HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Risks and Benefits of Lifelong Antiretroviral Treatment for Pregnant and Breastfeeding Women: A Review of the Evidence for the Option B+ Approach
Ahmed, S., Kim, M.H., and Abrams, E.J. Current Opinions in HIV and AIDS, (September 2013), Vol. 8 No. 5, pp. 474-489.
The authors reviewed evidence of Option B+ for prevention of mother-to-child transmission (PMTCT) of HIV (lifelong antiretroviral therapy [ART] for all pregnant and breastfeeding women through once-daily, fixed-dosed combination ART, irrespective of CD4 count) in terms of maternal and infant health and programmatic and public health impact. They highlighted potentially significant benefits and risks of Option B+, (e.g., health outcomes, safety, adherence, and resistance), and suggested research priorities. The authors indicated that many countries plan to adopt the Option B+, but there remain uncertainties that should be considered. Some studies show that Option B+ may be more protective of mothers and infants than other regimens in real world settings; however, Options A and B were found to have similar efficacy in clinical trials. Option B+ may be more feasible programmatically, as it simplifies service delivery; however, it could overwhelm resource-limited health structures. The authors also discussed Option B+ in relation to reduced transmission to partners, access and uptake, retention, and cost. Further research should compare efficacy of Option B+ with other regimens and assess its impact on health systems. Although there is much optimism about rapid elimination of mother-to-child transmission, the authors advocated a cautious approach while the full effects of Option B+ for PMTCT are being explored.
- Availability of HIV Prevention and Treatment Services for People Who Inject Drugs: Findings from 21 Countries
Petersen, Z., Myers, B., van Hout, M-C., et al. Harm Reduction Journal (August 2013), Vol. 10 No. 13.
The authors collected data on the prevalence of injection drug use (IDU) and of HIV among people who inject drugs (PWID), and the availability and coverage of antiretroviral therapy (ART) and harm reduction services for PWID in 21 low-and middle-income countries. They identified three key findings: First, the prevalence of IDU was high in some countries, while emerging in others, with an average of 22 percent of PWID living with HIV. Second, ART for HIV-positive PWID was reportedly available in all countries, but the numbers who receive treatment were low. Third, provision and coverage of harm reduction services for PWID varied. Needle and syringe programs were available in 20 countries, yet coverage data, available for 13 countries, indicated low use. Opioid substitution therapy was available in 17 countries. Prevalence of HIV-positive PWID ranged from 3 percent in Kazakhstan to 58 percent in Vietnam. Russia and Ukraine have the largest reported IDU rates; while, IDU remains uncommon in sub-Saharan Africa, it is increasing in Kenya, Nigeria, and Tanzania, and drives HIV in Mauritius. The authors emphasized the importance of collecting routine and standardized data on IDU trends and HIV rates, and monitoring the impact of scaling up ART and harm reduction services. These services should be scaled up for PWID, who are at high HIV risk.
- Potential Impact of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) on the Tuberculosis/HIV Co-Epidemic in Selected Sub-Saharan African Countries
Lima, V.D., Granich, R., Phillips, P., et al. Journal of Infectious Diseases (September 2013), E-publication ahead of print.
To address limited evidence on the impact of expanded HIV prevention activities on the tuberculosis (TB) epidemic, the authors conducted an ecological study to analyze and compare epidemiologic data on TB incidence and mortality before (1996-2002) and after the launch (2004-2007) of PEPFAR in 12 selected PEPFAR focus countries and 29 other countries (non-PEPFAR focus) in sub-Saharan Africa. They found important interactions between the HIV and TB epidemics, suggesting that investment in HIV also affects related diseases, including TB. While TB incidence was diminishing in all countries (despite increased HIV prevalence in some countries), incidence and TB mortality rates were lower in PEPFAR focus countries after the launch of PEPFAR. In certain PEPFAR focus countries, e.g., Kenya, Tanzania, Uganda, and Ethiopia, both epidemics experienced decreasing trends. The results supported increased investment in HIV and TB programs, yet it is unclear whether integrated TB/HIV programs will reach those most in need. Further operational research is warranted to accurately assess the impact of individual PEPFAR and Global Fund activities on the co-epidemic and the longitudinal effect of PEPFAR and Global Fund programs at the population level. Implementing strategies to find HIV and TB cases, combined with linkage to care and treatment, including HIV and TB treatment, may reduce the number of preventable deaths and new infections.
- From Coitus to Concurrency: Sexual Partnership Characteristics and Risk Behaviors of 15–19 Year Old Men Recruited from Urban Venues in Tanzania
Yamanis, T.J., Doherty, I.A., Weir, S.S., et al. AIDS and Behavior (2013), Vol. 17, pp. 2405-2415.
Within a project to assess determinants of sexual risk behavior among young men in a high-risk ward of Dar es Salaam, Tanzania, the authors present findings from a cross-sectional survey of men ages 15-19 (n=663) who socialized at 66 venues known for meeting sexual partners. They found that as male youth transitioned from early to late adolescence, engaging in concurrent sexual partnerships became a normative behavior. Increasing age was correlated with increasing sexual experience and gradually increasing prevalence of concurrency. The authors applied stratified models at ages 15-17 and 18-19. The six-month aggregate prevalence of concurrency was 29 percent; prevalence among sexually experienced youth was 42 percent. Concurrency increased by age: 5 and 44 percent among males age 15 and age 19, respectively. In both age groups, concurrency was associated with having had at least two sexual partners; visiting multiple social venues on the day the survey was conducted; and having met at least one partner at a venue. Alcohol use was frequently reported by older youth. Future studies should assess whether peer pressure to engage in risky sexual behavior is more common for young men than women, as the authors hypothesized. The authors called for further research to understand how venue-based social networks may influence young men's sexual risk behavior.
- Evolving Uses of Oral Reverse Transcriptase Inhibitors in the HIV-1 Epidemic: From Treatment to Prevention
Gupta, R., Van de Vijver, D.A.M.C., Manicklal, S., et al. Retrovirology (July 2013), Vol. 10 No. 82.
The authors reviewed antiretroviral therapy (ART) for HIV treatment and prevention, focusing on reverse transcriptase inhibitors (RTI) used for prevention of mother-to-child transmission (PMTCT) over the past two decades; which are being examined for application in adult HIV prevention through treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). The authors describe the potential impact of TasP and PrEP and drug resistance challenges. Data suggest that both approaches may achieve population-level impact in preventing HIV transmission, and that lessons learned from PMTCT can guide implementation. However, TasP and PrEP may result in the emergence and transmission of drug resistance. Optimal adherence has been determined to be critical to effectiveness, and continued research on adherence and drug resistance is imperative. Evidence shows that resistance to nucleoside RTIs, and especially non-nucleoside RTIs, has increased since ART scale-up, particularly in eastern Africa. While a trial and modeling studies have demonstrated the promise of TasP, practical barriers include adherence, poor retention in care, late diagnosis, and costs. Resistance is especially worrisome in resource-poor countries where genotypic resistance and point-of-care viral load testing are not standard of care. Clinical trials of PrEP have shown mixed efficacy, with adherence a critical factor, and concerns about drug resistance in individuals who continue to use PrEP after unknowingly becoming infected. New drug classes of HIV treatments that do not overlap with HIV prevention strategies, less frequent dosing, and reduced toxicities are needed.
- High HIV Testing Uptake and Linkage to Care in a Novel Program of Home-Based HIV Counseling and Testing With Facilitated Referral in KwaZulu-Natal, South Africa
van Rooyen, H., Barnabas, R.V., Baeten, J.M., et al., Journal of Acquired Immune Deficiency Syndromes (September 2013), Vol. 64 No. 1.
The authors assessed an innovative model of home-based counseling and testing (HBCT), HBCT Plus –included point-of-care (POC) CD4 testing and referrals to HIV care in rural KwaZulu-Natal, to determine if the model achieved high testing coverage; reached persons unaware of their HIV status; and reduced infectiousness and barriers to accessing HIV care through antiretroviral therapy (ART) adherence. HBCT Plus achieved high uptake of HIV testing and increased knowledge of HIV status; POC CD4 testing, referral, and follow-up from lay counselors attained nearly 100 percent linkage to HIV care and ART initiation. From March 2011 to March 2012, 671 participants were tested; of these, 201 were HIV-positive, and 73 (36 percent) newly identified as positive. The number of participants reporting ever visiting a HIV clinic increased from 116 (57 percent) to 196 (96 percent) at baseline and six-month follow-up, respectively. At follow-up, there was a significant reduction in the mean HIV viral load, and an increase in the proportion with a viral load <1000 copies per milliliter among those ART-eligible. The model could be combined with other effective mobile testing strategies; and while it is promising, its impact and cost-effectiveness should be assessed in remote areas with greater distances to referral clinics to inform national HIV programs.
- Home Visits during Pregnancy Enhance Male Partner HIV Counselling and Testing in Kenya: A Randomized Clinical Trial
Onyango, O.A., Grace, J.-S., James, K., et al. AIDS (August 2013), E-publication ahead of print.
The authors implemented a randomized, single-blind clinical trial in Nyanza Province, Kenya, to compare the accessibility and uptake of couples HIV testing and counseling (HTC) by male partners during home visits versus appointments at antenatal care (ANC) clinics. Home visits reached and tested at least twice as many partners, and identified and referred more HIV-positive men, compared with the clinic group. Pregnant women seeking ANC were randomized to receive home visits for couples HTC (n=150) or to invite their male partner to the clinic (n=150); 128 (85 percent of those reached) and 54 (36 percent of those reached) male partners underwent couples HTC at homes and the clinic, respectively. Couples were significantly more likely to learn that they were concordant negative tested at home (66 percent) rather than at the clinic (26 percent); yet home-visit couples were also three times more likely to be HIV-serodiscordant. Women whose partners were tested at home were more likely to report improved quality in the relationship (67 to 28 percent). Long-term studies are needed to monitor relationship outcomes. Home HTC visits were highly acceptable for couples, which may lessen barriers to reaching male partners. The authors concluded that the home visit strategy for couples HTC during pregnancy may achieve public health impact and increase uptake of prevention of mother-to-child transmission services in high-prevalence and low-income settings.
- Where to Deploy Pre-Exposure Prophylaxis (PrEP) in Sub-Saharan Africa?
Verguet, S., Stalcup, M., and Walsh, J.A. Sexually Transmitted Infections (August 2013), E-publication ahead of print.
The authors used a deterministic epidemiologic model to assess the impact and cost-effectiveness of implementing a pre-exposure prophylaxis (PrEP) intervention from 2013 to 2017 for the general adult population in 42 countries in sub-Saharan Africa. The findings suggest a large impact on HIV, with maximum impact and cost-effectiveness in general adult populations with low levels of male circumcision (MC) and high HIV prevalence. Southern African countries would benefit most from PrEP, whereas West and Central African countries would benefit least. PrEP would be most cost-effective in generalized epidemics; but in other contexts, PrEP should be prioritized for key populations. Over five years, PrEP could prevent 390,000 HIV infections, 53,000 deaths, and 5,400,000 disability-adjusted life years (DALYs) if implemented at 10 percent coverage in the region. The greatest impact would be in South Africa; the smallest in Djibouti (94,0000 and 200 infections averted, respectively). Overall, the cost-effectiveness of PrEP was U.S. $5,800/DALY. PrEP was very cost-effective in South Africa ($1,100/DALY) compared to in the Democratic Republic of the Congo ($18,500/DALY). In high-risk populations, PrEP would substantially increase protection (557,000 infections averted at $3,800/DALY). The authors provided a model that can be adapted to help make health policy decisions about PrEP interventions; decisions should align with country economic indicators and epidemiologic contexts. PrEP would likely be most cost-effective as a targeted intervention within a combination of HIV prevention strategies.
- Exploring the Potential of a Conditional Cash Transfer Intervention to Reduce HIV Risk among Young Women in Iringa, Tanzania
Kennedy, C.E., Brahmbhatt, H., Likindikoki, S., et al. AIDS Care (August 2013), E-publication ahead of print.
As part of a study examining combination HIV prevention interventions in Tanzania, the authors conducted qualitative, formative research through 116 in-depth interviews with Iringa residents and stakeholders, seeking to understand participants' perspectives on cash transfer programs for young women with high HIV risk. Qualitative analysis showed that respondents generally favored such a program, which could address poverty-driven behaviors associated with HIV vulnerability. However, informants highlighted concerns about jealousy, sustainability issues, dependence on the program, and corruption. The authors identified recommendations based on the findings for cash transfer programs, stressing that program planners should work with local stakeholders and educate communities on the goal of cash transfers. Most respondents believed that providing the funds directly to the target group would be most effective, and that the parents of younger girls in school should also receive funds. While many respondents had favorable attitudes towards cash transfers, others said that providing micro-credit loans to invest in small business may be more suitable for this population. The study did not explore linking transfers to complementary services, but respondents emphasized the need for education on HIV and financial management. The authors concluded that there was general understanding of the benefits of an intervention targeting the economic vulnerability of young women in Iringa, and provided additional considerations for implementing cash transfer programs.
- Gender-Transformative Interventions to Reduce HIV Risks and Violence with Heterosexually-Active Men: A Review of the Global Evidence
Dworkin, S.L., Treves-Kagan, S., & Lippman, S.A. AIDS and Behavior (August 2013), E-publication ahead of print.
The authors conducted a systematic literature review to identify gender-transformative interventions with impacts on prevention of HIV or sexually transmitted infections (STIs); reduction of violence against women; decreased risky sexual behavior; and/or changes to inequitable gender norms and attitudes. The evidence suggested that gender-transformative programs may increase protective sexual behaviors, improve attitudes, prevent gender-based violence, and reduce STI incidence, and should be scaled up; however, more rigorous research is needed. The authors examined 2,560 articles and found 15 studies that met the inclusion criteria, which included interventions that were mainly small group discussions, and only three randomized control or cluster trials. Most interventions were implemented in Africa and the United States, followed by Asia and Latin America. Only one study, assessing HIV/STI outcomes in South Africa, had no effect on HIV incidence, but reduced herpes simplex virus-2 among men. The overall findings gave partial evidence of positive effects on risk reduction, e.g., condom use, with some showing significant improvement. Interventions were associated with reductions, some significant, in violence against women; and some interventions influenced attitude changes about gender roles and masculinity. The authors concluded that gender-transformative interventions should be scaled up to complement programs to prevent HIV and violence, in addition to other types of interventions, e.g., structural or community-level programs, yet additional trials and long-term studies are needed for rigorous evaluation.
- Community Influences on Married Men’s Uptake of HIV Testing in Eight African Countries
Stephenson, R., Elfstrom, K.M., & Winter, A. AIDS and Behavior (September 2013), Vol. 17 No. 7, pp. 2352-2366.
The authors investigated associations among individual-, household-, and community-level factors and HIV testing uptake among men in eight African countries, using Demographic and Health Surveys (DHS) (from 2001-2006). The findings showed that a variety of site-specific community-level factors help to explain factors affecting men’s testing behavior. The proportion of men who reported having ever testing for HIV ranged from 7 percent to 29 percent, in Chad and Uganda, respectively. At the individual level, more education and media exposure were positively associated with HIV testing. Factors associated with increased testing included higher levels of education among both men and women; larger proportions of men employed; greater knowledge of HIV prevention measures among both men and women; and larger proportions of men reporting condom use at last sex. Associations between testing and other factors were mixed. For instance, the link between average number of sexual partners and testing behavior varied; in Zambia, Zimbabwe, and Nigeria, those with more sexual partners were more likely to report HIV testing. For Nigerian men, there was positive association between HIV testing and living in a community with higher tolerance for violence against women; however, this association was negative in Uganda. Further research on the determinants of testing uptake is critical, particularly in sub-Saharan Africa where heterosexual adults are at high HIV risk.
- Female Sex Workers in Three Cities in Russia: HIV Prevalence, Risk Factors and Experience with Targeted HIV Prevention
Decker, M.R., Wirtz, A.L., Moguilnyi, V., et al. AIDS and Behavior (August 2013), E-publication ahead of print.
The authors conducted a mixed methods assessment in Kazan, Krasnoyarsk, and Tomsk, Russia, to understand the environment of female sex workers (FSWs); determine HIV prevalence and risk factors; and review the acceptability of the Globus Consortium’s FSW-targeted HIV prevention services. Analysis confirmed high HIV risk among FSWs, and the need for increased HIV prevention and services to address their key risk factors: injecting drug use (IDU) and sexual violence. FSWs found the FSW-targeted prevention services highly acceptable, valuable, and non-stigmatizing. The authors conducted secondary analysis of the program evaluation; 35 in-depth interviews; 11 focus group discussions with 81 FSWs; and a survey and HIV screening with 754 FSWs. HIV prevalence was 3.9 percent across the sample of FSWs, and lifetime IDU, client violence, and physical violence from a pimp, or momka, were common and significantly associated with HIV. Sexual risk behaviors were also identified (e.g., more than three clients per day [46 percent] and inconsistent condom use [17 percent]). FSWs cited protection as the primary benefit of working with pimps, although many found the protection limited; and reported experiencing violence or exploitation. The acceptability of FSW-targeted services was reflected in high uptake of HIV testing and free condoms, and greater HIV knowledge. While further research is necessary, Russian FSWs should be considered a key high-risk population.
- Intimate Partner Violence Is Associated with Incident HIV Infection in Women in Uganda
Kouyoumdjian, F.G., Calzavara, L.M., Bondy, S.J., et al. AIDS (May 2013), Vol. 27 No. 8, pp. 1311-1338.
The authors used longitudinal data of 10,252 women to compare the risk of incident HIV infection among women who had and had not experienced intimate partner violence (IPV), as well as potential mediators of HIV and IPV interaction in Rakai, Uganda. IPV and incident HIV infection were significantly associated; women who had ever experienced any form of IPV had an adjusted incidence rate ratio (IRR) of 1.55 compared to women who had not experienced IPV. The adjusted population proportion of HIV attributable to IPV was approximately 22 percent. No evidence was found that condom use or number of partners changed the degree of association between IPV and HIV. Verbal abuse was most common, followed by physical and then sexual IPV, but many women experienced these concurrently. Further, long-term, frequent IPV led to a higher HIV risk than less frequent IPV (from an IRR of .84 for having experienced IPV once to 3.03 for having experienced IPV more than 20 times in the past year). The authors said that the findings are likely generalizable throughout Uganda. They concluded that HIV prevention programs should discuss IPV during HIV testing and counseling, and programs to prevent violence towards children and IPV in adulthood are critically needed, not only to address the physical and emotional consequences, but also to prevent HIV.
- Uncovering the Epidemic of HIV among Men Who Have Sex with Men in Central Asia
Wirtz, A.L., Kirey, A., Peryskina, A., et al. Drug and Alcohol Dependence (2013), E-publication ahead of print.
The authors reviewed 43 publications on evidence on the HIV prevalence and socio-behavioral risk factors of men who have sex with men (MSM) in five Central Asian countries and Mongolia, Afghanistan, and Xinjiang Province, China to understand HIV risks, identify data gaps, and suggest priorities for future research and surveillance. HIV research on MSM in Central Asia is still emerging; however, available data suggest that MSM in the region are at risk of HIV. Methodological, recruitment, and reporting variations among the studies made comparisons and generalization difficult. For example, surveillance data showed HIV prevalence between 1 and 2 percent in Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan, while a behavioral study found HIV prevalence as high as 20 percent in Kazakhstan; thus, differences in estimates were considerable. HIV risks among MSM included multiple and/or concurrent sexual partners, unprotected anal sex, transactional sex, and non-injection drugs and alcohol. HIV prevention and testing coverage for MSM ranged from 25 to 49 percent for Kyrgyzstan, Tajikistan, and Uzbekistan. MSM practices were documented among people who inject drugs. No current estimates of HIV treatment coverage were documented. The prevalence of violence, discrimination, and criminalization towards MSM was evident, and should be addressed. According to the authors, in-country leadership will be essential to improving the HIV response, and further research on risk behavior is needed.
- Respondent Driven Sampling for HIV Biological and Behavioral Surveillance in Latin America and the Caribbean
Montealegre, J.R., Johnston, L.G., Murrill, C., et al. AIDS and Behavior (September 2013), Vol. 17 No. 7, pp. 2313-2340.
In this review of respondent-driven sampling (RDS) recruitment for HIV biological and behavioral surveillance surveys (BBSS) among key populations in Latin America and Caribbean (LAC) countries, the authors described RDS approaches, challenges, and considerations for future studies using RDS. Respondent-driven sampling has commonly been used in HIV BBSS to access high-risk, hard-to-reach populations in LAC. However, many studies encountered operational challenges. The authors identified 87 studies (conducted between 2005 and 2011) in 15 countries, mainly in South America and primarily on men who have sex with men. All studies conducted formative research before applying RDS. The studies mainly identified social network size using face-to-face interviews, and nearly all studies that reported information about analysis, adjusted for biases in chain-referral sampling. All but three studies collected biological specimens, usually conducting non-invasive HIV screens, with few reported challenges. There were challenges regarding appropriate incentives for participants, but most studies did not alter the incentives during data collection. Most studies adequately defined eligibility criteria, but 11 percent lacked a geographic parameter. The authors recommended addressing challenges by conducting formative research to understand social networks and define operational issues; using strategies to estimate social network size, monitor recruitment, and account for sub-populations; and analyzing data to counter biases in chain-referral sampling. Lastly, the authors suggested using the same sampling methods in the same populations over time as a best practice for monitoring HIV trends or evaluating program effectiveness.
- Micro-Planning in Peer Led Outreach Programs: A Handbook Based on the Experiences of the Avahan India AIDS Initiative
Bill & Melinda Gates Foundation (May 2013), New Delhi.
Using the experiences of the Avahan India AIDS Initiative, the Bill & Melinda Gates Foundation created this handbook on micro-planning and its application for improving peer-led outreach. It also provides nine micro-planning tools and guidance on how to apply them. Micro-planning decentralizes the outreach process and facilitates decision by outreach workers and peer educators on how best to reach the community. Since 2003, the Avahan project has reached high HIV risks groups, e.g., sex workers, people who inject drugs, high-risk men who have sex with men, and transgender persons, through peer-led HIV prevention programs. While micro-planning may differ for key populations, the handbook provides general implementation guidelines. Section 1 provides an overview on micro-planning; section 2 offers micro-planning tools, processes, and forms; section 3 provides steps for implementing a new micro-planning program; and section 4 explores related issues for consideration. The handbook is intended for government programs, nongovernmental organizations, and communities interested in using micro-planning as a tool to improve peer-led outreach.