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Birungi, H., Mugisha, J. F., Obare, F., & Nyombi, J. K. Journal of Adolescent Health (2009), Vol. 44, pp. 184-187.
Many HIV-positive adolescents are sexually active or desire to be in relationships but engage in poor preventive practices, according to this qualitative study of 732 adolescents aged 15 to 19 years in four Ugandan districts. Using focus group discussions and in-depth interviews, the authors found one-third of the respondents to be sexually active, with 51 percent fearful of disclosing their status even to friends, and only 38 percent having disclosed their status to their partner. Only 37 percent used condoms at first sex, mostly for pregnancy prevention, and less than half of those currently using condoms reported consistent use. More than one-third (37 percent) of the respondents indicated a preference for a partner without HIV, mainly to avoid HIV re-infection, and of those currently in a relationship and aware of the HIV status of the partner, 39 percent were in discordant relationships. Providing preventive sexual and reproductive health information and services to adolescents living with HIV to empower them with the skills needed to negotiate disclosure and consistent condom use must be a priority.
Hawkins, K., Price, N., & Muss, F. Global Public Health (2009). Vol. 4, No. 2, pp. 169-182.
Current behavior change HIV prevention messages have little meaning in relation to young women’s perceived goals in a context in which structural conditions offer few opportunities and limited hope for a secure economic future. This peer-driven ethnographic research employed in-depth qualitative interviews to explore young women's construction of social identity and risk within age-disparate transactional sexual relationships in Maputo, Mozambique. The study highlights young women's perception of a positive identity and esteem linked to perceptions of modernity, consumption, and access to consumer goods. The structural conditions of gender relations that legitimize men’s power and constrain negotiation of safer sex practices by women in age-disparate relationships need to be challenged through approaches that directly address men and masculine norms and parents’ collusion. Interventions need to focus on increasing risk perception among young women and engendering peer support to deal with the risks inherent in the lifestyle. Peer support can increase uptake of STI and voluntary HIV counseling and testing referral services, as well as improve awareness of and access to antiretrovirals.
World Health Organization
This hands-on tool aimed at program managers and health care providers in the public and private sectors describes basic steps in gender-responsive HIV and AIDS programming and suggests practical actions to address key gender issues in four HIV and AIDS service delivery areas: HIV testing and counseling, prevention of mother-to-child transmission of HIV, HIV and AIDS treatment and care, and home-based care and support for people living with HIV.
The tool also provides examples of gender-responsive interventions from the field, and resources such as:
• Counseling role-plays for risk reduction and adherence to AIDS treatment.
• Examples of gender-sensitive communication messages.
• Protocols for addressing the risk of violence against women as a result of HIV status disclosure.
In addition to training program managers and service providers, this tool can be used to integrate gender into pre-service and/or in-service basic HIV and AIDS training curricula; to engender relevant national HIV and AIDS strategies, frameworks, guidelines and operational plans; and to integrate gender-responsive actions into district health and HIV and AIDS plans.
Swendeman, D., Basu, I., Das, S., et al. Social Science Medicine (2009). Vol. 69, pp. 1157-1166.
Compared to clinical and prevention services alone, empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs. Over a 16-month replication trial (2000-2001), the Sonagachi Project’s empowerment intervention strategies (community organizing and mobilization, rights-based framing, advocacy, and micro-finance) had broad impacts on factors that reduce vulnerability to HIV/STD infection. The intervention’s impacts on 21 measured variables, reflecting five common factors of effective programming, significantly 1) improved knowledge of STDs and condom protection from STDs and HIV, and maintained STD/HIV risk perceptions despite treatment; 2) provided a frame to motivate change based on reframing sex work as valid work, increasing disclosure of profession, and instilling a hopeful future orientation reflected in desire for more education or training; 3) improved skills in sexual and workplace negotiations reflected in increased refusal, condom decision-making, and ability to change work contract (but not ability to take leave); 4) built social support by increasing social interactions outside work, strengthening social function participation, and helping other sex workers; and 5) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income. The intervention did not, however, decrease loan taking or increase voting to build social capital.
Kilewo, C., Karlsson, K., Ngarina, M., et al. Journal of Acquired Immune Deficiency Syndrome (2009). In press.
This study suggests that highly active antiretroviral therapy (HAART) given to women living with HIV in late pregnancy and during breastfeeding resulted in low postnatal HIV-1 transmission similar to that previously demonstrated in the Mitra study. Ideally, the antiretroviral (ARV) treatment of pregnant women should start earlier than 34 weeks. Extended maternal prophylaxis with HAART should be further evaluated and compared with use of infant postnatal antiretroviral prophylaxis regarding safety and cost-effectiveness. The Mitra Plus open-label, nonrandomized, prospective cohort study treated women living with HIV in Dar es Salaam with HAART initiated at 34 weeks of gestation or earlier for symptomatic women, or those with CD4 cell counts below 200. Treatment was stopped at six months, except for those who needed HAART for their own health. For one week after birth, 441 infants received ZDV + 3TC, and mothers were advised to exclusively breastfeed and to wean abruptly between five and six months. The cumulative risk of HIV transmission between six weeks and six months was 1 percent, and between six months and 18 months, 1.1 percent. Viral load at enrollment and duration of HAART before delivery were significantly associated with transmission, but CD4 cell count at enrollment was not.
Roura, M., Wringe, A., Busza, J., et al. Biomed Central International Health and Human Rights (2009). Vol. 9, No. 1. In press.
Key community stakeholders should be trained and sensitized on HIV stigma to create an enabling environment for HIV disclosure, treatment continuation, and safer sexual behaviors. The potential positive effects of antiretroviral therapy (ART) provision on status disclosure, viral load reduction, and voluntary testing and counseling (VCT) uptake are at risk of being eroded by stigma. This qualitative study investigated the impact of ART availability on HIV perceptions in northern Tanzania and its implications for prevention. Semi-structured interviews and group activities were conducted with 53 ART clinic clients, service providers, and persons living with HIV. People on ART reported feeling increasingly comfortable with their status, reflecting a certain "normalization" of the disease. This was attributed to their seeing other people affected by HIV, regaining physical health, returning to productive activities, and receiving emotional support. Overcoming internalized feelings of shame facilitated disclosure of HIV status, helped sustain treatment, and stimulated VCT uptake. However, "blaming" stigma—where people living with HIV are considered responsible for acquiring a "moral disease"—persisted in the community, and high levels of anticipated stigma prevented disclosure and VCT uptake. Associations between anticipated stigma and non-disclosure may help explain why barriers to disclosure persist in spite of antiretroviral availability.
Lopman, B. A., Nyamukapa, C., Hallett, T. B., et al. Sexually Transmitted Infections (2009),
Widows and widowers in the high-prevalence setting of Manicaland, Zimbabwe, are more likely to enter into high-risk partnerships when reconnecting to a sexual network. Aspects of widow and widower sexual behavior is correlated with high risk of acquiring HIV and may be associated with 8 to 17 percent of all new HIV infections over a 20-year period. Counseling and testing services can provide support and knowledge needed to make safe sexual choices after the death of a spouse. Participation in support groups sponsored by faith-based or women’s organizations may provide psychosocial support and safer sex prevention messages, in addition to legal advice. Economic empowerment activities providing employment opportunities and economic independence may reduce the need for economic support from a new partner. This longitudinal, population-based study constructed a mathematical simulation model with the aim of estimating the contribution of widow behavior to heterosexual HIV transmission. The prevalence of HIV was exceptionally high among both widows (61 percent) and widowers (54 percent). Widows were more likely to have high rates of partner change and engage in a pattern of transactional sex than married women. Widowers took partners who were a median of 10 years younger than themselves.
Becker, S., Mlay, R., Schwandt, H. M., et al. AIDS and Behavior (2009). In press.
To increase uptake of low couples’ voluntary counseling and testing (CVCT) in the antenatal clinic setting, couple-friendly services are needed in multiple settings and should be offered at first encounter, and couples should be encouraged to visit testing sites together. This randomized study of 1,521 women selected to receive individual voluntary counseling and therapy (IVCT) during the current visit, or CVCT with their husbands at a subsequent visit, measured the acceptance and effectiveness of CVCT as compared to IVCT. In a setting where most women return for subsequent antenatal visits, 51 percent (391/760) of women randomized to the CVCT arm did not return to the antenatal clinic. The proportion of women receiving test results in the CVCT arm was significantly lower than in the IVCT arm (39 vs. 71 percent). HIV prevalence overall was 10 percent. In a subgroup analysis of women living with HIV, those who received CVCT were more likely to use preventive measures against transmission (90 vs. 60 percent) and to receive nevirapine for themselves (55 vs. 24 percent) and their infants (55 vs. 22 percent), compared with women randomized to IVCT. Nevirapine use was low among the women living with HIV in both study arms.
Hargreaves, J., Morison, L., Kim, J., et al. AIDS Care (2009). Vol. 28, No. 8, pp. 1058-1070.
Characteristics of sexual partnerships as well as those of individuals are important determinants of condom use and risk of HIV infection. Male characteristics may be particularly important because of men's greater capacity to make decisions about HIV prevention. This study describes characteristics of non-spousal sexual partnerships associated with condom use at last sex in eight South African villages. Based on an analysis of follow-up data collected in 2004, the data of 1,647 spousal sexual partnerships were analyzed alongside new infections over the previous three years among 762 individuals who were HIV-negative in 2001. Condom use at last sex was reported for 615/1,647 non-spousal sexual partnerships (37.3 percent), and was more commonly reported by individuals who were younger (particularly males), more educated, and aware of their HIV status. Additionally, condom use was more common in casual partnerships where sex was less frequent and where the respondent believed the partner to have other sexual contacts. New HIV infection in the last three years was identified for 87/762 individuals (11.4 percent) and was more common among females and those out of school. Findings suggest that age and/or economic power imbalances might influence condom use within partnerships.
World Health Organization & UNAIDS
Country Experiences in the Scale-up of Male Circumcision in the Eastern and Southern Africa Region: Two Years and Counting
Progress in Male Circumcision Scale-up: Country Implementation Update
A sub-regional consultation was held in Windhoek, Namibia (June 9 to 10, 2009), with the overall objective of reporting progress, sharing experiences, exchanging ideas, and forging collaborations in male circumcision efforts. The first report summarizes progress reports, lessons from program experience, and priorities for the next year for nine countries, including Malawi, Zimbabwe, Zambia, Botswana, South Africa, Namibia, Uganda, Swaziland, Kenya, and Tanzania. The second report details data from 13 countries in Southern and East African countries with high HIV prevalence, low levels of male circumcision, and heterosexual epidemics, and the progress the countries have made to scale up male circumcision.
A combination of two genetically engineered HIV vaccines, neither of which have worked before in humans, had a moderate effect on reducing the risk of infection in a large trial of 16,000 volunteers in Thailand. The trial (RV 144), a collaborative effort with the United States military, the National Institutes of Health, and the Thai Health Ministry, compared a regimen of vaccination with two products against vaccinations with an inactive dummy substance in participants enrolled since 2003. It is the first time any vaccine against the disease has even partly succeeded in a clinical trial, but scientists say the modest protective effect needs further analysis and that people should be cautious about overestimating the results.
Participants, aged 18 to 30 from two provinces in Thailand, were randomly assigned to receive an initial set of vaccinations with ALVAC and follow-up booster vaccinations with AIDSVAX (a product previously tested in large trials without evidence of success), or the placebo vaccination. The prime-boost combination lowered the rate of HIV infection by 31.2 percent compared with the placebo.
The results from the study, considered to be a "proof of concept" trial, will be used to inform the design of future vaccine trials.
The first participants of the Vaginal and Oral Interventions to Control the Epidemic (VOICE) study have been enrolled by the Microbicide Trials Network. The study, a new large-scale clinical trial testing two new uses of antiretroviral (ARV) drugs used to prevent HIV, will examine whether daily application of a vaginal microbicide gel containing ARV, or daily ingestion of an oral ARV tablet, can reduce a woman's risk of acquiring HIV. It is the first HIV prevention trial testing these two different approaches in the same study and the first effectiveness trial of a microbicide where women use the gel every day instead of only at the time of sex. An important question also addressed by VOICE is which of the two, the tablet or the gel, are women more inclined to use.
Up to 5,000 women will participate in clinical trial sites in Uganda, South Africa, Zambia, and Zimbabwe. Women will be randomly assigned to one of five blind study groups, with two groups applying tenofovir or a placebo gel with no active ingredient, and three groups taking a daily tablet of either tenofovir, truvada, or a placebo. The study will last an average of 22.5 months.
For the first time, 50 leading HIV prevention experts, including industry representatives, met in Chapel Hill, North Carolina, on May 13 and 14, 2009, to advance the development of HIV incidence assays, tests that are used to identify the number of new HIV cases in a population within a given time period. Among the most notable outcomes of the meeting were the identification of initial steps needed to develop improved HIV incidence assays and ways to make better use of existing assays. Additionally, the participants discussed the potential use of new biomarkers for HIV incidence assays, identified the infrastructure needed to develop and evaluate HIV incidence assays, and outlined the optimal specifications and requirements for new assays. The meeting was convened by Family Health International, with support from the Bill & Melinda Gates Foundation, the World Health Organization, the HIV Prevention Trials Network, and the Center for HIV/AIDS Vaccine Immunology.
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