HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- PEPFAR Guidance for the Prevention of Sexually Transmitted Infections
Office of the U.S. Global AIDS Coordinator (August 2011), for the President’s Emergency Plan for AIDS Relief (PEPFAR)
This PEPFAR guidance document is based on four overarching recommendations:
1. Set epidemiologically sound priorities.
2. Program for the social and cultural context.
3. Support a coordinated response.
4. Establish quality assurance, monitoring, and evaluation.
The document emphasizes the importance of using an array of behavioral, biomedical, and structural approaches, and endorses combination prevention for all PEPFAR country programs. It also calls for a comprehensive approach that relies on the “four knows”: knowing the epidemiological country data, the current response, the country context, and the costing data. The document includes a comprehensive section on evidenced-based interventions, as well as implementation guidance. It strongly emphasizes the value of providing effective services to most-at-risk populations (MARPs) and creating an enabling environment for people living with HIV. The final part of the document outlines a methodology based on a recent paper published in The Lancet on how to set priorities for an effective response to HIV. It encourages countries to include the following in any response:
• Overarching elements (e.g., assessing treatment coverage and addressing behavior)
• HIV testing and counseling
• Foundations for prevention (e.g., blood safety, universal precautions, programs for youth, post-exposure prophylaxis)
• Core interventions (e.g., prevention of mother-to-child transmission, voluntary medical male circumcision, condoms, programming for MARPs, programming for people living with HIV)
• Critical enablers (e.g., programs, services, and policies to address sexually transmitted infections, gender-based violence, structural constraints, stigma)
• Innovative evaluation approaches.
The document also links to the Global Health Initiative (GHI) and encourages country programs to coordinate with the GHI and other U.S. Government activities.
Related AIDSTAR-One Prevention Knowledge Base Topic: An Overview of Combination Prevention
- Addressing Social Drivers of HIV/AIDS for the Long-Term Response: Conceptual and Methodological Considerations
Auerbach, J. D., Parkhurst, J. O., & Caceres, C. E. Global Public Health (July 2011), e-publication ahead of print.
According to the authors, behavioral patterns and practices develop as a result of a combination of social-structural drivers that may increase vulnerability and lead to increased risk of HIV acquisition. These drivers involve a vast array of cultural, legal, political, and economic conditions. This paper provides a framework and recommendations for integrating and evaluating comprehensive social and structural components in any combination prevention approach. The authors discuss the importance of identifying “sociologically plausible” pathways between structural drivers and HIV beyond the single, causal determinants that have traditionally been associated with the risk of transmission. They also advocate for an expanded discussion on “how, in what circumstances, and for whom” a combination of structural drivers contributes to increased HIV vulnerability. The authors recommend several important steps for developing interventions to address social/structural factors:
• Conduct an assessment of potential social and structural factors.
• Hypothesize potential causal pathways between structural factors and individual and group behaviors.
• Identify possible interventions to influence the social and structural factors.
• Clarify assumptions and possible expected and unexpected consequences of the intervention or program.
• Create comprehensive evaluation mechanisms to measure assumptions, validity, effectiveness, outcomes, and impact of potential programming.
Finally, the authors recognize that although addressing social and structural factors may not yield short-term results, they are bound to have a significant long-term impact on the reduction of HIV and on overall health and well-being.
Related AIDSTAR-One Prevention Knowledge Base Topic: An Overview of Structural Approaches to HIV Prevention
- Antiretroviral Therapy for Prevention of HIV Transmission in HIV-Discordant Couples
Anglemyer, A., Rutherford, G. W., Baggaley, R. C., et al. Cochrane Database Systematic Reviews, No. 8 (August 2011).
This systematic review of one randomized controlled trial and seven observational studies finds that the use of antiretroviral therapy (ART) is safe and is associated with a decreased risk of HIV transmission in discordant couples in which the HIV-positive partner has no more than 550 CD4 cells/μL. According to the authors, all eight studies show that uninfected partners in serodiscordant relationships had at least a threefold lower risk of acquiring HIV if their HIV-positive partners were receiving ART. The authors found that the randomized trial (HPTN 052) provided clear data on the benefit of treating HIV-positive partners (in this case, long-term partners) with a count of between 350 and 550 CD4 cells/μL. According to the authors, since most of the couples in these eight studies were heterosexual, the findings may not be applicable to other most-at-risk populations, such as men who have sex with men. The article encourages additional costing studies to determine the financial implications of recommending ART for prevention. The authors question whether, based on this evidence, the World Health Organization’s guidelines should recommend ART for HIV-negative individuals involved in serodiscordant relationships whose partners’ count is ≥350 CD4 cells/μL. They also ponder some of the ethical questions involved in offering treatment for individuals with a CD4 count above 350, when treatment for individuals with less than 350 CD4 cells/μL is still limited. To increase effective implementation, they advocate for comprehensive programming that includes counseling, support, follow-up, and mutual disclosure.
Related AIDSTAR-One Prevention Knowledge Base Topic: Antiretroviral Therapy as an HIV Prevention Strategy
- Social Network-Based Interventions to Promote Condom Use: A Systematic Review
Wang, K., Brown, K., Shen, S. Y., & Tucker, J. AIDS and Behavior (August 2011), Vol. 15 No. 7, pp. 1298-1308.
According to the authors of this systematic review, the use of social networks—groups of individuals who knew each other prior to the intervention—in condom promotion campaigns leads to marked increases in condom use. The studies included social networks among people who inject drugs, female sex workers, men who have sex with men, and African-American youth. All of the 11 reviewed studies relied on social networks defined by the index participants themselves, and 10 of the 11 studies demonstrated significant improvements in condom use and high retention rates in the program, compared to non-network recruitment methods. Eight of the nine randomized controlled trials demonstrated improvement in at least one measure comparing control and intervention conditions. According to the authors, some challenges still remain in the recruitment of social networks, including motivating index participants to recruit and distribute information among their social networks, and identifying social networks among most-at-risk populations. The authors encourage further research to expand upon these results and discuss the scalability of network-based condom-promotion programming.
- Condom Use Decision Making in the Context of Hypothetical Pre-Exposure Prophylaxis Efficacy among Substance-Using Men Who Have Sex with Men: Project MIX
Koblin, B. A., Mansergh, G., Frye, V., et al. Journal of Acquired Immune Deficiency Syndrome (August 2011), e-publication ahead of print.
According to the authors, decision making for condom use among men who have sex with men (MSM) would be adversely affected by alcohol and drug use if pre-exposure prophylaxis (PrEP) were available. This study, which recruited 645 substance-using MSM from four U.S. cities who had never used PrEP, examined widely accepted psychosocial factors associated with condom use among MSM in the context of PrEP, and how these factors might inform future prevention messaging accompanying PrEP use among substance-using MSM. The men were placed into three different groups based on how they would determine whether to use a condom for receptive/insertive anal intercourse while using PrEP. The three groups broke down as follows, based on PrEP’s efficacy: (1) 72.5 percent of the study participants said they would not use a condom if PrEP had a high efficacy rate (above 50 percent), (2) 15.2 percent said they would not use a condom if PrEP had a mid-range efficacy rate (effective at least half the time or more, and (3) 12.3 percent said they would not use a condom if PrEP had a low efficacy rate (effective less than half the time). The study found that men in the mid-range efficacy group would have more difficulty communicating about safer sex while under the influence of alcohol or other substances than would the low-efficacy group. Compared to men in the high-efficacy group, the mid-range efficacy group scored lower on self-efficacy for safer sex and intention to use condoms and would likely give up condoms while using PrEP. Men in the low-efficacy group said they would most likely not use condoms regardless of PrEP efficacy rates. Based on these outcomes, the authors suggest that behavioral counseling should accompany the roll-out of PrEP among substance-using MSM, particularly those identified in the mid-range efficacy group. They also suggest that incorporating PrEP and targeted counseling into substance abuse treatment may serve as a way to provide access to PrEP for substance-using MSM.
Related AIDSTAR-One Prevention Knowledge Base Topic: Pre-exposure Prophylaxis (PrEP) for HIV Prevention
- Randomized Clinical Trial of Brief Risk Reduction Counseling for Sexually Transmitted Infection Clinic Patients in Cape Town, South Africa
Kalichman, S. C., Cain, D., & Eaton, L. American Journal of Public Health (September 2011), Vol. 101 No. 9, pp. e9-e17.
This study examines the effectiveness of a brief risk-reduction counseling intervention in reducing unprotected vaginal and anal intercourse and preventing sexually transmitted infections (STIs). According to the authors, the most frequent and most persistent high-risk behaviors were among the heaviest drinkers in the control group, and the intervention effects were less effective among heavier drinkers than among lighter drinkers. The brief risk-reduction counseling intervention demonstrated significant reductions in incident STIs (with 24 percent fewer STIs at the one-year follow-up) and in unprotected vaginal and anal intercourse among those receiving the intervention, and was greatest among those reporting fewer partners. Those in the control group also demonstrated lower risk-related substance use and reduced expectations that alcohol enhances sexual experiences. According to the authors, the intervention did not have any effect on the number of partners or condom use, and unprotected intercourse outcomes were no longer significant after nine months. The authors also did not find any correlation between increased HIV prevention knowledge and behavior change. However, the authors found that the diagnosis and treatment experience, along with standard of care interventions, did have an impact on risk-reduction behaviors, and they recommend single-session risk-reduction sessions for people who have contracted an STI. They also recommend a follow-up risk-reduction counseling session between three and six months after the initial intervention to increase the impact.
- Do Teenagers Respond to HIV Risk Information? Evidence from a Field Experiment in Kenya
Dupas, P. American Economic Journal: Applied Economics (January 2011), Vol. 3 No. 1, pp. 1-34.
Using the incidence of pregnancy as an objective proxy for the incidence of unprotected sex, this randomized controlled study measured the types of information that influence the sexual risk behavior of Kenyan teenagers, particularly girls in the last grade of primary school. Among adolescent participants at 71 primary schools in western Kenya who received information on the relative risk of HIV infection by partner’s age, there was a 61 percent decrease in the incidence of non-marital pregnancies with older (riskier) partners, with no increase in pregnancies with same-age partners. The authors also detected a 28 percent decrease in pregnancy overall and a shift toward same-age partners. In comparison, the official HIV and AIDS prevention curriculum for primary schools, which lacked information on risk distribution by age, did not demonstrate any impact on the incidence of unprotected sex, as measured by pregnancy rates. Based on these results, the authors stress that the effectiveness of a certain intervention may depend on providing information on the choice between the “intensive margin” (high- and low-risk varieties of an activity) rather than only on the “extensive margin” (the choice between some activity and no activity at all, as expressed, for example, in abstinence-only messaging), and that most individuals are more willing to demonstrate behavior change on the intensive margin rather than the extensive margin.
- Making Treatment as Prevention for HIV a Reality
Treatment as Prevention for HIV. The Lancet (August 2011), Vol. 11 No. 9, p. 651.
HIV Drug-Prevention Strategy Carries Risks. Hayden, E. Nature (August 2011), Vol. 476, pp. 260-261.
Complexity Surrounds HIV Prevention Advances. Cohen, J. Science (July 22, 2011), Vol. 333 No. 6041, pp. 393.
According to the editorial in The Lancet, “treatment as prevention” has recently become a mantra since the 2011 Sixth International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention and the release of the results of several major trials in the past year, including CAPRISA 004, iPrEx, and HPTN 052. The editorial acknowledges the breakthroughs these trials represent and the fact that effective treatment to control viral load is already helping to prevent transmission, yet warns that these results must be “tempered with caution.” According to the editorial, there are several challenges to making treatment as prevention a reality, including a treatment gap for HIV-positive individuals in need of treatment to prolong their lives, the risk of resistance to antiretroviral drugs, and risk disinhibition (i.e., increased high-risk behavior among populations because they believe themselves to be protected). The editorial reminds readers that any approach to treatment as prevention must include behavioral interventions and encourage a sustainable drug-development pipeline. Erika Hayden in her Nature editorial and Jon Cohen in his Science Magazine news analysis echo these concerns. They discuss the possible unintended public health consequences of treatment as prevention and the myriad of practical, ethical, and financial issues. Hayden describes the importance of testing and monitoring and the ethical questions that will arise about treating high-risk groups when those already infected are not receiving antiretroviral drugs. Cohen points out that no consensus exists on who should use pre-exposure prophylaxis and for how long.
Related AIDSTAR-One Prevention Knowledge Base Topic: Antiretroviral Therapy as an HIV Prevention Strategy
- Pediatric HIV—A Neglected Disease?
Lalleman, M., Chang, S., Cohen, R., & Pecoul, B. New England Journal of Medicine (August 2011), Vol. 365 No. 7, pp. 581-583.
The authors caution that treatment as prevention may take more than just having the drugs available. They point out that 15 years after the use of antiretrovirals (ARVs) began to eliminate mother-to-child transmission (MTCT) of HIV in high-income countries, prevention coverage for MTCT in sub-Saharan Africa and in Asia remains limited. According to the authors, less than one-third of children in need of ARVs are currently receiving treatment. Diagnosing HIV infection in infants remains a challenge, treatment options for children remain limited, appropriate dosing of ARVs for children remains an issue, antenatal care attendance remains low, access to HIV testing for pregnant women remains limited, and restricted alternatives to breastfeeding continue to hamper efforts to treat children. The authors call for an improved, affordable, first-line pediatric regimen for infants that is easily administered, better tolerated by children, and compatible with tuberculosis drugs. According to the authors, there is a limited pipeline of new products for pediatric HIV because vertical transmission of HIV has been virtually eliminated in the developed world, and resource-poor countries do not present a viable market for pharmaceutical companies. The authors insist that programs to eliminate new HIV infections in low- and middle-income countries not forget children already infected with HIV.
Related AIDSTAR-One Prevention Knowledge Base Topic: Prevention of Mother-to-Child Transmission of HIV
- Structural Determinants of Adolescent Girls’ Vulnerability to HIV: Views from Community Members in Botswana, Malawi, and Mozambique
Underwood, C., Skinner, J., Osman, N., et al. Social Science Medicine (July 2011), Vol. 73 No. 2, pp. 343-350.
This study expands the research on community views concerning adolescent girls’ vulnerability to HIV and appropriate responses. During focus group discussions in Botswana, Malawi, and Mozambique, community members identified being an orphan, poor school attendance, socioeconomic disparities, and lack of legal support as major causes of girls' vulnerability to HIV. Community respondents further identified a connection between these structural factors and exposure to unprotected sexual relationships, particularly those that are transactional and age-disparate. They pinpointed transactional-intergenerational sex as the primary driver of concurrent and unprotected sex among adolescent girls, and identified poverty and adolescent social identity (or desire for material goods), as well as access to alcohol, as key factors of girls’ vulnerability. Rather than propose individual-focused behavioral interventions and biomedical interventions such as counseling and testing, the community focused on structural interventions as key factors to address girls’ vulnerability. They called for enforcement of laws and regulations prohibiting the sale of alcohol to adolescents and additional security to protect girls against sexual violence and the threat of violence for sexual coercion. They also called for increased communication about sexual matters between adults and adolescents. One result of this study was a community mobilization plan developed to mitigate girls’ vulnerability, including economic strengthening, a school personnel training component, legal literacy, and an adult-child communication component.
Related AIDSTAR-One Prevention Knowledge Base Topics: Structural Interventions
- Increased Risk of HIV-1 Transmission in Pregnancy: A Prospective Study among African HIV-1 Serodiscordant Couples
Mugo, N. R., Heffron, R., Donnell, D., et al. AIDS (July 2011), Vol. 26 No. 15, pp. 1887-1895.
This prospective study of 3,321 African HIV-1 serodiscordant couples finds that risk of female-to-male HIV acquisition increases twofold during pregnancy. Pregnancy is associated with both increased incidence of HIV-1 acquisition in women and HIV-1 transmission from women to men. According to the authors, these results possibly signal biological changes (e.g., increased shedding of HIV -1 in female genital secretions) in pregnancy and the postpartum period that may facilitate HIV-1 transmission. The authors caution that sociocultural pressure on couples to conceive may outweigh serodiscordant couples’ desires to protect against transmission of HIV-1. The authors call for increased access to couples HIV testing and counseling, promotion of condom use, earlier access to combination antiretroviral therapy (ART), and strengthening of family planning and maternal health services for HIV-positive women and those at risk for HIV-1. These measures may reduce unwanted pregnancies, prevent mother-to-child transmission, and avert HIV-1 transmission to pregnant women and their partners. For serodiscordant couples who wish to conceive, the authors recommend preconception counseling, early access to combination ART use by the HIV-positive partner, and preexposure prophylaxis for the uninfected partner. The authors also advocate for repeat HIV-1 testing in pregnancy and increased male involvement in antenatal care settings to protect mothers, infants, and male partners from HIV-1.
Related AIDSTAR-One Prevention Knowledge Base Topic: HIV Prevention for Serodiscordant Couples
- Operational Guidelines for Monitoring and Evaluation of HIV Programmes for Sex Workers, Men Who Have Sex with Men, and Transgender People
Weir, S., et al. MEASURE Evaluation (August 2011).
This document, designed for program managers involved in HIV programming for men who have sex with men, sex workers and their clients, or transgender people, offers guidance in planning, monitoring, and evaluation, and complements the Operational Guidelines for Monitoring and Evaluation of HIV Programmes for People Who Inject Drugs. This consultation version, developed by the UNAIDS Monitoring and Evaluation Reference Group, serves as a reference for a final draft that will be available online in 2012. The Guidelines apply to countries with low-level, concentrated, and generalized HIV epidemics that require three levels of monitoring and evaluation: national, sub-national, and service delivery. The Guidelines are divided into four sections:
• Definitions of key concepts, including the “Eight Step Public Health Questions Model”
• Information for the national and sub-national level for each of the eight steps
• Guidance for the service delivery level, with a particular emphasis on providing high-quality services
• An appendix containing tools referenced throughout the Guidelines, a glossary of terms, and reference materials.
Sections II and III include rationale; flow charts of key questions; methods and data use; an overview of key questions and use of data, methods, and tools; a summary; and additional information for each of the eight steps.
Related AIDSTAR-One Prevention Knowledge Base Topic:
HIV Prevention for Hard-to-Reach Men Who Have Sex with Men
- President’s Emergency Plan for AIDS Relief 2012 Country Operational Plan Guidance
Office of the Global AIDS Coordinator (August 2011).
In early August 2011, the Office of the Global AIDS Coordinator (OGAC) released the 2012 Country Operational Plan (COP) Guidance. The COP documents annual investments and anticipated results for HIV efforts by the U.S. Government (USG), serves as a basis for approval of annual USG bilateral HIV funding in most countries, assists in the development of annual workplans, and provides data to the U.S. Congress and other key stakeholders. The Guidance serves as a framework for developing country COPs and offers recommendations by OGAC for developing COPs. This year’s Guidance highlights seven program priorities in non-hierarchical order, including increasing coverage and effectiveness of prevention of mother-to-child transmission (PMTCT), improving and refining country approaches to treatment, implementing programming for prevention, integrating TB and HIV services, expanding testing and counseling, training new health care providers, and increasing capacity building. These priorities are based on five basic approaches: integration, the continuum of the HIV response, attention to specific vulnerable populations, the Global Health Initiative, and country ownership. The Guidance emphasizes treatment coverage and includes a table to help country teams determine treatment scale-up targets. It also includes information on the mandatory earmarks, budgetary and reporting requirements, and the “soft” earmarks or programmatic priorities. The Guidance offers direction on family planning and refers to OGAC’s guidance for most-at-risk populations. Implementation science and public health evaluation are discussed in detail as new approaches, as are indicators and setting targets for COPs.
- Prevention Resources for People Living with HIV Website
President’s Emergency Plan for AIDS Relief (PEPFAR) Prevention with People Living with HIV Taskforce (August 2011).
The PEFPAR Prevention with People Living with HIV Taskforce, which includes participants from the Centers for Disease Control and Prevention (CDC), the U.S. Agency for International Development (USAID), and the Department of Defense (DoD), recently developed a website to help program and policy planners design, develop, and deliver effective clinic- or community-based programs to ensure that all HIV-positive people have access to evidence-based, comprehensive HIV prevention services. The site provides a summary of literature, curricula, and guidelines for comprehensive prevention strategies for people living with HIV (PLHIV) and include four main goals:
1. Protecting the physical health of PLHIV
2. Preventing transmission of HIV to sexual partner(s) and children of PLHIV
3. Protecting the mental health of PLHIV
4. Involving PLHIV in the provision of interventions and services, policy development, and advocacy efforts.
The site includes technical sections on acquisition and transmission of HIV, positive physical health, positive mental health, and involvement of PLHIV, and is open to submissions of literature, curricula, and guidelines.
- SAfAIDS 'Changing the River's Flow' Event
Southern Africa HIV and AIDS Information Dissemination Service.
The second Change the Flow event, sponsored by SAfAIDS, will be held from November 1-3 in Harare, Zimbabwe. This year's summit, held under the theme 'Sexual and Reproductive Health and Cultural Practices: A Linking, Learning and Sharing Platform for Interrogating HIV, Gender-based Violence and Maternal and Child Health Interventions in Southern Africa’, will provide a platform for participants to learn and share evidence on successful models, strategies and approaches for innovating and integrating HIV prevention, gender and sexual and reproductive health (SRH) interventions in southern African communities.