HIV Prevention Update: Monthly Summaries of the Must-read Literature
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- Integration of Family Planning Services into HIV Care and Treatment in Kenya: A Cluster-Randomized Trial
Grossman, D., Onono, M., Newmann, S.J., et al. AIDS (October 2013), Vol. 27 No.1, pp. S77-S85.
The authors assessed whether integrating family planning (FP) services into HIV care at facilities in Nyanza Province, Kenya improves uptake of more effective contraception methods (i.e., implants or oral contraceptives) compared to no or less effective methods (i.e., natural methods or condoms alone). The findings showed that use of more effective methods increased at clinics where FP and HIV care were integrated in a "one-stop shop," but condom use decreased slightly and pregnancy incidence was unchanged. The 12-month cluster-randomized trial compared contraceptive prevalence among HIV-positive women attending HIV-FP integrated clinics (12 intervention clinics) and HIV clinics that referred women to separate FP services at the facility (6 control clinics). The use of more effective FP increased from 16.7 to 36.6 percent at the integrated facilities and from 21.1 to 29.8 percent at the control facilities (baseline to follow-up). The use of less effective methods, primarily condoms alone, decreased at intervention facilities (from 50.7 to 36.9 percent), and marginally increased at control facilities (from 39.6 to 39.9 percent). Integration was not shown to affect pregnancy incidence, but this could have been due to the study's short duration. Use of any method increased at both types of facilities. Integrating HIV and FP services will require governments, donors, and stakeholders’ commitment to adequately addressing the unmet need for FP in sub-Saharan Africa.
- What Has Been Achieved in HIV Prevention, Treatment and Care for People Who Inject Drugs, 2010-2012? A Review of the Six Highest Burden Countries
Degenhardt, L., Mathers, B.M., Wirtz, A.L., et al. International Journal of Drug Policy (September 2013), E-publication ahead of print.
Following the international HIV community's recent commitment to “zero new infections among people who inject drugs (PWID),” the authors developed an “accountability matrix” in 2010 to measure epidemiological data and core indicators for HIV prevention and care in six countries with concentrated epidemics among PWID: China, Malaysia, Russia, Ukraine, Vietnam, and the United States (U.S.). This article presents updated epidemiologic data and key indicators based on review of 37 studies in peer-reviewed and gray literature published since 2009, and assesses progress as measured by the accountability matrix. The results showed improvements over the past two years, including policy shifts favoring evidence-based interventions and greater access to HIV prevention and treatment in Asia and Ukraine. However, challenges persist. The U.S. and Russia have not advanced in terms of access to key interventions for PWID. Many existing policies penalize drug use, which hinders public health programs. Further, antiretroviral treatment coverage estimates for PWID remained low overall in all six countries. National and international stakeholders must increase their leadership and commit to supporting evidence-based strategies to address HIV among PWID to meet the goal of zero new infections, especially considering resource constraints and the recent adoption of policies that impede effective HIV prevention and treatment for PWID by the U.S. and Russia.
- PEPFAR Guide to Monitoring and Reporting Voluntary Medical Male Circumcision (VMMC) Indicators
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (July 2013), Version 1.
This document provides guidance on best practices for collecting, monitoring, and using data, and for timely and accurate reporting on PEPFAR VMMC indicators within the context of national health management information systems (HMIS). Although the guidance primarily targets PEPFAR implementing partners, who are required to report on PEPFAR indicators, it aims to cover broader ground than PEPFAR requirements alone. The document provides recommendations on VMMC monitoring and reporting within a national HMIS, and on the categories of workflow for VMMC service delivery in which data elements would be captured. It also presents PEPFAR-specific VMMC indicators that must be reported (e.g., the number of males circumcised as part of a minimum package for VMMC and the number of health care providers who successfully completed in-service training program), along with other essential or recommended PEPFAR monitoring and reporting practices for VMMC. Additionally, the document includes examples of measurement approaches that can be used for the indicators and of monitoring and reporting forms, registers, and flow charts, and guidance on assessing data quality, building capacity, and establishing links to other HIV prevention activities. Monitoring and reporting are essential for the success of VMMC programs, but they should be integrated into the larger health systems to support the sustainability of the national HMIS.
- Effects of Partnership Change on Microbicide Gel Adherence in a Clinical Trial (HPTN 035)
Gorbach, P.M., Kelly, C.W., Borgerding, J.A., et al. AIDS and Behavior (October 2013), E-publication ahead of print.
The authors examined the effect of sexual partnership changes on women’s adherence to microbicide gel use in the HIV Prevention Trial Network (HPTN) 035 trial. Self-reported adherence among women with ongoing partners (n=1,571) and among women with new partners (n=123) was compared. The findings showed that having a new partner affected self-reported adherence to a microbicide gel—those who indicated having a new partner reported using a microbicide gel less frequently than women reporting having an ongoing partner. Reported gel use at last vaginal sex was 100 percent among women with ongoing partners compared to 75 percent for women with new partners. Factors associated with self-reported high adherence included having an ongoing partner, older age, and higher rates of reported sex in the past week. Further, more women with new partners acquired HIV compared to those with an ongoing partner (9.8 versus 4.5 percent). The findings emphasize the importance of evaluating partnership status among women in similar trials. However, the authors suggested that future studies refine methods for measuring partner status to further understand its effects. They advocated for male-focused outreach to promote awareness of new HIV prevention methods, along with high-quality counseling for women to encourage them to introduce these methods to new partners.
- Risky Behaviours among Young People Living with HIV Attending Care and Treatment Clinics in Dar Es Salaam, Tanzania: Implications for Prevention with a Positive Approach
Mhalu, A., Leyna, G.H., and Mmbaga, E.J. Journal of the International AIDS Society (October 2013), Vol. 16 No 1., pp. 17342.
The authors conducted a cross-sectional study to describe common HIV risk behaviors among 282 youth living with HIV (ages 15-24; 73 percent female) at eight urban care and treatment sites in Tanzania. The prevalence of unprotected sex was 40 percent among males and 37.5 percent among females. Approximately 16 and 11 percent of females and males, respectively, reported engaging in multiple sexual partnerships. Knowledge about sexually transmitted infection (STI) prevention and transmission was low overall, but knowledge about STI symptoms and complications was relatively high. The majority reported engaging in risk behaviors with partners of unknown HIV status, and younger respondents (ages 15-19) were three times more likely than older youth to engage in unprotected sex. Respondents with family support reported having fewer sexual partners (0-1) compared to those without family support (87 versus 75 percent). Respondents who were using antiretroviral therapy (ART) were significantly less likely to engage in risky sexual behaviors, including multiple sexual partners, compared to those not on ART. Those who did not drink alcohol were 60 percent less likely to report unprotected sex. The authors advocated for prevention with a positive approach in HIV care to address STI knowledge gaps and target alcohol use and other risky behaviors.
- Who is Taking Up Voluntary Medical Male Circumcision? Early Evidence from Tanzania
Gummerson, E., Maughan-Brown, B., and Venkataramani, A. AIDS (October 2013), Vol. 27 No. 16, pp. 2657-2659.
Using Demographic and Health Survey (DHS) data, the authors assessed the initial impacts of voluntary medical male circumcision (VMMC) scale-up in eight targeted regions in Tanzania. The scale-up seeks 80 percent uptake of VMMC among men aged 10-34 by 2015. The authors examined data from men aged 15-34 in the DHS 2008 (n=1,577) as baseline, and in the DHS 2011-2012 (n=2,576) as follow-up data. Uptake of VMMC services increased in targeted regions; but the greatest increases were among educated and wealthier young men (ages 15-24), suggesting that the VMMC campaign has been more successful in reaching relatively privileged populations. The proportion of circumcised men in targeted regions increased from 37.5 to 47.6 percent overall from baseline to follow-up: from 32 to 47.3 percent among younger men and from 45.9 to 47.9 in men aged 25-34. VMMC adopters were more likely to have completed secondary education or higher, and to live in wealthier households and urban areas. Additionally, they were significantly more likely to have been tested for HIV (44 versus 24 percent of non-adopters) and reported more consistent condom use. The authors concluded that 1) innovative approaches are needed to reach the VMMC coverage goal by 2015, since few 25-34 year olds were reached; and 2) it will be necessary to reach more vulnerable, high-risk populations in future VMMC campaigns to reduce men's HIV risk.
- Acceptability of Pre-Exposure Prophylaxis among Men Who Have Sex with Men and Transgender Women in Northern Thailand
Yang, D., Chariyalertsak, C., Wongthanee, A., et al. PLOS One (October 2013), Vol. 8 No. 10, pp. e76650.
Given the limited research on transgender (TG) populations, particularly regarding their attitudes towards pre-exposure prophylaxis (PrEP), the authors conducted a survey in 2012 with Thai TGs (n=107) and men who have sex with men (MSM) (n=131) to explore PrEP awareness and acceptability, and patterns of medication use among TG and MSM. Awareness was high—two-thirds of participants had knowledge of PrEP—and acceptability was 41 and 37 percent for MSM and TGs, respectively. The findings showed that these populations differ in terms of HIV risk behaviors, medication use, and factors associated with PrEP acceptability. More TG participants primarily engaged in receptive anal sex than MSM (74 versus 24 percent). Nearly half of TGs reported regularly taking oral medication (compared to 21 percent of MSM); further, 45 percent of TGs reported taking female hormones (versus 6 percent of MSM). Having private insurance and knowledge of PrEP were independently associated with PrEP acceptability among TG, while factors for MSM were previous HIV testing, history of sexually transmitted infections, infrequent sex, and regularly planned sex. Of those taking medications, 68 and 73 percent of MSM and TG, respectively, feared drug interactions. Since most TGs take regular medication, this behavior should be leveraged to improve PrEP adherence. The authors called for continued research and PrEP educational campaigns that discuss treatment interactions.
- Immunogenicity of ALVAC-HIV vCP1521 in Infants of HIV-1 Infected Women in Uganda (HPTN 027): The First Pediatric HIV Vaccine Trial in Africa
Kaleebu, P., Njai, H.F., Wang, L., et al. Journal of Acquired Immune Deficiency Syndromes (October 2013), E-publication ahead of print.
The HIV Prevention Trial Network-027 trial – the first pediatric HIV-1 vaccine study in Africa – evaluated the safety and immunogenicity of ALVAC-HIV vCP1521 (ALVAC) in infants born to HIV-infected Ugandan women through a randomized, double-blind, placebo-controlled phase I trial. The results showed the ability of the infant immune system to respond, although at low levels, to the ALVAC HIV-1 vaccine, but the correlates of immunity for a pediatric HIV-1 vaccine remain unknown. From October 2006 to May 2007, 60 infants were born to 93 eligible women attending antenatal clinics and randomized to vaccine (n=48) and placebo (n=12) study arms. Vaccinations occurred at birth and at four, eight, and 12 weeks. Overall, 47 infants (38 vaccine, 9 placebo) received all vaccinations (detection of HIV led to discontinuation). In the vaccine arm, 19 infants showed no cellular immune responses; of the remaining 19, 10 had a positive response on one assay, eight on two assays, and one on three assays. The one HIV-uninfected vaccine recipient sustained antibody positivity at 18 and 24 months. There was a non-significant trend toward higher cellular immune response rates in vaccine recipients compared to placebo. The authors called for more pediatric studies on potential HIV vaccines, including Phase III clinical trials, to identify effective vaccines for HIV-exposed infants.
- Adherence Challenges with Drugs for Pre-Exposure Prophylaxis to Prevent HIV Infection
Gengiah, T.N., Moosa, A., Naidoo, A., et al. International Journal of Clinical Pharmacy (October 2013), E-publication ahead of print.
The authors reviewed phase II and III clinical trials of antiretroviral (ARV) and non-ARV drugs for oral pre-exposure prophylaxis (PrEP) and topical microbicides for HIV prevention conducted over the past 20 years, focusing on the role of adherence. Most trials reported adherence as a major challenge, and several demonstrated links between moderate to high adherence and PrEP effectiveness, and between suboptimal adherence and product failure. Dosage form, strategy, and interval may also affect adherence. Between 2007 and 2012, seven trials of oral PrEP were conducted, with self-reports and pill counts used as standard adherence measures (although some studies also monitored drug levels in blood). Daily use was effective for oral PrEP, but users’ motivation and risk perception were crucial. Barriers to PrEP adherence included age (under 25), marital status (unmarried women), intermittent dosing, and low risk perception. Thirteen trials of topical microbicides were completed (1992 -2012). Before 2010, all microbicide trials failed to show effectiveness; the first to show effectiveness (CAPRISA 004) used an ARV drug with adherence support for dosing instructions. For microbicides, intermittent dosing strategies (applying the gel around sexual intercourse) are more effective than daily application. Promising candidate agents in pre-clinical and phase I trials for HIV prevention include combination and multipurpose technologies, which may improve adherence by focusing on formulation, ease of dosing, and multi-use.
- Evaluating Traditional Healers Knowledge and Practices Related to HIV Testing and Treatment in South Africa
George, G., Chitindingu, E., and Gow, J. BMC International Health and Human Rights (2013), Vol. 13 No. 1, pp. 45. E-publication ahead of print.
The authors implemented a cross-sectional survey in 2010 with 186 traditional healers (THs) in South Africa, assessing their knowledge of HIV and their willingness to collaborate with the formal medical system, to determine whether THs can adequately support HIV prevention and treatment efforts. The findings suggest that THs are a suitable but underused cadre for HIV services, particularly at the community level. South African THs reported regularly interacting with HIV-positive individuals. Sixty percent had previously received formal HIV training. Although HIV knowledge levels were relatively low, THs with previous HIV training had better outcomes. Most THs reported a willingness to collaborate with the medical system (70 percent of trained participants; 83 percent with no previous training). Thirty-six and 43 percent of trained and non-trained THs, respectively, believed that there is a cure for HIV. However, a significant proportion of all THs understood that having unprotected sex with an HIV-positive person poses a risk for HIV transmission, and the majority (61 percent) reported that they recommend condom use. Respondents in both groups (89 percent of trained and 61 percent of non-trained THs) agreed that HIV can become resistant if antiretroviral doses are skipped. The authors concluded that an important next step is to develop HIV training programs to further educate THs.
- Conceptualizing Community Mobilization for HIV Prevention: Implications for HIV Prevention Programming in the African Context
Lippman, S.A., Maman, S., MacPhail, C., et al. PLOS One (October 2013), Vol. 8 No. 10, p. e78208.
The authors classified key domains of community mobilization (CM) and applied them to the South African context to guide CM efforts, particularly within HIV prevention programs. First, they synthesized literature from various disciples and hypothesized six CM domains: shared concern, critical consciousness/community sensitization, organizational structure/networks, leadership, collective actions, and shared cohesion. Secondly, to explore the relevance of these domains to CM processes in South Africa, they conducted qualitative research with 64 community members in a rural setting where an HIV prevention trial that includes a CM intervention is underway. Findings showed that most of the domains were relevant with little adaptation to CM processes in South Africa. For instance, addressing challenges required leadership and promotion of critical consciousness, collective action, and community dialogue. Two domains— organizations/networks and social cohesion—were not as applicable in this context and would require some adaptation. For instance, community networks tended to be family-based. The authors suggested that interventions should focus on CM objectives simultaneously with program objectives. In similar contexts, HIV programs that include CM should re-frame HIV as a community rather than individual concern, and implementers should identify ways to promote leadership. The authors plan to validate these domains during this trial by monitoring changes in gender norms and HIV prevention behaviors, and are validating measurements of CM domains for use as evaluation tools.
- Investing in Communities: Evaluating the Added Value of Community Mobilization on HIV Prevention Outcomes among FSWs in India
Kuhlmann, A.S., Galavotti, C., Hastings, P., et al. AIDS and Behavior (October 2013), E-publication ahead of print.
To address the limited documentation of the impact of community mobilization on HIV prevention outcomes, the authors conducted a theory-based evaluation of the Avahan-India AIDS Initiative, describing the impact of community mobilization on HIV prevention outcomes among female sex workers (FSWs) in the state of Andhra Pradesh. They presented findings on community mobilization, measured by geographical clusters (104 clusters sampled; 1,986 FSWs) and used psychosocial scales to measure mobilization within the population. The authors’ model hypothesized that stronger community mobilization would act on psychosocial factors, which in turn would support positive HIV prevention outcomes. The findings demonstrated that Avahan’s community mobilization added value in key HIV prevention outcomes, e.g., positive indirect effects on consistent condom use and perceived discrimination. Although each cluster received the same intervention activities, the level of community mobilization varied; clusters with greater community mobilization showed more positive outcomes. Greater social cohesion and increased collective efficacy were associated with improved consistency of condom use and higher reported levels of equitable treatment in public places, respectively. The average rate of volunteering for program committees (a measurement of the strength of community mobilization) was 45 percent among FSWs. Future interventions should incorporate evaluation of community mobilization processes and outcomes. More robust measures of community mobilization are needed.
- Expanding Coverage of Voluntary Medical Male Circumcision through the Private Sector in Namibia
Strengthening Health Outcomes through the Private Sectors (SHOPS) Project (October 2013).
The SHOPS project collaborated with the public and private sectors in Namibia – the first country to cover voluntary medical male circumcision (VMMC) through private health insurance – to standardize the private-sector fee for VMMC and train health care providers, with the aim of increasing opportunities for and access to VMMC through the private sector. With approval from the Ministry of Health and Social Services (MOHSS), the SHOPS project worked with actuaries to conduct a cost analysis of VMMC, using an activity-based costing method. The Namibia Association of Medical Aid Funds (NAMAF), regulators of the private health insurance industry, recommended in 2012 that private insurance companies include the fee; by January 2013, nine of 10 insurers opted for its inclusion. The SHOPS project and MOHSS invested in a VMMC training program for private providers to ensure quality and standardize VMMC provision. In next steps, SHOPS will give the curriculum to local training partners to allow flexibility and ensure consistency, and will establish linkages between NAMAF and MOHSS to create a reporting system. While the adoption of the fee for VMMC by most private health insurances is an important step for scale-up, it may be necessary to enhance demand creation to complement the supply-side investment. The success of the fee-standardization initiative illustrates how private-sector resources can be leveraged to help sustain donor-funded projects.
- Can the UNAIDS Modes of Transmission Model be Improved?: A Comparison of the Original and Revised Model Projections using Data from a Setting in West Africa
Prudden, H.J., Watts, C.H., Vickerman, P., et al. AIDS (October 2013), Vol. 27 No. 16, pp. 2623-2635.
The Modes of Transmission Model (MoT), developed by the Joint United Nations Program on HIV/AIDS (UNAIDS), uses the HIV prevalence and behavioral patterns of subpopulations to estimate the distribution of HIV infections. The authors acknowledged the benefits of the model's simplicity, but called for its revision on the grounds that the current MoT may provide misleading estimates, particularly in settings with key differences in subpopulations. The authors compared current MoT projections for Cross River state in Nigeria (2009) with a revised MoT projection that more explicitly defined heterogeneous subgroups and used updated parameters. In the revised MoT projection, "female sex workers (FSWs)" are recategorized as "brothel-based," "non-brothel-based," and "engaging in transactional sex," and "discordant couples" are disaggregated from the category "low-risk group." While the original analysis showed most new HIV infections (73 percent) occurring through heterosexual sex in the general population, the revised model revealed a higher burden (34 percent) among discordant couples. The revised model also indicated significantly more infections among key populations compared to the original MoT (45 versus 21 percent), and showed that brothel-based FSWs and women involved in transactional sex contribute most of the HIV infections that occur within key populations. These results emphasize the importance of identifying high-risk subpopulations to provide them effective prevention options.
- The Global Transmission Network of HIV-1
Wertheim, J.O., Brown, A.J.L., Hepler, N.L., et al. Journal of Infectious Diseases (October 2013), E-publication ahead of print.
To characterize the current global HIV-1 transmission network, the authors applied a network approach by constructing HIV-1 transmission clusters using close genetic links to identify potential transmission partners. Clusters were defined as connected groups of potential transmission partners. The global transmission network included all published HIV-1 sequences (n=84,527), representing 141 countries or regions, and incorporated expanded known transmission clusters and previous transmission clusters not considered in the global context. The analysis showed the contemporary pattern of HIV-1 transmission across international borders, with “local” epidemics often including international transmission links; individuals from 72 of the 106 countries or regions represented in transmission clusters had a potential transmission partner from another country. Furthermore, nearly 23 percent of potential transmission partners were from different countries, likely associated with the interconnectedness of larger, international transmission networks. The current network appears to have been established by the early 2000s. The authors argued that analysis at the global scale is critical for assessing the scope of transmission clusters, and should be standard practice. They suggested that using this approach with HIV surveillance data would yield a more robust analysis, and concluded that the global-network approach enables researchers to determine, nearly in real-time, if newly isolated HIV-1 sequences occur in known transmission clusters.
- Engagement with HIV Prevention Treatment and Care among Female Sex Workers in Zimbabwe: A Respondent Driven Sampling Survey
Cowan, F.M., Mtetwa, S., Davey, C., et al. PLOS One (October 213), Vol. 8 No. 10, p e77080.
As part of a national program for female sex workers (FSWs) established in 2009, the authors conducted a survey to estimate FSWs' HIV prevalence and use of HIV prevention, treatment, and care services at three sites in Zimbabwe. They found exceptionally high HIV prevalence and inadequate HIV service uptake among Zimbabwean FSWs. The study confirmed that FSWs are at an increased risk of HIV compared to the general population, and also revealed that they experience high rates of intimate partner violence, police harassment, and discrimination. Using respondent-driving sampling, the authors recruited 370, 237, and 229 FSWs in Mutare, Hwange, and Victoria Falls, respectively. The majority of FSWs (50 to 70 percent) were HIV-positive. Of most concern were FSWs with laboratory-confirmed HIV (finger prick blood samples were collected and tested as part of the study) but unaware of their status, either because they had never previously been tested or collected HIV test results before the study. In all three sites, these FSWs accounted for half of all HIV-positive participants. Further, the majority (62 to 74 percent) with confirmed HIV were not on antiretroviral therapy. Most HIV-negative FSWs were also unaware of their status. FSWs were more likely to report consistent condom use with commercial partners than with permanent partners. Interventions to increase Zimbabwean FSWs’ engagement with HIV services are critical to protect both FSWs and general public health.