HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Realizing an AIDS-Free Generation
Clinton, H. (November 8, 2011), National Institutes of Health, Bethesda, Maryland.
In a speech to public health scientists, advocates, and policymakers, U.S. Secretary of State Hillary Clinton made a bold statement calling on the United States and other countries to work toward the goal of creating an AIDS-free generation. She defined this as a generation where virtually no children are born with the virus, where children entering adolescence and adulthood have access to effective HIV prevention interventions, and where those who do become HIV-positive have access to treatment that lowers the possibility of developing AIDS and of transmitting the virus to others. She cited evidence from recent groundbreaking research on HIV prevention interventions as showing that this goal is possible. These include voluntary medical male circumcision (VMMC), which lowers the rate of female-to-male HIV infection by 60 percent, and the use of antiretrovirals for treatment as prevention, which demonstrates a 96 percent reduction of HIV transmission among serodiscordant heterosexual couples, as shown in the HPTN 052 trials. Secretary Clinton said that combining these two types of interventions with programs to eliminate mother-to-child HIV transmission, a third scientifically proven prevention tool, could achieve the goal of an AIDS-free generation. She also said that when combined with other lifesaving behavioral and structural interventions, such as condoms and stigma reduction, the global rate of new infections could drop by 40 to 60 percent. Increased country ownership of AIDS programs and greater involvement of other donor nations to support global financing mechanisms—such as the Global Fund to Fight AIDS, Tuberculosis and Malaria—are critically important to reach this goal. Secretary Clinton also announced a new initiative of U.S.$60 million aimed at assessing the benefits of combination prevention interventions in four countries in sub-Saharan Africa.
- Revolutionizing the AIDS Response: Building AIDS Resilient Communities
Ogden, J., Gupta, R., Warner, A., et al. Global Public Health (October 2011), e-publication ahead of print.
According to the authors, structural approaches that address social, economic, and political factors beyond the control of individuals are still lacking in both the global and national responses to HIV. This synthesis paper outlines six key recommendations and provides specific guidance from the Social Drivers Working Group of the aids 2031 initiative. These actions are designed to operationalize structural approaches that will increase uptake and sustainability of behavioral and biomedical prevention approaches. The authors argue that addressing the root causes of vulnerability, such as gender inequity, may have the greatest effect in reducing vulnerability to HIV. The six actions identified by the working group include the following:
• Integration of HIV efforts with broader health and development should be supported through intersectoral AIDS coalitions.
• Governments and donors should invest in sociological assessments to identify the social context as part of routine efforts to “know your epidemic.”
• Civil society and affected communities—including women living with HIV, networks of affected persons, and young people—must be fully engaged in planning and priority-setting activities.
• Substantial and long-term structural approaches should be funded for project cycles of 5 to 15 years or more.
• Monitoring and evaluation frameworks must account for multidimensional changes in the social, economic, and political environments.
• Laws that reduce stigma and protect human rights and equity must be effectively implemented and monitored.
• Integration of HIV efforts with broader health and development should be supported through intersectoral AIDS coalitions.
Related HIV Prevention Knowledge Topic: Structural Interventions
- Two Sides to the HIV Prevention Coin: Efficacy and Effectiveness
Kippax, S., Reis, E., & de Wit, J. AIDS Education and Prevention (October 2011), Vol. 23 No. 5, pp. 393-396.
Kippax and colleagues argue that strict differentiation between biomedical interventions and behavior change interventions makes little sense because almost all HIV interventions require behavioral change that must be sustained over time. For example, biomedical interventions require widespread social change to address the social, economic, and political barriers that often impede successful implementation. The authors call for increased attention to effectiveness and warn that HIV prevention efforts may falter because of ineffective promotion of efficacious strategies. In countries such as Australia and the United States, which have high levels of testing among most-at-risk populations and offer ready access to antiretroviral therapy (ART), HIV incidence has not decreased within those populations. The authors believe that the effectiveness of a “test and treat” strategy depends on the adoption of annual testing and the sustained use of ART for those testing HIV-positive. They call for close examination of the possible unintended negative consequences of HIV testing and counseling and of treatment as prevention. For example, they theorize that promoting “test and treat” may cause some governments to further resist other politically difficult prevention strategies, such as needle and syringe programs. They also call for social and political scientists to work collaboratively with biomedical scientists to determine how to make efficacious technologies accessible to all.
- Male Circumcision for HIV Prevention: Current Evidence and Implementation in Sub-Saharan Africa
Wamai, R., Morris, B., Bailis, S., et al. Journal of the International AIDS Society (October 2011), Vol. 14 No. 49, pp. 1-62.
According to the authors of this meta-analysis of the state of evidence of voluntary medical male circumcision (VMMC) programs in 14 high-priority African countries, the time is ripe to scale up VMMC programs in countries with generalized heterosexual epidemics, as well as in countries where HIV prevalence is low. The authors found a 58 percent protective effect of VMMC—53 percent for general populations and 69 percent for high-risk populations—among 13 studies based primarily in sub-Saharan Africa. The authors note that 74 percent of the 555,202 cumulative circumcisions performed from 2008 to 2010 occurred in 2010 alone. Although growing, this number accounts for only 2.7 percent of the 20.8 million target for VMMC scale-up. To reach this target, they predict that five high-prevalence countries would need to perform one million circumcisions in 2012 alone. Based on these results, the authors recommend that VMMC be considered a major component in a combination HIV prevention approach and call for increased funding for scale-up. They recognize that challenges to effective implementation of VMMC programming still exist, including cost, lack of training, health system barriers, and sociocultural beliefs. To combat these, they call for increased research on a variety of issues, including the most cost-effective service models, integrating VMMC messages into existing prevention programs, and integrating routine newborn male circumcision into maternal-child health programs.
- Topical Tenofovir, a Microbicide Effective against HIV, Inhibits Herpes Simplex Virus-2 Replication
Andrei, G., Lisco, A., Vanpouille, C., et al. Cell Host & Microbe (October 2011), Vol. 10 No. 4, pp. 379-389.
Tenofovir gel displays a dual benefit of reducing HIV infection and inhibiting the replication of the herpes simplex virus in this recent study. According to the authors, tenofovir gel was responsible for a 39 percent reduction of HIV sexual transmission and a 51 percent reduction of herpes simplex virus-2 (HSV-2). The research demonstrates that tenofovir gel disables a key DNA enzyme of the herpes virus. Examining individual cells and groups of cells infected with HSV-2, the authors found that tenofovir gel prevents the virus from reproducing and does not damage cells, including the cells that line the vagina. Examining the effects of tenofovir in tissue samples, they found tenofovir blocks viral reproduction in tissues infected with both HIV and HSV-2. In contrast, oral tenofovir does not produce the same protective effect against HSV-2. According to the authors, HIV infection is closely associated with herpes viral infection, and these findings may help prevent both HIV and its co-pathogens. The authors stress these findings may also save millions of dollars because tenofovir is an already approved drug that does not need to undergo testing for safety and effectiveness for new uses.
- Antiretroviral Therapy in Prevention of HIV and TB: Update on Current Research Efforts
Granich, R., Gupta, S., Suthar, A., et al. Current HIV Research (October 2011), Vol. 9 No. 6, pp. 446-469.
According to the authors, although treatment as prevention has proven effective for limiting transmission of both HIV and tuberculosis (TB), continued coordinated research is needed to answer such questions as when to start antiretroviral therapy (ART), how to determine costs, how to increase the accessibility and feasibility of interventions, how to expand coverage, and how to use trial data in operational settings. This study outlines a comprehensive list of 50 ongoing and planned research activities in 52 countries evaluating ART as prevention for HIV and TB (24 are randomized controlled trials). The authors found that most of the studies use similar methodologies, interventions, and geographical locations (20 were conducted in North America, 22 in Africa, 4 in Asia, and 1 in Europe; 3 were multisite international studies). The authors stress that these studies will advance our knowledge but that key questions, such as determining when to initiate ART and calculating the population-level impact of expanding access to ART at higher CD4 counts, may remain unanswered or only partially answered. Although the World Health Organization relies on randomized controlled trials to issue normative guidelines, the authors recommend a more rapid operational research approach to answer some of these questions. They advocate for a mix of research methodologies that provide near-, medium-, and long-term evidence. They also call for more research on the potential risks and benefits of human rights and community support interventions.
- The Future of Microbicides
Omar, R., & Bergeron, M. International Journal of Infectious Diseases (October 2011), Vol. 15 No. 10, pp. e656-660.
The authors of this study outline 15 years of microbicide research and discuss the future of microbicides. They compare the use of microbicides as pre-exposure prophylaxis (PrEP) targeting only HIV to a broad-based microbicide that offers universal protection against several sexually transmitted infections (STIs). According to the authors, interest has grown over the past few years in developing oral, vaginal, or rectal microbicides based on already approved antiretroviral drugs (ARVs). The authors caution that this shift may be premature and that broad-based microbicides that offer protection against HIV as well as other STIs, including herpes simplex virus, syphilis, gonorrhea, and trichomoniasis, may still offer the best female-controlled protection against HIV and other STIs. According to the authors, some of the major reasons that microbicide candidates failed in Phase III effectiveness trials include mucosal toxicity, failed application into the vagina, and poor adherence. In addition, HIV incidence within high-risk populations at clinical sites may have been overestimated, possibly skewing the data. They express concern that a limited focus on using ARVs as PrEP for HIV prevention ignores some of the shortcomings of this mechanism, including resistance. To address these issues, they recommend that HIV testing and ongoing monitoring of infection status be incorporated into prevention programs using ARVs.
- Antiretrovirals for Prevention: Realizing the Potential
Sidibé, M. Current HIV Research (October 2011), Vol. 9 No. 6, pp. 470-472.
This editorial by Michel Sidibé, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), calls the use of antiretroviral therapy for prevention a “game changer” that may effectively limit the transmission of the virus to those uninfected while also averting illness in HIV-positive individuals. According to Sidibé, this approach, in combination with other prevention activities, may dramatically slow the epidemic and tip the scales from a growing epidemic to one in decisive decline. To make this shift happen, Sidibé calls for the use of combination prevention, simpler treatment regimens, community-centered program delivery, and a focus on resolving cost issues for treatment as prevention. He reminds us that loss to follow-up of people on treatment in some countries (up to 40 percent within three years) remains an important issue and that UNAIDS and the World Health Organization’s Treatment 2.0 report call for a “smarter, better pill” to improve adherence and efficacy: less toxic, longer acting, less expensive, and easier to use. He writes that cost reduction of antiretrovirals still depends on competition from generic drug producers, reliance on the Medicines Patent Pool, and challenges to any trade agreements that seek to limit the flexibility of trade-related aspects of intellectual property rights. He advocates for treatment literacy and high-quality alternative service delivery at the community level (e.g., mobilizing additional community health workers) and encourages donors to scale up integrated services, including human rights protection, for most-at-risk populations.
- Modeling the Impact on the HIV Epidemic of Treating Discordant Couples with Antiretrovirals to Prevent Transmission
El-Sadr, W., Coburn, B., & Blower, S. AIDS (November 2011), Vol. 25 No. 18, pp. 2295-2299.
This article describes a mathematical modeling exercise that predicts that treating discordant couples in Rwanda, Lesotho, Malawi, and Ghana would reduce HIV incidence. The authors provide a framework to identify which countries may benefit most from treating discordant couples to prevent transmission. The authors found that countries with high HIV prevalence and a greater percentage of couples in discordant partnerships, such as Lesotho, will experience the greatest reduction in HIV incidence. However, population size, HIV prevalence, and the percentage of couples that are discordant determine country-specific differences in the number of infections prevented. For example, Malawi shows a large reduction in incidence and number of infections prevented, while Ghana shows only a small reduction in incidence but a large number of averted infections. Although country-specific indicators on incidence and number of infections prevented depend on an array of factors, the authors found that countries with a higher proportion of stable partnerships, whether concordant or discordant, may benefit the most from discordant couple interventions. They warn that finding discordant couples is still a challenge, particularly in countries with larger populations, and that efforts must be made to identify and rapidly assess these couples, initiate antiretroviral therapy to prevent transmission, and provide supportive services to enable adherence to longer-term treatment.
- Efficacy of Structural-Level Condom Distribution Interventions: A Meta-Analysis of U.S. and International Studies 1998-2007
Charania, M., Crepaz, N., Guenther-Gray, C., et al. AIDS and Behavior (October 2011), Vol. 15 No. 7, pp. 1283-1297.
According to the authors of this systematic review, structural-level condom distribution interventions (SLCDIs) are an efficacious tool for prevention of HIV and sexually transmitted infections (STIs) within various groups, including youth, adults, males, sex workers, clinic populations, and populations in areas with high STI incidence. Examining 21 U.S. and international studies dating from January 1988 to September 2007, the authors found that SLCDIs have had significant effects on condom use, condom acquisition/condom carrying, delayed sexual initiation among youth (because of associated prevention messaging), and reduced incident STIs. They point out that SLCDI interventions focusing only on a structural component are efficacious, and that when these are combined with additional individual, small group, or community-level activities, they demonstrate even greater efficacy. The authors hypothesize that the increased efficacy of combined multi-level interventions is due to addressing a number of influencing factors, such as norms, knowledge, skills, motivation, and access, as well as the prevention needs of individuals in affected communities. They also found that interventions that increase availability and accessibility to condoms as a distribution strategy are efficacious in increasing condom use behaviors. They advocate for further research on the most effective strategies for maximizing reach and impact of condom distribution programs.
- HIV Prevention Interventions for Female Sexual Partners of Injection Drug Users in Hanoi, Vietnam: 24-Month Evaluation Results
Hammett, T., Kling, R., Van, N., et al. AIDS and Behavior (October 2011), e-publication ahead of print.
This evaluative assessment of peer-based HIV-prevention interventions for female sexual partners (SPs) of people who inject drugs (PWID) found 3.5 times higher condom use among participant SPs targeted by the intervention than among non-participants. The study, based in Hanoi, Vietnam, targeted 3,026 wives and cohabiting girlfriends of male PWID over a 24-month period. The authors found that this population is accessible and that risk factors among the population can be reduced. Higher rates of condom use at last sex were found among participants in interventions than among non-participants. The authors also found declining prevalence of characteristics that may reflect troubled relationships that are HIV-serodiscordant or of unknown status. Given the high levels of risk of HIV infection within these relationships, the authors see these results as promising. They call for increasing the provision of preventive services, including access to condoms, regular HIV testing, and antiretroviral treatment as prevention for SPs. They also advocate that governments of countries with concentrated epidemics include prevention activities for SPs in their strategic planning and programmatic budget allocations.
- Transactional Sex Amongst AIDS-Orphaned and AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty
Cluver, L., Orkin, M., Boyes, M., et al. Journal of Acquired Immune Deficiency Syndromes (October 2011), Vol. 58 No. 3, pp. 336-343.
AIDS-affected youth are at a higher risk for severe emotional and physical abuse, but not necessarily sexual abuse. Dual-affected youth—youth who are both AIDS orphans and have a caregiver who is experiencing an illness due to AIDS—are particularly vulnerable. These results come from the first known study, conducted in South Africa, to examine whether being an orphan due to AIDS and/or having a caregiver sick with AIDS predicts emotional, physical, and sexual abuse, as well as vulnerability to transactional sexual exploitation. The authors also found that AIDS orphanhood and caregiver AIDS illness are associated with heightened risk of transactional sex but no other sexual risk behaviors. According to the authors, this result goes against the long-held belief, based primarily on qualitative research, that transactional sex is “normative” in Southern African contexts. They emphasize that the heightened levels of transactional sex are more related to increased levels of food insecurity and exposure to physical and emotional abuse. The authors do note that caregiver sickness or orphanhood due to other illnesses do not predict the same outcomes related to abuse or transactional sex, and suggest that this may point to a relationship between HIV and AIDS and certain risk factors. Based on these results, the authors hypothesize that abuse and transactional sexual exploitation may be possible links between orphanhood and HIV infection.
- The Global Fund’s Resource Allocation Decisions for HIV Programmes: Addressing Those in Need
Avdeeva, O., Lazarus, J., Aziz, M., et al. Journal of the International AIDS Society (October 2011), Vol. 14 No. 51, pp. 3-33.
Using the UNAIDS National AIDS Spending Assessment framework, this study assesses how the U.S.$12 billion invested by the Global Fund to Fight AIDS, Tuberculosis and Malaria for HIV activities in 145 countries from 2002 to 2010 targeted key populations in relation to disease burden and national income. The authors found that U.S.$6.1 billion (52 percent) of the overall Global Fund HIV funding went to low- and low-middle-income countries, slightly more than half of which are in sub-Saharan Africa. Funding was allocated to HIV treatment and care (35 percent), general prevention activities (29 percent), and other activities, such as health systems strengthening. The authors found that most of the funding from both the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR) went to countries with generalized epidemics and focused on HIV care and treatment activities, while domestic and international funding for prevention remained low. The analysis demonstrated that in countries with low-level and concentrated epidemics, only 13 percent and 18 percent of Global Fund prevention funding, respectively, was targeted to most-at-risk populations, including sex workers, people who inject drugs, and men who have sex with men. The authors did find that, although these numbers were low, the only major funding source targeting prevention activities in Eastern Europe and Central Asia to most-at-risk groups is the Global Fund, and that the Global Fund investment by country is positively correlated with national adult HIV prevalence.
- Assessment of Population-Level Effect of Avahan, an HIV-Prevention Initiative in India
Ng, M., Gakidou, E., Levin-Rector, A., et al. The Lancet (October 2011), Vol. 378 No. 9803, pp. 1643-1652.
More than 100,000 infections (61 percent in men) may have been averted in three populous southern Indian states due to the work of the Avahan project from 2003 to 2008. This result is from a study assessing the population-level effect of the first phase of Avahan, a U.S.$258 million HIV prevention project launched in 2003 in six states in India. The project, funded by the Bill & Melinda Gates Foundation, targeted high-risk groups, including female sex workers and their clients, men who have sex with men, people who inject drugs, and truck drivers. Activities included one-on-one safe-sex counseling, free condoms, needle exchange, clinic-based treatment of sexually transmitted infections, and advocacy. According to the authors, the project was most successful in lowering HIV prevalence at the population level in the states of Andhra Pradesh, Karnataka, and Maharashtra, but did not demonstrate any significant effects in Tamil Nadu, Manipur, and Nagaland. HIV prevalence in the general population declined by a range of 2.4 percent in Maharashtra to 12.7 percent in Karnataka. Based on these findings, the authors suggest that investing in evidence-based prevention in non-generalized epidemics, such as in India, may have a beneficial effect at the population level. They urge that careful consideration be given to the types of interventions, the settings where they are implemented, and the most effective modes of delivery.
Related AIDSTAR-One Case Study: The Avahan-India AIDS Initiative
- Ensuring Equality: A Guide to Addressing and Eliminating Stigma and Discrimination in the Health Sector
Physicians for Human Rights (July 2011).
This guide, developed by Physicians for Human Rights (PHR) and geared to policymakers, health workers, and civil society, provides a framework outlining a comprehensive approach to addressing stigma and discrimination in the health sector and to securing patients’ rights. The guide provides definitions and examples of health stigma and discrimination and offers strategies for minimizing these barriers to accessing health care. The guide includes many examples from the HIV and AIDS context, but also examines the broad range of stigmatization that undermines health and dignity overall. It provides examples, primarily from Africa and Asia, of training activities for health workers, activities to demand patients’ rights, charter and enforcement mechanisms, laws and policies, and activities to address discrimination beyond the health sector. The guide discusses the policies and health facility arrangements necessary to address structural changes. As an accompaniment to the guide, PHR has developed three fact sheets—one each for policymakers, health care workers, and civil society—to orient them to their specific roles and responsibilities.
- Taking Evidence to Impact: Making a Difference for Vulnerable Children Living in a World with HIV and AIDS
UNICEF (September 2011).
This guidance, developed in collaboration with practitioners, international technical advisers, governments, and donors, builds upon UNICEF’s 2004 Framework for the Protection, Care and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS and calls for greater accountability and sustainability in programming for vulnerable children. The guidance updates the evidence on child vulnerability in the context of HIV and on the resilience of families, and recommends that policymakers and donors move away from focusing only on orphans to including all vulnerable children. The guidance continues to support activities that focus on strengthening family capacity to care for and protect children, combating poverty and stigma, and providing support to HIV-affected families, including cash transfers, livelihood programs, microfinance, savings and loans, free health and education, pensions, and public works. It also recognizes the need to build on and strengthen existing social welfare and child protection services, as well as community systems geared toward reaching the most vulnerable children. The guidance acknowledges the importance of prevention of mother-to-child transmission and stresses the need for more comprehensive interventions in this area, including couples testing and counseling; HIV treatment, care, and support; linkages with HIV testing and treatment within child health services; and early childhood development programs.