HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Ending Overly Broad Criminalisation of HIV Non-Disclosure, Exposure and Transmission: Critical Scientific, Medical and Legal Considerations
Joint United Nations Programme on HIV/AIDS (UNAIDS). (2013). Guidance Note.
In 2008, UNAIDS issued a policy brief responding to the broad use of criminal law in instances of HIV non-disclosure, exposure, and transmission. UNAIDS restated their endorsement of prosecuting only cases of intentional transmission (i.e., an individual knows his or her HIV-positive status, had intention to transmit HIV, and actually transmits HIV). UNAIDS is concerned with the use of criminal law beyond these limits, such as cases of unintended transmission, non-disclosure, or exposure to HIV without transmission. The guidance includes recommendations on addressing these concerns for governments, legal authorities, civil society (including people living with HIV), and international partners/donors, using current scientific and medical evidence and legal principles. The considerations critical for assessment include: the level of harm, if any, caused to another person; whether the nature or level of HIV risk from a sexual act merits criminal liability; defenses against charges; and the advantages and limitations of methods used to obtain evidence. These considerations primarily apply to sexual relations, but may also pertain to transmission from mother to child and through shared drug injection equipment. UNAIDS instructs countries to implement evidence- and rights-based public health approaches, wherein HIV programs enable individuals to protect themselves and prevent transmission, and ensure that HIV services are accessible. Key stakeholders should translate this guidance into legal, policy, and programmatic changes.
- Oral Antiretroviral Drugs as Public Health Tools for HIV Prevention: Global Implications for Adherence, Drug Resistance, and the Success of HIV Treatment Programs
Gupta, R.K., Wainberg, M.A., Brun-Vezinet, F., et al. The Journal of Infectious Diseases (2013), Vol. 207 Suppl. No. 2, pp. S101-S106.
Recent studies on treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) show that antiretroviral (ARV) drugs can be used for HIV prevention. The authors of this review acknowledged concerns about the use of ARV drugs for prevention in the "real world," but support moving forward, adding that regular HIV testing and monitoring of adherence are critical. Optimal adherence to antiretroviral therapy (ART) in both TasP and PrEP studies has been strongly linked with effectiveness. As first-generation treatment coformulations move to second-generation coformulations based on tenofovir – also used in prevention strategies – the authors warn against using the same drugs for both PrEP and first-line treatment, to prevent drug resistance. Real-world use of ARVs for PrEP and TasP, they said, will require better understanding of risk perception and also of the link between adherence and prevention. While poor adherence reduced prevention benefits, no evidence of resistance development exists in published PrEP trials. Poor adherence, lack of awareness of HIV status, and loss to-follow-up may challenge the long-term public health benefits of TasP programs. In advance of large-scale use of PrEP and TasP, the authors conclude, there is a need for high-quality data on PrEP and resistance to tenofovir, as well as studies implemented in real-world settings.
- Antiretroviral Prophylaxis for HIV Infection in Injecting Drug Users in Bangkok, Thailand (the Bangkok Tenofovir Study): A Randomised, Double-Blind, Placebo-Controlled Phase 3 Trial
Choopanya, K., Martin, M., Suntharasamai, P., et al. The Lancet (June 2013), E-publication ahead of print.
The authors reported findings from the Bangkok Tenofovir Study, which assessed whether pre-exposure prophylaxis (PrEP) with daily oral tenofovir would reduce the risk of HIV among people who inject drugs (PWID) in Bangkok, Thailand. Findings showed that PrEP with daily oral tenofovir, combined with HIV prevention interventions, decreased HIV risk by nearly 49 percent among PWID. High adherence was associated with treatment efficacy. A total of 2,143 HIV-negative participants aged 20 to 60 (averaging age 31) from 17 drug-treatment facilities were randomly assigned to receive daily oral tenofovir (n=1,204) or a placebo (n=1,209), and consented to directly observed therapy or monthly follow-up visits. Fifty-two participants became infected with HIV (33 percent in the tenofovir arm [incidence rate of 0.35 per 100 person-years (PY)]; 67 percent in the placebo arm [incidence rate of 0.68 per 100 PY]). Adherence was similar between the groups. The estimated efficacy of tenofovir increased from 46 percent to 56 percent among adherent participants; efficacy was among two adherent groups--women and participants aged 40 or older. Reported use of injection drugs, needle-sharing, and sex with multiple partners decreased during the three-month follow-up. Tenofovir resistance in HIV-positive participants was not detected. The authors concluded that HIV prevention package for PWID should include PrEP with tenofovir.
- Context Matters: The Moderating Role of Bar Context in the Association between Substance Use During Sex and Condom Use Among Male Clients of Female Sex Workers in Tijuana, Mexico
Pitpitan, E.V., Wagner, K.D., Goodman-Meza, D., et al. AIDS and Behavior (May 2013), E-publication ahead of print.
The authors assessed the interaction between alcohol use during sex and the physical setting to examine condom use with female sex workers (FSWs) among male clients in Tijuana, Mexico. They focused on whether having sex at a bar determines the association between alcohol or drug use during sex and sexual risk behavior. Of 375 male clients (191 from Tijuana, 184 from San Diego) recruited from September 2012 to March 2013, 14 percent reported having sex with a FSW in a bar in the past four months and were less likely to live in the United States and more likely to be married. Among these clients, more frequent intoxication with alcohol during sex was associated with more unprotected sex. This association was not found among clients who did not report having sex with FSWs at a bar. Clients who reported having sex with a FSW in a bar indicated various reasons for inconsistent condom use, such as unavailability of condoms, belief that the FSW did not have sexually transmitted infections, and withdrawal before ejaculation. The authors recommended an integrated approach entailing structural- and individual-level HIV prevention interventions, e.g., targeting sex work venues and clients’ HIV knowledge and risk perceptions.
- Reducing the Risk of HIV Infection During Pregnancy among South African Women: A Randomized Controlled Trial
Jones, D.L., Peltzer, K., Villar-Loubet, O., et al. AIDS Care (2013), Vol. 25 No. 6, pp. 702-709.
The authors used a group-randomized controlled study in rural South Africa to evaluate a “PartnerPlus” prevention of mother-to-child transmission (PMTCT) intervention. The intervention was conducted with 239 couples at 12 antenatal care (ANC) clinics. Of these couples, 119 were randomly assigned to receive the intervention (increasing male participation during pregnancy, condom use and HIV knowledge, and sexual communication through four weekly sessions on cognitive skills), and 120 couples received standard PMTCT with time-matched health education videos (control). At baseline, 32 percent of women and 16 percent of men were HIV-positive (24 percent of men declined testing); 26 couples were serodiscordant. At follow-up (32 weeks' gestation) unprotected sex had decreased, and no women had seroconverted in the intervention. While baseline HIV knowledge scores were similar, knowledge increased among intervention participants. The intervention group had an estimated 5.1 odds of increased condom use compared with the control. Further, sexual communication/negotiation strategies increased, and intimate partner violence diminished among intervention couples. Findings suggest that interventions targeting men during pregnancy may be more effective than only encouraging ANC attendance. Because neither group attained complete coverage of male HIV testing or mutual disclosure, future research should explore relevant interventions. The authors emphasized the importance of shared engagement between couples to reduce sexual risk behaviors during pregnancy.
- The Acceptability and Safety of the Shang Ring for Adult Male Circumcision in Rakai, Uganda
Kigozi, G., Musoke, R., Watya, S., et al. Journal of Acquired Immune Deficiency Syndromes (2013), e-publication ahead of print.
The authors investigated the acceptability and safety of the Shang Ring—a method of medical male circumcision (MMC) little used in sub-Saharan Africa—compared with conventional surgery (dorsal slit method) in Uganda among HIV-negative men. The Shang Ring was found very acceptable, with 82 percent of men opting for this method, and was a safe and efficient MMC method. Of 621 men, 113 chose the dorsal slit and 508 chose the Shang Ring procedure. Four men had Ring placement failure, likely a result of provider inexperience; and four others did not receive the Ring because of stockouts. Placement failure highlights the need for more surgical facilities. The Shang Ring was a faster procedure; average surgery times were 6.1 and 17.7 minutes for the Shang Ring and dorsal slit, respectively. An average of 2.2 minutes was needed for Ring removal. Moderate to severe adverse events occurred in 1 percent of Shang Ring procedures and 0.8 percent dorsal slit procedures. Further, more men who received the dorsal slit than the Shang Ring method (15 percent versus 7 percent) reported having intercourse before the four-week follow-up, which may be another advantage of the Ring, since resuming intercourse early is associated with increased risks. The Shang Ring could increase the efficiency of MMC operations; however, the need for removal may represent a barrier.
- The Impact of Revised PMTCT Guidelines: A View from a Public Sector ARV Clinic in Cape Town, South Africa
Van Schalkwyk, M., Andersson, M.I., Zeier, M.D., et al. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 No. 2, pp. 234-238.
The authors conducted a retrospective review of cohorts of pregnant women who initiated highly active antiretroviral therapy (HAART) between January 2008 and December 2010, and presented mother-to-child transmission (MTCT) rates to assess the impact of the 2010 revised Western Cape, South Africa prevention of mother-to-child transmission guidelines. Findings suggest that the new guidelines led to earlier treatment initiation at higher CD4 counts and less MTCT occurred; however, referral for HAART initiation remained a challenge. Among the 250 pregnant women receiving HAART between 2009 and 2010, median gestation at first antenatal care (ANC) visit and HAART initiation decreased from 30 weeks to 23 weeks, and median CD4 count at first ANC visit was higher. More women received HAART for more than eight weeks before delivery (from 48 percent to 74 percent). However, loss-to-follow-up rates were high; nearly 38 percent within one year. Among 256 live births, MTCT rates were 4.7, 7.0, and 0.0 percent in 2008, 2009, and 2010, respectively. Integrating ANC and ART services could streamline therapy initiation and referral. Future studies should assess impact on maternal health of starting HAART at higher CD4 counts and strategies to improve retention. The authors concluded that HIV prevention programs should educate women on the benefits of earlier HAART initiation and retention in care.
- High HIV Prevalence Among Men Who Have Sex With Men in Nigeria: Implications for Combination Prevention
Vu, L., Adebajo, S., Tun, W., et al. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 No. 2, pp. 221-227.
The authors of this study aimed to provide HIV prevalence estimates and understand risk factors of men who have sex with men (MSM) in Abuja, Ibadan, and Lagos, Nigeria. The results indicated a high HIV burden among MSM: 4 to 10 times the general HIV prevalence. MSM also reported risky sexual behaviors, yet many had never tested for HIV (44, 68, and 62 percent in Abuja, Ibadan and Lagos, respectively). In total, 712 participants in Abuja (n=194), Lagos (n=308), and Ibadan (n=210) were interviewed between August and September 2010. Population-based HIV estimates among MSM were 35 percent (Abuja), 11 percent (Ibadan), and 15 percent (Lagos). More MSM reported having sex with both men and women in Ibadan and Lagos than in Abuja. Approximately 20 to 30 percent and over 50 percent of MSM reported multiple female and multiple male partners, respectively. Unprotected intercourse was common. In Lagos, one-third of MSM reported that their last male sexual partner had been a commercial sex worker, and over half of MSM reported transactional sex in the past six months. A comprehensive combination prevention approach, including structural interventions to build a supportive and less homophobic environment will be essential to mitigate HIV among MSM, their female partners, and hidden MSM subgroups. The authors advocated considering antiretroviral-based prevention and decriminalization of same-sex relationships.
- Maximizing the Impact of HIV Prevention Efforts: Interventions for Couples
Medley, A., Baggaley, R., Bachanas, P., et al. AIDS Care (May 2013). E-publication ahead of print.
The authors described HIV interventions that should be offered to couples, both in generalized and concentrated epidemics, to decrease the risk of transmission to HIV-negative partners and children and to support HIV-positive partners in accessing necessary HIV services. An emphasis on couples-focused HIV services, rather than traditional, individual HIV services, is urgently needed, and could potentially reduce population-level HIV incidence. This article complements the World Health Organization’s couples HIV testing and counseling (CHTC) guidelines. Interventions appropriate for couples included antiretroviral treatment (ART) for the HIV-positive partner; ART adherence counseling and support; risk reduction counseling (including supplying condoms); linking HIV-positive mothers with services for prevention of mother-to-child transmission; counseling on family planning and safer contraception and pregnancy; pre-exposure prophylaxis treatment for the HIV-negative partner; voluntary medical male circumcision for the HIV-negative male partner in serodiscordant relationships; screening and treatment for sexually transmitted infections; and routine HTC for HIV-negative partners or for HIV-negative couples in high-prevalence contexts. Reaching and engaging men in HIV prevention, care and treatment services will be critical to the scale-up of couple-focused HIV interventions, the authors said. Also, because of reported high rates of intimate partner violence (IPV) and the potential barriers they create for access and utilization, health care workers should be aware of and trained to screen for and address IPV.
- Teachers' Attitudes towards Adolescent Sexuality and Life Skills Education in Rural South Africa
Smith, K.A. and Harrison, A. Sex Education (2013), Vol. 13 No. 1, pp. 68-81.
The authors conducted qualitative research with 43 secondary school teachers and administrators from 19 schools in rural KwaZulu Natal, South Africa to understand their attitudes towards sexuality education, HIV, and adolescent sexuality; and to determine the level of implementation of the school-based life skills curriculum for HIV prevention. Informants’ strong views on morality and young people’s sexuality, particularly regarding girls and pregnant students, may pose barriers to implementing education on HIV prevention and sexuality. Stigma towards HIV within the general community was apparent. Pregnant students were often pressured to leave school, and sexual behaviors and relationships were discouraged. Most respondents reported that dissemination of the life skills curriculum was very informal because of limited time and high workloads, but they discussed other school-based sexual education, which revealed varying levels of comfort in presenting these topics. Most informants ardently supported this education, including for teachers, and offered strategies, e.g., inviting external HIV programs into schools. Most teachers were knowledgeable about HIV transmission and prevention but less knowledgeable about testing and treatment. Some teachers supported traditional practices such as virginity testing and believed themselves socioeconomically superior to the student community. School-based initiatives may enhance HIV prevention in South Africa, yet future interventions should assess teachers’ knowledge of HIV and perceptions of adolescent sexuality, and should address young people's varied life and sexual experiences.
- Community Environments Shaping Transactional Sex among Sexually Active Men in Malawi, Nigeria, and Tanzania
Stephenson, R., Winter, A., and Elfstrom, M. AIDS Care (2013), Vol. 25 No. 6, pp. 784-792.
The authors analyzed Demographic and Health Surveys to examine how individual- and community-level factors affect reported risky transactional sex among men. The analysis included 2,893 men in Malawi, 2,110 in Tanzania, and 1,799 in Nigeria. While several community characteristics are linked to higher reported engagement in risky transactional sex, community-level variations remained in all countries. Reports of risky transactional sex were 12.4 percent, 9.8 percent and 6.7 percent in Malawi, Nigeria, and Tanzania, respectively. Tanzanian men with any education, and Nigerian men with primary education, were more likely to engage in risky transactional sex. In Nigeria, fewer never-married men reported risky transactional sex than married, cohabitating, or divorced men; and more men in lower wealth quintiles reported the behavior. Gender equity appeared to affect risky transactional sex: where a greater proportion of women had at least some education (and, in Nigeria, where more women were employed), men were less likely to report risky transactional sex. The average number of sexual partners in the past 12 months was associated with more risky transactional sex. Factors associated with reduced reporting of the behavior include condom use at last intercourse (Malawi), greater knowledge among men and women of three HIV prevention measures (Nigeria and Tanzania), and women's older average age at first birth (Malawi and Tanzania). The authors advocated for incorporating gender issues and community-level factors into HIV interventions.
- The Cost-Effectiveness of Repeat HIV Testing During Pregnancy in a Resource-Limited Setting
Kim, L.H., Cohan, D.L., Sparks, T.N., et al. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 No. 2, pp. 195-200.
The authors assessed the cumulative cost-effectiveness of three HIV testing strategies, compared to standard care, for the prevention of perinatal transmission in Uganda. The four strategies assessed were: 1) standard of care–rapid HIV antibody testing at the first prenatal visit; 2) standard of care plus HIV RNA (viral load) at initial visit; 3) standard of care plus repeat HIV antibody testing at delivery; and 4) strategy 3 plus HIV RNA at delivery. The results indicated that repeat rapid HIV testing at delivery (strategy 3) was cost-effective and led to the greatest total maternal and child life-years saved. The authors applied a decision analytic model from a health care system perspective to follow a hypothetical cohort of 10,000 Ugandan women in antenatal care. Life-years saved for each strategy were: 414,227 (strategy 1); 414,296 (strategy 2); 415,765 (strategy 3); and 415,794 (strategy 4). Standard care was least expensive. Applying the World Health Organization’s definition (≤3 times the gross domestic product per capita) as the cost-effectiveness threshold, strategy 3 was the most economical option in terms of life-years and remained so in univariate sensitivity analysis. Yet when HIV incidence was more than 8 percent, strategy 4 became the most cost-effective strategy. The findings should inform policies on HIV testing during pregnancy in sub-Saharan Africa.
- Gender Disparities in HIV Risk Behavior and Access to Health Care in St. Petersburg, Russia
Vasquez, C., Lioznov, D., Nikolaenko, S., et al. AIDS Patient Care and STDs (2013), Vol. 27 No. 5, pp. 304-310.
The authors assessed differences in risk factors between male and female HIV clients at two HIV referral facilities in St. Petersburg, Russia. Injecting drug use and sex were the main HIV risks in both males and females, but significant differences affected their uptake of HIV and related services. From March to May 2011, surveys were conducted with 152 clients (52 percent of these were women). Comorbidities included tuberculosis among men and sexually transmitted infections among women. Men were more likely than women to report HIV risk related to drug use (78 percent to 45 percent, respectively) and a history of injecting drug use (86 percent versus 49 percent). More women than men reported unprotected sex (61 percent to 18 percent). Men cited drug use as the primary reason for seeking HIV testing; women cited drug use, unprotected sex, and worries about their partner’s health. About half of males and females abused alcohol. Participants had high levels of HIV treatment knowledge, but delayed seeking care (47 percent and 35 percent); anecdotal reports identified stigma as a barrier. Women were more likely to access psychosocial services, yet men and women similarly accessed services for mental health care and injecting drug use, HIV, and group meetings. Gender-related differences in access and uptake of services should help inform HIV resource distribution in Russia.
- HIV Incidence in Asia: A Review of Available Data and Assessment of the Epidemic
Dokubo, E.K., Kim, A.A., Linh-Vi, L. et al. AIDS Reviews (2013), Vol. 15, pp. 67-76.
The authors conducted a systematic review of studies on HIV incidence in Asia (Bangladesh, Cambodia, China, India, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Taiwan, Thailand and Vietnam) conducted in the past 30 years. The results showed that studies on HIV incidence are not routinely conducted or published across Asia, but shed light on estimated HIV incidences and risk factors, mostly among key populations. HIV incidence rates varied; the highest were 43.6 among people who inject drugs (PWID); 27.8 per 100 person-years among commercial sex workers (CSW); and 15.0 among men who have sex with men (MSM). A few studies identified commonly known HIV risk factors, e.g., cervical infection among CSW; young age and frequent needle sharing among PWID; and having multiple sexual partners among MSM. Of the 111 studies included (70 publications and 41 conference abstracts), most were from Thailand, China, and India (53, 26, and 17 studies, respectively). The prospective cohort methodology remains most commonly used in studies of HIV incidence, and the use of antibody-based laboratory assays for detecting HIV infection has recently increased. While surveillance can be challenging among hidden key populations, it is necessary to establish routine surveillance systems to obtain data on new HIV infection rates and risk factors, both among key populations and the general population, to better understand and address the HIV epidemic in Asia.
- Statement by the Office of the U.S. Global AIDS Coordinator (OGAC) on World Health Organization Prequalification of First Medical Device for Adult Voluntary Medical Male Circumcision
OGAC. U.S. Department of State: Diplomacy in Action (May 31, 2013).
The World Health Organization (WHO) has prequalified PrePex™, the first medical device for adult male circumcision. Prequalification ensures that medical devices and equipment for high-burden diseases meets safety and efficacy standards. The WHO conducted studies in Rwanda, Zimbabwe and Uganda as part of the prequalification process. The device has the potential to streamline the procedure and improve men’s experience of male circumcision. Given that the U.S. President’s Plan for Emergency AIDS Relief (PEPFAR) has supported implementation of voluntary medical male circumcision in 14 countries in eastern and southern Africa, OGAC’s Ambassador, Eric P. Goosby, voiced his support for countries that plan to implement PrePex™. PEPFAR is supporting Ministries of Health and/or Defense in other African countries to conduct an initial assessment of the acceptability and safety of the device in various contexts, which is required before PEPFAR provides support for large-scale programs using the device.