HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Behavior Change Interventions to Prevent HIV Infection among Women Living in Low and Middle Income Countries: A Systematic Review
McCoy, S. I., Knagwende, R. A., & Padian, N. S. AIDS Behavior (June 2010), Vol. 14, pp. 469-482.
Behavioral interventions to prevent HIV infection in women and girls in low- and middle-income countries are limited in effectiveness, conclude the authors of this study. Yet, due to the lack of a vaccine or alternative female-controlled biomedical prevention methods, they remain an important means of preventing sexual transmission of HIV. To assess the effectiveness of behavioral strategies, the authors conducted a systematic review of eleven analyses of eight unique behavior change interventions. These interventions included programs aimed at delaying age of sexual debut, reducing the number of sexual partners and concurrent partnerships, increasing the proportion of protected sexual acts, increasing acceptability of counseling and testing, and improving adherence to successful biomedical prevention strategies. Only two of the eleven analyses demonstrated statistically significant effects on HIV incidence, and only three of ten analyses reduced any measure of HIV-related risk behavior. The data also demonstrated that elements of behavior change (e.g., information or motivation skills) may continue to complement and improve uptake, adherence, and proper use of biomedical interventions. Given these results, however, the question remains whether behavior change interventions can be implemented as independent components in HIV prevention packages for women, or only as complements to existing biomedical prevention strategies.
Related HIV Prevention Knowledge Base Topic: Emerging Areas: Multiple and Concurrent Sexual Partnerships
Related HIV Prevention Knowledge Base Topic: Behavioral Interventions: Abstinence and Delayed Sexual Debut
- Using Incentives to Prevent HIV Infections
Over, M. Center for Global Development Essay (May 2010).
HIV prevention interventions can reduce the number of new HIV infections, according to the author, if bilateral and multilateral organizations create and implement Performance Based Incentives (PBIs) for both measurement and achievement. Building upon a companion essay that outlines an “AIDS Transition” (a gradual reduction in the number of people infected with HIV even as those infected live longer), Over argues that HIV prevention can work if the proper incentives are provided. Although acknowledging that few rigorous cost-effectiveness studies of HIV prevention interventions have been conducted, Over identifies some of the most promising prevention interventions— adult male circumcision, integration of family planning services into HIV testing and AIDS treatment facilities, and the reorientation of HIV testing for in-home services for couples—and describes their potential for increased effectiveness if implemented with a PBI reward structure. PBIs are relatively short-term (for example, monthly or quarterly) improvements in patient- or facility-level outcomes applied at the individual and collective levels on both the demand and supply sides (individual clients on the demand side and service providers on the supply side). Over also proposes “Cash on Delivery” (COD), a new approach to foreign assistance that could reduce the number of new HIV infections by offering incentives to top levels of government to achieve longer-term commitments and specific social objectives.
- Heterosexual HIV-1 Transmission After Initiation of Antiretroviral Therapy: A Prospective Cohort Analysis
Donnell, D., Baeten, J. M., Kiarie, J., et al. The Lancet (June 2010), Vol. 375. No. 9731, pp. 2092-2098.
The authors of an observational study of 3,400 heterosexual HIV-discordant couples from seven African countries found that treating HIV-positive individuals with ART reduced the risk of HIV transmission to their sexual partners by 92 percent. ART substantially reduces HIV-1 infectiousness and transmission risk by decreasing plasma HIV-1 RNA concentrations. Participants were drawn from the Partners in Prevention HSV/HIV Transmission Study of acyclovir HSV-2 suppressive therapy versus placebo. All couples, followed up for 24 months, underwent counseling and received prevention messaging, and 349 HIV-infected partners initiated ART according to national guidelines. Of the 103 people who became infected during the study, only one person contracted the virus from a participant who had initiated treatment. Initially the HIV-positive participants were not receiving any ARV treatment and had high CD4 counts. The virus was suppressed to very low levels in nearly 70 percent of the cases, with the greatest effect among participants with CD4 cell counts lower than 200 cells per μL. The authors caution that while the results are encouraging at the population level, individual counseling is necessary to reinforce the message that HIV transmission is still possible after initiating treatment.
Related HIV Prevention Knowlege Base Topic: Biomedical Interventions: HIV Post-exposure Prophylaxis (PEP)
- Global Prevention of HIV Infection for Neglected Populations: Men Who Have Sex with Men
Beyrer, C. Clinical Infectious Diseases (May 2010), Vol. 50 Suppl. 3, pp. 108-113.
Considering the reemergence since 2000 of HIV among men who have sex with men (MSM) in developed countries and emerging epidemics among MSM in developing countries, the author of this study calls for greater emphasis on improving prevention interventions for MSM in both settings. The author calls for renewed focus in resource-constrained areas on basic prevention messaging to MSM, with at least a tenfold increase in funding commensurate with need. Moreover, support for structural interventions, such as decriminalization of same-sex behavior and anti-stigma campaigns, should accompany any fundamental prevention information. Among resource-sufficient countries, the focus should expand from a sole focus on behavioral prevention messaging to include such biomedical prevention approaches as pre-exposure prophylaxis, test-and-treat strategies, targeted male circumcision, and use of rectal microbicides. A minimum package of services should be developed that includes health education, behavioral interventions, voluntary counseling and testing, diagnosis and treatment of STIs, access to care and support, antiretrovirals as appropriate, and other structural interventions.
Related HIV Prevention Knowledge Base Topic: Emerging: HIV Prevention for Hard-to-reach Men Who Have Sex with Men
- Optimal Provision of Needle and Syringe Programmes for Injecting Drug Users: A Systematic Review
Jones L, Pickering L, Sumnall H, McVeigh J, Bellis MA. Int J Drug Policy. 2010 Feb 25. [Epub ahead of print]
There is compelling evidence that needle and syringe programs (NSP) reduce injection risk behaviors among injecting drug users (IDUs), yet there have been relatively few studies on whether the delivery model of the NSP programs produces different results on impact. This systematic review analyzed the optimal provision of 16 distinct NSPs for IDUs in terms of delivery modes and the additional harm reduction services that may be delivered alongside the distribution of injecting equipment to create impact. Based on a systematic review of 11 studies, the authors found no evidence that the manner in which needle and syringe exchange programs are organized and delivered relates to effectiveness on drug injecting behaviors. The programmatic settings varied, while the majority of the programs evaluated combined needle-syringe distribution with other harm reduction services, including outreach, distribution of materials, and testing for blood-borne pathogens. Younger IDUs and those with higher risk profiles appeared to prefer mobile van sites and vending machines. One long-term study in Amsterdam, the Netherlands, demonstrated the effectiveness of reducing incidence of HIV and hepatitis C among drug-using populations by combining methadone treatment and full participation in NSPs. The authors advocate further studies to evaluate how the diversity of the populations attending NSPs, as well as the influence of the social, organizational, and political context, may impact effectiveness.
- HIV Prevention for South African Youth: Which Interventions Work? A Systematic Review of Current Evidence
Harrison, A., Newell, M. L., Imrie, J., et al. BMC Public Health (February 2010), Vol. 10, pp. 1-12.
As South Africa enters its “third generation” of youth affected by HIV, certain lessons learned can be applied to create effective and efficient youth-targeted HIV prevention interventions. To assess the evidence base, the authors conducted a systematic, analytical review of eight “second-generation” HIV prevention interventions targeting youth since early 2000. Several recommendations emerged from this country with one of the world’s highest rates of HIV prevalence among youth aged 15 to 24. Risk can be reduced when such underlying structural factors as gender inequity, sexual coercion, alcohol abuse, and economic challenges are addressed. Additionally, structural interventions altering the context of HIV risk for youth can change individual behavior, and changes in social norms surrounding HIV risk and protective behavior can foster self-esteem and individual empowerment. Moreover, new approaches targeting school-level factors engage schools at the community, parental, and teacher level to move from didactic learning to a more group-based, participatory experience. The use of older youth as “mentors” also complements those teachers who resist teaching sexual education. The authors concluded that all future trials assessing interventions must employ rigorous designs and measurements of multi- versus single-component interventions, as well as such developmental considerations as age, gender, sexual activity, and schooling status.
Related HIV Prevention Knowledge Base Topic: Structural: An Overview of Structural Approaches to HIV Prevention
- Adherence to Antiretroviral Therapy and HIV Transmission Risks: Implications for Test and Treat Approaches to HIV Prevention
Kalichmann, S. C., Cherry, C., & Amaral, C. M. AIDS Patient Care and STDs (May 2010), Vol. 24 No. 5, pp. 271-275.
Use of antiretroviral therapy (ART) can have a significant impact on efforts to stem the HIV epidemic. However, nonadherence issues, which are also associated with transmission risk factors, may affect the outcome of test-and-treat strategies. Alcohol and drug use may contribute to multiple risk behaviors, but substance use does not account for the association between nonadherence and other risk factors. A study conducted between January 2008 and June 2009 examined the association of nonadherence versus adherence to HIV transmission risk among 226 men living with HIV/AIDS who receive ART. Existing research documents that individuals reduce condom use when they believe they are less infectious. Adding to this research, the authors found that men who have an undetectable viral load, and who believe that this undetectable viral load reduces their infectiousness, are significantly more likely to contract a new STI. Infectiousness beliefs were significantly associated with greater numbers of sex partners, less condom use, and a greater likelihood of having HIV-serodiscordant sex partners, while no association was observed between actual viral load and sexual behaviors. The authors contend that failure to invest in aggressive detection and treatment of STIs in people living with HIV and AIDS will undermine test-and-treat HIV prevention programs and possibly facilitate HIV transmission.
- Elevations in Mortality Associated with Weaning Persist into the Second Year of Life among Uninfected Children Born to HIV-Infected Mothers
Kurn, L., Sinkala, M., Semrau, K., et al. Clinical Infectious Diseases (February 2010), Vol. 50, pp. 437-444.
Uninfected children born to mothers living with HIV in low-resource settings are more likely to die the longer breastfeeding continues. A randomized trial of early weaning of 749 uninfected infants of mothers living with HIV in Lusaka, Zambia, found infants four times more likely to die if weaning continues to eighteen months, and only two times more likely if breastfeeding is shortened to four or five months. The trial, designed to determine a safe age for weaning, examined associations between uninfected child mortality and actual breastfeeding duration, and potential confounding and effect modification. The cohort arm that weaned at four months received a fortified weaning cereal, and all infants in the study received trimethoprimsulfamethoxazole. Weaning at four to five months of age was associated with a 2.03-fold increased risk of mortality, while weaning at six to eleven months of age was associated with a 3.54-fold increase, and at twelve to eighteen months of age a 4.22-fold increase. Intensive nutritional and counseling interventions, such as education about preparation of replacement feeds and about hygiene and growth monitoring reduced but did not eliminate this excess mortality. Higher CD4 cell counts (>350/ μL) among mothers represented higher risks with weaning.
- Male Circumcision for HIV Prevention—A Cross-Sectional Study on Awareness among Young People and Adults in Rural Uganda
Wilcken, A., Miiro-Nakayima, F., Hizaamu, R. N. B., et al. BMC Public Health (April 2010), Vol. 10 Issue 209, pp. 2-27.
Community-based approaches using messaging on the beneficial effects of male circumcision (MC), and targeting young people, women, and those with less education, are recommended to increase the uptake of MC in Uganda. A qualitative study of 452 Ugandan participants (267 adults older than 24 years of age, and 185 youths 14 to 25 years) identified socio-demographic factors determining awareness of MC for HIV prevention among youth and adult residents in rural communities. The study assessed male participants’ circumcision status, circumcision practices, and general knowledge on and attitudes about MC. More than one-third of all male participants reported to be circumcised, and although the majority were aware of the preventive benefits of MC, improved hygiene and culture were the main reasons given. A high level of awareness of MC as a protective measure against HIV was detected among both adults and youth, with age only marginally influencing awareness. For adult respondents, those with a higher education level were significantly more aware of the beneficial effects of MC, and among youth awareness was higher for males. No other socio-demographic factors, such as marital status, religion, district, ethnicity, employment status, or circumcision status significantly affected awareness levels.
Related HIV Prevention Knowledge Base Topic: Biomedical Interventions: Male Circumcision
- Nonoccupational HIV-Post Exposure Prophylaxis: A 10-Year Retrospective Analysis
Tissot, F., Erard, V., Dang, T., et al. HIV Medicine (March 2010), pp. 1-9.
The most cost-effective method of avoiding an unnecessary 28-day regimen of antiretroviral drugs in cases of non-occupational exposure to HIV is to contact the possible original source and encourage sharing of HIV status. If the HIV status cannot be determined, individual evaluation of risk factors should determine the decision to offer prophylaxis. These results are derived from largest large retrospective analysis of administration of non-occupational post-exposure prophylaxis (n-PEP) in one single location in Lausanne, Switzerland. The study, conducted between 1998 and 2007, analyzed characteristics of 910 exposed patients, source patients, the type of exposure, and clinical and serological outcomes. Requests for n-PEP increased by 850 percent over the 10-year period. Due to rigorous education about potential side effects and costs to patients of n-PEP, an extraordinarily high number of source persons of unknown HIV status were tested (42 percent). This strategy helped interrupt or avoid unnecessary n-PEP in 31 percent of eligible events. Twenty-three percent of the sources were found to be HIV-positive (a prevalence 10 times that of the general Swiss population), with 11 individuals unaware of their status. The effectiveness of this strategy varied by type of exposure: Those experiencing heterosexual contact and sexual assaults were more likely to have the source tested than those exposed through homosexual contact or the sharing of equipment during injecting drug use.
Related HIV Prevention Knowledge Base Topic: Biomedical Interventions: HIV Post-exposure Prophylaxis (PEP)
- Relationships over Time between Mental Health Symptoms and Transmission among People Living with HIV
Comulada, W. S., Rotheram-Borus, M. J., Pequengnat, W., et al. Psychology of Addictive Behaviors (2010), Vol. 24 No. 1, pp. 109-118.
Although the relationship between mental health symptoms and HIV transmission behaviors has been well established through cross-sectional studies, there is still a dearth of information on how these relationships are sustained over time. This longitudinal study of 936 individuals living with HIV examined the relationship between mental health symptoms, such as anxiety and depression, and risky behaviors for HIV transmission, such as substance use and risky sexual behavior, over a two-year period. All participants reported unprotected vaginal or anal sex with a partner whose HIV serostatus was negative or unknown in the three months prior to enrolling in the study. At baseline, 40 percent of the participants demonstrated clinically significant levels of depression, and another 36 percent displayed anxiety symptoms. Confirming previous research that sexual risk taking is associated with both positive and negative moods, over the course of two years groups expressing increasing depression and/or anxiety, and groups expressing an increasingly positive state of mind, decreased the numbers of seronegative sexual partners as well as use of drugs and alcohol. Relationships between baseline levels of substance use and mental health trends were not found, suggesting that the theory of using drugs to self-medicate for symptoms of depression or anxiety does not always apply. The authors also found that mental health symptoms and changes in sexual risk-taking often occur simultaneously.
- Flashblood: Blood Sharing among Female Injecting Drug Users in Tanzania
McCurdy, S. A., Ross. M. W., Williams, M. L., et al. Addiction (March 2010), Vol. 105, pp. 1062-1070.
New unsafe injecting practices are emerging among drug users due to worsening socio-economic and political forces that alter the availability, quality, and cost of drugs. Since 2005, a new blood-sharing practice, “flashblood” (a syringe full of blood drawn back immediately after initial injection passed to another to inject), has emerged as an altruistic survival mechanism among women in Tanzania and Zanzibar. The belief among those practicing flashblood is that the syringe full of blood contains enough heroin to avoid withdrawal symptoms. This study of 169 female injecting drug users (IDUs) analyzed the use of flashblood and socio-demographic factors, HIV serostatus, and variables associated with risky sex and drug behaviors. Variables significantly associated with flashblood use include living in current housing for a short period, having been forced as a child to have sex by a family member, and not currently living with parents. Also identified as variables were being married, injecting heroin in the last 30 days, smoking marijuana at an earlier age, using contaminated rinse water, and pooling money to share drugs. No association was found between income and flashblood use. The authors encourage a closer examination of the relationships between use of flashblood and the social environment, access to treatment and social services, and repressive policies toward drug users.
Related HIV Prevention Knowledge Base Topic: Structural: Interventions Addressing Policy and Political Factors
- HIV Is The Biggest Killer of Women—But Is It?
Germaine, A., & Dixon-Mueller, R. The Lancet Commentary (May 2010), Vol. 375, pp. 1592-1593
According to this commentary, women need comprehensive care more than care specifically targeted to HIV prevention and treatment. Although one of the leading story lines from WHO’s 2009 report, Women and Health, cites HIV as the leading cause of death and disease in women of reproductive age, the authors find that except for Africa, women aged 15 to 44 are far more likely to die from pregnancy-related causes (five to seven times more in South and Southeast Asia and in the eastern Mediterranean region) and from cancer, cardiovascular diseases, and injuries. Pregnancy-related disability adjusted life years (DALYs) outnumber HIV-related DALYs, while sexually transmitted infections other than HIV are responsible for more disabilities than HIV/AIDS. By changing the headline, the authors contend that instead of focusing on current vertical HIV treatment and vaccine development, more resources will be sought for comprehensive sexual and reproductive health education and services, more empowerment activities, improved health services, and an increase in programs to fight gender-based violence. This holistic and rights-based approach will ultimately lead to comprehensive HIV, sexual, and reproductive health services benefiting increasing numbers of women and girls.
Related HIV Prevention Knowledge Base Topic: Biomedical: Contraception to Prevent Unintended Pregnancies among Women with HIV
- Exploring HIV Risk among MSM in Kigali, Rwanda
Measure Evaluation (March 2010).
Condom use among men who have sex with men (MSM) in Kigali is low, although MSM in Kigali are at increased risk for HIV infection compared to the general population. These findings are from a Kigali-based behavioral surveillance study (BSS) conducted from 2008 to 2009 exploring the nature of sexual activity among a population of 98 MSM, aged 18 to 52. Ninety-four respondents reported previous anal sex with another man, with an average of two male sexual partners in the 12 months prior to the survey, while 37 respondents reported casual anal sex in the month prior to the survey. MSM in Kigali reported wide sexual networks, with one-quarter of respondents reporting sex with a woman and one in seven men reporting commercial or transactional sex with a woman in the year prior to the survey. The report offers recommendations for HIV/STI prevention programming for MSM, including a rights-based approach, MSM-friendly services, access to such psychosocial services as counseling, and procurement and distribution of condoms and appropriate lubricants.
Related HIV Prevention Knowledge Base Topic: Emerging: HIV Prevention for Hard-to-reach Men Who Have Sex with Men
Related HIV Prevention Knowledge Base Topic: Emerging: Multiple and Concurrent Sexual Partnerships
- Important and New Research from the International Microbicides Conference
The sixth biennial meeting of the International Microbicides Conference, held in Pittsburgh, Pennsylvania, in late May 2010, revealed several new and important studies. Two studies examined whether drug resistance may affect the outcome of pre-exposure prophylaxis (PrEP) (providing antiretroviral [ARV] drugs for HIV prevention), with both studies agreeing that resistance may become an issue if individuals who are unknowingly infected are administered ARVs for prevention. Several other studies highlighted what is needed to ensure that PrEP offers the most benefit with the least amount of risk. Ongoing trials of microbicides and PrEP using established classes of HIV drugs were presented alongside studies of new classes of drugs, such as an integrase inhibitor and the CCR5 inhibitor, maraviroc (Celsentri). Other studies presented evidence that lubricants may cause STIs. One found that men and women who used lubricants for anal sex were three times more likely to contract gonorrhea, chlamydia, or syphilis than those who did not use a lubricant, while another examined the toxicity of different lubricants. The authors of both studies cautioned that larger studies are needed to further investigate the risk of different lubricants and possibly introduce more stringent safety checks prior to issuing over-the-counter licensing. An additional study found that male partners of HIV-positive women are more than twice as likely to become infected with HIV if their partner is pregnant. The authors hypothesized that this increase may be due to physiological and immunological changes that occur during pregnancy.
Related HIV Prevention Knowledge Base Topic: Biomedical: Pre-exposure Prophylaxis (PrEP) for HIV Prevention
- Global Fund Launches “Born HIV Free” Campaign
As ambassador to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, France’s first lady, Carla Bruni-Sarkozy, recently launched the “Born HIV Free” campaign to increase public support for the eradication of mother-to-child transmission of HIV by 2015. The campaign is designed to increase public and government support through a series of Internet videos and creative films that ask citizens to sign up for, and political leaders to back, the Global Fund’s goal of an HIV-free generation within the next five years. Several major companies, such as Google and You Tube, as well as hundreds of other media organizations are participating in this multilingual campaign bridging digital and traditional media. The logo features two different ribbons, a small ribbon representing a child embraced by a larger gray ribbon symbolizing the love and care of a mother.
