimation methods and assumptions, exploring various methods and analyses of primary data. While national surveys have been the gold standard for over 10 years, there is doubt as to whether the surveys provide unbiased estimates of prevalence because of those who do not participate in them. Another issue explored is risk and size of key groups, particularly the length of time individuals remain at risk. The authors further highlight the range of articles about HIV estimates, methods, and trends. These include mortality after initiating HIV treatment despite improving treatment coverage, new estimates of mother-to-child transmission risks, trends in HIV prevalence among young people, HIV transmission dynamics in different regions, and use of alternative data sources such as registered deaths to help assess the validity of model estimates. While the authors recognize the challenges of accurately estimating the extent of the HIV pandemic, they also note that collaborative efforts to improve estimation processes have been useful. Although continued improvements and updates are needed, this approach should be a model for tracking other diseases.
- Changes in HIV-Related Behaviours, Knowledge and Testing among Refugees and Surrounding National Populations: A Multicountry Study
Dahab, M., Spiegel, P.B., Njogu, P.M., et al. AIDS Care (January 2013), Epub ahead of print.
To address research gaps about the relationship between sexual risk behaviors among refugees, the United Nations Refugee Agency and the Great Lakes Initiative on HIV/AIDS conducted behavioral surveillance surveys (baseline years were 2004 and2005; follow-up years were 2010 and 2011) to estimate the change in prevalence of key HIV-related indicators among refugee camp inhabitants and members of neighboring communities in Kenya, Tanzania, and Uganda. In total, 11,582 participants were interviewed (6,448 at baseline and 5,134 at follow-up). The results indicated a significant and consistent decrease in multiple and casual partnerships among adults, and the same results were also generally observed across age and gender subgroups. Notably, the prevalence of multiple partners and casual sex in Kenyan and Ugandan refugee camps was slightly lower than in the surrounding community. Rates of HIV testing substantially increased at all sites, and improvements in HIV knowledge were also found in the Tanzanian refugee camp and community and in the Ugandan refugee camp. Although the authors note that the positive behavioral changes may be associated with recent increases in HIV prevention efforts, this data is not reflected in the study. Abstinence and condom use significantly increased in all of the groups studied, and forced sex against females decreased in the Kenyan camp. However, despite these improvements, the overall levels of risky sexual partnerships remained high in casual sex among youth and multiple partners among men.
- HIV Prevention Technical Briefs Prepared for the Southern African Development Community (SADC)
Management Sciences for Health. (December 2012).
The Building Local Capacity for Delivery of HIV Service in Southern Africa (BLC) project, implemented by Management Sciences for Health, provides leadership, management and government technical assistance, and organizational development to address HIV and AIDS in Angola, Botswana, Lesotho, Namibia, South Africa, and Swaziland. BLC applies technical assistance in three areas: care and support for orphans and vulnerable children, HIV prevention, and community-based care. In October 2011, BLC, in collaboration with the Southern African Development Community (SADC), developed five technical briefs on priority HIV prevention. The briefs were intended to provide policymakers and program planners with accessible evidence and promising practices from across the region to enable technical discussion at the SADC HIV Prevention and Research Meeting in Johannesburg, South Africa in October 2012. The five briefs are: "Antiretroviral Treatment as Prevention: Opportunities and Challenges";" Positive Health, Dignity and Prevention: Engaging People Living with HIV in Prevention"; "Prevention of Mother-to-Child Transmission of HIV"; "Strengthening Behavior Change Communication for Prevention"; and "Voluntary Medical Male Circumcision for HIV Prevention." The series is helping to inform adaptation of an existing evidence-based HIV prevention training program, which will be piloted in Swaziland and then scaled up throughout the region.
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