Articles tagged as "Blood / body fluids and HIV prevention"

More evidence on men who have sex with men in Central Asia needed

Uncovering the epidemic of HIV among men who have sex with men in Central Asia.

Wirtz AL, Kirey A, Peryskina A, Houdart F, Beyrer C. Drug Alcohol Depend. 2013 Nov;132 Suppl 1:S17-24. doi: 10.1016/j.drugalcdep.2013.06.031. Epub 2013 Jul 29.

Background: Research among people who inject drugs (PWID) in Central Asia has described same sex behavior among male PWID and may be associated with HIV and other infections. Little is known about the population of men who have sex with men (MSM) and the burden of HIV among MSM in Central Asian countries.

Methods: We conducted a comprehensive search of peer-reviewed publications and gray literature on MSM and HIV in the region. Search strategies included terms for MSM combined with five Central Asian countries and neighbors, including Mongolia, Afghanistan, and Xinjiang Province, China.

Results: 230 sources were identified with 43 eligible for inclusion: 12 provided HIV prevalence and population size estimates for MSM, none provided incidence estimates, and no publications for Turkmenistan were identified. National reports estimate HIV prevalence among MSM to range from 1 to 2% in Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan, Xinjiang, to 10% in Mongolia. Biobehavioral studies estimated HIV prevalence at 0.4% in Afghanistan and 20.2% in Kazakhstan. Sexual identities and behaviors vary across countries. Injection drug use was relatively low among MSM (<5% for most). Non-injection drugs, alcohol use prior to sex, and binge drinking were more common and potentially associated with violence. Criminalization of homosexuality (Afghanistan, Uzbekistan, and Turkmenistan) and stigma has limited research and HIV prevention.

Conclusion: Improved understanding of risks, including potential linkages between sexual exposures and substance use, among MSM are important for response. The little known about HIV among MSM in Central Asia speaks to the urgency of improvements in HIV research, prevention, and care.

Abstract access

Editor’s notes: In Central Asia, the HIV epidemic has historically been characterised as primarily being driven by injecting drug use. However, this is an over-simplification, and research with people who inject drugs is starting to show that some men who inject drugs, also have sex with men. This review compiled existing evidence about HIV among men who have sex with men (MSM) in the region, from both the academic and grey literature. The paper is important, both because of the insights that the findings provide, as well as because of the large gaps in data that it illustrates. Currently there is extremely limited data that can be used to characterise the burden of HIV and risk factors for HIV acquisition and transmission among MSM, including men who use drugs. This provides an incomplete picture of the HIV epidemic in the region. Stronger evidence about the broader range of vulnerable populations, and the interactions and overlapping of risk behaviours, is needed.  This is necessary to better understand and characterise the epidemic in each country in the region; and to help shape a more effective response.  

Asia
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Serosorting unproven as a an HIV risk-reduction strategy in men who have sex with men

Is serosorting effective in reducing the risk of HIV-infection among men who have sex with men with casual sex partners?

van den Boom W, Konings R, Davidovich U, Sandfort T, Prins M, Stolte IG. J Acquir Immune Defic Syndr. 2013 Nov 20.  [Epub ahead of print]

Background: We investigated the prevalence and protective value of serosorting (i.e., establishing HIV-concordance in advance to practice unprotected anal intercourse [UAI]) with casual partners (CP) among HIV-negative MSM using longitudinal data from 2007 to 2011.

Methods: Men of the Amsterdam Cohort Studies (ACS) were tested biannually for HIV-1 antibodies and filled in questionnaires about sexual behavior in the preceding 6 months. HIV-incidence was examined among men who practiced UAI, UAI with serosorting, or consistent condom use, using Poisson regression.

Results: Of 445 MSM with CPs, 31 seroconverted for HIV during a total follow-up of 1 107 person-years (PY). Overall observed HIV-incidence rate was 2.8/100PY. Consistent condom use was reported in 64%; UAI in 25%; and UAI with serosorting in 11% of the 2 137 follow-up visits. MSM who practiced serosorting were less likely to seroconvert (adjusted Incidence Rate Ratio [aIRR]=0.46; 95% confidence interval [95%CI]=0.13-1.59) than MSM who had UAI, but more likely to seroconvert than MSM who consistently used condoms (aIRR=1.32; 95%CI=0.37-4.62), although differences in both directions were not statistically significant. MSM who consistently used condoms were less likely to seroconvert than MSM who had UAI (aIRR=0.37; 95%CI=0.18-0.77).

Discussion: The protective effect for serosorting we found was not statistically significant. Consistent condom use was found to be most protective against HIV infection. Larger studies are needed to demonstrate whether serosorting with CPs offers sufficient protection against HIV-infection, and if not, why it fails to do so.

Abstract access  

Editor’s notes: Serosorting is the practice of using HIV status as a decision-making tool in sexual behaviour. For example, by selecting a partner of the same HIV status in order to have unprotected intercourse. In this cohort study of men who have sex with men in Amsterdam, there was some evidence that serosorting was more risky than consistent condom use but less risky than unprotected anal intercourse among casual partners.  The number of seroconversions in the study was relatively small (n=31), precluding more conclusive evidence. One of the barriers to serosorting as a strategy to reduce HIV risk is the process of establishing valid HIV seroconcordance between casual partners. The quality of rapid (home) HIV testing is likely to improve and may lead to an increase in self-testing. In this case, serosorting may become an effective additional HIV risk-reduction strategy in MSM. In the meantime, this study highlights the importance of continuing to encourage consistent condom use for anal intercourse with casual partners.

Europe
Netherlands
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Little clinical evidence for behavioural interventions promoting condom use for dual protection against both pregnancy and HIV/STI

Behavioral interventions for improving condom use for dual protection.

Lopez LM, Otterness C, Chen M, Steiner M, Gallo MF. Cochrane Database Syst Rev. 2013 Oct 26;10:CD010662. doi: 10.1002/14651858.CD010662.pub2.

Background: Unprotected sex is a major risk factor for disease, disability, and mortality in many areas of the world due to the prevalence and incidence of sexually transmitted infections (STI) including HIV. The male condom is one of the oldest contraceptive methods and the earliest method for preventing the spread of HIV. When used correctly and consistently, condoms can provide dual protection, i.e., against both pregnancy and HIV/STI.

Objectives: We examined comparative studies of behavioral interventions for improving condom use. We were interested in identifying interventions associated with effective condom use as measured with biological assessments, which can provide objective evidence of protection.

Search methods: Through September 2013, we searched computerized databases for comparative studies of behavioral interventions for improving condom use: MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, OpenGrey, COPAC, ClinicalTrials.gov, and ICTRP. We wrote to investigators for missing data.

Selection criteria: Studies could be either randomized or nonrandomized. They examined a behavioral intervention for improving condom use. The comparison could be another behavioral intervention, usual care, or no intervention. The experimental intervention had an educational or counseling component to encourage or improve condom use. It addressed preventing pregnancy as well as the transmission of HIV/STI. The focus could be on male or female condoms and targeted to individuals, couples, or communities. Potential participants included heterosexual women and heterosexual men. Studies had to provide data from test results or records on a biological outcome: pregnancy, HIV/STI, or presence of semen as assessed with a biological marker, e.g., prostate-specific antigen. We did not include self-reported data on protected or unprotected sex, due to the limitations of recall and social desirability bias. Outcomes were measured at least three months after the behavioral intervention started.

Data collection and analysis: Two authors evaluated abstracts for eligibility and extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures.

Main results: Seven studies met our eligibility criteria. All were randomized controlled trials; six assigned clusters and one randomized individuals. Sample sizes for the cluster-randomized trials ranged from 2 157 to 15 614; the number of clusters ranged from 18 to 70. Four trials took place in African countries, two in the USA, and one in England. Three were based mainly in schools, two were in community settings, one took place during military training, and one was clinic-based. Five studies provided data on pregnancy, either from pregnancy tests or national records of abortions and live births. Four trials assessed the incidence or prevalence of HIV and HSV-2. Three trials examined other STI. The trials showed or reported no significant difference between study groups for pregnancy or HIV, but favorable effects were evident for some STI. Two showed a lower incidence of HSV-2 for the behavioral-intervention group compared to the usual-care group, with reported adjusted rate ratios (ARR) of 0.65 (95% CI 0.43 to 0.97) and 0.67 (95% CI 0.47 to 0.97), while HIV did not differ significantly. One also reported lower syphilis incidence and gonorrhea prevalence for the behavioral intervention plus STI management compared to the usual-care group. The reported ARR were 0.58 (95% CI 0.35 to 0.96) and 0.28 (95% CI 0.11 to 0.70), respectively. Another study reported a negative effect on gonorrhea for young women in the intervention group versus the control group (ARR 1.93; 95% CI 1.01 to 3.71). The difference occurred among those with only one year of the intervention.

Authors' conclusions: We found few studies and little clinical evidence of effectiveness for interventions promoting condom use for dual protection. We did not find favorable results for pregnancy or HIV, and only found some for other STI. The overall quality of evidence was moderate to low; losses to follow up were high. Effective interventions for improving condom use are needed to prevent pregnancy and HIV/STI transmission. Interventions should be feasible for resource-limited settings and tested using valid and reliable outcome measures.

Abstract  Full-text [free] access 

Editor’s notes: This Cochrane Review focussed on the clinical effectiveness of behavioural interventions for promoting condoms for dual protection against pregnancy and HIV/STI. Studies that compared a behavioural intervention with another behavioural intervention, usual care, or no intervention, for improving condom use were eligible for inclusion. Studies had to provide data on pregnancy (test result of birth record), HIV (test result), STI (test result) or presence of semen as assessed with a biological marker. Self-reported data on protected or unprotected sex were not included because of the limitations of recall and social desirability bias. Although both randomised and non-randomised designs were considered, only seven studies were identified. All were randomised controlled trials, of which six assigned clusters and one assigned individuals. Interventions varied from one motivational counselling session with a booster session to 15 lessons per year for up to three years and included a variety of behaviour change models and theories. The authors judged the overall quality of the trials to be moderate to low. This was mainly due to the high rates of losses to follow-up (more than 20% for five studies) in both treatment and control groups and limited information on intervention fidelity. The review found little clinical evidence of interventions to promote condom use for dual protection and highlighted the need for more rigorous testing of behavioural interventions using valid and reliable outcome measures.  

Africa, Europe, Northern America
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Adolescent mothers are not linking to care

HIV-Infected adolescent mothers and their infants: low coverage of HIV services and high risk of HIV transmission in KwaZulu-Natal, South Africa.  

Horwood C, Butler LM, Haskins L, Phakathi S, Rollins N. PLoS One. 2013 Sep 20;8(9):e74568. doi: 10.1371/journal.pone.0074568.

Objectives: Rates of pregnancy and HIV infection are high among South African adolescents, yet little is known about rates of mother-to-child transmission of HIV (MTCT) in this group. We report a comparison of the characteristics of adolescent mothers and adult mothers, including HIV prevalence and MTCT rates.

Methods: We examined patterns of health service utilization during the antenatal and early postnatal period, HIV prevalence and MTCT amongst adolescent (20-years-old) and adult (20 to 39-years-old) mothers with infants aged 16 weeks attending immunization clinics in six districts of KwaZulu-Natal between May 2008 and April 2009.

Findings: Interviews were conducted with 19 093 mothers aged between 12 and 39 years whose infants were aged 16 weeks. Most mothers had attended antenatal care four or more times during their last pregnancy (80.3%), and reported having an HIV test (98.2%). A greater proportion of HIV-infected adult mothers, compared to adolescent mothers, reported themselves as HIV-positive (41.2% vs. 15.9%, p,0.0001), reported having a CD4 count taken during their pregnancy (81.0% vs. 66.5%, p,0.0001), and having received the CD4 count result (84.4% vs. 75.7%, p,0.0001). Significantly fewer adolescent mothers received the recommended PMTCT regimen. HIV antibody was detected in 40.4% of 7 800 infants aged 4–8 weeks tested for HIV, indicating HIV exposure. This was higher among infants of adult mothers (47.4%) compared to adolescent mothers (17.9%, p,0.0001). The MTCT rate at 4–8 weeks of age was significantly higher amongst infants of adolescent mothers compared to adult mothers (35/325 [10.8%] vs. 185/2,800 [6.1%], OR 1.7, 95% CI 1.2–2.4).

Conclusion: Despite high levels of antenatal clinic attendance among pregnant adolescents in KwaZulu-Natal, the MTCT risk is higher among infants of HIV-infected adolescent mothers compared to adult mothers. Access to adolescent-friendly family planning and PMTCT services should be prioritised for this vulnerable group.

Abstract  Full-text [free] access

Editorial notes:   Adolescents have high pregnancy rates in South Africa, with one third reporting a pregnancy by the age of 20 years. Adolescents are also at disproportionately high risk of HIV infection. A high proportion of lifetime HIV risk is accrued before age 25 years. This study from KwaZulu-Natal, comparing health service utilization and mother-to-child transmission rates between adult and adolescent mothers, report some concerning disparities.  The majority of mothers had attended frequently for antenatal care and been tested for HIV.  Adolescent mothers were more likely to have tested late (in the last trimester of pregnancy or postnatally), less likely to have had a CD4 count or to have received an effective prevention of mother-to-child transmission regimen.  In addition, adolescent mothers were more likely to be living in adverse social conditions than their adult counterparts.  These disparities resulted in higher HIV mother-to-child transmission rates among adolescents than in adults.

The findings highlight the differential service delivery, access to care and service uptake in the adolescent age-group.  Given the high rates of pregnancy and HIV in this age-group, there is a need to focus on adolescents if elimination of new HIV infections among children is to be achieved. Strategies to make reproductive health services more accessible to adolescents are urgently required. This must include addressing the particular vulnerabilities of adolescents as well as training of healthcare providers.     

Africa
South Africa
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Do progestin-only injectable contraceptives increase HIV risk? Evidence is still inconclusive.

Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence.

Polis CB, Curtis KM. Lancet Infect Dis. 2013 Sep;13(9):797-808. doi: 10.1016/S1473-3099(13)70155-5. Epub 2013 Jul 19.

Whether or not the use of hormonal contraception affects risk of HIV acquisition is an important question for public health. We did a systematic review, searching PubMed and Embase, aiming to explore the possibility of an association between various forms of hormonal contraception and risk of HIV acquisition. We identified 20 relevant prospective studies, eight of which met our minimum quality criteria. Of these eight, all reported findings for progestin-only injectables, and seven also reported findings for oral contraceptive pills. Most of the studies that assessed the use of oral contraceptive pills showed no significant association with HIV acquisition. None of the three studies that assessed the use of injectable norethisterone enanthate showed a significant association with HIV acquisition. Studies that assessed the use of depot-medroxyprogesterone acetate (DMPA) or non-specified injectable contraceptives had heterogeneous methods and mixed results, with some investigators noting a 1·5-2·2 times increased risk of HIV acquisition, and others reporting no association. Thus, some, but not all, observational data raise concern about a potential association between use of DMPA and risk of HIV acquisition. More definitive evidence for the existence and size of any potential effect could inform appropriate counselling and policy responses in countries with varied profiles of HIV risk, maternal mortality, and access to contraceptive services.

Abstract access 

Editor’s notes: There has been increasing focus on the question of whether women using progesterone-only injectable contraceptives may be at increased risk of HIV acquisition. This systematic review illustrates the difficulty in drawing conclusions from a relatively small number of observational studies. The data show little evidence of an association between the use of oral contraceptives and HIV acquisition, but the data on injectable contraceptives are inconclusive. Relatively few studies met the minimum quality criteria (n=8). These studies are difficult to interpret due to methodological issues such as residual confounding by differing patterns of condom use or other sexual behaviours, and long inter-survey intervals which reduces accuracy of measuring time-dependent variables (both exposures and the outcome). The message to women therefore remains the same as the current WHO recommendations – the current data are not sufficiently conclusive to change policy, but women who use progestin-only injectables should be strongly advised to always use condoms and other HIV preventive measures to prevent HIV.

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No evidence of sexual disinhibition with early ART

Effect of early antiretroviral therapy on sexual behaviors and HIV-1 transmission risk in adults with diverse heterosexual partnership status in Cote d'Ivoire.

Jean K, Gabillard D, Moh R, Danel C, Fassassi R, Desgrees-du-Lou A, Eholie S, Lert F, Anglaret X, Dray-Spira R. J Infect Dis. 2013 Aug 29. [Epub ahead of print]

Background:  The effect of early antiretroviral therapy (ART) on sexual behaviors and HIV-1 transmission risk has not been documented beyond the specific population of stable serodiscordant couples.

Methods:  Based on a behavioral study nested in a randomized controlled trial (Temprano-ANRS12136) of early ART, we compared proportions of risky sex (unprotected sex with a partner of negative/unknown HIV status) reported 12 months after inclusion between participants randomized to initiate ART immediately ('early ART') or according to WHO criteria ('standard ART'). Group-specific HIV-transmission rates were estimated based on sexual behaviors and viral load-specific per-act HIV-1 transmission probabilities. Their ratio was computed to estimate the protective effect of early ART.

Results:  Among 957 participants (baseline CD4: 478/mm3), 46.0% reported sexual activity in the past month, 41.5% of them with non-cohabiting partners. Proportion of risky sex was 10.0% vs. 12.8%, respectively, in participants on early vs. standard ART (p=0.17). Accounting for sexual behaviors and viral load, the estimated protective effect of early ART was 90% (95%CI 81-95%).

Conclusion:  Twelve months after inclusion, patients on early and standard ART reported similar sexual behaviors. Early ART decreased the estimated risk of HIV transmission by 90%, suggesting a major prevention benefit among both stable and casual partners.

Abstract Full-text [free] access

Editor’s notes: As interest grows in using ART as treatment and prevention, the effect of early ART on sexual behaviour becomes ever more pertinent. This study in Cote d’Ivoire is nested in a four-arm clinical trial which examines the risks and benefits for individual health of early ART compared with “standard ART”, in combination with and without Isoniazid preventive therapy. A key finding was that there was no difference observed in reported “risky” sex (defined as unprotected sex with a partner who was not already known to be HIV-positive if the index patient had a VL ≥300 copies /mm3). In addition, there was a more complete viral suppression with immediate treatment over the duration of infection. This led to a 90% protective effect from early ART. The observation that 42% of sexually active trial patients had their last sexual encounter with a non-cohabiting partner is a reminder of the limitations of focusing HIV prevention efforts on stable serodiscordant relationships. The authors estimate that 161 infections could be averted per 10 000 patients in the first year by using early vs standard ART. While evidence from large-scale community randomized trials on the effect of treatment as prevention on population level HIV incidence is awaited, the information from this study is encouraging.

Africa
Côte d'Ivoire
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Needle syringe programmes are effective structural interventions

Effectiveness of Structural-Level Needle/Syringe Programs to Reduce HCV and HIV Infection Among People Who Inject Drugs: A Systematic Review.

Abdul-Quader AS, Feelemyer J, Modi S, Stein ES, Briceno A, Semaan S, Horvath T, Kennedy GE, Des Jarlais DC. AIDS Behav. 2013 Aug 22. [Epub ahead of print]

Needle-syringe programs (NSP) have been effective in reducing HIV and hepatitis C (HCV) infection among people who inject drugs (PWID). Achieving sustainable reductions in these blood-borne infections requires addressing structural factors so PWID can legally access NSP services. Systematic literature searches collected information on NSP coverage and changes in HIV or HCV infection prevalence or incidence at the population level. Included studies had to document biomarkers (HIV or HCV) coupled with structural-level NSP, defined by a minimum 50% coverage of PWID and distribution of 10 or more needles/syringe per PWID per year. Fifteen studies reported structural-level NSP and changes in HIV or HCV infection prevalence/incidence. Nine reported decreases in HIV prevalence, six in HCV infection prevalence, and three reported decreases in HIV incidence. The results support NSP as a structural-level intervention to reduce population-level infection and implementation of NSP for prevention and treatment of HIV and HCV infection.

Abstract access

Editor’s notes: Injection drug use is one of the most efficient modes of transmission of human immunodeficiency virus (HIV), hepatitis C (HCV), and other blood-borne diseases. There are an estimated 16 million people who inject drugs (PWID) worldwide, of whom approximately 3 million are estimated to be HIV-positive. Structural interventions focus on contextual or environmental factors that influence risk behaviour, rather than characteristics of individuals who engage in risk behaviours. This paper reviewed evidence from studies that included interventions that evaluated changes in policies, laws and regulations in relation to access and availability of sterile injecting equipment, use of public funds for establishing structural level large-scale syringe access programmes (NSP), and distribution of sterile equipment at the population level. The findings highlight the importance of establishing structural-level large-scale syringe access programmes for HIV prevention, especially early in an epidemic among PWID.  Further, it emphasizes that significant public health benefits can be obtained even when at least 50% of the injecting population in a community receive at least 10 or more sterile syringes per year.

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Efficacy of male circumcision against HIV infection persists long-term in Kenyan cohort

The long term efficacy of medical male circumcision against HIV acquisition.

Mehta SD, Moses S, Agot K, Odoyo-June E, Li H, Maclean I, Hedeker D, Bailey RC.,  AIDS. 2013 Jul 3. [Epub ahead of print]

Background: In three randomized trials, medical male circumcision (MMC) reduced HIV acquisition in heterosexual men in sub-Saharan Africa by approximately 60%, after 21-24 months of follow-up. We estimated the 72-month efficacy of MMC against HIV among men retained in the Kisumu randomized trial, where HIV acquisition was reduced by 60% after 24 months.

Methods: From 2002-2005, 2 784 men aged 18-24 were enrolled and randomized 1:1 to immediate circumcision or control. At trial end in December 2006, control men were offered free circumcision. Follow-up continued through September 2010. Cox proportional hazards regression incorporating stabilized inverse probability of treatment and censoring weights generated through marginal structural modeling, was used to account for potential time-varying confounding and censoring to estimate the efficacy of MMC on HIV risk.

Results: The cumulative 72-month HIV incidence was 7.21% [95% CI: 5.98-8.68%]: 4.81% among circumcised men, 11.0% among uncircumcised men. The crude hazard ratio (HR) of HIV seroconversion for circumcised vs. uncircumcised men was 0.38 [95% CI: 0.26-0.55]. In weight-adjusted Cox regression, the HR was 0.42 [95% CI: 0.26-0.66].

Conclusions: The efficacy of MMC was sustained at 58% at 72 months, similar to overall findings of the three trials under conditions of randomization. These findings provide an estimate of the long-term efficacy of circumcision against HIV acquisition. Our results support programmatic scale-up recommendations that are based on assumptions of sustained efficacy.

Abstract access

Editor’s notes: This study confirms results from two other randomized trials, that the efficacy of MMC against HIV infection in heterosexual men is sustained long-term.  This is biologically plausible, as circumcision is a one-time procedure requiring no adherence.  The results are not based on a fully randomised comparison, as approximately 50% of the men originally randomized to the control arm chose to become circumcised when the initial trial results were announced. Analyses using methods to reduce the bias introduced by self-selection to become circumcised showed a similar effect to a non-weighted method (58% vs. 55% efficacy at 72 months).  The other main risk factors for HIV seroconversion in the cohort were lack of condom use at last sex, HSV-2 infection, genital ulcer disease, infection with N. gonorrhoeae, and self-reported abrasions or cuts of the penile skin after sex.  These results are reassuring to the ongoing scale-up of VMMC in southern and eastern Africa, and support the assumptions of modelling studies of the population-level impact of VMMC in high prevalence settings. 

Africa
Kenya
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Condoms

Determinants of condom breakage among female sex workers in Karnataka, India

Bradley J, Rajaram S, Alary M, Isac S, Washington R, Moses S, Ramesh B. BMC Public Health. 2011 Dec 29;11 Suppl 6:S14. [Epub ahead of print]

Condoms are effective in preventing the transmission of HIV and other sexually transmitted infections, when properly used. However, recent data from surveys of female sex workers in Karnataka in south India, suggest that condom breakage rates may be quite high. It is important therefore to quantify condom breakage rates, and examine what factors might precipitate condom breakage, so that programmers can identify those at risk, and develop appropriate interventions. Bradley and colleagues explored determinants of reported condom breakage in the previous month among 1,928 female sex workers in four districts of Karnataka using data from cross-sectional surveys undertaken from July 2008 to February 2009. Using stepwise multivariate logistic regression, the authors examined the possible determinants of condom breakage, controlling for several independent variables including the district and client load. Overall, 11.4% of female sex workers reported at least one condom break in the previous month. Female sex workers were much more likely to report breakage if under 20 years of age (AOR 3.43, p = 0.005); if divorced/separated/widowed (AOR 1.52, p = 0.012); if they were regular alcohol users (AOR 1.63, p = 0.005); if they mostly entertained clients in lodges/rented rooms (AOR 2.99, p = 0.029) or brothels (AOR 4.77, p = 0.003), compared to street based sex workers; if they had ever had anal sex (AOR 2.03, p = 0.006); if the sex worker herself (as opposed to the client) applied the condom at last use (AOR 1.90, p < 0.001); if they were inconsistent condom users (AOR 2.77, p < 0.001); and if they had never seen a condom demonstration (AOR 2.37, p < 0.001). The reported incidence of condom breakage was high in this study, and this is a major concern for HIV/STI prevention programs, for which condom use is a key prevention tool. Younger and more marginalized female sex workers were most vulnerable to condom breakage. Special effort is therefore required to seek out such women and to provide information and skills on correct condom use. More research is also needed on what specific situational parameters might be important in predisposing women to condom breakage.

For abstract access click here.

Editor’s note: Learning from sex workers about the frequency of condom breakage and the factors that contribute to it makes a lot of sense. In this study in Karnataka, reported condom breakage was high at 11% at least once in the previous month, with those who used government condoms provided by a peer educator much less likely to report a condom break. One wonders about the quality and integrity of non-government condoms, as well as whether condom packages from a peer educator are less likely to have been exposed for long periods to heat, such as they can be in roadside convenience shops. Never having seen a condom demonstration and inconsistency of condom use also stand out as key contributing factors. No information is available about the frequency of condom breakage in the previous month, nor of the type of sex act during which the condom broke. Women who reported anal sex were more likely to report a condom break in the previous month. Women under 20 were more than 3 times as likely to report a breakage, suggesting that inexperience and lack of information on correct condom usage may contribute. Since these findings may apply in many sex work settings worldwide, it is important that HIV prevention programmes engage sex workers in determining the extent of condom breakage in sex work locally, the contributing factors, and how best to minimise it. In addition to protecting sex workers and their clients, these strategies could help condom users everywhere.

India
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Nutrition and People Living with HIV

Dietary intervention prevents dyslipidemia associated with highly active antiretroviral therapy in human immunodeficiency virus type 1-infected individuals: a randomized trial

Lazzaretti RK, Kuhmmer R, Sprinz E, Polanczyk CA, Ribeiro JP. J Am Coll Cardiol. 2012 Mar 13;59(11):979-88

The purpose of this study was to evaluate the efficacy of dietary intervention on blood lipids of human immunodeficiency virus (HIV)-1-infected patients who are started on highly active antiretroviral therapy. Current guidelines recommend diet as first-step intervention for HIV-1-infected individuals with antiretroviral treatment-related dyslipidemia, but there is no evidence from randomized trials to support this recommendation. Eighty-three HIV-1-infected patients, naive from antiretroviral treatment, were randomly assigned to antiretroviral treatment with dietary intervention (diet group, n = 43) or antiretroviral treatment without dietary intervention (control group, n = 40) for 12 months. Diet, according to the National Cholesterol Education Program, was given every 3 months. Before and after intervention, 24-h food records and lipid profile were obtained. Data were analysed by intention to treat, using mixed-effects models. Diet resulted in reduction of percentage of fat intake (from 31 ± 7% to 21 ± 3% of calories), while controls presented no change in percentage of fat intake. Plasma cholesterol (from 151 ± 29 mg/dl to 190 ± 33 mg/dl) and low-density lipoprotein cholesterol (from 85 ± 24 mg/dl to 106 ± 31 mg/dl) increased in the control group and were unchanged in the diet group. Plasma triglycerides were reduced by diet (from 135 ± 67 mg/dl to 101 ± 42 mg/dl) and increased in the control group (from 134 ± 70 mg/dl to 160 ± 76 mg/dl). After 1-year follow-up, 21% of patients who received diet had lipid profile compatible with dyslipidemia compared with 68% (p < 0.001) of controls. Among HIV-1-positive individuals naive of previous treatment, diet prevents dyslipidemia associated with antiretroviral treatment.

For abstract access click here. 

Editor’s note: Weight gain, fat redistribution, high triglycerides, and high cholesterol have replaced malnutrition as new nutritional challenges for people living with HIV on antiretroviral treatment. The striking results of this Brazilian trial should be shared with patients starting on HIV treatment and should inform nutritional counselling. The intervention was simple: quarterly nutritional guidance from a registered dietician focused on preventing lipid abnormalities. Diets were planned individually, based on nutritional needs, socioeconomic status, and dietary habits, to maintain or reduce weight as needed. Caloric intake was divided between lipids (5% saturated, 10% monounsaturated, and 10% polyunsaturated fatty acids), proteins (15%), and carbohydrates (60%, including 30 grams of fibre and 200 mg of dietary cholesterol). Trans fatty acids were to be avoided completely. Dietary recall for food and beverages consumed during the previous 24 hours helped tailor the counselling. At the start of the study, both groups were instructed about nutrition and lifestyle, focusing on the benefits of having a healthy diet, and neither group received advice on physical activity. The intervention group reduced their total calorie intake, cholesterol, and per cent fat intake, including reduced saturated fats, and increased their carbohydrate and fibre consumption. The result was reduced weight gain, fat redistribution, and lipid abnormalities in the first year on antiretroviral treatment. This should translate into lower risk of cardiovascular events and serve as good advice for us all.

Brazil
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