HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- The New Role of Antiretrovirals in Combination HIV Prevention: A Mathematical Modelling Analysis
Cremin, I., Alsallaq, R., Dybul, M. et al. AIDS (November 2012), e-publication ahead of print.
Antiretroviral (ARV)-based HIV prevention strategies, such as pre-exposure prophylaxis (PrEP) and early antiretroviral therapy (ART) to lower viral load, are unlikely to have a major impact on HIV incidence as stand-alone interventions, according to this analysis. Mathematical modeling was used to estimate the epidemiological impact and cost-effectiveness of these types of interventions in a hyper-endemic setting such as KwaZulu-Natal, South Africa. The authors tested 16 different implementation scenarios that combined or staggered PrEP, early ART, and such non-ARV-based HIV prevention approaches as medical male circumcision, or that tested each intervention alone. They found that PrEP is too costly to offer widely to non-infected individuals and thus, by itself, has little potential for achieving a population-level prevention effect. On the other hand, the authors found that, while early ART for infected individuals alone is less expensive, it is also less effective in decreasing HIV incidence to low levels. The authors conclude that ARV-based prevention approaches work best and most affordably as part of a larger combination HIV prevention strategy that achieves an optimal balance between cost and effectiveness in providing ARVs for infected and uninfected individuals. They suggest that implementing PrEP and early ART together with medical male circumcision and other prevention interventions at high coverage could achieve a dramatic and cost-effective drop in HIV incidence at the population level.
- The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Blueprint: Creating an AIDS-free Generation
PEPFAR (November 2012).
An “AIDS-free generation”—a goal that has finally become realizable due to the effectiveness of recent HIV prevention and treatment breakthroughs—has become a rallying cry for the international response to HIV over the past year. This strategy report released by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) describes how the U.S. Government plans to contribute to this objective. The Blueprint is based on five principles: (1) investing in evidence-based approaches to scale up core interventions, (2) working with a broad array of partner countries, donors, civil society, the private sector, and other stakeholders to mobilize and share resources, (3) improving gender equality in HIV services by focusing on women and girls, (4) ending stigma and discrimination against key populations and people living with HIV, and (5) creating benchmarks to determine whether goals are met. Four “road maps” detail the steps to be taken to achieve these goals. The Road Map for Saving Lives calls for scaling up combination HIV prevention and treatment interventions and eliminating new HIV infections among children by 2015. The Road Map for Smart Investments explains how to target funding to interventions that reach populations most at risk. The Road Map for Shared Responsibility outlines how PEPFAR will build partnerships with other countries and build support for civil society, while the Road Map for Driving Results with Science supports implementation research and other ways to build the evidence base.
- Results (UNAIDS World AIDS Day Report 2012)
Joint United Nations Programme on HIV/AIDS (UNAIDS) (November 2012).
The rate of new HIV infections has dropped by more than 50 percent in 25 low- and middle-income countries (more than half in Africa), according to this report issued by UNAIDS. This is one of several striking epidemiological findings cited in this report, which describes the acceleration of progress in HIV prevention and treatment in the recent past due to global scale-up of successful evidence-based programming. For example, several countries that have had the highest HIV prevalence show dramatic decreases since 2001: by 71 percent in Botswana, 73 percent in Malawi, 50 percent in Zimbabwe, and 41 percent in South Africa and Swaziland. In the past two years, half of these reductions in new infections are in children, demonstrating the possibility of achieving zero new pediatric infections in the near future. Treatment efforts are also demonstrating impressive effectiveness: in sub-Saharan Africa, AIDS-related deaths have dropped by one-third in the past six years, and the number of people receiving antiretroviral therapy (ART) has increased by 59 percent. The report credits ART for saving many lives that earlier might have been lost to AIDS. The document also points to rising domestic investments in HIV programming in low- and middle-income countries—despite declining health budgets—as an important factor in moving toward controlling the epidemic. Not all goals have been achieved; for example, nearly 7 million HIV-positive individuals eligible for treatment are unable to get it.
- Associations between Mode of HIV Testing and Consent, Confidentiality, and Referral: A Comparative Analysis in Four African Countries
Obermeyer, C.M., Neuman, M., Desclaux, A. et al. PLOS Medicine, Vol. 9 No. 10, p. e1001329.
This article describes the Multi-Country African Testing and Counseling for HIV (MATCH) study, which undertook research to compare voluntary counseling and testing (VCT) and provider-initiated testing for HIV and investigate how each method approaches such human rights issues as consent, confidentiality, and referral. MATCH conducted surveys in four countries—Burkina Faso, Kenya, Malawi, and Uganda—within three types of facilities: integrated testing and medical care facilities, stand-alone VCT centers, and facilities focusing on prevention of mother-to-child transmission (PMTCT). A total of 2,116 respondents reported on their testing experience; assessment of their responses was based on eight outcome measures of pre- and post-test counseling, consent, confidentiality, interactions with providers, and referral for care. Across all four countries and both modes of testing, high levels of respondents reported satisfaction with the services they received. The authors found that individuals who had a pre-test meeting at an integrated facility were more likely to have completed consent procedures and pre-test counseling. Individuals who had tested at integrated and PMTCT facilities were more likely to receive post-testing counseling than at a stand-alone VCT facility. Overall, according to the authors, the data show that respondents reported good outcomes for consent, confidentiality, and referral, no matter the counseling mode, which suggests that scaling up testing through multiple modes is a promising strategy.
- A Systematic Review of Behavioral Interventions to Prevent HIV Infection and Transmission among Heterosexual, Adult Men in Low- and Middle-Income Countries
Townsend, L., Mathews, C., & Zembe, Y. Prevention Science (November 2012), e-publication ahead of print.
This systematic review and synthesis discusses 19 articles published between January 2001 and May 2010 on behavioral HIV prevention interventions for heterosexual men in 12 lower- and middle-income countries with a high burden of HIV. These articles report on a variety of interventions focusing on condom use, numbers of sexual partners, alcohol use alone or associated with sexual acts, and intimate partner violence (IPV). Overall, the majority of interventions led to positive behavior change in condom use, reduced IPV, and mixed results in behavior change in alcohol use, but had little effect on reducing the number of sexual partners. The authors argue that, as shown by how few studies they were able to identify for review, heterosexual men are an underserved population for prevention programming, particularly interventions to address multiple sex partnerships and alcohol use. The authors also offer other tentative conclusions: interventions to improve condom use would benefit from individual-level counseling strategies, peer education may not be an appropriate strategy for increasing condom use among people who inject drugs, and the information-motivation-behavioral (IMB) skills model in group settings is a promising approach for reducing the number of sexual partners as well as alcohol consumption. The authors further recommend including biological measures—HIV prevalence or incidence—in research designs.
- HIV Testing and Counseling Leads to Immediate Consistent Condom Use among South African Stable HIV-discordant Couples
Rosenberg, N.E., Pettifor, A.E., De Bruyn, G. et al. Journal of Acquired Immune Deficiency Syndromes (October 2012), e-publication ahead of print.
Receiving an HIV-positive test result can prompt individuals to cut back on unprotected sex, especially after they become aware that they’re in an HIV-discordant relationship, according to this study. The authors report on an analysis of data derived from the Partners in Prevention HSV/HIV Transmission Study, a four-year randomized trial of the effectiveness of acyclovir in preventing sexual transmission of herpes simplex virus 2 and HIV-1. That study gathered self-reported behavioral data from 508 HIV-infected study participants at three sites in South Africa, including information collected at baseline on the timing of sexual behavior change after one partner received a positive HIV test result. Comparing the behaviors of participants at baseline and at months one, six, and twelve, the authors found that HIV testing and counseling (HTC), particularly HTC for couples, helps HIV-discordant stable couples decide to adopt consistent condom use, with increased condom uptake beginning in the first week after couples HTC. For example, 71 percent of HIV-infected partners in discordant relationships reported unprotected sex at the time of their diagnosis, which dropped significantly to 8 percent after only one month. The authors conclude that mutual awareness of discordancy within a relationship results in more HIV-protective behaviors than individual awareness of one’s HIV-positive serostatus.
- High Acceptability of HIV Pre-exposure Prophylaxis but Challenges in Adherence and Use: Qualitative Insights from a Phase I Trial of Intermittent and Daily PrEP in At-Risk Populations in Kenya
Van der Elst, E.M., Mbogua, J., Operario, D. et al. AIDS and Behavior (October 2012), e-publication ahead of print.
The authors report on the results of a qualitative study of men who have sex with men (MSM) and of female sex workers (FSWs) participating in a four-month trial of pre-exposure prophylaxis (PrEP) in two Kenyan cities. Ten focus group discussions and seven in-depth discussions were held with a sub-population of 51: 46 MSM and 5 FSWs representing a sample of “good,” “moderate,” and “low” adherers. Discussion topics included the pros and cons of the pill being used for the study, dosing scheduling and adherence measures, and issues experienced by the participants during the study. The authors found that these key populations at high risk of HIV infection find PrEP to be highly acceptable, although dosing and social and adherence issues present challenges to successful implementation. Several FSWs compared PrEP favorably to condoms as a prevention strategy, since client consent is not required. A number of participants reported side effects, including diarrhea and headaches, but overall, these were not perceived as too severe to inhibit adherence. One widespread experience was fear of stigma should others learn that a participant was taking PrEP, so many participants took their PrEP medications secretly or lied about what kind of pills they were taking.
- HIV/STI Risk Among Venue-Based Female Sex Workers Across the Globe: A Look Back and the Way Forward
Pitpitan, E.V., Kalichman, S.C., Eaton, L.A. et al. Current HIV/AIDS Reports (November 2012), e-publication ahead of print.
The authors conducted a qualitative review of 37 studies of venue-based female sex workers (FSWs) to explore whether categorizing sex work by venue or type is a valid way to assess levels of HIV risk for designing targeted prevention interventions. They also investigated the common characterization of sex work as either “direct” (the exchange of sex for a fee by women, for whom sex work is the primary source of income) or as “indirect” (when women have legitimate work where they may also provide sex to clients) as a prime factor in determining seroprevalence of HIV or other sexually transmitted infections (STIs). They also examined typologies of venue—brothel-based, street-based, bar-based, and so on—as determinants of levels of infection. The authors found that the “direct vs. indirect” dichotomy does in fact influence levels of HIV/STI infection among samples of FSWs. Venue, on the other hand, is not clearly associated with specific levels of HIV risk. The authors conclude that broad typologies based on venue or type are insufficient by themselves without close examination of structural factors that contribute to the risk environment. They recommend that researchers use both quantitative and qualitative methods in sex work studies to achieve a more nuanced assessment of HIV risk in sex work.
- Property Rights Violations as a Structural Driver of Women's HIV Risks: A Qualitative Study in Nyanza and Western Provinces, Kenya
Dworkin, S.L., Grabe, S., Lu, T. et al. Archives of Sexual Behavior (November 2012), e-publication ahead of print.
This qualitative study examines the role that property rights violations play in increasing sexual transmission of HIV in two rural areas of Kenya with high HIV prevalence. The authors interviewed 50 people—legal professionals, community leaders, and other implementers—involved in a community-based program to help women protect themselves from property rights violations, disinheritance, asset stripping, and related HIV risk. They asked these implementers to explain how they perceive the loss of property rights as influencing primary and secondary HIV transmission in the region. Many reported that the program’s home-based caregivers discovered that some women clients “disappeared” suddenly, usually after a husband died and in-laws evicted her from the home. Nearly every implementer said that in-laws justify these actions by blaming women for infecting their sons or brothers. Another widely shared perception is that these violations exacerbate the epidemic by driving newly impoverished widows and often their children into migration, food insecurity, and sometimes commercial or transactional sex work. The study also queried implementers about such cultural practices as wife inheritance and “sexual cleansing” that can increase risk of HIV infection. The authors recommend that research continue on property rights violations to devise more effective responses and informed policy initiatives to counter this structural challenge to HIV prevention for women.
- Social and Cultural Contexts of Concurrency in a Township in Cape Town, South Africa
Mah, T.L. & Maughan-Brown, B. Culture, Health, and Sexuality (November 2012), e-publication ahead of print.
This qualitative study examines the social, cultural, and economic factors that drive concurrent sexual partnerships in Khayelitsha, a township in Cape Town, South Africa. The authors conducted small-group discussions and focus groups with men and women who had participated in the Khayelitsha Panel Study on sexual partnerships. All participants expressed the belief that concurrent partnerships are very common in their community, as research shows is the case across South Africa. The two primary reasons given for the practice of concurrent relationships were monetary gain in the form of financial or material exchange, with men expected to provide for female partners, and sexual frustration with a main or secondary partner; both explanations are in line with findings from earlier research. Separation from a main partner and alcohol use were also cited as reasons for having concurrent partnerships. Despite widespread awareness about the increased risk of HIV, most respondents said this does not deter most people from multiple partnerships. Concluding that concurrent partnerships are in fact a social norm in this community, the authors opine that the practice may be difficult to curtail. They suggest that individual-level interventions such as improving economic status and increasing sexual satisfaction within relationships could contribute to reducing concurrency. Prevention messaging that focuses on protecting a primary partner by using condoms with other partners may also be beneficial.
- The Highest Attainable Standard of Evidence (HASTE) for HIV/AIDS Interventions: Toward a Public Health Approach to Defining Evidence
Baral, S.D., Wirtz, A., Sifakis, F. et al. Public Health Reports (November 2012), Vol. 127 No. 6, pp. 572-84.
In recent years, more demanding standards for developing public health policy and programming call for decisions based on evidence. While randomized controlled trials (RCTs) are considered the gold standard for gathering evidence, they are very costly, may not be feasible because they require large study populations, and often present ethical challenges, particularly in HIV-related studies. The authors discuss an affordable new method they developed to build evidence, the Highest Attainable Standard of Evidence (HASTE) system, which uses data from existing studies and program implementation to assess HIV interventions specifically for men who have sex with men (MSM). The HASTE process—which is a modification of several evaluation tools—triangulates efficacy data, implementation data, and biological and public health plausibility to assess interventions for MSM, using a multidisciplinary team to review these data. HASTE then applies four grades to classify the evidence: Strong, Conditional, Insufficient, and Inappropriate. The authors argue that HASTE is an appropriate method for assessing evidence on MSM because much of the data about key populations comes not from RCTs but from the programming experience of small-scale organizations that implement interventions. The authors recommend that HASTE be used to develop an evidence base for advocacy for MSM programming in low- and middle-income settings.
- New HIV Prevention Technologies and Their Relevance to MARPs in African Epidemics
Rebe, K., Semugoma, P., & McIntyre, J.A. SAHARA-J: Journal of Social Aspects of HIV/AIDS (September 2012), Vol. 9 No. 3, pp. 164-66.
As new prevention technologies dramatically change the global response to HIV, researchers and programmers must explore how to implement them effectively for such key populations as African men who have sex with men (MSM), according to the authors. This highly stigmatized population has been practically excluded from research and from prevention and treatment efforts since the early days of the epidemic. Early antiretroviral therapy (ART) for serodiscordant MSM couples has not been tested, although epidemiological evidence shows that ART for HIV-positive MSM may be lowering incidence in some places. In the iPrEX study, pre-exposure prophylaxis (PrEP) has achieved proof of concept among MSM, but too few Africans were enrolled to determine its efficacy for them. The authors speculate that it may be difficult to convince African governments to create PrEP programs for MSM when ART for treatment is still not universally available. Microbicides for rectal use are still in development, while medical male circumcision has not yet been shown to specifically benefit MSM. The authors suggest that combination programming that offers a “menu” of prevention choices could be the best strategy for MSM, who are very diverse in lifestyles, access to health care, and levels of HIV risk. The authors recommend advocacy and community activism for a human rights agenda to support HIV prevention efforts for African MSM. (This article appears in a special issue of SAHARA-J, also reviewed this month.)
- Forced Sexual Initiation, Sexual Intimate Partner Violence and HIV Risk in Women: A Global Review of the Literature
Stockman, J.C., Lucea, M.B., & Campbell, J.C. AIDS and Behavior (November 2012), e-publication ahead of print.
Research on forced sexual initiation and sexual intimate partner violence (IPV) shows that these practices contribute significantly to HIV infection risk for women in low- and middle-income countries, according to this systematic review. The authors analyzed 21 studies published since 2000 that examine a broad and complex set of correlations between HIV risk and sexual violence against women in six countries. The authors found that these associations vary by study population; for example, one study in Uganda found that women 20 to 44 years old had significantly elevated HIV risk if they had experienced forced or coerced first sex before they were 18. Different studies set in different parts of the world show that women’s experience of violence can also significantly increase such high-risk behaviors as low condom use, involvement in multiple partnerships, and injection drug use, as well as having a history of sexually transmitted infections. The authors point out several barriers to gathering data to develop anti-violence strategies for women, including very low reporting to law enforcement and a lack of precise terminology to use in this field, as well as different cultural perceptions of what constitutes IPV. They recommend the use of culturally tailored screening to identify victims of sexual IPV at health clinics, law enforcement settings and shelters, and HIV program settings.
- Rewriting the Narrative of the Epidemiology of HIV in Sub-Saharan Africa
Baral, S. & Phaswana-Mafuya, N. SAHARA-J: Journal of Social Aspects of HIV/AIDS (September 2012), Vol. 9 No. 3, pp. 127-30.
This introductory article to a special issue of SAHARA-J challenges long-held assumptions that key populations such as men who have sex with men (MSM), female sex workers (FSWs), transgendered people (TG), and people who inject drugs (PWID) are not significant factors in the generalized HIV epidemics of sub-Saharan Africa (SSA). The authors argue that this misconception results from the exclusion of these groups from the HIV surveillance systems of African countries, leaving them outside the public health and policy responses to HIV, without targeted education and prevention programming and treatment. The 10 articles in this issue present evidence that key populations in SSA live with high burdens of HIV and discuss the dearth of data, research, and programming for them. Articles by Mbwambo (on PWID), Muraguri (on MSM), Ngugi (on FSW), and Jobson (on TG) all cite the paucity of data for key populations other than prevalence data from convenience samples, which have yielded consistently conservative figures underestimating the actual burden of disease. Articles by Scheibe and by Rebe and co-authors argue that existing evidence-based prevention strategies are appropriate for African FSW and MSM but that combination approaches that address all levels of risk are most effective. Grosso and colleagues describe how criminalization of these groups throughout SSA inhibits robust data collection. Overall, articles in this issue recommend that SSA countries recognize their epidemics as mixed, not generalized, and that they put aside denial to focus on collecting data on all at-risk populations.
- AVAC Report 2012: Achieving the End—One Year and Counting
AVAC (November 2012).
This report issued by the Global Advocacy for HIV Prevention (AVAC) calls for the launch of an ambitious global effort to end the HIV epidemic, a goal articulated more than a year ago by U.S. Secretary of State Hillary Clinton and other political and public health leaders after new prevention approaches made such a possibility seem finally achievable. For this effort to be successful, increasing the pace of advocacy, programming, and research; halting funding cuts and even increasing funding, despite current budget shortfalls; and strengthening global commitment and leadership are necessary. AVAC argues that current modeling points to an upcoming “window” of epidemiological opportunity, when the rate of scale-up of treatment will exceed the rate of new HIV infections, so action must be taken quickly. The report lists five priorities for 2013: (1) end confusion about combination prevention, (2) narrow gaps in the treatment cascade (when attrition causes uptake of treatment services to plummet over time), (3) prepare for emerging non-surgical devices for male circumcision, (4) create and launch a core package of demonstration projects for pre-exposure prophylaxis (PrEP), and (5) safeguard funding for HIV prevention research. The report points out that important global players—the U.S. President’s Emergency Plan for AIDS Relief, the Global Fund, and UNAIDS, among others—are releasing new strategies, operational plans, and clinical guidance, and urges ongoing robust leadership to accomplish the goal of vanquishing HIV.
- World Bank Key Population Studies [sex workers, people who inject drugs]
World Bank and partners (December 2012).
Two key populations—sex workers and people who inject drugs (PWID)—with a high burden of HIV globally are the focus of new reports released by the World Bank and several partners on World AIDS Day. (An earlier report in the same series focused on another key population: men who have sex with men.) HIV disproportionately affects these two groups, who are both marginalized by stigma and largely overlooked in HIV programming in many regions. For example, HIV prevalence among female sex workers in sub-Saharan Africa is 36.9 percent; across all regions worldwide, HIV prevalence for female sex workers is 13.5 times higher than for the general population of women from 15 to 49 years old. HIV prevalence is also significantly higher among PWID than for the general population, yet the report finds that this group has inadequate access to antiretroviral treatment and prevention interventions, even though programming for PWID—including needle exchange programs, medically assisted therapy, and HIV counseling and testing—is widely considered a cost-effective public health investment. The reports strongly recommend that, in the global campaign to achieve an AIDS-free world, governments and donors work to provide better prevention and treatment programming for these at-risk populations. Collaborating with the World Bank on the reports were the United Nations Populations Fund, the Johns Hopkins Bloomberg School of Public Health, and the Futures Group.