HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- A Systematic Review of Interventions to Reduce HIV-Related Stigma and Discrimination from 2002 to 2013: How Far Have We Come?
Stangl, A.N., Lloyd, J.K., Brady, L.M. et al. Journal of the International AIDS Society (November 2013), Vol. 16 Suppl. 2.
Following a systematic literature review of interventions targeting HIV-related stigma and discrimination, Stangl et al. found substantial progress in stigma reduction over the past ten years. However, continuing challenges and gaps hinder the scale-up of effective interventions. The authors emphasized addressing stigma from the core of the HIV response: reflected in funding, policy, research, and programs. The 48 studies identified were mostly implemented in in East and Southern Africa and Asia and the Pacific region (there were none from Eastern Europe and Central Asia). Most interventions targeted students, health care workers, community members, and people living with HIV (PLHIV); only three addressed key populations. Approaches were largely information-based; only six studies used structural approaches and four used biomedical approaches. Eighty-one percent of studies targeted a single stigma domain and 85 percent intervened at only one socio-ecological level, usually the individual level. Despite variations in measurement, most studies reported statistically significant reductions in all stigma measures. Current interventions do not adequately address stigma manifestations, e.g., shame and discrimination or community attitudes. There are insufficient interventions supporting PLHIV or targeting the “intersecting stigmas” experienced by key populations. Future needs include multi-component interventions (including rigorous evaluation), validated measures for assessing stigma domains, and research on the influence of stigma reduction on behavioral and biomedical outcomes.
- Antiretroviral Treatment of HIV-1 Prevents Transmission of HIV-1: Where Do We Go from Here?
Cohen, M.S., Kumi Smith, M., Muessig, K.E., et al. The Lancet (November 2013), Vol. 382No. 9903, pp. 1515-1524.
Cohen et al. reviewed and assessed studies on antiretroviral therapy (ART) used for treatment as prevention (TasP) of HIV, a key component of combination prevention approaches that has sparked enthusiasm for an AIDS-free generation. Various studies and one randomized controlled trial (RCT) have demonstrated that ART can prevent sexual HIV transmission. Notably, in the HIV Prevention Trials Network-052 study, transmission diminished by 96.4 percent among serodiscordant couples. These findings led to policy changes recommending ART for serodiscordant couples regardless of CD4 cell count. This policy remains debated—for example, generalizability to other populations is unknown; and not all studies reported TasP benefits, particularly among men who have sex with men. Translating TasP into practice has been challenging, and population-level benefits remain unproven. Implementation challenges include identifying and treating high-risk populations, gaps in the HIV treatment cascade, and disagreement about when to initiate ART. Nonetheless, more than 50 studies are planned or underway, including community-based RCTs. Recent model analyses suggest that long-term benefits from ART expansion will outweigh its cost and risks. Logistical challenges to early ART initiation should not be a reason to disregard broader or earlier treatment. Continuing studies will inform HIV incidence estimates under various circumstances for TasP, HIV resistance, and population-level behavior change; the authors hope to see progress and learn how to improve TasP implementation.
- Voluntary Medical Male Circumcision – Southern and Eastern Africa, 2010 – 2012
Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (November 29, 2013), Vol. 62 No. 47, pp. 953-957.
The CDC presented outcomes of voluntary medical male circumcision (VMMC) scale-up from 2010 to 2012 in nine sub-Saharan African countries. The CDC and Ministries of Health are supporting the scale-up as part of the the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) two-year financial commitment to increase VMMC, announced on World AIDS Day in 2011. VMMC rates for HIV prevention increased in all nine counties, with few adverse events; uptake of HIV testing and counseling (HTC) also increased. During 2010-2012, over one million males were circumcised at CDC-supported sites in Botswana, Kenya, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda, and Zambia, with rates of VMMC acceptance increasing annually. Programs in Kenya and Uganda achieved the highest VMMC rates. In countries that reported HTC data for VMMC clients, approximately 87 percent of 533,143 men accepted HTC; while uptake varied during that period, acceptance remained high overall. In countries that reported on postoperative follow-up visits, nearly 59 percent of 359,881 clients returned within 14 days of surgery. Among returning clients, the postoperative adverse event rate was low (less than 1 percent). Lastly, for 986,392 (97 percent) VMMC clients with age reported, the proportion aged 15 or older increased (from 67 to 79 percent between 2010 and 2012).
- Intimate Partner Violence and Condom and Diaphragm Nonadherence Among Women in an HIV Prevention Trial in Southern Africa
Kacanek, D., Bostrom, A., Montgomery, E.T., et al. Journal of Acquired Immune Deficiency Syndromes (December 2013), Vol. 64 No. 4, pp. 400-408.
The authors conducted a longitudinal study investigating the relationship between patterns of intimate partner violence (IPV) and condom and diaphragm nonadherence among 4,505 women participating in the Methods for Improving Reproductive Health in Africa study. Over half (55 percent) of women reported recent IPV, which was associated with nonadherence to using a diaphragm and condoms throughout the study. These findings imply that IPV may hinder adherence to HIV prevention interventions, including those designed to enhance women’s self-protection. Forty-one, 38, 16, and 15 percent of women reported fearing violence, emotional violence, physical assault, and forced sex, respectively, from their regular male partner. Women who reported fearing or experiencing IPV had higher odds of diaphragm nonadherence than women without such fears. Continuing forced sex was associated with condom nonadherence. Policies and interventions that specifically address IPV and related HIV risk are urgently needed, and clinical trials should include counseling and protection for women who experience IPV. It is critical to target men in IPV prevention and promote their involvement in women’s product use. Research priorities include understanding determinants of men’s perpetration of IPV and interventions targeting young men and women.
- Acceptability and Challenges of Rapid ART Initiation among Pregnant Women in a Pilot Programme, Cape Town, South Africa
Black, S., Zulliger, R., Marcus, R., et al. AIDS Care (November 2013), E-publication ahead of print.
The authors implemented a rapid antiretroviral therapy (ART) initiation in pregnancy (RAP) program in South Africa, seeking to reduce service-level barriers to timely ART initiation for women in prevention of mother-to-child transmission (PMTCT) programs. The RAP program provided simultaneous treatment counseling and ART initiation. This article presents interview findings with 27 RAP program clients and seven service providers to assess their experiences with RAP. The findings suggest that rapid ART initiation among pregnant women was acceptable, but implementation factors must be considered, particularly the importance of counseling. The three most common barriers to ART initiation had to do with women's acceptance of their situation: being pregnant, HIV positive, and eligible for ART. Other barriers were stigma, concerns about side effects, daily pill regimens, personal challenges, and non-disclosure (including disclosure consequences, e.g., rejection by a partner). The primary facilitator for beginning ART was protecting the unborn child from HIV. Other facilitators included personal health, counseling, social support, disclosure, and for some women, family and community role models. The majority of interviewees viewed RAP favorably, since it expedited treatment access. Because the program was integrated into antenatal care, women mentioned additional benefits, such as reduced transportation costs. PMTCT programs should reinforce the importance of continued ART adherence, and should shift messages from prevention of vertical transmission to women’s long-term health.
- The Development of Rectal Microbicides for HIV Prevention
McGowan, I. Expert Opinion on Drug Delivery (November 2013), E-publication ahead of print.
McGowan summarized the status of rectal microbicides (RM) for HIV prevention research and presented opportunities, challenges, and future directions. Current global HIV epidemiology points to the need for new prevention methods in populations at risk of HIV through unprotected receptive anal intercourse (URAI). McGowan outlined the rationale for RM development, populations at risk through URAI; common use of lubricants to facilitate anal sex; and preclinical efficacy data. URAI is associated with high HIV rates among men who have sex with men and transgender women. Production of a RM that could be used as a sexual lubricant is likely to be acceptable, and in turn, may increase product adherence among targeted populations. Further, RM may be more culturally acceptable than oral pre-exposure prophylaxis. Initial RM studies evaluated the rectal safety of vaginal microbicides, but subsequent studies are investigating rectal-specific products with research focused on antiretroviral (ARV) microbicides. Preclinical studies in primates and mice provide evidence that the RM concept is a feasible HIV prevention strategy. Development of a tenofovir (TFV) 1 percent gel RM, the lead RM candidate, is currently in Phase II evaluation in the Microbicide Trials Network (MTN)-017. Future Phase 1 studies will evaluate combination ARV RM formulations. McGowan concluded that the MTN-017 study will offer important findings on the levels of RM use, and that the future of RM research may be dependent upon the outcomes.
- Efficacy and Safety of an Extended Nevirapine Regimen in Infants of Breastfeeding Mothers with HIV-1 Infection for Prevention of HIV-1 Transmission (HPTN 046): 18-Month Results of a Randomized, Double-Blind, Placebo-Controlled Trial
Fowler, M.G., Coovadia, H., Herron, C.M., et al. Journal of Acquired Immune Deficiency Syndromes (November 2013), E-publication ahead of print.
Early results from the HIV Prevention Trials Network (HPTN)-046 (South Africa, Tanzania, Uganda, and Zimbabwe) demonstrated a reduction in postnatal HIV transmission at age six months with extended once-daily infant nevirapine (NVP) prophylaxis among breastfed HIV-exposed infants whose mothers were counseled to stop breastfeeding at six months. Eligible HIV-uninfected infants, who received standard of care NVP for the first six weeks, were then randomized to receive extended daily NVP or placebo, from age six weeks to six months. The authors analyzed longer-term safety and efficacy at eighteen months after prophylaxis had ended (759 infants in the NVP arm; 763 in the control arm). While there was a statistically significant reduction in transmission risk in the NVP group from age six weeks to six months, no differences were found in postnatal transmission rates between six and eighteen months. These results suggest that infant NVP is effective during the first six months of breastfeeding, but its effectiveness weakens after prophylaxis ends. However, cumulative transmission rates between six weeks and eighteen months were low. The authors concluded that the finding of early, but not late differences, in postnatal transmission between the NVP and control groups highlights the importance of continued prophylaxis throughout breastfeeding.
- Uganda’s New National Laboratory Sample Transport System: A Successful Model for Improving Access to Diagnostic Services for Early Infant HIV Diagnosis and Other Programs
Kiyaga, C., Sendagire, H., Joseph, E., et al. PLOS One (November 2013), Vol. 8 No. 11, p. e78609.
The authors conducted a retrospective study on a specimen transport network system in Uganda, developed to overcome testing and reporting challenges of early infant diagnosis (EID). EID samples from HIV-exposed infants were originally transported to eight laboratories by ad-hoc methods. Over 12 months in 2011/2012, the EID program mapped 19 facilities to serve as coordinating transport “hubs,” each providing daily motorcycle delivery for 20 to 40 of a total of 616 health facilities. Following a one-year pilot, EID sample testing volumes increased by 36 percent in Jinja and 52 percent in Kampala; sample turnaround time decreased by 47 percent, from 49 to 26 days. Costs increased by U.S.$285,000 in the first year, mainly due to start-up expenses; transport-specific costs would substantially diminish over time, and four-year estimates showed a savings of over U.S.$1 million compared to the ad-hoc system. The system is expanding to include other specimen types, e.g., sputum and malaria smears, also facing transport challenges; and aims to improve quality of laboratories through this expansion. The authors concluded that this model can be applied to other health systems strengthening approaches. Despite challenges, a national transport system would increase access to diagnostic and treatment monitoring services, improve laboratory quality, and reduce turnaround times and long-term costs.
- Scale-Up and Case-Finding Effectiveness of an HIV Partner Services Program in Cameroon: An Innovative HIV Prevention Intervention for Developing Countries
Henley, C., Forgwei, G., Welty, T., et al. Sexually Transmitted Diseases (December 2013), Vol. 40 No. 12, pp. 909-914.
HIV partner services—wherein trained staff interview persons diagnosed with HIV about their sexual partners in an effort to notify and test partners—are uncommon in low-income countries. The authors evaluated a HIV partner services program implemented in Cameroon since 2007. The findings showed that the HIV partner services implemented in various testing facilities were feasible, can identify many HIV-positive persons and link them to care, and offer an avenue for reaching HIV-positive men. Health providers interviewed 1,462 index cases during the study (73 percent female), receiving information on 1,607 partners. A notification plan was developed for 93 percent of partners; 60 percent of clients chose to have providers notify their partners. In total, 1,347 (84 percent) of partners were successfully notified; partners of married index cases were more likely to be informed. Nine hundred partners (67 percent) were tested for HIV; 50 percent were positive (and most were linked to HIV care and treatment). The program has expanded into prevention of mother-to-child transmission programs. Future research should evaluate the effect of HIV partner services on partnerships, and the program’s cost-effectiveness, potential negative consequences, and impact on perinatal transmission and sexual risk behavior in discordant couples; operational studies should investigate populations where partner services programs can be most effective.
- Scaling Up HIV Prevention Efforts Targeting People Who Inject Drugs in Central Asia: A Review of Key Challenges and Ways Forward
Boltaev, A.A., El-Bassel, N., Deryabina, A.P., et al. Drug and Alcohol Dependence (November 2013), Vol. 132 Suppl. 1, pp. S41-S47.
Boltaev et al. reviewed the status and trends of national HIV responses for people who inject drugs (PWID) in Central Asia, highlighting structural and social barriers that enable HIV transmission among PWID, including barriers to key harm reduction services. While an increasing number of health facilities provide evidence-based interventions for PWID, structural causes of HIV risk behavior and transmission remain inadequately addressed. Barriers to an effective HIV response include discriminatory legal environments that violate the human rights of PWID, though Tajikistan and Kazakhstan have taken some action toward liberalizing drug laws. Several challenges limit implementation of evidence-based interventions. Opioid substitution therapy remains one of the region’s most politicized interventions. Other barriers include lack of qualified health care providers to address the needs of PWID, dependence on external donors, low resource allocation for key services for PWID, poorly integrated HIV services, and limited engagement of PWID in the HIV response. Effective responses to the HIV and drug use epidemics must eliminate stigma and discrimination, which requires more research. PWID must contribute to strengthening HIV service delivery. Central Asia must recognize the need for increased coverage through combinations of services to reduce HIV among PWID, and identify strategies to implement multi-level interventions.
- Randomized Community-Level HIV Prevention Intervention Trial for Men who Drink in South African Alcohol-Serving Venues
Kalichman, S.C., Simbayi, L.C., Cain, D., et al. European Journal of Public Health (November 2013), E-publication ahead of print.
The authors evaluated a randomized individual- and community-level HIV prevention intervention seeking to reduce HIV-related sexual risks and shift social norms among South African men at high-risk, informal drinking venues (shebeens) in 12 Cape Town townships. Men randomized to the intervention workshops (497) received skill-building on risk reduction and communication to promote conversations about safer sex within social networks, along with related community events. Men in the control workshops (478) received messages on preventing violence in relationships. The intervention had greatest impact on condom use at the individual level, and a modest, inconsistent impact on community-level risk reduction and social norms. Men in the intervention group demonstrated significantly greater use of condoms over the one-year follow-up period, and engaged in more conversations about HIV and condom use. At the community level, at eight months post-baseline, condom use increased by 9 percent in the intervention shebeens while decreasing by 12 percent in the control communities. However, increased condom use was not found at the final follow-up at the community level. The authors suggested that individual- and community-level behavior, conversation, and normative changes may have synergistic effects. While more research is needed to evaluate multi-level interventions, the findings support previous research showing that shebeens may serve as platforms for HIV prevention.
- Factors Associated with Willingness to Accept Oral Fluid HIV Rapid Testing among Most-At-Risk Populations in China
Xun, H., Kang, D., Huang, T., et al. PLOS One (November 2013), Vol. 8 No. 11, p. e80594
The authors assessed acceptability of oral fluid HIV rapid testing among most-at-risk populations (MARPs) in Shandong Province, China (n=1,137). Results showed that despite limited knowledge and experience of taking oral fluid HIV rapid tests, 71 percent of MARPs surveyed found the test acceptable, with no statistical differences among men who have sex with men (MSM), female sex workers (FSWs), or voluntary counseling and testing (VCT) clients. The most commonly cited factors associated with willingness to accept the test were its noninvasiveness, painlessness, and rapid test results; common concerns were having never heard of the method and test accuracy. Approximately half of participants considered using the test. Independent predictors of willingness to accept the test were previous HIV testing (VCT clients and MSM) educational levels (MSM), and risk behaviors over the past three months (FSW). Less educated MSM and FSWs engaged in HIV risk behaviors should be targeted for this type of testing, along with HIV prevention education. The median price participants were willing to pay for this test was: U.S.$6.50, $4.80, and $8.10 among MSM, FSWs, and VCT clients, respectively. Oral fluid HIV rapid testing provides an alternative testing option that may increase test acceptance rates among Chinese MARPs; yet appropriate pricing, safe testing venues, and increased education about the method may increase the method's acceptability.
- A Brief, Standardized Tool for Measuring HIV-related Stigma among Health Facility Staff: Results of Field Testing in China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis
Nyblade, L., Jain, A., Benkirane, M., et al. Journal of the International AIDS Society (November 2013), Vol. 16 Suppl. 2, p. 18718.
The authors described an international collaboration to develop, test, and refine two tools for measuring HIV stigma among health care providers, focusing on the first tool, a questionnaire that measures drivers of HIV-related stigma within health facilities. Early findings demonstrated the feasibility of a standardized stigma measurement tool that is applicable across diverse settings and health worker cadres, and showed that stigma remains widespread. The collaboration entailed developing a pool of questions through a comprehensive literature search; implementing a content-development workshop in which 22 experts, including people living with HIV (PLHIV), reviewed and prioritized the items finally chosen for inclusion; field-testing in the six countries between February 2012 and January 2013; and analyzing data to evaluate performance and refine as needed. Workshop participants were asked to identify gaps in current measures. They noted that health facility policies and stigma towards key populations were two gaps, and developed related questions to fill them. Future research should assess the tool’s performance over time, and in other high-prevalence settings, to expand measurement of stigma toward key populations; but this brief questionnaire, currently available in five languages, can be used now to help address HIV stigma in facilities and ensure that PLHIV receive quality, stigma-free care.
- 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., and Lippman, S.A. AIDS and Behavior (November 2013), Vol. 17 No. 9, pp. 2845-2863.
The authors conducted a systematic review of published evidence on the effect of gender-transformative interventions targeting heterosexual men on outcomes for HIV and sexually transmitted infections (STIs) and gender. Evidence from 15 eligible studies in four continents suggests that gender-transformative strategies can lead to protective sexual behaviors, attitude changes, violence prevention, and reductions in STIs/HIV. Twelve interventions used small group learning, which was the most common intervention; five of these incorporated a community-level component. Three studies were randomized control/cluster trials. One study, Stepping Stones (South Africa), included biomarkers to evaluate impacts on HIV and herpes simplex virus-2 (HSV-2); although no effect on HIV was found, there was a 28 percent reduction in HSV-2 incidence among men. Further, results on sexual risk behavior outcomes (11 interventions; nine statistically significant reductions) provided partial evidence that these interventions decreased sexual risk behavior. Findings suggested that these interventions help reduce perpetration of violence against women (eight interventions; six statistically significant outcomes). Of 12 programs assessing change in gender norms, 11 found at least some statistically significant changes in normative attitudes. More rigorous study designs and intervention formats are needed, including initiatives to modify community-level norms. Future research should include interventions engaging both men and women. The authors concluded that gender-transformative interventions can reduce risk behaviors and partner violence, and should continue and be scaled up.
- Development of Methods for Cross-Sectional HIV Incidence Estimation in a Large, Community Randomized Trial
Laeyendecker, O., Kulich, M., Donnell, D., et al. PLOS One (November 2013), Vol. 8 No. 11, p. e78818.
The authors described the development of laboratory and statistical methods used to estimate HIV incidence in Project Accept, a Phase III community randomized controlled trial in Africa and Thailand. They focused on identifying a multiple-assay algorithm (MAA) to estimate HIV incidence in the trial’s African communities, using validation samples from seven cohorts (4,166 samples from approximately 2,300 individuals; subtype D samples were removed). Findings demonstrated that HIV incidence and intervention effects can be accurately estimated using MAA in cross-sectional surveys. In total, 403 MAAs were evaluated, including the BED capture immunoassay (BED-CEIA) alone, an avidity assay alone, and combinations of these assays with various cutoff values and without CD4 or viral load testing on samples. Testing algorithms that included multiple assays outperformed single serologic assays; incidence estimates had lower bias and better precision. Epidemic simulation exercises were conducted to demonstrate that the chosen MAA provided more accurate estimates of intervention and control incidence rates than would have been found by monitoring a cohort for seroconversion over a six-month period. Future studies should evaluate different test methods (e.g., different assays and/or different cutoffs) to identify an effective method for cross-sectional HIV incidence estimation in subtype D epidemics. The authors' methods could be applied for cross-sectional incidence assessment in non-subtype D epidemics in Southern Africa for HIV surveillance and prevention research.
- NIH Announces Plan to Increase Funding Towards a Cure for HIV/AIDS
National Institutes of Health. (December 2013).
The National Institutes of Health (NIH) is committed to the goal of achieving a world without AIDS. On the 25th annual World AIDS Day, President Obama announced that over the next three fiscal years the NIH plans to invest an additional U.S.$100 million (U.S. dollars) in research to find a cure for HIV, a promising area of HIV research. According to Anthony S. Fauci, director of the NIH’s National Institute of Allergy and Infectious Diseases, in terms of the public health and scientific rationale for this research, “…the development of a cure is critically important, as it may not be feasible for tens of millions of people living with HIV infection to access and adhere to a lifetime of antiretroviral treatment.” Fauci also noted the opportune timing for expanded research, given increasing understanding of HIV reservoirs (“cellular hiding places”) and development of strategies to minimize the reservoirs. A substantial portion of investment will support basic HIV research, e.g., viral reservoirs and viral latency that will benefit HIV as well as other diseases. Other high-priority research will also continue, e.g., biomedical and behavioral prevention research (vaccines and microbicides), and examination of how genetic determinants and other factors, such as stigma, interact to affect treatment outcomes. This new research plan will require global collaboration, including public-private partnerships and innovative leadership, to share expertise and advance the search for a cure for HIV and AIDS.
- AIDSTAR-One’s Contributions to PEPFAR’s Roadmap for Creating an AIDS-Free Generation
AIDS Support and Technical Assistance Resources (AIDSTAR-One). (December 2013).
From 2008 to 2013, AIDSTAR-One has provided rapid technical assistance to the U.S. Agency for International Development (USAID) and U.S. Government (USG) country teams to build effective, well-managed, and sustainable HIV and AIDS programs, and to promote new leadership in the global campaign against HIV. Join AIDSTAR-One and the USAID Office of HIV/AIDS on Thursday, January 16, 2014, at the National Press Club in Washington, DC, to learn how the six-year project has supported the development and implementation of initiatives by USAID and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) to create an AIDS-free generation. Managed by the Implementation Support Division of USAID’s Office of HIV/AIDS and implemented by John Snow, Inc. and its partners, AIDSTAR-One provided targeted assistance in knowledge management, program implementation support, technical leadership, support for program sustainability, and strategic planning.
The meeting will include tools and materials relevant and useful to implementing partners and USG staff as they work together to contribute to an AIDS-free generation.
Presentations will include:
- • Structural Approaches to HIV Prevention
- • AIDSTAR-One Adolescent Activities
- • Integrating Mental Health Services into HIV Care in Zimbabwean Communities
- • Increasing Access and Uptake of HIV Services for Healthier Trans Communities
- • Midterm Evaluation: PEPFAR Caribbean Regional Program
- • Supporting India’s Planning for National AIDS Control Program IV
(Event details: Thursday, January 16, 2014, National Press Club, Conference Rooms 529 14th St. NW, Washington, DC 20045; 8:00 a.m. - 12:15 p.m. EST; Light breakfast provided. Register here.)