HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Financing the Response to HIV in Low-Income and Middle-Income Countries
Izazola-Licea, J. A., Wiegelmann, J., Aran, C., et al. Journal of Acquired Immune Deficiency Syndromes (2009). Vol. 52, No. 2, pp. 119-126.
A report by the Financing and Economics Division of the Joint United Nations Program on AIDS demonstrates a mismatch between types of HIV epidemics and resource allocation in 50 low- and middle-income countries. The report examined national HIV spending and programmatic allocations by type of epidemic and country income, finding that current expenditures for most-at-risk populations represented less than 1 percent in countries with generalized epidemics, and only 7 percent in those with low-level or concentrated epidemics. Of the US $2.6 billion, or 5.8 billion in international dollars (I$) spent on HIV in 2006 in the countries studied, 87 percent of the funding for the 17 low-income countries came from international donors. Per capita spending was I$1.5 in nine countries with low-level HIV epidemics, I$1.6 in 27 countries with concentrated HIV epidemics, and I$9.5 in 14 countries with generalized HIV epidemics. On average, spending on care and treatment represented half of AIDS expenditures, while spending on prevention represented 21 percent. The treatment-to-prevention spending ratio was 1.5:1, 3:1, and 2:1 in countries with low-level, concentrated, and generalized epidemics, respectively. The authors conclude that countries, especially those with high aid dependency, need to make evidence-based decisions about resource allocation.
- Case Study: CEPEHRG and Maritime, Ghana: Engaging New Partners and New Technologies to Prevent HIV among Men Who Have Sex with Men
Robertson, J. AIDSTAR-One Case Study (2009)
Men who have sex with men (MSM) have been neglected in HIV programming in sub-Saharan Africa, frequently ignored in national strategies, and overlooked due to intolerance, stigmatization, and punitive laws. In Ghana, community-based organizations (CBOs) have been at the forefront of HIV interventions for MSM. Among the small number of CBOs working with this highly vulnerable population are the Accra-based Center for Popular Education and Human Rights, Ghana (CEPEHRG), and the Maritime Life Precious Foundation (Maritime) in Takoradi. With the support of the President’s Emergency Plan for AIDS Relief, these two organizations have been part of much-needed efforts to reach MSM with prevention messages, condoms, and lubricant, and to use cellphone-based communications to increase uptake of HIV-related services.
- Expert Panel Provides Recommendations for Scaling up Programs to Prevent Mother-to-Child Transmission
PEPFAR Expert Panel on PMTCT
An independent panel of experts, established under the Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, provides an objective review of activities to prevent mother-to-child transmission of HIV and makes recommendations to Congress and the U.S. Global AIDS Coordinator for the scale-up of prevention of mother-to-child transmission (PMTCT) services. The report makes specific recommendations for strengthening 1) service delivery; 2) health workforce; 3) health information systems, targets, and monitoring and evaluation; 4) research and innovations; 5) financing; 6) leadership and governance; and 7) collaboration and coordination.
To reduce mother-to-child transmission, the panel recommends a comprehensive continuum of services that is consistent with the woman- and family-centered approach articulated as a priority for U.S. government initiatives. Among other themes, the report emphasized the need for improved engagement, better measurement, cost-effective practices, improved training and mentoring, and service integration.
- The Impact of Exposure to Mass Media Campaigns and Social Support on Levels and Trends of HIV-Related Stigma and Discrimination in Nigeria: Tools for Enhancing Effective HIV Prevention Programmes
Fakolade, R., Adebayo, S. B., Anyanti, J., et al. Journal of Biosocial Science (2009), In press.
People living with HIV and AIDS (PLWH) often face stigma and discrimination, especially in developing countries. HIV-related stigma is expressed through social ostracism, personal rejection, direct and indirect discrimination, and denial from families and friends. Consequently, the stigma is associated with reduced adoption of preventive and care behaviors, including condom use, seeking HIV testing, and care-seeking behavior subsequent to diagnosis. This paper monitors trends in the level of accepting attitudes toward PLWH in Nigeria between 2003 and 2007, and evaluates the impact of exposure to mass media and social support on the levels of accepting attitudes toward PLWH. The paper also evaluates the impact of exposure to mass media and social support on the levels of accepting attitudes toward PLWH, as ignorance about the epidemiology of the disease on modes of transmission and prevention aggravates HIV-related stigma. Behavior change communication activities through mass media have been shown to be an effective approach in improving people's knowledge about the disease; results indicate that a significant and positive trend of increasing accepting attitudes of PLWH was evident between 2003 and 2007 (p<0.0001). Furthermore, exposure to mass media communications on HIV and AIDS issues and social support were significantly related to reduced stigma and discrimination against PLWH.
- Illness during Pregnancy and Bacterial Vaginosis Are Associated with In-Utero HIV-1 Transmission
Farquhar, C., Mbori-Noacha, D., Overbaugh, J., et al. AIDS (2010). Vol. 24, No. 1, pp. 153-155.
HIV-1 transmission in-utero accounts for 20 to 30 percent of vertical transmission events in breastfeeding populations. As interventions that target intrapartum and breast-milk transmission become more widely available, in-utero transmission is likely to contribute to an increased proportion of mother-to-child transmission events. According to the authors, determining factors associated with HIV-1 transmission in-utero is an important step toward adapting interventions designed to further prevent infant HIV-1 infection. The goal of the current study was to define correlates of in-utero transmission within a prospective cohort of 463 HIV-1-infected Kenyan women and infants. The women were followed biweekly during pregnancy. At 34 to 36 weeks of pregnancy, the women began oral zidovudine, which they continued through delivery. Sexually transmitted infections (syphilis, gonorrhea, chlamydia, trichomoniasis) and candida were treated following Kenya National Guidelines. Study results demonstrate that antenatal diagnosis of a sexually transmitted infection was not associated with increased risk of transmission when examined individually or combined into a single variable. However, bacterial vaginosis was significantly more prevalent among women who transmitted in-utero: 59 percent of transmitters vs. 35 percent of women who did not transmit had bacterial vaginosis. In addition, illness during pregnancy was associated with a 2.6-fold increased risk of in-utero HIV-1 transmission.
- Heterosexual Risk of HIV-1 Infection per Sexual Act: Systematic Review and Meta-analysis of Observational Studies
Boily, M. C., Baggaley, R. F., Wang, L., et al. The Lancet (2009). Vol. 9, No. 2, pp. 118-29.
This systematic review of 43 publications based on 25 study populations aims to quantify the risk of HIV infection after sexual intercourse with an infected partner; specifically, the authors provide estimates of HIV transmission per heterosexual contact, explore variations across studies, and estimate the influence of risk factors on infectivity. Results in this study indicate that the heterogeneity of higher transmission probabilities for low- rather than for high-income country studies possibly signifies poorer study quality, greater heterogeneity of risk factors, or under-reporting of high-risk behavior. Pooled female-to male (.04 percent per act) and male-to-female (.08 percent per act) transmission estimates in high-income countries indicated a low risk of infection in the absence of antiretrovirals. Findings across several of the studies averaged .072 percent per sex act, or less than one infection per 1,300 acts of intercourse. In meta-regression analysis, the infectivity across estimates in the absence of commercial sex exposure was significantly associated with sex, setting, the interaction between setting and sex, and antenatal HIV prevalence. Study estimates of infectivity among non-circumcised men were at least twice those among circumcised men. The authors conclude that efforts are needed to better understand these differences and to quantify infectivity in low-income countries.
- Oral Pre-Exposure Prophylaxis for HIV Prevention
Garcia-Lerma, J. G., Paxton, L., Kilmarx, P. H., et al. Trends in Pharmacological Sciences (2009). Vol. 31, No. 2, pp. 74-81.
This article provides an overview of the rationale behind pre-exposure prophylaxis (PrEP) and discusses the next steps in PrEP research, including the need to better define the ability of current drugs to reach and accumulate in mucosal tissues and protect cells that are primary targets during early HIV infection. Recent animal studies using macaques or humanized mice models of mucosal transmission of SIV or HIV have shown that daily or intermittent PrEP with tenofovir disoproxil fumarate and emtricitabine can exploit early virus vulnerabilities and effectively prevent infection. These preclinical findings have fueled interest in evaluating the safety and efficacy of PrEP in humans. According to the authors, many currently available drugs for treatment have desirable characteristics for PrEP, but can differ in their ability to reach and accumulate in genital and rectal tissues, which may be critical to prevent sexual HIV transmission. Data from PrEP trials will become available in the coming two years and will help define the role of PrEP as a strategy to prevent HIV transmission.
- The Effects of HIV/AIDS on Rural Communities in East Africa: A 20-Year Perspective
Seeley, J., Dercon, S., Barnett, T.,Tropical Medicine and International Health (2010). In press.
Much of the research on implications of the HIV epidemic for individual households and broader rural economies in the 1980s and early 1990s predicted progressive declines in agricultural production, with dire consequences for rural livelihoods. Re-studies in Tanzania and Uganda show that from 1986 to the present, HIV and AIDS have sometimes thrown households into disarray and poverty, but more often have hampered countrywide development. According to this retrospective study, the progressive and systematic decline predicted in earlier work on East Africa has not come to pass. In Uganda and Tanzania, long-term modeling of the effects of the epidemic on human capital suggests societal level losses, and yet the evidence surveyed in this article also suggests resilience, continuity, and no profound adverse effects. The authors indicate the need to separate the short-term impacts of HIV and AIDS morbidity and mortality at the household level, which can be severe, from the longer-term impacts aggregated over larger populations, which are generally less dramatic.
- Vertical HIV Transmission Should Be Excluded from Criminal Prosecution
Csete, J., Pearshouse, R., Symington, A., Reproductive Health Matters (2009). Vol. 34, pp. 154-162.
Prevention of mother-to-child transmission (PMTCT) of HIV is an important part of global and national responses to HIV and AIDS. In recent years, many countries have adopted laws to criminalize HIV transmission and exposure. Many of these laws are broadly written and have provisions that enable criminal prosecution of vertical transmission in some circumstances. Even if prosecutions have not yet materialized, the use of these laws against HIV-positive pregnant women could compound the stigma they already face, and have a chilling effect on women's utilization of PMTCT programs. Based on an extensive search of the literature of laws that may criminalize vertical transmission of HIV, this article recommends that criminal laws on HIV transmission and exposure be reviewed and revised to ensure that vertical transmission is explicitly excluded as an object of criminal prosecution. Instead, scaling up PMTCT services and ensuring that they are affordable, accessible, welcoming, and of good quality, is the more effective strategy for reducing vertical transmission of HIV, and should be the primary strategy in all countries.
- Causal Links between Binge Drinking Patterns, Unsafe Sex and HIV in South Africa: It's Time to Intervene
Chersich, M. F., and Rees, H. V., International Journal of STDS and AIDS (2010). Vol. 21, No. 1, pp. 2-7.
Alcohol and HIV have an especially intimate link—in Africa, for instance, people with problem drinking have a two-fold higher risk for HIV. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. This article examines the link between alcohol and HIV, strategies to reduce this link, the effect of alcohol use on sexual behavior, and future research priorities. The authors conclude that although campaigns against alcohol harm may take time to alter sexual behaviors, they are as essential as more direct HIV prevention methods such as condom promotion, and far-reaching structural measures like alcohol control create the conditions necessary for achieving sustained HIV prevention results. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising, and provision of Brief Interventions. Alcohol counseling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence; however, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable outcomes, including unsafe sex, sexual violence, unintended pregnancy, and, likely, HIV transmission.
- Male Circumcision and Risk of Male-to-Female HIV-1 Transmission: A Multinational Prospective Study in African HIV-1-Serodiscordant Couples
Baeten, J. M., Donnell, D., Kapiga, S. H., et al., AIDS (2009). Vol. 24, pp. 1-8.
Male circumcision reduces female-to-male HIV-1 transmission risk by approximately 60 percent. Data assessing the effect of circumcision on male-to-female HIV-1 transmission are conflicting; one observational study among HIV-1-serodiscordant couples shows reduced transmission, while a randomized trial suggests no short-term benefit of circumcision. In this prospective observational study among HIV-1-serodiscordant couples in which the HIV-1-seropositive partner was male, the authors observed no increased risk, and potentially decreased risk from circumcision on male-to-female transmission. A total of 1,096 HIV-1-serodiscordant couples in which the male partner was HIV-1-infected were followed for a median of 18 months; 374 (34 percent) male partners were circumcised. Condom use was very high among the couples who received ongoing individual and couples risk-reduction counseling. Sixty-four female partners seroconverted to HIV-1 (incidence 3.8 per 100 person-years). Circumcision of the male partner was associated with a non-statistically significant reduction in risk of HIV -1 acquisition by the female partner of approximately 40 percent. The magnitude of this effect was similar when restricted to the subset of HIV-1 transmission events confirmed by viral sequencing to have occurred within the partnership, after adjustment for male partner plasma HIV-1 concentrations, and when excluding follow-up time for male partners who initiated antiretroviral therapy.
- Alcohol Use among Female Sex Workers and Male Clients: An Integrative Review of Global Literature
Li, Q., Li, X., Stanton, B. Alcohol and Alcoholism (2010), Vol. 45, No. 2, pp. 188-199.
Synthesizing the patterns, contexts, and impacts of alcohol use associated with commercial sex, the authors reviewed the literature of alcohol consumption among female sex workers (FSWs) or male clients from 1980 to 2008, identifying 76 studies (64 quantitative and 12 qualitative). A socio-ecological framework concerning social contexts at individual, occupational, and environmental levels was employed. The studies, increasing over time with geographic concentration in Asia and North America, show alcohol use among FSWs and clients, as well as multilevel contexts of alcohol use in the sex work environment, to facilitate transition into and practice of commercial sex among both FSWs and male clients, and for self-medication among FSWs. The association between alcohol use and a higher incidence of HIV/sexually transmitted infections or unprotected sex was inconclusive, although alcohol use was associated with numerous physical and mental health problems among FSWs. The review underscores the need for additional research in diverse settings, the use of standardized measures, and the importance of integrated interventions for alcohol use and related problems in multilevel contexts to effectively reduce alcohol use among FSWs and their clients.
- Together We Must End! End Violence against Women and Girls and HIV & AIDS
UNIFEM and ActionAid
As violence against women and girls and HIV and AIDS are mutually reinforcing pandemics, the need and opportunity for integrated approaches addressing their intersection are increasingly evident. Profiling 10 organizations, this report highlights key elements to consider in an integrated approach. The document is organized around four broad-based strategies for tackling the intersection: community mobilization to transform harmful gender norms; engagement of marginalized groups that are often more vulnerable to the twin pandemics; development of integrated approaches to support and care; and advocacy for greater accountability among funding agencies and policymakers. Together, these strategies offer valuable lessons and promising practices for other organizations and highlight the need for formal program evaluations to better understand and enhance their impact. The report prioritizes five key recommendations, including 1) encourage more research to identify and evaluate effective strategies, 2) increase collection and dissemination of national and global data on violence against women and girls, and on HIV and AIDS and the connections between them, 3) expand use of standardized protocols and training for health care personnel, 4) make efforts to engage excluded population groups, and 5) gain community buy-in from a broad range of stakeholders.
- U.S. President's Emergency Plan for AIDS Relief Launches Five-Year Strategy Annexes
The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) recently released three annexes to supplement the PEPFAR Five-Year Strategy launched on December 1, 2009. The annexes, which include "PEPFAR and Prevention, Care, and Treatment," "PEPFAR and the Global Context of HIV," and "PEPFAR's Contributions to the Global Health Initiative” provide additional detail on the high-level direction of PEPFAR outlined in the Five-Year Strategy. The annex on "PEPFAR and Prevention, Care, and Treatment,” indicates that PEPFAR will build on successful in-country HIV programs, as well as strengthen broader health systems, and transition prevention, care, and treatment efforts into greater country control over the next five years. PEPFAR will not only continue quality delivery of HIV prevention, care, and treatment services, but will also create a durable response that will be sustainable long into the future. The strategy is broken down into two phases. Phase one, during the first two years, entails working with governments to collect evidence on what works, and developing a road map for a basic package of prevention, care, and treatment services. Phase two outlines the subsequent three years, supporting countries to scale up the evidence-based approaches indentified in the first two years.
- U.S. Congress Repeals Ban on Syringe Exchange Funding
The fiscal year 2010 Consolidated Appropriations Act, signed into law in December, 2009, includes language lifting the ban on federal funding for domestic and international syringe exchange initiatives to prevent the spread of HIV. With passage of this legislation, the Office of the Global AIDS Coordinator is preparing to revise the President’s Emergency Plan for AIDS Relief guidance for needle exchange programs. Excerpts of U.S. House Speaker Nancy Pelosi's statement in support of lifting the ban are below.
"The scientific support for syringe exchange could not be more clear. As Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at the NIH has said, 'Clearly, needle exchange programs work. There is no doubt about that.’ More specifically, as Dr. Fauci confirmed during a 2008 hearing before the House Committee on Oversight and Government Reform, the science shows syringe exchanges effectively reduce new HIV infections without increasing the use of illegal drugs.
"Injection drug use is linked to 12 percent of new HIV infections, as well as most Hepatitis C infections. Lifting the ban on federal funding for syringe exchange is a big victory for science and for public health….We simply cannot rest until we have done everything possible to prevent new HIV infections, including ensuring access to proven interventions such as syringe exchange."
