Articles tagged as "Biomedical interventions and prevention tools"

Testing for acute HIV infection feasible but impact remains uncertain

Incorporating acute HIV screening into routine HIV testing at sexually transmitted infection clinics and HIV testing and counseling centers in Lilongwe, Malawi.

Rutstein SE, Pettifor AE, Phiri S, Kamanga G, Hoffman IF, Hosseinipour MC, Rosenberg NE, Nsona D, Pasquale D, Tegha G, Powers K, Phiri M, Tembo B, Chege W, Miller WC. J Acquir Immune Defic Syndr. 2015 Sep 29. [Epub ahead of print]

Background and objectives: Integrating acute HIV infection (AHI) testing into clinical settings is critical to prevent transmission and realize potential treatment-as-prevention benefits. We evaluated acceptability of AHI testing and compared AHI prevalence at sexually transmitted infection (STI) and HIV testing and counseling (HTC) clinics in Lilongwe, Malawi.

Methods: We conducted HIV RNA testing for HIV-seronegative patients visiting STI and HTC clinics. AHI was defined as positive RNA and negative/discordant rapid antibody tests. We evaluated demographic, behavioral, and transmission-risk differences between STI and HTC patients and assessed performance of a risk-score for targeted screening.

Results: Nearly two-thirds (62.8%, 9280/14 755) of eligible patients consented to AHI testing. We identified 59 persons with AHI (prevalence=0.64%) - a 0.9% case-identification increase. Prevalence was higher at STI (1.03% (44/4255)) than HTC clinics (0.3% (15/5025), p<0.01), accounting for 2.3% of new diagnoses, vs 0.3% at HTC. Median viral load (VL) was 758 050 copies/ml; 25% (15/59) had VL ≥10 000 000 copies/ml. Median VL was higher at STI (1 000 000 copies/ml) compared to HTC (153 125 copies/ml, p=0.2). Among persons with AHI, those tested at STI clinics were more likely to report genital sores compared to those tested at HTC (54.6% versus 6.7%, p<0.01). The risk score algorithm performed well in identifying persons with AHI at HTC (sensitivity=73%, specificity=89%).

Conclusions: The majority of patients consented to AHI testing. AHI prevalence was substantially higher in STI clinics than HTC. Remarkably high VLs and concomitant genital sores demonstrates the potential for transmission. Universal AHI screening at STI clinics, and targeted screening at HTC centers, should be considered.

Abstract access 

Editor’s notes: Acute HIV infection (AHI) is defined as the time from HIV acquisition to the appearance of detectable antibodies. Individuals with AHI are highly infectious, at least partly due to high viral load. Effective strategies to identify and treat people with AHI could increase the impact of treatment as prevention strategies, although there continues to be debate around the contribution of AHI to HIV transmission at population level.

This study in Malawi was part of a clinical trial evaluating the impact of behavioural and antiretroviral programmes during AHI. The study was done in four high-volume urban facilities. Pooled HIV RNA testing was performed on blood from participants with negative or discordant rapid HIV tests, according to the routine testing algorithm (discordant defined as one positive and two negative tests). Overall participation rates were relatively low, with only one in three individuals with negative or discordant rapid HIV tests included. Most of the loss was due to potentially eligible persons not being screened. The reasons for this are not mentioned, although more than a third that were screened did not consent. Overall, one in 150 participants had AHI. This was higher, at one in 100, at the STI clinics. The proportion with AHI was lower than previous research in Malawi, which could reflect a decline in HIV incidence at population level.

The potential risk of HIV transmission during AHI is highlighted by the characteristics of the people with AHI. Almost half had HIV RNA >6 log10 copies/ml, a similar proportion had genital ulcers, and only one in five reported condom use at last sex. The algorithm for focussing AHI testing, previously developed in the same setting, had suboptimal performance across all sites. 

This study adds to a body of evidence that suggests testing for AHI is feasible and will increase the overall yield of HIV testing by a small amount. We now need more evidence around whether programmatic implementation of AHI testing would have an impact on HIV transmission, and on the cost-effectiveness of different testing strategies. Data from treatment as prevention trials, none of which have included specific strategies to diagnose AHI, will also indirectly inform whether this should become a higher priority for public health programmes. 

Africa
Malawi
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PEP is an unknown option for women at high risk in Nairobi

Barriers to the uptake of postexposure prophylaxis among Nairobi-based female sex workers.

Olsthoorn AV, Sivachandran N, Bogoch I, Kwantampora J, Kimani M, Kimani J, Kaul R. AIDS. 2015 Sep 13. [Epub ahead of print]

Introduction: Female sex workers (FSWs) in sub-Saharan Africa are at a particularly high risk for HIV infection. Postexposure prophylaxis (PEP) is available as part of an HIV care and prevention program through dedicated FSW clinics in Nairobi, Kenya, but is underutilized. We evaluated PEP knowledge, access, and adherence among clinic attendees.

Methods: An anonymous questionnaire was administered to unselected HIV-uninfected FSWs. Participants were dichotomized into high and low HIV risk categories based on self-reported sexual practices, and prior PEP use, knowledge, and adherence were then evaluated.

Results: One hundred thirty-four HIV-uninfected FSWs participated, with 64 (48%) categorized as being at high risk for HIV acquisition. High-risk FSWs were less likely to have heard of or accessed PEP than lower risk FSWs (37.5 vs. 58.6%, P = 0.014; and 21.9 vs. 40.6%, P = 0.019, respectively). Among higher risk FSWs, those who had accessed PEP were more likely to report treatment for a genital infection (71.4 vs. 42.0%, P = 0.049) or sex with an HIV-infected man (62.5 vs. 37.5%, P = 0.042) during the last 6 months. However, only 35.7% of high-risk women accessing PEP completed a full course of treatment, and noncompleters were more likely to report prior unprotected sex with an HIV-infected man (P = 0.023).

Conclusion: Despite freely available PEP for Nairobi-based FSWs, women at highest risk were less likely to have heard of PEP, access PEP, or complete the full course of therapy once initiated. Program delivery needs to be improved to ensure that FSW most at risk are able to benefit from this resource.

Abstract access

Editor’s notes: There is currently in the field a strong buzz around antiretroviral (ARV)-based prevention following the results from recently completed oral pre-exposure prophylaxis studies (PrEP). This excitement is also driven by the new guidelines from the World Health Organization which recommend immediate treatment of any individual testing HIV positive at any CD4 count and initiation of PrEP for individuals at substantially high risk for acquiring HIV. On the other hand, post-exposure prophylaxis (PEP), involving giving a one month supply of daily ARVs to someone recently exposed or suspected to be exposed to HIV, has been in existence for almost two decades.  Yet despite new WHO guidelines released in 2014 it struggles to be successfully implemented in instances of suspected sexual exposure. This paper presents a case illustrating how despite support from national policy and availability in clinics, women at high risk do not know about PEP and do not access it as they could. This study was able to correlate association of risk and the need to care for children with accessing and completing PEP regimens. This is a valuable insight into how messaging and education around PEP could be constructed. PEP could be a powerful tool in the ARV-based prevention tool box, and the broader combination prevention strategies in countries. However it is clear that efforts to improve access and uptake will need directed attention and excitement along with support for the other prevention options coming on to the market.

Africa
Kenya
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Condoms or PrEP? Women’s decision-making for the prevention of HIV-transmission in Kenya and South Africa

Motivations for reducing other HIV risk-reduction practices if taking pre-exposure prophylaxis: findings from a qualitative study among women in Kenya and South Africa.

Corneli A, Namey E, Ahmed K, Agot K, Skhosana J, Odhiambo J, Guest G. AIDS Patient Care STDS. 2015 Sep;29(9):503-9. doi: 10.1089/apc.2015.0038. Epub 2015 Jul 21.

Findings from a survey conducted among women at high risk for HIV in Bondo, Kenya, and Pretoria, South Africa, demonstrated that a substantial proportion would be inclined to reduce their use of other HIV risk-reduction practices if they were taking pre-exposure prophylaxis (PrEP). To explore the motivations for their anticipated behavior change, we conducted qualitative interviews with 60 women whose survey responses suggested they would be more likely to reduce condom use or have sex with a new partner if they were taking PrEP compared to if they were not taking PrEP. Three interrelated themes were identified: (1) "PrEP protects"-PrEP was perceived as an effective HIV prevention method that replaced the need for condoms; (2) condoms were a source of conflict in relationships, and PrEP would provide an opportunity to resolve or avoid this conflict; and (3) having sex without a condom or having sex with a new partner was necessary for receiving material goods and financial assistance-PrEP would provide reassurance in these situations. Many believed that PrEP alone would be a sufficient HIV risk-reduction strategy. These findings suggest that participants' HIV risk-reduction intentions, if they were to use PrEP, were based predominately on their understanding of the high efficacy of PrEP and their experiences with the limitations of condoms. Enhanced counseling is needed to promote informed decision making and to ensure overall sexual health for women using PrEP for HIV prevention, particularly with respect to the prevention of pregnancy and other sexually transmitted infections when PrEP is used alone.

Abstract access

Editor’s notes: New HIV-prevention methods and messages may be understood differently by different people. For example, the protection from HIV infection for men ‘at about 60%’ that is afforded by medical male circumcision is not always well understood. Some men assume higher protection levels. The authors of this paper describe women’s HIV-prevention method intentions, should pre-exposure prophylaxis (PrEP) be available.  The study is of women’s intention, not actual behaviour, but the findings provide useful insights into the way in which prevention messages are interpreted. In this case, the new method is seen to offer an alternative to using condoms. The authors describe the reasons women give for not using condoms based on their belief that PrEP would protect them from infection. The authors suggest that counselling to inform women of the other benefits of condoms, beyond HIV-infection, is necessary where PrEP is introduced as a HIV-prevention method. This may be so, but underlying the reasons the women gave for not wanting to use condoms was inequitable relationships with their partners. The decision to use condoms often rests mainly with the man. While some women actively disliked condoms because of a reduction in sexual pleasure, many saw not using condoms as a way to sustain their relationship. The authors note that prevention strategies not only need to support women’s choices; but they also need to engage with women who lack choice.  

Africa
Kenya, South Africa
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Male circumcision may reduce HIV transmission among MSM in China

Lower HIV risk among circumcised men who have sex with men in China: Interaction with anal sex role in a cross-sectional study.

Qian HZ, Ruan Y, Liu Y, Milam DF, HM LS, Yin L, Li D, Shepherd BE, Shao Y, Vermund SH. J Acquir Immune Defic Syndr. 2015 Sep 21. [Epub ahead of print]

Background: Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain.

Methods: Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed.

Results: Among 1155 participants (242 known seropositives and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by exam) was associated with 47% lower odds of being HIV seropositive (adjusted odds ratio [aOR], 0.53; 95% confidence interval [CI], 0.27-1.02) after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR, 0.38, 95%CI, 0.09-1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR, 0.54, 95%CI, 0.25-1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR, 0.15; 95%CI, 0.04-0.65). Circumcision was not associated clearly with lower syphilis risk (aOR, 0.91; 95%CI, 0.51-1.61).

Conclusions: Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed.

Abstract access

Editor’s notes: Randomised controlled trials in areas of high HIV prevalence in Africa have demonstrated that voluntary medical male circumcision (VMMC) can reduce heterosexual acquisition of HIV in men by around 60%.  However the evidence is less clear that the protection conferred by VMMC also applies to gay men and other men who have sex with men by reducing HIV acquisition through insertive anal sex. This cross-sectional study of gay men and other men who have sex with men in China suggests that, overall, the odds of being HIV positive among circumcised men were about half that in uncircumcised men, after adjusting for differences in demographic factors and sexual behaviour. Biologically, circumcision is likely to protect gay men and other men who have sex with men who are exclusively or mainly the insertive partner, and among men in this group, there was a slightly larger protective effect, although not statistically significant. This supports a meta-analysis which found a similar finding among gay men and other men who have sex with men who practiced insertive anal sex. There was no association of VMMC and syphilis infection in this population, in line with other studies. The authors note that HIV prevention strategies among gay men and other men who have sex with men are still limited in China, and suggest studies to assess the feasibility of a multicentre randomised controlled trial of the effect of VMMC on HIV acquisition among gay men and other men who have sex with men in this setting.

Asia
China
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In which settings is Xpert® MTB/RIF and LED microscopy screening for Tuberculosis for people living with HIV cost-effective?

Screening for tuberculosis among adults newly diagnosed with HIV in sub-Saharan Africa: a cost-effectiveness analysis.

Zwerling AA, Sahu M, Ngwira LG, Khundi M, Harawa T, Corbett EL, Chaisson RE, Dowdy DW. J Acquir Immune Defic Syndr. 2015 Sep 1;70(1):83-90. doi: 10.1097/QAI.0000000000000712.

Objective: New tools, including light-emitting diode (LED) fluorescence microscopy and the molecular assay Xpert® MTB/RIF, offer increased sensitivity for tuberculosis (TB) in persons with HIV but come with higher costs. Using operational data from rural Malawi, we explored the potential cost-effectiveness of on-demand screening for TB in low-income countries of sub-Saharan Africa.

Design and methods: Costs were empirically collected in 4 clinics and in 1 hospital using a microcosting approach, through direct interview and observation from the national TB program perspective. Using decision analysis, newly diagnosed persons with HIV were modeled as being screened by 1 of the 3 strategies: Xpert®, LED, or standard of care (ie, at the discretion of the treating physician).

Results: Cost-effectiveness of TB screening among persons newly diagnosed with HIV was largely determined by 2 factors: prevalence of active TB among patients newly diagnosed with HIV and volume of testing. In facilities screening at least 50 people with a 6.5% prevalence of TB, or at least 500 people with a 2.5% TB prevalence, Xpert® is likely to be cost-effective. At lower prevalence-including that observed in Malawi-LED microscopy may be the preferred strategy, whereas in settings of lower TB prevalence or small numbers of eligible patients, no screening may be reasonable (such that resources can be deployed elsewhere).

Conclusions: TB screening at the point of HIV diagnosis may be cost-effective in low-income countries of sub-Saharan Africa, but only if a relatively large population with high prevalence of TB can be identified for screening.

Abstract access 

Editor’s notes: This study provides guidance on when screening people newly diagnosed with HIV for tuberculosis (TB) using Xpert® MTB/RIF or LED microscopy is likely to be cost-effective. Previous studies suggest that both TB screening technologies may be cost-effective, but that cost-effectiveness will depend on how tests are implemented. In highly resource constrained settings, the affordability of TB screening, particularly using Xpert® MTB/RIF, remains a concern. It therefore may not be feasible to place screening equipment at all locations, and more guidance is required on the types of setting where these investments may have the most benefit.

The study finds that two factors are particularly important in the choice of TB screening at any specific site. First, the authors find that test volumes are critical to cost-effectiveness. This finding supports earlier studies from South Africa prior to Xpert® MTB/RIF roll-out – that suggest that ‘economies of scale’ drive the unit costs per test. The authors of this study add to this previous evidence by providing a detailed example from a low income setting. Second, on the effect side, TB prevalence is found to be a key driver of cost-effectiveness.

The authors provide an illustration of a simple approach and model that can be used by countries to select the different TB screening tests required. It should be noted however, that the authors are not able to fully consider some factors that may have an important impact on the cost-effectiveness of TB screening, due to data scarcity. For example, the extent and speed to which people are appropriately treated for TB under each option (including the standard of care). This has been shown to be an important consideration in other studies investigating the cost-effectiveness of Xpert® MTB/RIF. It should also be noted that the study determines cost-effectiveness using an approach that may not fully reflect financial constraints. Therefore additional analyses, using local data, are still required before applying the study’s results in different settings.  

Africa
Malawi
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Tenofovir vaginal gel offers significant protection against HSV-2 infection

Tenofovir gel for the prevention of herpes simplex virus type 2 infection.

Abdool Karim SS, Abdool Karim Q, Kharsany AB, Baxter C, Grobler AC, Werner L, Kashuba A, Mansoor LE, Samsunder N, Mindel A, Gengiah TN, Group CT. N Engl J Med. 2015 Aug 6;373(6):530-9. doi: 10.1056/NEJMoa1410649.

Background: Globally, herpes simplex virus type 2 (HSV-2) infection is the most common cause of genital ulcer disease. Effective prevention strategies for HSV-2 infection are needed to achieve the goals of the World Health Organization global strategy for the prevention and control of sexually transmitted infections.

Methods: We assessed the effectiveness of pericoital tenofovir gel, an antiviral microbicide, in preventing HSV-2 acquisition in a subgroup of 422 HSV-2-negative women enrolled in the Centre for the AIDS Programme of Research in South Africa (CAPRISA) 004 study, a double-blind, randomized, placebo-controlled trial. Incident HSV-2 cases were identified by evidence of seroconversion on an HSV-2 IgG enzyme-linked immunosorbent assay between study enrollment and exit. A confirmatory analysis was performed by Western blot testing.

Results: The HSV-2 incidence rate was 10.2 cases per 100 person-years (95% confidence interval [CI], 6.8 to 14.7) among 202 women assigned to tenofovir gel, as compared with 21.0 cases per 100 person-years (95% CI, 16.0 to 27.2) among 222 women assigned to placebo gel (incidence rate ratio, 0.49; 95% CI, 0.30 to 0.77; P=0.003). The HSV-2 incidence rate among the 25 women with vaginal tenofovir concentrations of 10 000 ng per milliliter or more was 5.7 cases per 100 person-years, as compared with 15.5 cases per 100 person-years among the 103 women with no detectable vaginal tenofovir (incidence rate ratio, 0.37; 95% CI, 0.04 to 1.51; P=0.14). As confirmed by Western blot testing, there were 16 HSV-2 seroconversions among women assigned to tenofovir gel as compared with 36 among those assigned to the placebo gel (incidence rate ratio, 0.45; 95% CI, 0.23 to 0.82; P=0.005).

Conclusions: In this study in South Africa, pericoital application of tenofovir gel reduced HSV-2 acquisition in women.

Abstract access 

Editor’s notes: Oral tenofovir is widely used to prevent and treat HIV infection, but application of a topical tenofovir vaginal-gel formulation has not been found to be protective against HIV, likely because of low rates of adherence. In contrast, analyses of tenofovir gel protection against HSV-2, herpes simplex virus, has showed some promise. This paper presents additional data and analyses from the CAPRISA004 study which found the modest effect of protection against HIV, but significant protection against HSV-2 (51% effectiveness). A sub-analysis confirmed that those people with higher vaginal tenofovir concentrations were almost three times less likely to acquire the herpes virus than those people with no detectable drug concentration. In the absence of an effective vaccine or cure for HSV-2 infection, pericoital tenofovir gel has the potential to increase the options for HSV-2 prevention, and have an indirect effect on HIV infection. 

Africa
South Africa
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Antiretroviral therapy coverage associated with reduced HIV incidence in Kenya

Impact of community antiretroviral therapy coverage on HIV incidence in Kenyan female sex workers: a 15-year prospective cohort study.

McClelland RS, Richardson BA, Cherutich P, Mandaliya K, John-Stewart G, Miregwa B, Odem-Davis K, Jaoko W, Kimanga D, Overbaugh J. AIDS. 2015 Jul 31. [Epub ahead of print]

Objective: To test the hypothesis that increasing community antiretroviral therapy (ART) coverage would be associated with lower HIV incidence in female sex workers (FSWs) in Mombasa District, Kenya.

Design: Prospective cohort study.

Methods: From 1998 to 2012, HIV-negative FSWs were asked to return monthly for an interview regarding risk behavior and testing for sexually transmitted infections including HIV. We evaluated the association between community ART coverage and FSW's risk of becoming HIV infected using Cox proportional hazards models adjusted for potential confounding factors.

Results: One thousand four hundred four FSWs contributed 4335 woman-years of follow-up, with 145 acquiring HIV infection (incidence 3.35/100 woman-years). The ART rollout began in 2003. By 2012, an estimated 52% of HIV-positive individuals were receiving treatment. Community ART coverage was inversely associated with HIV incidence (adjusted hazard ratio 0.77; 95% confidence interval 0.61-0.98; P = 0.03), suggesting that each 10% increase in coverage was associated with a 23% reduction in FSWs' risk of HIV acquisition. Community ART coverage had no impact on herpes simplex virus type-2 incidence (adjusted hazard ratio 0.97; 95% confidence interval 0.79-1.20; P = 0.8).

Conclusion: Increasing general population ART coverage was associated with lower HIV incidence in FSWs. The association with HIV incidence, but not herpes simplex virus type-2 incidence, suggests that the effect of community ART coverage may be specific to HIV. Interventions such as preexposure prophylaxis and antiretroviral-containing microbicides have produced disappointing results in HIV prevention trials with FSWs. These results suggest that FSWs' risk of acquiring HIV infection might be reduced through the indirect approach of increasing ART coverage in the community.

Abstract access

Editor’s notes: The individual-level benefit of antiretroviral therapy (ART) on reducing HIV transmission between serodiscordant partners is established, but less is known about a possible population-level effect of ART on key populations such as female sex workers. In this study of 1404 initially HIV-negative female sex workers in Mombasa, Kenya, increased community ART coverage was strongly associated with reduced HIV incidence. HIV incidence was 23% lower for every 10% increase in ART coverage, after adjusting for HIV prevalence and participants’ behavioural characteristics. However, the authors note that HIV incidence was already declining prior to the introduction of ART (from 11.4 cases/100 woman-years in 1998 to 7.6/100 woman-years in 2002), due to other factors including changes in risk behaviour and HIV-prevention efforts in the community. Despite this, the present study suggests that in the setting of ongoing high-quality HIV prevention services, the risk of HIV acquisition among female sex workers is likely to be reduced by increasing ART coverage in the community. Moves to increase coverage of ART in the community will potentially have a substantial HIV prevention benefit on this key population.

Africa
Kenya
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Careful planning may be the best strategy for safer conception

Benefits of PrEP as an adjunctive method of HIV prevention during attempted conception between HIV-uninfected women and HIV-infected male partners.

Hoffman RM, Jaycocks A, Vardavas R, Wagner G, Lake JE, Mindry D, Currier JS, Landovitz RJ. J Infect Dis. 2015 Jun 19. pii: jiv305. [Epub ahead of print]

Background: Data on effectiveness of preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)-uninfected women attempting conception with HIV-infected male partners are limited to observational studies.

Methods: To explore the benefits of PrEP for conception, we developed a model to estimate the average annual probability of a woman remaining HIV-uninfected and having a child ("successful" outcome) via condomless sex with an HIV-infected male. The outcome likelihood is dependent upon parameters defining HIV-1 infectivity. We simulated 2 scenarios: optimal (condomless sex acts limited to the ovulation window), and suboptimal (acts not limited to ovulation).

Results: In the optimal scenario when the male is on antiretroviral therapy (ART), the average annual probability of the successful outcome is 29.1%, increasing to 29.2% with the addition of PrEP (P = .45). In the suboptimal scenario, the probability is 26.8% with ART alone versus 27.3% with ART/PrEP (P < .0001). Older maternal age reduces the probability of success in both scenarios, particularly after age 30.

Conclusions: In our model, PrEP provides little added benefit when the HIV-infected male partner is on ART, condomless sex is limited to the ovulation window, and other modifiable transmission risks are optimized. Older female age decreases the probability of success by increasing the number of condomless sex acts required for conception.

Abstract access

Editor’s notes: Antiretrovirals (ARVs) have been shown in several studies to be highly effective in preventing both the acquisition of HIV in HIV negative individuals, and the transmission of HIV from HIV positive people to HIV negative people. However, the real-world application of these activities is still being investigated. This paper explores a strategy currently in discussion to use ARVs for safer conception in which the HIV negative partner might take pre-exposure prophylaxis (PrEP) and the HIV positive partner may be taking HIV treatment. The model employed in this paper looked specifically at the added benefit of the HIV negative woman taking PrEP. The results of the model illustrated that there was no added benefit of the woman taking PrEP if her HIV positive partner was taking HIV treatment consistently and they kept the number of condomless sex acts to the minimum required for the best chance of conception. Interestingly, as the woman in the model increases in age so do the number of condomless sex acts required to conceive, thus increasing the risk of acquiring HIV. While this paper illustrated that PrEP may not be worth the added expense, there may be situations where it still can provide added security to couples. Ultimately, models cannot completely account for what happens in real-life, and as the paper counsels, it will be up to physicians and their patients to decide what is best on a case by case basis. 

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Sexual risk reduction and behavioural programme increases uptake of circumcision in hard-to-reach men

A cluster randomized controlled trial to increase the availability and acceptability of voluntary medical male circumcision in Zambia: the Spear and Shield Project.

Weiss SM, Zulu R, Jones DL, Redding CA, Cook R, Chitalu N. Lancet HIV. 2015 May 1;2(5):e181-e189.

Background: Widespread voluntary medical male circumcision in Africa could avert an estimated 3.436 million HIV infections and 300 000 deaths over the next 10 years. Most Zambian men have expressed little interest in the procedure. We tested the effect of the Spear and Shield intervention designed to increase demand for voluntary medical male circumcision among these hard-to-reach men.

Methods: This cluster randomised controlled trial was done between Feb 1, 2012, and Oct 31, 2014, in Lusaka, Zambia, where HIV prevalence is 20.8%. 13 community health centres were stratified by HIV voluntary counselling and testing rates and patient census, and randomly assigned (5:5:3) to experimental (the intervention), control, or observation-only conditions. Community health centre health-care providers at all 13 sites received training in voluntary medical male circumcision. Eligible participants were aged at least 18 years, HIV-negative, uncircumcised, and had not proactively requested or planned for voluntary medical male circumcision at the time of enrolment. Trial statisticians did not participate in randomisation. After voluntary counselling and HIV testing, participants were recruited; female partners were invited to participate. The primary outcomes at the individual level were the likelihood of voluntary medical male circumcision by 12 months post intervention, and condom use after voluntary medical male circumcision among participants receiving the intervention. The trial is registered with ClinicalTrials.gov, number NCT01688167.

Findings: 800 uncircumcised HIV-negative men (400 in the experimental group, 400 in the control group) were enrolled. 161 participants in the experimental group and 96 in the control group had voluntary medical male circumcision (adjusted odds ratio 2.45, 95% CI 1.24–4.90; p=0.02). Condom use was examined in participants who had voluntary medical male circumcision and reported sexual activity within 1 month of a post-circumcision assessment (88 in the experimental group and 64 in the control group). Condom use over time increased in the experimental group (p=0.03) but not in the control group (p=0.2). One patient died in each group; no adverse events related to study participation were reported.

Interpretation: Comprehensive HIV prevention programmes can increase the demand for and uptake of voluntary medical male circumcision services.

Abstract access

Editor’s notes: Voluntary medical male circumcision reduces the risk of HIV acquisition in men by approximately 60%, yet in some high-prevalence countries uptake is low. This presents challenges in meeting WHO targets of 80% coverage. In Zambia, only 37% of the national target has been achieved. In this cluster randomised trial, 13 community health centres were randomised to receive training in the “Spear and Shield” programme, control (training for an equivalent period of time on general disease prevention strategies) or observation only. The Spear and Shield programme consisted of four weekly 90 minute group sessions. Men in the programme group had about 2.5 times the odds of having male circumcision, compared to the control group participants. This increase in uptake of male circumcision was not associated with an increase in sexual risk behaviours. In fact there was an increase in condom use in the programme group. According to WHO, demand creation continues to be the major challenge in meeting male circumcision coverage goals. The authors propose that scaling up an evidence-informed programme such as Spear and Shield, while training community health care workers to perform circumcisions, might be one of the best and most cost-effective ways to significantly reduce HIV rates in high-incidence settings.

Africa
Zambia
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Where are the weak links in prevention of mother-to-child HIV transmission programmes?

Reconstructing the PMTCT cascade using cross-sectional household survey data: The PEARL Study.

Chi BH, Tih PM, Zanolini A, Stinson K, Ekouevi DK, Coetzee D, Welty TK, Bweupe M, Shaffer N, Dabis F, Stringer EM, Stringer JS. J Acquir Immune Defic Syndr. 2015 Jun 11. [Epub ahead of print]

Background: Given the ambitious targets to reduce pediatric AIDS worldwide, ongoing assessment of programs to prevent mother-to-child HIV transmission (PMTCT) is critical. The concept of a "PMTCT cascade" has been used widely to identify bottlenecks in program implementation; however, most efforts to reconstruct the cascade have relied on facility-based approaches that may limit external validity.

Methods: We analyzed data from the PEARL household survey, which measured PMTCT effectiveness in 26 communities across Zambia, South Africa, Cote d'Ivoire, and Cameroon. We recruited women who reported a delivery in the past two years. Among mothers confirmed to be HIV-infected at the time of survey, we reconstructed the PMTCT cascade with self-reported participant information. We also analyzed data about the child's vital status; for those still alive, HIV testing was performed via DNA PCR.

Results: Of the 976 eligible women, only 355 (36%) completed every step of the PMTCT cascade. Among the 621 mother-child pairs who did not, 22 (4%) reported never seeking antenatal care, 103 (17%) were not tested for HIV during pregnancy, 395 (64%) reported testing but never received their HIV-positive result, 48 (8%) did not receive maternal antiretroviral prophylaxis, and 53 (9%) did not receive infant antiretroviral prophylaxis. The lowest prevalence of infant HIV infection or death was observed in those completing the cascade (10%, 95%CI: 7%-12%).

Conclusions: Future efforts to measure population PMTCT impact should incorporate dimensions explored in the PEARL Study - including HIV testing of HIV-exposed children in household surveys - to better understand program effectiveness.

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Editor’s notes: Programmes to prevent the transmission of HIV from mother-to-child can virtually eliminate transmission when conducted with adequate coverage and quality. This population-based study recruited women living with HIV who had given birth in the past 24 months from four sub-Saharan African countries including Cameroon, Côte d’Ivoire, South Africa and Zambia. The 976 mothers allowed their children to be tested for HIV, and reported on the level of maternal health services they received for that child, the “prevention of mother-to-child HIV transmission cascade”. While 98% of mothers had at least one contact with antenatal care services, only 36% eventually received services considered to be adequate for preventing transmission of HIV to their children. This study is notable for highlighting exactly where coverage gaps exist along the treatment pathway. In particular, 53% of mothers did not receive the result of an HIV test, and so would not have received follow-up services to prevent transmission. As a population-based study, these data provide a fuller picture of service coverage which cannot be captured by traditional monitoring and evaluations systems. These results can inform where systems strengthening must occur along the “prevention of mother-to-child HIV transmission cascade”, so that transmission risk is minimized for all children born to women living with HIV.

Africa
Cameroon, Côte d'Ivoire, South Africa, Zambia
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