HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Global Report: UNAIDS Report on the Global AIDS Epidemic 2013
Joint United Nations Programme on HIV/AIDS (UNAIDS) (September 2013).
This report, which follows the endorsement of the 2011 United Nations Political Declaration on HIV and AIDS outlining global targets to achieve by 2015, summarizes progress towards 10 key targets and reviews commitments and future steps. While recognizing significant achievements, UNAIDS warns of slowing progress in meeting some targets. In 2012, there were 35 million people living with HIV (PLHIV), and 2.3 million new infections—a 33 percent decrease from 2001, including significant reductions in new infections among children. More people than ever are on antiretroviral therapy (ART). Twenty-six countries have achieved the global target of halving sexual HIV transmission by 2015, but other countries are not on track to meet this target, hence the need to enhance prevention efforts. Globally, countries have made limited progress in reducing HIV transmission by 50 percent among people who inject drugs. While ART coverage is high, and approaching the target of 15 million PLHIV on treatment, coverage in low- and middle-income countries represented only 34 percent of 28 million eligible PLHIV in 2013. Stigma, discrimination and criminalization towards PLHIV continue; specifically, 60 percent of countries report laws that inhibit access to HIV services by key populations. The results of this report should be used by countries to refocus and maintain their commitments. The authors urged strengthened global commitment to achieve the goal of zero new HIV infections, discrimination, and AIDS-related deaths.
- Shang Ring Versus Forceps-Guided Adult Male Circumcision: A Randomized, Controlled Effectiveness Study in Southwestern Uganda
Kanyago, S., Riding, D.M., Mutakooha, E., et al. Journal of Acquired Immune Deficiency Syndromes (October 2013), Vol. 64 No. 2, pp. 130-133.
The authors of this randomized, controlled study compared the effectiveness of two methods of adult medical male circumcision (MMC)—the Shang Ring (SR) and forceps-guided (FG)— in a public hospital in Uganda. 138 adult students attending Mbarara University were randomly assigned to SR and FG groups (73 and 65 participants, respectively). The findings showed that the SR is a relatively quick, simple MC method that may enhance uptake and acceptability in similar resource-limited contexts, and validated other studies that showed alternative methods of MC to be more time-saving than standard surgical methods. The SR method enabled an earlier return to normal activity (95 percent of the SR group were able to attend university classes on the first postoperative day, compared to 51 percent in the FG group). However, the incidence of minor postoperative complications was significantly higher in the SR than the FG method (57 versus 18 percent), which might reflect providers’ lack of experience with SR. The SR procedure time was significantly shorter than the FG time, with 71 percent of SR procedures (and none of the FG procedures) completed within 10 minutes. Acceptability and time to complete healing were comparable between both groups. The results emphasize the need for more large-scale, randomized controlled studies to compare the SR with other rapid MC methods and traditional surgical methods.
- Policy Analysis and Advocacy Decision Model for HIV-Related Services: People Who Inject Drugs
Beardsley, K., and Latypov, A. Health Policy Project (June 2012), Futures Group.
Violations of human rights, stigma and discrimination, and restrictive or absent policies impose barriers to services for people who inject drugs (PWID). The Decision Model was developed under the Health Policy Project as a customizable tool that country stakeholders can use to survey, assess, and promote policies leading to sustainable, accessible services for PWID, ultimately with a view to enhancing and strengthening policies based on human rights. Specifically, the tool can be used to identify service-specific policies to determine weaknesses and identify opportunities for creating and advocating for equitable policies. It can also address questions about the integration of PWID-specific policies into prevention and treatment services for HIV, hepatitis, and tuberculosis, e.g., accessible HIV testing and counseling, antiretroviral therapy, and opioid substitution therapy. The model addresses three policy-related barriers—restrictive policies, ineffectively written policies, and absence of policies—that can impede the implementation or sustainability of services. The components of a productive policy environment that are aligned with human rights guidelines include: national framework; community partnership/involvement of PWID; legal environment; and intervention/service development, access, and implementation. Policymakers and other stakeholders can use the Decision Model to improve the policy and legal environment for PWID which, in turn, can improve the quality and accessibility to services for PWID.
- Barriers to and Acceptability of Provider-Initiated HIV Testing and Counselling and Adopting HIV Prevention Behaviours in Rural Uganda: A Qualitative Study
Kiene, S.M., Sileo, K., Wanyenze, R.K., et al. Journal of Health Psychology (September 2013), E-publication ahead of print.
The authors conducted formative research to identify factors affecting the HIV prevention behaviors of Ugandan men and women receiving provider-initiated testing and counseling (PITC) in a public hospital. They conducted focus group discussions with 56 clients and 23 hospital staff, and key informant interviews with four additional staff, to obtain perspectives about the community’s HIV prevention behaviors and how to improve PITC services. The findings revealed important individual, interpersonal, and structural or community-level factors that influenced HIV prevention behaviors and PITC acceptability. While clients were knowledgeable about the benefits of HIV testing and counseling, information gaps and misconceptions were common. Attitudes toward PITC were generally favorable; however, motivation to test was hindered by fear of testing, finding out one’s status, and disclosing results to a partner. Fear of lack of confidentiality and poor provider counseling skills also limited clients' motivation. Structural factors also exerted significant impacts. Gender inequity influenced behavior, including women’s ability to negotiate safe sex. Stigma towards HIV-positive persons comprised a barrier to PITC and prevention behaviors, and affected confidentiality and trust in client-provider relationships, which emphasized the need to conduct PITC privately. Interventions must address structural-level factors, e.g., stigma and gender norms, to increase HIV prevention behaviors. Client-centered, non-judgmental counseling during PITC may increase positive prevention behaviors among clients.
- Modelling HIV Incidence and Survival from Age-Specific Seroprevalence after Antiretroviral Treatment Scale-Up in Rural South Africa
Mossong, J., Grapsa, E., Tanser, F., et al. AIDS (September 2013), Vol. 27 No. 15, pp. 2471-2479.
The authors modeled age-specific seroprevalence data (examining the periods 2003-2005, 2006-2008, and 2009-2011) to estimate trends in HIV incidence and survival among those aged 15-49 in KwaZulu-Natal during national antiretroviral (ART) scale-up. The model demonstrated a survival benefit for HIV-positive persons following ART rollout in 2004 and suggested greater improvement in survival if ART coverage is maintained or increased. The age at peak incidence varied slightly between women (21.4 to 22.1 years) and men (27.3 to 29.4 years), ranging from .06 to .08 per year and .04 to .06 per year, respectively. However, the estimated incidence rates do not suggest a significant decrease in HIV incidence. Median survival after becoming HIV-positive was 10.0, 12.6 and 14.2 years during the respective calendar periods for women, with a highly significant difference between the first and last periods. For men, median survival was 10.0, 9.8 and 14.0 years, respectively. The increase in survival reflected an increase in HIV prevalence, particularly among women aged 30-49 and men aged 45-49. Future studies should extend this model to estimate sexual mixing patterns, and refine estimates by incorporating other existing data, e.g., age-specific HIV mortality, that can provide insight into other age-related epidemiologic processes. The authors concluded that using cross-sectional seroprevalence data could help monitor HIV survival and incidence trends in similar contexts.
- Attitudes of Married Men to the Use of Vaginal Microbicides by their Female Partners in Pune, India
Kohli, R., Desphande, S., Tolley, E., et al. International Health (September 2012), Vol. 4 No. 3, pp. 200-203.
The authors conducted a survey with 305 married women and 151 of their husbands in Pune, India to understand factors that influence men’s acceptance of vaginal microbicides for HIV prevention with their regular female partners. Approximately 90 percent of men reported willingness to use a microbicide with their partners, but over half (58 percent) did not support concealed use by their partners. However, men who engaged in high-risk sexual behaviors, e.g., multiple sex partners, were twice as likely to approve of concealed use by their partners, compared to men who did not engage in high-risk behaviors. Those who had previously used contraceptives were also three times more likely to support concealed use of microbicides. Men younger than age 34 and men who reported better quality relationships with their partners were eight and seven times more willing to use microbicides with their partners, respectively. The study's findings show that strategies for developing and marketing microbicide use in India must involve men as well as women, recognizing that different approaches will be needed for different populations of men.
- Cutting to the Chase: Participation Factors, Behavioral Effects, and Cultural Perspectives of Participants in an Adult Circumcision Campaign
Limburgh, C.M., van Schalkwyk, G.I., Lee, K-H., et al. AIDS Care (October 2013), Vol. 25 No. 10, pp. 1278-1283.
To add to the limited evidence on risk compensation following medical male circumcision (MMC) in South Africa, the authors conducted 29 semi-structured interviews with men who received counseling about circumcision at a local hospital in Northern Cape Providence. While circumcision has great public health potential, the findings showed some areas of risk. Interviewees mainly contemplated circumcision to reduce the risk of sexually transmitted infections, particularly HIV, or to enhance sexual experiences. All interviewees initially indicated that they would continue to use condoms after circumcision; however, when asked about this behavior by other men, they suggested further counseling to reduce the risk of inconsistent condom use, saying that circumcision could lead to increases in sexual encounters. Analysis suggested that the counseling the interviewees received effectively conveyed the need to continue using condoms postoperatively. However, interviewees’ views of others men’s potential behaviors raise concern that they themselves did not actually intend to use condoms, possibly believing themselves at less risk. Some participants mentioned the intention to have a child as a situation where they might not use condoms post-circumcision, and the authors noted this as a potential risk that merits further study. Lastly, men favored MMC over traditional circumcision. Contextual analysis should precede circumcision campaigns, because perceptions of medical and traditional circumcision may vary culturally.
- Integration of Tuberculosis and Prevention of Mother-to-Child Transmission of HIV Programmes in South Africa
Uwimana, J., and Jackson, D. The International Journal of Tuberculosis and Lung Disease (October 2013), Vol. 17 No. 10, pp. 1285-1290.
The authors assessed the integration of tuberculosis (TB) services with prevention of mother-to-child transmission (PMTCT) services at antenatal care (ANC) clinics in Sisonke District in South Africa’s KwaZulu-Natal province. They conducted surveys with 150 ANC clients and interviews with 26 program managers, and reviewed data from 1,700 registered ANC clients (2008 to 2009). While there was some integration, active TB case finding among pregnant HIV-positive women was substandard. TB prevalence among pregnant clients was 1.3 percent overall and 8 percent among HIV-positive clients (2 of 26 HIV-positive women). TB diagnosis was statistically associated with HIV status. In total, 83 clients (56 percent) reported being screened for TB; 75 percent of clients interviewed reported receiving education about TB. Among all registered clients, 55 percent of HIV-positive pregnant women (n=298) were screened for TB, with four women diagnosed and on TB treatment. However, there was no record of treatment outcomes or screening for isoniazid preventative therapy (IPT) for latent TB infection. Most key informants found integration inadequate because of insufficient coordination and supervision, staff shortages, referral structures between services, and poor monitoring and evaluation of integrated services. Programs need to address health system barriers and develop key indicators to measure integration. The authors concluded that improving integration is vital and will require strong leadership and supportive supervision for health care workers.
- Community-Based Intervention to Enhance Provision of Integrated TB-HIV and PMTCT Services in South Africa
Uwimana, J., Zarowsky, C., Hausler, H., et al. The International Journal of Tuberculosis and Lung Disease (October 2013), Vol. 17 No. 10, pp. S48-S55.
The authors assessed the effectiveness of a community-based intervention to integrate tuberculosis (TB), HIV, and prevention of mother-to-child transmission (PMTCT) services in Sisonke District of KwaZulu Natal, South Africa. The intervention entailed training community care workers (CCWs) to provide comprehensive services. Integrated TB/HIV/PMTCT services provided by CCWs were feasible, acceptable, and effective. Pre- and post-intervention data were collected and analyzed from 1,976 intervention and 1,608 control households. Significantly more intervention respondents received health education, HIV testing and counseling (HTC), screening for TB and sexually transmitted infections, and support for anti-TB and antiretroviral therapy; had sputum collected; and had access to PMTCT services. Intervention households were nearly five times more likely to be screened for TB. Higher education and income were associated with access to these services. Willingness to disclose HTC history increased from 68 percent to 92 percent among 2,449 respondents pre-intervention and 3,584 respondents post-intervention, respectively; and reports of receiving HTC increased from 57 to 75 percent. Community care workers performed more poorly than control providers in furnishing education on integrated management of childhood illnesses, vital documents, and referral for social grants, but performed better in referral for weighing and immunization. The authors highlighted the need to ensure comprehensive TB/HIV services, and to examine socioeconomic inequalities and access to community-based services and intervention cost-effectiveness.
- Sex Work and HIV in Cambodia: Trajectories of Risk and Disease in Two Cohorts of High-Risk Young Women in Phnom Penh, Cambodia
Page, K., Stein, E., Sansothy, N., et al. BMJ Open (September 2013), Vol. 3 No. 9, pp. e003095.
In 2008, the Cambodian government implemented laws to combat human trafficking and sexual exploitation, including banning brothel-based sex work and labeling female sex workers (FSWs) "entertainment workers” (EWs). The authors conducted two prospective studies on high-risk FSWs, aged 15-29, in Phnom Penh (cohort 1: 2007-2008, n=160 and cohort 2: 2009-2010, n=153) to explore changes in the HIV risk environment. Women in cohort 2 had higher education, fewer sexual partners, less time working as FSWs, and significantly lower HIV prevalence compared to those in cohort 1 (9.2 versus 23 percent). More women from cohort 2 had worked in entertainment establishments during the previous 30 days. Women in cohort 2 reported more alcohol use but fewer days drunk during the previous 30 days, and fewer reported ever using amphetamine-type stimulants (ATS). Cohort 2 EWs reported less alcohol and ATS use, but brothel-based or street FSWs reported significantly more ATS use. The protective effects of entertainment-based venues may include having a manager; the odds of having HIV were lower among women who reported having a manager than among those who did not. The authors noted that HIV incidence may increase among FSWs at the population level because of the increase of women engaging in sex work; hence a possible increase in occupational HIV risk among FSWs. While more research is needed, the need for combination HIV prevention services for Cambodian FSWs is evident.
- Interventions to Prevent the Initiation of Injection Drug Use: A Systematic Review
Werb, D., Buxton, J., Shoveller, J., et al. Drug and Alcohol Dependence (September 2013), E-publication ahead of print.
The authors systematically examined peer-reviewed evaluations of interventions to prevent initiation of injection drug use (IDU) to assess their effectiveness and inform development of preventive policies. Of 78 candidate studies, eight studies published between 1992 and 2011 were included. The findings suggested that interventions involving peer-based behavior change or enrollment in treatment addiction programs may be effective in preventing IDU initiation. However, further research and new approaches to prevention are warranted, given the limited evidence and the proven risks of IDU, including HIV. Five studies were implemented in North America, and one each in Europe, Australia, and Central Asia. Four types of prevention interventions were evaluated: social marketing, peer-based behavior change, access to addiction treatment programs, and drug law enforcement/deterrence. Half of the studies found that peer-based behavior change and treatment-based approaches had significant impacts in reducing the exposure of injection-naïve drug users to injection environments. Interventions that applied drug law enforcement as a deterrent were less effective. The positive impact of peer-based behavior modification interventions shows that the impact of social networks should not be overlooked. Overall, though, there is insufficient evidence on these interventions to inform scale-up. The authors called for further research, concluding that there must be clear scientific evidence of impact before taking broad actions to scale up policies or interventions to prevent IDU initiation.
- Increasing Condom Use and Declining STI Prevalence in High-Risk MSM and TGs: Evaluation of a Large-Scale Prevention Program in Tamil Nadu, India
Subramanian, T., Ramakrishnan, L., Aridoss, S., et al. BMC Public Health (September 2013), Vol. 13 No. 1, pp. 857.
This evaluation of Avahan, an Indian AIDS initiative that engaged high-risk men who have sex with men (MSM) and transgender persons (TG) in Tamil Nadu (January 2005-March 2009), assessed Avahan's coverage and impact on condom use and HIV and sexually transmitted infections (STIs) prevalence. Avahan attained high coverage and service uptake by both populations, increased in program scale, and was associated with increased condom use by MSM with commercial and regular partners (81 to 94 percent and 33 to 46 percent, respectively). Condom use with casual male partners among TGs improved slightly, but declined significantly with commercial male partners (from 93 to 80 percent). The proportion of MSM and TGs ever contacted by peer educators increased from 82 percent to 100 percent of estimated populations between 2006 and 2009; the proportion of these who had ever visited STI clinics saw similar increases. Changes in HIV prevalence were not significant (9.7 to 10.9 percent, MSM; 12 to 9.8 percent, TG); however, the prevalence of urethral syphilis declined significantly among MSM and TG (14.3 to 6.8 percent and 16.6 to 4.2 percent, respectively). The authors concluded that public health programs should target MSM and TG separately. Although further research is needed to better understand factors that affect MSM and TG individuals’ condom use with different partners, these findings could be used to improve behavior change communication programs.
- More Health for the Money: Putting Incentives to Work for the Global Fund and its Partners
The Center for Global Development (September 2013), Washington, DC.
This report from the Center's Value for Money Working Group offers practical strategies for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) to apply in its four-phase grant-making cycle. These strategies aim at achieving “more health value for the money”: investing resources cost-effectively to obtain a higher global health impact. The report describes key issues within each phase of the grant cycle—allocation, contracts, cost and spending, and performance verification—and makes several recommendations for improvement. In allocation of resources, to support evidence-based best practices, the Global Fund should specifically select scientifically proven and cost-effective interventions and commodities. To improve contracts and agreements to create stronger incentives, the Global Fund should direct some funding to the documentation of incremental performance progress, particularly against the most important indicators, and focus some funding on partners’ achievement of end-program goals. Within cost and spending, the Global Fund should improve monitoring and reporting by tracking unit costs of services delivered, sharing costing data with partners, and using unit-cost data throughout the entire grant cycle. To improve performance verification, the Global Fund should identify more rigorous measurement and reporting tools and verify data with population-based measurement. The working group suggested that the Global Fund and its partners adopt these strategies to ultimately improve their impact on reducing the global disease burden and improving health worldwide.
- Hormonal Contraception and HIV: Technical Brief
PEPFAR and USAID. (September 2013). Washington, DC.
This brief, directed to national policymakers, U.S. Government (USG) program managers, and implementing partners, summarizes evidence and recommendations on hormonal contraception (HC) and HIV, and identifies implications for policies and programs. The report discusses HC use in terms of whether HIV-negative women will acquire HIV, women living with HIV will infect male sexual partners, women living with HIV will have quicker disease progression, and whether women being treated for HIV will experience drug interactions. HC use does not protect against HIV, and since evidence on increased risk with use of progestogen-only injectable contraception is inconclusive, women at risk who use HC should be advised to consistently use condoms and other preventive measures. Hormonal contraception does not protect against onward HIV transmission; thus, HIV-positive women should be advised to use condoms. If any HC method is found to increase HIV risk, it should be balanced against the life-saving benefits of effective methods to prevent unintended pregnancy. Policies should aim for the greatest public health benefit, which will vary according to the epidemiologic context. HIV testing and counseling should be available through family planning services, and the World Health Organization’s HC/HIV guidelines should be used to develop country guidelines. The USG supports research to develop multipurpose prevention technologies, and to improve understanding of potential associations between HC and HIV.
- Families Matter! Presexual Risk Prevention Intervention
Miller, K.S., Lasswell, S.M., Riley, D.B., et al. American Journal of Public Health (November 2013), Vol. 103 No. 11, pp. e16-e20.
This report discusses the Families Matter! Program (FMP), which is an evidence-based behavioral intervention that uses a five-session curriculum for parents and children aged 9-12. FMP seeks to delay sexual debut and decrease sexual risk behaviors through positive parent-child communication about HIV, sexually transmitted infections, and pregnancy prevention. It is implemented in eight sub-Saharan African countries with support from the U.S. Centers of Disease Control and Prevention through the U.S. President’s Plan for Emergency AIDS Relief. The intervention was initially adapted in Kenya (2003-2004) from the US-based Parents Matter! program; an evaluation in 2006 showed high acceptability and effectiveness, with an average of 90 percent of participants attending all sessions. FMP is currently being adapted to create a program for preventing sexual abuse against children, which will be tested in 2013. Several longitudinal studies on FMP are planned in 2013 and 2014, and the program may be adapted for older adolescents aged 13-18. The program’s five-step capacity building model supports FMP users to determine a community's need, engage local stakeholders to ensure cultural relevancy, ensure understanding and correct delivery by implementers; continuously monitor participants' attendance and satisfaction, and respond flexibly to the context while maintaining the vision of the intervention. It has been used by local governments and partners with high intervention fidelity and participant retention. The FMP may be useful in similar resource-constrained contexts.