HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Antiretrovirals and HIV Prevention: New Insights, Challenges, and New Directions
Mayer, K.H., ed. Current Opinion in HIV and AIDS (October 2012), e-publication ahead of print.
In his introduction to this special issue of the journal, Mayer presents an overview of recent research on the use of antiretroviral (ARV) drugs for HIV prevention. He points out that, despite the remarkable proof of concept achieved in results from trials of vaginal microbicides containing ARVs (CAPRISA 004), pre-exposure ARV prophylaxis or PrEP (iPrEX), and early initiation of treatment for serodiscordant couples (HPTN052) , other studies of the same ARVs (FEMPrEP and VOICE) have not shown efficacy for prevention. As research continues, Mayer urges close examination of these contradictory results to move the field forward. The 15 additional articles in the issue review a wide range of studies and propose next steps for research. Hendrix addresses complex pharmacological issues related to dosing that could explain differences between trial results. Aspects of acceptability and adherence are covered by Van Damme and Szpir, Amico, Paxton, and others. Baral, Poynten, and their co-authors focus on research targeting key populations such as men who have sex with men and people who inject drugs, while McGowan describes progress toward Phase 2 trials for rectal microbicides. An article by Schackman and Eggman recommends cost-effectiveness studies to improve PrEP implementation and lessen the impact on health budgets. Abraham and Gulick discuss the potential for using ARVs other than the standard tenofovir and emtricitabine for prevention.
- HIV Risk and Prevention Among Men Who Have Sex with Men (MSM) in Peri-Urban Townships in Cape Town, South Africa
Jobson, G., de Swardt, G., Rebe, K. et al. AIDS and Behavior (October 2012), e-publication ahead of print.
The authors of this exploratory study conducted ten interviews and three focus group discussions to examine HIV risk for men who have sex with men (MSM) in Cape Town, South Africa. Using a socio-ecological framework, the authors propose a multidimensional approach to understanding risk to MSM of different racial identities at multiple levels: the distal (structural and cultural), proximal (interpersonal and community), and personal (within the individual). The authors posit that, while risk behaviors among their multiracial sample of 31 MSM may be similar, the different societal contexts in which these men live—created in part by the legacy of apartheid—affect their social interactions and sexual relationships, and thus their individual HIV risk. For example, the authors found that, at the distal level, homophobia may keep certain MSM from using MSM-friendly health services, while socioeconomic factors such as poverty and unemployment may drive some to practice transactional sex or may make health care unaffordable. At the proximal level are alcohol use and experiences of discrimination, as well as gender dynamics that may make it hard to negotiate safer sex. Self-esteem, self-efficacy, and internalized homophobia are examples of factors at the personal level. The authors conclude that recognizing the links between risk environments and risk situations is critical for effective MSM programming.
- Risky Sexual Behavior Among Orphan and Non-Orphan Adolescents in Nyanza Province, Western Kenya
Juma, M., Alaii, J., Bartholomew, L.K. et al. AIDS and Behavior (October 2012), e-publication ahead of print.
As described in this article, a household survey of 546 orphan and non-orphan adolescents, female and male, in four districts of Kenya’s Nyanza Province found no association between orphanhood and engaging in risky sex. The survey gathered information on specific behaviors, such as condom use, ever having sex, and experience with transactional sex, as well as parental/caretaker oversight of adolescents’ social activities and levels of psychosocial and financial support. The authors found that 44 percent of respondents reported ever having sex, 42 percent of whom had engaged in transactional sex; 25 percent reported condom use at last sex. Significantly more boys than girls had had sex (50 versus 37 percent), but girls were more likely than boys (52 versus 36 percent) to be involved in transactional sex. Factors that increased risk included sleeping unsupervised in a different house from the head of the household and participating in social activities at night. Older adolescents were more likely to have engaged in sex but also more likely to have used condoms. Adolescents who could discuss HIV with parents/caregivers or who perceived that their basic needs were met by their families were less likely to engage in sex.
- Can Women ‘Refuse’ Condoms? Dilemmas of Condom Negotiation among Men Living with HIV in South Africa
Mfecane, S. Culture, Health & Sexuality (October 2012), e-publication ahead of print.
This ethnographic study explored the gender and relationship dynamics behind women’s rejection of condom use initiated by their male partners. Over the course of 14 months, the author followed a sample of 25 HIV-positive South African men participating in HIV support groups. Encouraged within their groups to change behaviors and adopt safer sex practices, many of the men attempted to use condoms with their female partners. However, not all disclosed their HIV-positive status to each partner for multiple reasons, including fear of abandonment and of stigmatization. According to the author, several of the female partners, most of them unaware of their partners’ positive serostatus, rejected condom use. The author interprets the women’s refusal to accept condoms as one way to challenge male authority over sexual decision-making, pointing out that many South African women feel their social value is determined by their childbearing capacity, so they may reject condoms as contraception. While the men were often willing to abandon more casual partners who refused condom use, they did not leave wives or long-term girlfriends who did the same. The author concludes that it’s important for interventions to promote better interpersonal communications about sex to facilitate disclosure of HIV status and encourage joint decision-making on condom use to protect HIV-negative partners.
- Adaptation of a U.S. Evidence-based Positive Prevention Intervention for Youth Living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo
Parker, L., Maman, S., Pettifor, A. et al. Evaluation and Program Planning (September 2012), Vol. 36 No. 1, pp. 124-35.
This article describes how an evidence-based intervention (EBI) that originated in the United States was successfully adapted for use with young people living with HIV (PLHIV) in Kinshasa, Democratic Republic of the Congo (DRC). Formative research at four clinics serving young PLHIV in Kinshasa had found that, due to low levels of condom use and disclosure, this population was at risk of transmitting the virus to partners. To choose an intervention model and re-design it for a pediatric hospital setting in Kinshasa, the study team used the first four steps of the ADAPT framework, designed by the U.S. Centers for Disease Control and Prevention (CDC). The resulting Supporting Youth and Motivating Positive Action (SYMPA) project for young PLHIV delivered risk reduction programming through a six-session intervention. The article explains how SYMPA was adapted from the Healthy Living Project, a U.S.-based EBI, starting with an in-depth assessment of the target population and a literature review. Components of the original intervention were then changed to increase staff capacity and meet the specific needs of young PLHIV within the reduced resources of the DRC. The authors conclude that SYMPA shows how EBIs developed in a wealthy country such as the U.S. can be successfully adapted to a low-resource setting and a very different culture.
- Consistent Condom Use Among Men with Non-marital Partners in Four Sub-Saharan African Countries
Reynolds, H.W., Luseno, W.K., & Speizer, I.S. AIDS Care (October 2012), e-publication ahead of print.
Consistent condom use remains a difficult goal for most men to achieve, especially those in casual sexual relationships, according to the authors. These findings are based on an analysis of interview data from four African countries with generalized epidemics—Namibia, Swaziland, Tanzania, and Zambia—on the effect of marital status and number of partners on consistent condom use. The research team limited the sample population of 6,800 men to those who in the previous year had any casual (non-marital, non-cohabiting) sex partners. The data reveal that 41 percent of study participants in Zambia and 70 percent in Namibia used a condom every time with at least one partner; most were unmarried and non-cohabiting. Multivariate results in Swaziland and Zambia show that unmarried/non-cohabiting men with one casual partner were significantly less likely to use condoms consistently than were married/cohabiting men with casual partners. According to the authors, these results indicate that prevention programming should concentrate on increasing condom use by men in casual or multiple partnerships and similar risky sexual relationships. In general, higher education, religious affiliation, knowing one’s HIV status, having an STI, having a single lifetime partner, and positive attitudes about condoms were significantly associated with using a condom every time with any partner. The authors recommend that condom use messaging be targeted to men according to the number and types of relationships they have.
- Rectal Microbicide Development
McGowan, I. Current Opinion in HIV and AIDS (November 2012), Vol. 7 No. 6, pp. 526-33.
This article describes the progress made in recent years to develop microbicides—gels, suppositories, or other topical formulations that prevent HIV—for rectal use. The design and results of early vaginal microbicide trials informed the research direction for evaluating potential rectal microbicide candidates, as did early acceptability studies among men who have sex with men, who are highly vulnerable to HIV because of the common practice of unprotected receptive anal intercourse. Most rectal microbicides in the pipeline have reached only the preclinical study stage. Only two products—UC781, a non-nucleoside reverse transcriptase inhibitor, and tenofovir, a nucleotide inhibitor—have reached the clinical study stage, although L’644, a promising fusion inhibitor, is now also being evaluated. Qualitative and clinical studies of acceptability for different rectal microbicide formulations have found gels to be most acceptable. Rectal safety became the focus of research soon after researchers found that vaginal microbicide candidates were not optimal for rectal use, causing mucosal damage in the rectum; recent research findings show that reducing the glycerin in the formulation may be less harmful. The author describes the preclinical evaluation of four rectal microbicide candidates that have undergone Phase I trials: HIVNET-008 (N9 gel), RMP-01 (UC781 gel), RMP-02/MTN-006 (tenofovir gel), and MTN-007 (tenofovir gel with reduced glycerin). In his conclusion, the author suggests that Phase I studies on rectal microbicides will continue to produce important data on safety, acceptability, and pharmacokinetics that will contribute to early product development.
- Hormonal Contraceptive Use and Female-to-Male HIV Transmission: A Systematic Review of the Epidemiologic Evidence
Polis, C.B., Phillips, S.J., & Curtis, K.M. AIDS (October 2012), e-publication ahead of print.
This systematic review examines epidemiological evidence of the effects of hormonal contraception (HC) on the risk of HIV transmission from an HIV-positive woman to an HIV-negative man. The authors reviewed 12 studies with both direct evidence on HC use and HIV transmission and indirect evidence based on such proxy measures for infectivity in women as genital shedding or plasma viral load. The review identified only one study with direct evidence that both oral contraceptive pills and injectable HCs raise HIV risk (although only the estimates for injectables are significant). The 11 studies that yielded indirect evidence were very heterogeneous in size and approach, using different methods and providing a wide range of largely inconclusive results. For example, evidence of association with genital viral shedding was inconsistent for oral contraceptives and limited for injectables. The authors strongly recommend that, given how little direct evidence is available, more research be conducted on different HCs to determine their impact on HIV transmission. They note that understanding the effect of HCs on HIV transmission is especially important to support programmatic efforts to expand contraceptive choice for women in developing countries while simultaneously promoting HIV prevention efforts.
- Opiate Substitution Treatment and HIV Transmission in People Who Inject Drugs: Systematic Review and Meta-analysis
MacArthur, G.J., Minozzi, S., Martin, N. et al. BMJ (October 2012), e-publication ahead of print.
This systematic literature review and meta-analysis found that opiate substitution treatment is associated with a 54 percent reduction in HIV risk for people who inject drugs (PWID). A second but weaker finding is that longer exposure to opiate substitution treatment may provide HIV prevention benefits for PWID. According to the authors, these findings are in line with the hypothesis that successful substitution treatment removes PWID from risky injection situations. These results come from the authors’ review of data from 12 published and 3 unpublished observational studies on opiate substitution treatment, specifically methadone maintenance. Their analysis was based on pooled data from nine of the studies, which together yielded 819 incident HIV infections over 23,608 person-years of follow-up. Despite the clear evidence of the benefits of opiate substitution treatment, the authors point out that only an estimated 6 to 12 percent of PWID worldwide are enrolled in this form of therapy. The authors argue that, given rising HIV incidence among PWID in many regions of the world, their findings support opiate substitution treatment for this key population. The authors conclude by urging support for interventions that combine proven prevention approaches for PWID, including opiate substitution therapy, needle and syringe exchange, and other forms of harm reduction programming.
- Is Concurrency Driving HIV Transmission in Sub-Saharan African Sexual Networks? The Significance of Sexual Partnership Typology
Kretzschmar, M. & Caraël, M. AIDS and Behavior (October 2012), Vol. 16 No. 7, pp. 1746-52.
There has been strong disagreement in the past few years about the role that concurrent partnerships play in HIV transmission. With few empirical studies to back up the mathematical modeling that supports the concurrency theory, particularly in regions of very high HIV prevalence such as Southern Africa, the authors explore the difficulties of testing the “seemingly simple hypothesis” of concurrency as a primary driver of HIV transmission. First, they question whether mathematical modeling efforts—which abstract sexual behavior and thus create idealized factors to explain the spread of epidemics—are sufficiently sensitive to assess the real-world complexities of sexual networking at the population level. The authors also cite the difficulties inherent in defining quantities that can be measured in fieldwork and in HIV incidence, and in working without a universal standard definition of concurrency. They recommend developing a typology of concurrent partnerships that classifies by social determinants and sexual behavior within partnerships to better analyze sexual network structure and, ultimately, the impact of concurrency. In their conclusion, the authors argue that, while concurrent partnerships in theory play an important role in HIV transmission, concurrency has not yet been proven to be a “driving force” in the epidemic. They urge epidemiologists and mathematical modelers to work together to improve methods of investigating the impact of concurrency.
- An Urgent Need to Scale-up Injecting Drug Harm Reduction Services in Tanzania: Prevalence of Blood-borne Viruses Among Drug Users in Temeke District, Dar-es-Salaam, 2011
Bowring, A.L., Luhmann, N., Pont, S. et al. International Journal of Drug Policy (October 2012), e-publication ahead of print.
Injecting drug use in Tanzania, once relatively scarce, is on the rise, and with it the potential of increased transmission of blood-borne disease among populations of people who inject drugs (PWID). The HIV epidemic in mainland Tanzania is generalized, with overall national prevalence at about 5.7 percent; in Dar-es-Salaam, HIV prevalence among females and males in the general population is 10.2 and 7.2 percent, respectively. The authors report on the outcome of a rapid assessment of HIV and hepatitis C virus (HCV) prevalence among a sample of 267 PWID and 163 non-injecting drug users (NIDUs) in the low-income Temeke District of Dar-es-Salaam. After a quantitative questionnaire about patterns of drug use, socio-demographics, injecting risk behaviors, and knowledge about HIV and HCV, the study participants received counseling and testing for HIV and HCV. Among PWID, 30 percent of males and 67 percent of females tested HIV-positive; among NIDUs, 3 percent of males and 41 percent of females tested positive. Among PWID and NIDUs, 28 percent and 8 percent, respectively, tested positive for HCV. Survey analysis found that HIV-positive PWID selectively engage in risky injecting practices and that few get regular HIV testing, and that access to clean needles/syringes is inadequate. The authors recommend rapid expansion of harm reduction programming nationwide.
- HIV Surveillance: The Conscience of the Epidemic
Sullivan, P.S. & Delpech, V. The Open AIDS Journal (2012), Vol. 6 Suppl. 1, pp. 65-66.
This editorial introduces a special journal issue about the development of HIV surveillance systems and their contribution over time to understanding the spread of the epidemic. Sullivan and Delpech note that surveillance methodologies have evolved to respond to new advances—in health infrastructure and public health technologies—and to meet such challenges as drug resistance. They point out that the issue’s 21 articles collectively express the importance of widespread dissemination of surveillance data, especially in an open access format. Within this issue, Frankel and co-authors describe the three-stage probability sampling method used by the Medical Monitoring Project. Lansky and co-authors analyze city-specific data collected using respondent-driven sampling to test assumptions about its appropriateness for sampling specific populations. Sanchez and co-authors report that internet-based sampling may reach more higher-risk men who have sex with men (MSM) than venue-based sampling, while Purcell and co-authors describe how the U.S Centers for Disease Control and Prevention used surveillance surveys to estimate the population size of MSM in the United States. Other articles focus on reporting laboratory data through HIV surveillance, estimating risk factors for Rwandan sex workers with incidence tests, using HIV case surveillance to design site-randomized HIV prevention intervention studies, using HIV surveillance data to reveal missed opportunities for linkage to medical care, and auditing national HIV guidelines and policies in the United Kingdom through its CD4 surveillance system.
- Fiscal Year 2013 Country Operational Plan Guidance
The U.S. President’s Emergency Plan for AIDS Relief (October 2012).
Key populations that are at high risk for HIV—men who have sex with men, people who inject drugs, sex workers—get special focus in this latest guidance from the Office of the Global AIDS Coordinator. The guidance for writing country operational plans (COPs) reflects goals for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to be met by the end of 2013, as elucidated by President Obama, who called this era “the beginning of the end of AIDS” on World AIDS Day 2011. In addition to key populations, the guidance also puts greater focus on programming for HIV-related tuberculosis and specifically directs PEPFAR teams in countries with severe epidemics to increase budgetary allocations to HIV treatment. Other goals include treating more than 1.5 million HIV-positive pregnant women with antiretroviral (ARV) drugs to prevent mother-to-child transmission, supporting more than 4.7 million voluntary medical male circumcisions in Africa, supporting more than 6 million HIV-positive people on ARVs, and distributing more than 1 billion condoms. The contents include preparing COPs, setting priorities, meeting earmarks, following reporting requirements, preparing budgets to conduct activities, and managing operations. COPs for each of 31 countries required to prepare one reflect the input of all U.S. Government agencies working in HIV activities in that country and thus encourage teamwork in planning and achieving goals.
- PEPFAR Scientific Advisory Board Meeting Proceedings
The U.S. President’s Emergency Plan for AIDS Relief (October 2012).
This page on the website of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) links to speeches, presentations, an executive summary, and other materials from the third meeting of the PEPFAR Scientific Advisory Board (SAB), held in Washington on October 2 and 3, 2012. The SAB advises U.S. Global AIDS Coordinator Eric Goosby on scientific, implementation, and policy issues related to the global HIV epidemic. The executive summary identifies five key issues discussed at the meeting:
• Linkage and retention in care and treatment: The many complex challenges that impede the entry and retention of newly HIV-diagnosed persons into treatment and care services can result in greater morbidity and mortality and in biased assessments of effectiveness. Among other recommendations, the SAB urged use of special sampling techniques that discern loss to follow-up.
• Ethics and key populations: The SAB presented a framework to help PEPFAR engage ethically with key populations that experience stigmatization and discrimination.
• Combination prevention: The SAB recommended that a special meeting be scheduled to help three PEPFAR combination prevention studies in Southern Africa coordinate their study designs and methods.
• Children and adolescents: The multiple needs of children affected by HIV are not being fully addressed. The SAB recommended conducting more research on at-risk youth and following HIV-positive children as they transition into adolescent and then adult care.
• Data: The SAB recommended creating a PEPFAR knowledge portal as well as making the agency’s data collection public.
- WHO 2012 Global Tuberculosis Report
World Health Organization (October 2012)
Significant progress has been made in the global response to tuberculosis (TB) in recent years, with decreased incidence, greater access to care, and deaths from TB plummeting by 40 percent since the 1990s. While important goals have been attained, progress in ending the TB epidemic has not reached all areas of Africa, Asia, and Europe. As this World Health Organization (WHO) report points out, of infectious diseases, TB remains the second leading cause of death around the world, responsible for 1.4 million deaths in 2011. The report discusses both advances and remaining challenges in stopping TB’s spread, notably in regions such as sub-Saharan Africa, where co-infection with HIV is as high as 80 percent and is responsible for failure to meet TB control goals. While sizable price reductions have made the GeneXpert diagnostic tests affordable for more than 60 resource-limited countries, other countries are still using diagnostics based on 50-year-old technology. New drugs are being developed for multi-drug-resistant TB, but funding gaps—$3 billion per year between 2013 and 2015—are predicted for care, treatment, research, and development. Funding also remains a priority for basic research into the pathology of TB. To fill funding gaps that threaten to halt forward movement in combating TB, the WHO recommends targeted international donor funding.