HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Men Who Have Sex with Men Inadequately Addressed in African HIV National Strategic Plans
Makafane, K., Gueborguo, C., Lyons, D., et al. Global Public Health (2013), Vol. 8 No. 2, pp. 129-143.
The authors sought to understand how the HIV epidemic among men who have sex with men (MSM) was addressed by HIV national strategic plans (NSPs) in African countries. Of the forty-six country NSPs identified, thirty-four mentioned MSM, but these included limited epidemiological evidence. Only half of the NSPs included interventions that targeted MSM, and even fewer discussed previous government-led interventions for MSM. Most interventions outlined for MSM were aligned with World Health Organization recommendations. In two-thirds of the NSPs, MSM were represented as vulnerable to HIV, and commonly categorized within key populations. Ten NSPs mentioned stigma and marginalization of MSM; only three countries mentioned the association between stigma and limited access to HIV services by MSM. Although twenty-four of the NSPs that mentioned MSM criminalize same-sex sexual acts, less than half of those acknowledged this. Some NSPs recognized the human rights of MSM; in some, however, MSM were represented as a public health threat—specifically, as posing a risk of HIV transmission to female partners. Fifteen NSPs included plans to monitor the epidemic among MSM. Seventeen plans mentioned HIV prevention interventions, and nine plans aimed to target stigma, but few NSPs included structural interventions. The authors concluded that NSPs must address the needs of MSM, and that stakeholders should seek to improve their understanding of epidemiologic drivers and to strengthen government commitment to the inclusion of MSM in national HIV responses.
- Overview of the Current State of the Epidemic
Hankins, C. Current HIV/AIDS Reports (June 2013), Vol. 10 No. 2, pp. 113-123.
An estimated 34 million people were living with HIV at the end of 2011, yet only 50 percent of those knew their HIV status. While sub-Saharan Africa has the greatest HIV burden, from 2001 to 2011, HIV prevalence increased globally, linked with the scale-up of life-prolonging antiretroviral therapy (ART). From 2003 to 2011, there was a 20-fold increase in the number of people living with HIV (PLHIV) on ART, yet 6.8 million PLHIV who are eligible for treatment do not have access. HIV incidence decreased from 3.2 million infections in 2001 to 2.5 million infections in 2011. In 2010 and 2011, HIV incidence in children decreased by 24 percent, which has been linked mainly to expansion of prevention of mother-to-child transmission programs. Some countries have substantially advanced in HIV prevention, while others lag behind. The Strategic Timing of Antiretroviral Therapy trial is underway to determine the clinical benefits of early treatment, which may influence “test and treat” strategies. As the number of PLHIV increases, HIV subtype diversity will expand. Key populations must be actively engaged in all stages of national HIV prevention responses. Implementing a combination of programs and strategies will be most cost-effective in reducing new infections. Properly allocating resources for HIV prevention and tracking community viral load will support further reduction in HIV incidence; however, the behavior of individuals and communities and the actions of policymakers and program planners will influence future HIV trends.
- Reducing HIV and AIDS in Adolescents: Opportunities and Challenges
Kasedde, S., Luo, C., McClure, C., et al. Current HIV/AIDS Reports (June 2013), Vol. 10 No. 2, pp. 159-168.
By the end of 2011, approximately 2.1 million adolescents were living with HIV globally, primarily in sub-Saharan Africa. HIV prevalence is highest among certain subgroups of adolescents who face significant barriers to access HIV prevention, treatment, and care services. Reducing HIV incidence, risk, transmission, morbidity, and mortality among adolescents requires targeting three priority groups: girls, key populations (i.e., people who inject drugs, those exploited through or involved in commercial sex, and young men who have sex with men), and adolescents living with HIV. Each priority group has unique challenges and vulnerabilities. For example, social and biological factors, low levels of knowledge, failures in protection, and gender-based violence contribute to disproportionately high levels of HIV among adolescent girls. Similarly, adolescents who inject drugs are most commonly found within marginalized populations, such as orphans. Interventions and services need to leverage opportunities that are relevant to adolescents in local contexts. The authors of this study recommend the following activities to attain an AIDS-free generation of adolescents: strengthening political efforts, commitment, and capacity to scale up high-impact HIV programs and improve existing integrated services for adolescents; working with adolescents to identify legal, policy, and structural barriers to access and uptake of interventions and services; addressing social norms that promote vulnerability; and improving monitoring and reporting systems on services for and the health outcomes of adolescents.
- Moderno Love: Sexual Role-Based Identities and HIV/STI Prevention among Men Who Have Sex with Men in Lima, Peru
Clark, J., Salvatierra, J., Segura, E., et al. AIDS and Behavior (May 2013), Vol. 17 No. 4, pp.1313-1328.
This study analyzed social and behavioral factors that influence sexual identities, and how they affect patterns of HIV among men who have sex with men (MSM) in Lima, Peru. Findings showed that gender-based sexual roles among MSM were both reinforced and transformed by new sexual identities, roles, and practices. Further, social networks and behaviors affect HIV transmission by influencing relationship dynamics. Of 532 MSM, 38 percent categorized themselves as homosexual, 20 percent as transgender, 4 percent as bisexual, and 25 percent as heterosexual and were evenly divided between activo, pasivo, and moderno (a role-based, gender-versatile identity). Focus groups in 2008 and 2011 revealed four themes: 1) the pasivo MSM role is culturally associated with femininity; 2) the activo role is associated with masculinity, though sexual behaviors may threaten heterosexual masculinity; 3) moderno MSM viewed themselves as representing homosexuality and masculinity, while other MSM viewed the moderno identity as disrupting traditional gender and sexual norms; and 4) defined sexual roles provide a structure for sexual practices, identities, and social and sexual networks. Seventy-two percent of moderno and over half of other MSM reported unprotected sex. HIV prevalence was highest among pasivo and moderno MSM. The authors conclude that, although further research is needed to understand how the identities are defined and influence HIV transmission, sexual and identity roles among MSM in Peru provide a framework for HIV prevention.
- Risk for Heterosexual HIV Transmission Among Non-Injecting Female Partners of Injection Drug Users in Estonia
Uusküla, A., McMahon, J.M., Kals, M., et al. AIDS and Behavior (March 2013), Vol. 17 No. 3, pp. 879-888.
The authors assessed HIV prevalence among injection drug users (IDUs) and their heterosexual non-injecting main sexual partners. They applied HIV transmission modeling using data collected on self-reported behaviors to estimate HIV risk from IDUs to their sex partners in Kohtla-Järve, Estonia. The estimated risk of HIV transmission for non-IDU females with a male IDU partner was high– between 3.24 and 4.94 HIV seroconversions per 100 person-years. Condom use accounted for notable differences in estimated incidence: estimates were five times greater among women who did not use or inconsistently used condoms with partners compared to those who consistently used condoms. The estimated range of incidence highlights the impact of acute-stage HIV infection on transmission rates. The study used respondent-driven sampling to recruit IDUs. The majority of recruited IDUs were men (n=298); 69 male IDUs successfully recruited a non-injecting partner. Of 82 women screened, 69 enrolled. HIV prevalence among male IDUs and among non-IDU partners was estimated at approximately 70 percent and 35 percent, respectively. Slightly over half of the couples were concordant in HIV status. The authors concluded that non-IDUs who have sexual partners who inject drugs are at an increased risk for HIV, and future studies should assess whether this will contribute to advancing the HIV epidemic beyond key populations in Estonia.
- Uptake to HIV Post-Exposure Prophylaxis in Haiti: Opportunities to Align Sexual Violence, HIV PEP and Mental Health
Marc, L., Honore, J-G., Néjuste, P., et al. American Journal of Reproductive Immunology (2013), Vol. 69 No. 1, pp. 133-141.
An initiative to provide post-rape care at the largest, public hospital in Haiti–supported through the U.S. President’s Emergency Plan for AIDS Relief and the Haitian Ministry of Public Health and Population–reportedly shows low uptake of antiretroviral post-exposure prophylaxis (PEP) among female rape survivors. A mixed methods cross-sectional study, implemented from 2008 to 2010, examined rape survivors’ uptake of PEP at the hospital through interviews with health care personnel and surveillance data. Post-rape care services are inadequate overall. Uptake of post-rape care services is very low among young girls, yet the barriers are unclear. From 2004 to 2010, 2,193 adult and pediatric clients reported rape and sought appropriate services. Of 479 clients in 2008 and 2009, only 45 percent initiated the first dose of treatment within 72 hours (38 percent of pediatric clients and 60 percent of adult women; the difference was statistically significant). Women infrequently disclosed that they had been raped for fear of being stigmatized, preferring to seek care through the voluntary counseling and testing program. Mental health (MH) service-seeking behavior is low within this population, and MH service-seeking factors are unknown. The authors concluded that future research should assess factors associated with delays in seeking health and MH care following rape, barriers to PEP uptake, disclosure of rape, and clinical indications of post-rape psychopathology.
- Field Effectiveness of Combination Antiretroviral Prophylaxis for the Prevention of Mother-to-Child HIV Transmission in Rural Zambia
Gartland, M.G., Chintu, N.T., Li, M.S., et al. AIDS (2013), Vol. 27 No. 8, pp. 1253-1262.
The authors of this study assessed the effectiveness of combination antiretroviral therapy (ART) prophylaxis for prevention of mother-to-child transmission (PMTCT) in public health facilities in Zambia. The intervention group, which received combination ART prophylaxis during pregnancy and breastfeeding, experienced fewer infant HIV infections, compared with control participants, who received short-course antenatal zidovudine and peripartum nevirapine, and with mothers with high CD4 cell counts (above 350/µL). The results support scale up of ART prophylaxis to all women regardless of CD4 cell count. From 2004 to 2011, 143 and 141 HIV-positive women participated in the intervention and control groups, respectively. Baseline CD4 cell count was lower in the intervention group. Adherence data for 103 invention participants revealed that 20, 45, and 35 percent had poor adherence, sub-optimal adherence, and optimal adherence to ART prophylaxis, respectively. After loss to follow-up prior to delivery, the analysis cohort included 129 intervention and 134 control live-born infants. After one year, 15 infants were HIV-positive (only one in the intervention group). Nearly 59 percent of all live-born infants were born to mothers with CD4 cell count above 350 cells/ µL at the time of regimen initiation (38 percent in the intervention; 62 percent in the control). The authors conclude that adherence problems and patient attrition could lessen effectiveness of benefits of ART prophylaxis; therefore, resources to improve access to and retention in care are critical.
- Portfolios of Biomedical HIV Interventions in South Africa: A Cost-Effectiveness Analysis
Long, E.F., and Stavert, R.R. Journal of General Internal Medicine (April 2013), e-publication ahead of print.
The authors applied a mathematical model using epidemiologic and behavioral data of South African adults to assess the cost-effectiveness and health impact of concurrently scaling up three biomedical HIV prevention interventions. The scenarios included: status quo (current HIV testing and treatment levels); expansion of HIV testing and treatment services; and implementation of a comprehensive intervention approach. The comprehensive intervention included expanded HIV testing and treatment and three biomedical interventions (male circumcision, vaginal microbicides, and oral pre-exposure prophylaxis [PrEP]). The comprehensive approach had the greatest impact, estimated at a 62 percent reduction in HIV incidence after 10 years–preventing 2.1 million HIV infections–and was considered cost-effective ($9,990 per quality-adjusted life year [QALY] gained). Even with the uncertainty of program effectiveness, the comprehensive program considerably reduced new infections over 10 years. Simultaneously expanding access to HIV testing and treatment would prevent 34 percent of infections, for approximately $1,000 per QALY gained. Male circumcision was the most economical, although it primarily benefits men. Minor reductions in secondary transmission were observed from male circumcision and microbicides individually. With limited resources, the authors concluded that male circumcision should be prioritized, followed by more frequent HIV testing, vaginal microbicides, and increased HIV treatment. Of all the methods, PrEP was least cost-effective. The authors concluded that a combination approach of expanded treatment with biomedical interventions could considerably lessen the HIV epidemic in South Africa.
- Prevalence of HIV-1 Drug Resistance among Women Screening for HIV Prevention Trials in KwaZulu-Natal, South Africa (MTN-009)
Parikh, U.M., Kiepiela, P., Ganesh, S., et al. PLOS One (April 2013), Vol. 8 No. 4, p. e59787.
From 2010 to 2011, a cross-sectional study in KwaZulu-Natal, the Microbicides Trial Network (MTN)-009, estimated antiretroviral (ARV) resistance prevalence among a subgroup of women being screened for an HIV prevention trial, Vaginal and Oral Interventions to Control the Epidemic (VOICE) MTN-003. Of the 1,073 women enrolled in MTN-009, 37 percent (400) were confirmed as HIV-positive. Most (61 percent) had a CD4 cell count above 350 cells/mm3; 39 percent qualified for ART (below 350 cells/mm3); and 13 percent had counts below 200 cells/mm3. Nearly 9 percent had plasma HIV-1 RNA (viral load) levels below detectable ranges; another 3 percent were at or below 200 copies/ml–a surprisingly high count for women presumably untreated. Resistance testing of 352 women with HIV genotypes indicated that most HIV samples had no ARV resistance mutations; however, 26 (7.4 percent) had at least one known mutation. Resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI) class was most frequent; however, the cause of NNRTI resistance was not determined. With increased use of ARVs for both HIV treatment and prevention, especially in settings where initiatives are being implemented concurrently, monitoring drug resistance will be critical. The authors concluded that routine HIV testing is needed, particularly in high-prevalence settings, and potential resistance should be minimized by ensuring that HIV-positive persons avoid ARV-based HIV prevention products.
- Antiretroviral Resource Allocation for HIV Prevention
Singh, J.A. AIDS (March 2013), Vol. 27 No. 6, pp. 863-865.
In this article, J.A. Singh discusses the ongoing debate surrounding the designation of antiretroviral (ARV) resources for HIV treatment versus HIV prevention. According to Singh, HIV treatment and prevention, utilizing pre-exposure prophylaxis (PrEP), should be implemented simultaneously, and also concurrently with an expanded HIV testing and counseling (HTC) program. Treatment and prevention should not be viewed as incompatible. It is unethical to deny ARV treatment for prevention because many people are at high risk of HIV, yet unable to protect themselves. Treatment as prevention, with its dual objectives of treatment and prevention is flawed in settings where HIV prevalence is high, multiple concurrent partnerships are common, and the implementation of HTC for couples is challenging. ARV allocation for HIV prevention is a human rights responsibility. Many countries have accepted the International Covenant on Economic, Social and Cultural Rights to provide “minimum core obligations.” Importantly, this covenant includes vulnerable populations with limited or no access to HIV services. Multisectoral stakeholders must identify vulnerable groups that are in urgent need of prioritized access. Policies will need to be adopted to ensure sustainable programmatic implementation of HIV treatment and PrEP. The author concluded that implementing the strategies concurrently, with scaled-up HTC access, may help achieve the "AIDS-free generation" goal of the Joint United Nations Program on HIV and AIDS.
- A Taxonomy for Community-Based Care Programs Focused on HIV/AIDS Prevention, Treatment, and Care in Resource-Poor Settings
Rachlis, B., Sodhi, S., Burciul, B. et al. Global Health Action (April 2013), Vol. 6.
The authors conducted a literature review to classify HIV-related community-based care (CBC) programs in terms of key characteristics, programming gaps, and roles in HIV programming. They identified 21 CBC programs, primarily in sub-Saharan Africa, that met the inclusion criteria. The taxonomy specified nine programmatic characteristics, classified by region, and the authors developed a logic model for effective and sustainable CBC programs. The most common and second most common visions were to improve the lives of people living with HIV and the lives of other populations affected by HIV, respectively. Few programs targeted vulnerable or marginalized populations, and gender-specific data were limited. Programs offered a range of HIV services and most services were offered in homes and community settings. Operational models differed, often according to the level of community engagement and collaboration among community groups, members, and leaders. Funding sources varied, as did organizational structures, in terms of the type of community health worker involved. Key factors that influenced sustainability were availability of funding and retention of staff. The authors also noted that the majority of programs included some regular monitoring, but many provided limited information about their monitoring and evaluation strategies. The authors concluded that although further research is needed, the findings provide an understanding of CBC models and could be used to develop an evidence base for sustainable HIV services in resource-constrained countries.
- Young Men Who Have Sex with Men: Health, Access, and HIV
Beck, J., Santos, G-M., and Ayala, G. The Global Forum on MSM and HIV (April 2013), Oakland, California.
Analyzing data from the Global Men’s Health and Rights Survey 2012 from the Global Forum on Men Who Have Sex with Men (MSM) and HIV, the authors explored HIV risk factors and access to health services among young men who have sex with men (YMSM) compared with older MSM. YMSM (MSM aged 30 years and below) experienced significantly less access to stable housing, health care, and HIV services, and were more likely to experience homophobia and violence, compared with older MSM. The study recruited 5,779 MSM from 165 countries, including 2,491 YMSM, primarily from Asia, Eastern Europe, and Latin America. Forty-four percent of YMSM who are eligible for HIV treatment are not on treatment, compared with 17 percent of MSM. Additionally, YMSM had lower levels of community engagement, comfort with health care providers, and association with the MSM community. The authors provided recommendations for governments, multilateral organizations, and international donors to address YMSM, including: improving housing stability and economic independence; providing comprehensive HIV prevention services that engage YMSM; improving HIV care and treatment for those living with HIV; involving YMSM to address factors that affect access to services; and advocating for leadership and involvement in the HIV response by YMSM.
- An Assessment of a Large-Scale HIV Prevention Programme for High-Risk MSM and TG in Andra Pradesh, India: Using Data from Routine Programme Monitoring and Repeated Cross-Sectional Surveys
Goswami, P., Rachakulla, H.K., Ramakrishnan, L., et al. British Medical Journal Open (2013), Vol. 3.
The authors assessed a large-scale HIV prevention program, the Avahan India AIDS Initiative, which targeted high-risk men who have sex with men (MSM) and transgender (TG) populations in Andhra Pradesh, evaluating program coverage, intermediate outcomes, and HIV and sexually transmitted infection (STI) rates using program monitoring data and data from two cross-sectional surveys. From initial coverage of 8 percent (2005), the Avahan program scaled up with strong outreach; peer educators contacted 83 percent of the target population monthly by 2008. MSM and TG populations were significantly more likely to report high and consistent condom use with male partners in the second survey round; however, low consistent condom use was reported with regular female partners. Those exposed to the initiative were more likely to use condoms with their male partners compared with those unexposed. The proportion who reported having ever visited an STI clinic increased from 1 to 80 percent from 2005 to 2008. There was no significant change in HIV incidence. The study’s authors argue that there is an urgent need to continue or develop new HIV prevention activities targeting this population, particularly emphasizing regular STI clinic visits and consistent condom use with all partners, to reduce HIV transmission among MSM and TG populations in India.
- U.S. President’s Emergency Plan for AIDS Relief (PEPFAR): Addressing Gender and HIV/AIDS
PEPFAR. (March 2013).
Under the interagency Gender Technical Working Group, PEPFAR’s Gender Strategy urges all HIV programs to incorporate gender norms and inequalities within their activities. Specific actions include: increasing gender equity in HIV and reproductive health services; preventing and addressing gender-based violence (GBV); addressing social norms and behaviors among men and boys; and increasing protection of women and girls and their access to productive resources, including education. Over the past three years, PEPFAR has invested over U.S. $215 million in GBV programs. Following findings of high rates of GBV from violence against children surveys in four sub-Saharan African countries, the U.S. Government developed the U.S. Strategy to Prevent and Respond to Gender-based Violence in August 2012. PEPFAR integrates GBV prevention into existing HIV programs. In January 2013, President Obama signed a presidential memorandum committing to improving women's and girls’ rights as a key to U.S. diplomacy. PEPFAR also has centrally-funded gender initiatives to build evidence for expanding programs, including the PEPFAR Gender Challenge Fund, the GBV Response Initiative, and the Secretary of State’s Office of Global Women’s Issues–PEPFAR GBV Small Grants program, and supports various partnerships to improve the health and wellbeing of women and girls. Through these commitments, PEPFAR has significantly improved the lives of women and girls, and has supported the cause of gender equity globally.
- Technical Consultation on Innovative Uses of Communication Technology for HIV Programming for MSM and TG Populations
The goal of this two-day technical consultation was to provide a forum for key stakeholders in HIV research, programming, implementation, and evaluation to take stock of important developments in the field and develop strategies to improve communication technology for enhanced HIV services. During the meeting, which was co-sponsored by the U.S. President's Emergency Plan for AIDS Relief, the National Institute of Mental Health, and the American Foundation for AIDS Research, participants shared perspectives, programs, and research from the public and private sectors and learned about programmatic examples from Africa, Asia, Latin America, Europe. Australia, and the United States. Presentations and other materials from the consultation are available on AIDSTAR-One's website; a summary report is in development and will be available soon.