Articles tagged as "Sexual transmission and prevention"

The power of soccer to increase voluntary medical male circumcision uptake in adolescents

A sport-based intervention to increase uptake of voluntary medical male circumcision among adolescent male students: results from the MCUTS 2 cluster-randomized trial in Bulawayo, Zimbabwe.

Kaufman ZA, DeCelles J, Bhauti K, Hershow RB, Weiss HA, Chaibva C, Moyo N, Mantula F, Hatzold K, Ross DA. J Acquir Immune Defic Syndr. 2016 Aug 15;72 Suppl 4:S292-8. doi: 10.1097/QAI.0000000000001046.

Background: Mathematical models suggest that 570 000 HIV infections could be averted between 2011 and 2025 in Zimbabwe if the country reaches 80% voluntary medical male circumcision (VMMC) coverage among 15- to 49-year-old male subjects. Yet national coverage remains well below this target, and there is a need to evaluate interventions to increase the uptake.

Methods: A cluster-randomized trial was conducted to assess the effectiveness of Make-The-Cut-Plus (MTC+), a single, 60-minute, sport-based intervention to increase VMMC uptake targeting secondary school boys (14-20 years). Twenty-six schools in Bulawayo, Zimbabwe, were randomized to either receive MTC+ at the start (intervention) or end (control) of a 4-month period (March to June 2014). VMMC uptake over these 4 months was measured via probabilistic matching of participants in the trial database (n = 1226 male participants; age, 14-20 years; median age, 16.2 years) and the registers in Bulawayo's 2 free VMMC clinics (n = 5713), using 8 identifying variables.

Results: There was strong evidence that the MTC+ intervention increased the odds of VMMC uptake by approximately 2.5 fold (odds ratio = 2.53; 95% confidence interval, 1.21 to 5.30). Restricting to participants who did not report being already circumcised at baseline, MTC+ increased VMMC uptake by 7.6% (12.2% vs 4.6%, odds ratio = 2.65; 95% confidence interval, 1.19 to 5.86). Sensitivity analyses related to the probabilistic matching did not change these findings substantively. The number of participants who would need to be exposed to the demand creation intervention to yield one additional VMMC client was 22.7 (or 13.2 reporting not already being circumcised). This translated to approximately US dollar 49 per additional VMMC client.

Conclusions: The MTC+ intervention was an effective and cost-effective strategy for increasing VMMC uptake among school-going adolescent male subjects in Bulawayo.

Abstract access  

Editor’s notes: WHO and UNAIDS have stressed the importance of focusing on schools and sports to increase uptake of voluntary medical male circumcision (VMMC) among adolescent males. Adolescents have the maximum potential gain from VMMC in terms of prevented infections, and the paper illustrates that the soccer-based ‘Make The Cut’ programme significantly increased VMMC in school-based adolescents. This follows an earlier trial of the programme in adult men in which the proportion accepting VMMC was 4.8% compared with 0.5% in the control arm.

The programme was designed to be brief and low cost. A trained, recently circumcised young male ‘coach’ led a one hour soccer-themed session in school. After the session the coach contacted participants who expressed an interest in VMMC, and arranged transport to a VMMC clinic. The trial team faced the common problem that the clinics where they collected outcome data used a handwritten register rather than electronic records. To address this, the team linked the clinic records to trial participants using probabilistic matching of names and contact details.

Both the prevalence and background incidence of circumcision were higher than expected. Almost half of participants (48%) said they were already circumcised at the beginning of the trial (the authors anticipated 20%), reflecting the recent increased uptake in VMMC in Zimbabwe. Although the trial illustrates significant increase in VMMC, the absolute uptake remained relatively low in the programme arm (12.2%), and a combination of successful VMMC demand creation activities (for example including monetary or non-monetary incentives) are necessary to reach global targets. 

Africa
Zimbabwe
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Updated evidence that DMPA increases HIV risk among women

Update on hormonal contraceptive methods and risk of HIV acquisition in women: a systematic review of epidemiological evidence, 2016.

Polis CB, Curtis KM, Hannaford PC, Phillips SJ, Chipato T, Kiarie JN, Westreich DJ, Steyn PS. AIDS. 2016 Aug 5. [Epub ahead of print]

Objective and design: Some studies suggest that specific hormonal contraceptive (HC) methods (particularly depot medroxyprogesterone acetate [DMPA]) may increase women's HIV acquisition risk. We updated a systematic review to incorporate recent epidemiological data.

Methods: We searched for articles published between 1/15/2014-1/15/2016, and hand-searched reference lists. We identified longitudinal studies comparing users of a specific HC method against either (1) non-users of HC, or (2) users of another specific HC method. We added newly identified studies to those in the previous review, assessed study quality, created forest plots to display results, and conducted a meta-analysis for data on DMPA versus no HC.

Results: We identified ten new reports: five were considered "unlikely to inform the primary question". We focus on the other five reports, along with 9 from the previous review, considered "informative but with important limitations". The preponderance of data for oral contraceptive pills, injectable norethisterone enanthate (NET-EN), and levonorgestrel implants do not suggest an association with HIV acquisition, though data for implants are limited. The new, higher-quality studies on DMPA (or non-disaggregated injectables), which had mixed results in terms of statistical significance, had hazard ratios (HR) between 1.2 and 1.7, consistent with our meta-analytic estimate for all higher-quality studies of HR 1.4.

Conclusions: While confounding in these observational data cannot be excluded, new information increases concerns about DMPA and HIV acquisition risk in women. If the association is causal, the magnitude of effect is likely ≤HR 1.5. Data for other hormonal contraceptive methods, including NET-EN, are largely reassuring.

Abstract access

Editor’s notes: For several years there has been debate about whether the risk of HIV acquisition in women may be increased by the use of hormonal contraception. A systematic review published in 2014 included a meta-analysis of data from 22 studies, and this paper adds 10 new studies to the analysis. While these new papers carried some of the previous review’s limitations which cannot be ignored, the new data also lends further strength to the evidence and renewed analysis. The authors found some encouraging results which suggest that there is no significant increased risk of HIV with the use of oral contraceptives and the NET-EN injectable. However, this analysis does suggest that there is an increased risk of 1.4-1.5 of HIV with the use of DMPA. This is particularly concerning given the widespread use of this product throughout the world, and especially in areas where high rates of new HIV infections continue to persist, such as sub-Saharan Africa. Studies continue to explore this association of risk, and will hopefully produce evidence in the near future to definitively provide guidance as to how clinicians should direct the use of DMPA in women at risk of HIV. 

Africa, Northern America
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Antiretroviral therapy dramatically reduces transmission of HIV to sexual partners

Antiretroviral therapy for the prevention of HIV-1 transmission.

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, Kumwenda J, Grinsztejn B, Pilotto JH, Godbole SV, Chariyalertsak S, Santos BR, Mayer KH, Hoffman IF, Eshleman SH, Piwowar-Manning E, Cottle L, Zhang XC, Makhema J, Mills LA, Panchia R, Faesen S, Eron J, Gallant J, Havlir D, Swindells S, Elharrar V, Burns D, Taha TE, Nielsen-Saines K, Celentano DD, Essex M, Hudelson SE, Redd AD, Fleming TR. N Engl J Med. 2016 Jul 18. [Epub ahead of print]

Background: An interim analysis of data from the HIV Prevention Trials Network (HPTN) 052 trial showed that antiretroviral therapy (ART) prevented more than 96% of genetically linked infections caused by human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples. ART was then offered to all patients with HIV-1 infection (index participants). The study included more than 5 years of follow-up to assess the durability of such therapy for the prevention of HIV-1 transmission.

Methods: We randomly assigned 1763 index participants to receive either early or delayed ART. In the early-ART group, 886 participants started therapy at enrollment (CD4+ count, 350 to 550 cells per cubic millimeter). In the delayed-ART group, 877 participants started therapy after two consecutive CD4+ counts fell below 250 cells per cubic millimeter or if an illness indicative of the acquired immunodeficiency syndrome (i.e., an AIDS-defining illness) developed. The primary study end point was the diagnosis of genetically linked HIV-1 infection in the previously HIV-1-negative partner in an intention-to-treat analysis.

Results: Index participants were followed for 10,031 person-years; partners were followed for 8509 person-years. Among partners, 78 HIV-1 infections were observed during the trial (annual incidence, 0.9%; 95% confidence interval [CI], 0.7 to 1.1). Viral-linkage status was determined for 72 (92%) of the partner infections. Of these infections, 46 were linked (3 in the early-ART group and 43 in the delayed-ART group; incidence, 0.5%; 95% CI, 0.4 to 0.7) and 26 were unlinked (14 in the early-ART group and 12 in the delayed-ART group; incidence, 0.3%; 95% CI, 0.2 to 0.4). Early ART was associated with a 93% lower risk of linked partner infection than was delayed ART (hazard ratio, 0.07; 95% CI, 0.02 to 0.22). No linked infections were observed when HIV-1 infection was stably suppressed by ART in the index participant.

Conclusions: The early initiation of ART led to a sustained decrease in genetically linked HIV-1 infections in sexual partners. (Funded by the National Institute of Allergy and Infectious Diseases; HPTN 052 ClinicalTrials.gov number, NCT00074581.).

Abstract access

Editor’s notes: The HPTN 052 trial has been a landmark study in establishing antiretroviral therapy as a strategy for preventing onward transmission of HIV. It was a study of more than 800 couples. More than half of the couples were in African countries. In each couple, one sexual partner was HIV positive and the other HIV negative.  The participants living with HIV were randomised either to receive immediate antiretroviral therapy or to delay until their CD4 count fell to 350, an approved approach at that time. The HIV negative partners were then monitored for acquisition of HIV.  When new HIV infections occurred, the virus was studied for genetic similarity to the virus of the known positive partner. The interim analysis was published in 2011.  It illustrated the programme to be so effective that the randomisation was ended and all the participants living with HIV were offered antiretroviral therapy. 

This article presents data after five years of follow-up, and if anything the results are even more remarkable. In more than 10 000 person-years of follow up, there were only eight transmissions of genetically linked virus from participants receiving antiretroviral therapy. Of these transmissions, four occurred early in treatment when the viral load would not be expected to be suppressed.  The other four occurred after treatment failure. In this enormous study, there were therefore no linked transmissions from participants who were stable on treatment without detectable viraemia. The study provides powerful support for the UNAIDS 90-90-90 treatment target.  The widest possible effective use of antiretroviral therapy will not only improve the health of people treated but could have a dramatic effect on new HIV infections.

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Identifying important proximal epidemiological parameters for HIV prevention

Prospects for HIV control in South Africa: a model-based analysis.

Johnson LF, Chiu C, Myer L, Davies MA, Dorrington RE, Bekker LG, Boulle A, Meyer-Rath G. Glob Health Action. 2016 Jun 8;9:30314. doi: 10.3402/gha.v9.30314. eCollection 2016.

Background: The goal of virtual elimination of horizontal and mother-to-child HIV transmission in South Africa (SA) has been proposed, but there have been few systematic investigations of which interventions are likely to be most critical to reducing HIV incidence.

Objective: This study aims to evaluate SA's potential to achieve virtual elimination targets and to identify which interventions will be most critical to achieving HIV incidence reductions.

Design: A mathematical model was developed to simulate the population-level impact of different HIV interventions in SA. Probability distributions were specified to represent uncertainty around 32 epidemiological parameters that could be influenced by interventions, and correlation coefficients (r) were calculated to assess the sensitivity of the adult HIV incidence rates and mother-to-child transmission rates (2015-2035) to each epidemiological parameter.

Results: HIV incidence in SA adults (ages 15-49) is expected to decline from 1.4% in 2011-2012 to 0.29% by 2035 (95% CI: 0.10-0.62%). The parameters most strongly correlated with future adult HIV incidence are the rate of viral suppression after initiating antiretroviral treatment (ART) (r=-0.56), the level of condom use in non-marital relationships (r=-0.40), the phase-in of intensified risk-reduction counselling for HIV-positive adults (r=0.29), the uptake of medical male circumcision (r=-0.24) and the phase-in of universal ART eligibility (r=0.22). The paediatric HIV parameters most strongly associated with mother-to-child transmission rates are the relative risk of transmission through breastfeeding when the mother is receiving ART (r=0.70) and the rate of ART initiation during pregnancy (r=-0.16).

Conclusions: The virtual elimination target of a 0.1% incidence rate in adults will be difficult to achieve. Interventions that address the infectiousness of patients after ART initiation will be particularly critical to achieving long-term HIV incidence declines in South Africa.

Abstract  Full-text [free] access 

Editor’s notes: Despite substantial progress in controlling HIV in South Africa, incidence rates remain very high. There is a continued need to identify and prioritise HIV prevention programmes to improve the impact of existing programmes. A deterministic compartmental model was used to simulate the impact of HIV programmes in South Africa. The modeling study aimed at identifying proximal epidemiological parameters that are important in reducing HIV incidence. The authors of this paper also aimed to evaluate the possibility of achieving the ‘virtual elimination’ targets that have been suggested for both heterosexual and mother-to-child transmission and the UNAIDS 90-90-90 treatment target. The model was parameterised using behavioural and demographic data for South Africa.  The results from the study suggest that for the purpose of preventing heterosexual and mother-to-child transmission of HIV in South Africa, the most important proximal epidemiological parameter to focus on is the infectiousness of people receiving antiretroviral therapy. The model predicts that the virtual elimination target of a 0.1% incidence rate in adults will be difficult to achieve. The authors emphasized on the need to scale-up existing HIV prevention and treatment programmes in order to reduce HIV incidence in South Africa.

Africa
South Africa
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Task-shifting reduces costs for early infant male circumcision

Comparative cost of early infant male circumcision by nurse-midwives and doctors in Zimbabwe.

Mangenah C, Mavhu W, Hatzold K, Biddle AK, Ncube G, Mugurungi O, Ticklay I, Cowan FM, Thirumurthy H. Glob Health Sci Pract. 2016 Jul 13;4 Suppl 1:S68-75. doi: 10.9745/GHSP-D-15-00201. Published online 2016 Jul 2.

Background: The 14 countries that are scaling up voluntary male medical circumcision (VMMC) for HIV prevention are also considering early infant male circumcision (EIMC) to ensure longer-term reductions in HIV incidence. The cost of implementing EIMC is an important factor in scale-up decisions. We conducted a comparative cost analysis of EIMC performed by nurse-midwives and doctors using the AccuCirc device in Zimbabwe.

Methods: Between August 2013 and July 2014, nurse-midwives performed EIMC on 500 male infants using AccuCirc in a field trial. We analyzed the overall unit cost and identified key cost drivers of EIMC performed by nurse-midwives and compared these with costing data previously collected during a randomized noninferiority comparison trial of 2 devices (AccuCirc and the Mogen clamp) in which doctors performed EIMC. We assessed direct costs (consumable and nonconsumable supplies, device, personnel, associated staff training, and waste management costs) and indirect costs (capital and support personnel costs). We performed one-way sensitivity analyses to assess cost changes when we varied key component costs.

Results: The unit costs of EIMC performed by nurse-midwives and doctors in vertical programs were US$38.87 and US$49.77, respectively. Key cost drivers of EIMC were consumable supplies, personnel costs, and the device price. In this cost analysis, major cost drivers that explained the differences between EIMC performed by nurse-midwives and doctors were personnel and training costs, both of which were lower for nurse-midwives.

Conclusions: EIMC unit costs were lower when performed by nurse-midwives compared with doctors. To minimize costs, countries planning to scale up EIMC should consider using nurse-midwives, who are in greater supply than doctors and are the main providers at the primary health care level, where most infants are born.

Abstract  Full-text [free] access 

Editor’s notes: The evidence behind the efficacy for male circumcision in HIV prevention has been proven beyond a reasonable doubt, and 14 countries with a high HIV prevalence are currently scaling up voluntary medical male circumcision. To improve future HIV prevention, WHO and UNICEF also recommend that early infant male circumcision be performed within the first 60 days of life in countries with a high HIV prevalence. In countries such as Zimbabwe, an acute shortage of human resources for health has the potential to hinder scale-up of early infant male circumcision.  However, with new devices such as the AccuCirc® , early infant male circumcision can be performed without advanced surgical skills – raising the potential for task shifting as a way to alleviate pressure on human resources.  

This study compares the unit cost of early infant male circumcision using the AccuCirc® , as performed by doctors and by nurse-midwives. Nurse-midwives on average took a longer time to complete a circumcision (average 18 minutes) as compared to doctors (average 16 minutes).  However, the reductions in salary costs offset this increased time, reducing the unit cost of early infant male circumcision overall. Integrating early infant male circumcision into a public health facility (as compared to a vertical programme) would further reduce the costs. 

This study suggests that countries seeking to scale up early infant male circumcision should consider task shifting as a way to reduce costs. Task shifting does pose the risk of increasing workload for lower-level personnel; more nurse-midwives will need to be trained to cope with additional responsibilities to avoid over-burdening existing personnel. However, this is a promising solution to enable scale-up of early infant male circumcision quickly and affordably in settings such as Zimbabwe.

Africa
Zimbabwe
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Women are successful in promoting HIV self-testing in Kenyan men

Promoting male partner HIV testing and safer sexual decision making through secondary distribution of self-tests by HIV-negative female sex workers and women receiving antenatal and post-partum care in Kenya: a cohort study.

Thirumurthy H, Masters SH, Mavedzenge SN, Maman S, Omanga E, Agot K. Lancet HIV. 2016 Jun;3(6):e266-74. doi: 10.1016/S2352-3018(16)00041-2. Epub 2016 Apr 8.

Background: Increased uptake of HIV testing by men in sub-Saharan Africa is essential for the success of combination prevention. Self-testing is an emerging approach with high acceptability, but little evidence exists on the best strategies for test distribution. We assessed an approach of providing multiple self-tests to women at high risk of HIV acquisition to promote partner HIV testing and to facilitate safer sexual decision making.

Methods: In this cohort study, HIV-negative women aged 18-39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal and post-partum clinics and a drop-in centre for female sex workers. Participants gave informed consent and were instructed on use of oral fluid based rapid HIV tests. Participants enrolled at the health facility received three self-tests and those at the drop-in centre received five self-tests. Structured interviews were conducted with participants at enrolment and over 3 months to determine how self-tests were used. Outcomes included the number of self-tests distributed by participants, the proportion of participants whose sexual partners used a self-test, couples testing, and sexual behaviour after self-testing.

Findings: Between Jan 14, 2015, and March 13, 2015, 280 participants were enrolled (61 in antenatal care, 117 in post-partum care, and 102 female sex workers); follow-up interviews were completed for 265 (96%). Most participants with primary sexual partners distributed self-tests to partners: 53 (91%) of 58 participants in antenatal care, 91 (86%) of 106 in post-partum care, and 64 (75%) of 85 female sex workers. 82 (81%) of 101 female sex workers distributed more than one self-test to commercial sex clients. Among self-tests distributed to and used by primary sexual partners of participants, couples testing occurred in 27 (51%) of 53 in antenatal care, 62 (68%) of 91 from post-partum care, and 53 (83%) of 64 female sex workers. Among tests received by primary and non-primary sexual partners, two (4%) of 53 tests from participants in antenatal care, two (2%) of 91 in post-partum care, and 41 (14%) of 298 from female sex workers had positive results. Participants reported sexual intercourse with 235 (62%) of 380 sexual partners who tested HIV-negative, compared with eight (18%) of 45 who tested HIV-positive (p<0.0001); condoms were used in all eight intercourse events after positive results compared with 104 (44%) after of negative results (p<0.0018). Four participants reported intimate partner violence as a result of self-test distribution: two in the post-partum care group and two female sex workers. No other adverse events were reported.

Interpretation: Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programmes.

Abstract access

Editor’s notes: This paper presents a novel approach to promoting HIV self-testing strategies among men and couples, by distributing self-tests through social and sexual networks of women. Women attending antenatal clinics, post-partum care, and sex workers were briefly trained on how to use the Ora-Quick self-test kit, and then given five kits to take with them and give to people in their networks. This strategy allowed women and their partners to choose when and where they tested, often together and in the comfort of their own environments. The majority of women reported having distributed self-test kits to partners/clients and undertaking couples testing. Further, according to participant’s report, 58% of people testing positive linked to HIV care (and linkage was unknown in 35%). Interestingly, the on-the-spot, or point-of-sex testing allowed individuals to decide whether to continue with sexual encounters according to status, which reportedly proved to be especially useful to the female sex workers. There were four reported cases of violence resulting from test use, and this should be closely watched in future research. This is the first study to assess the potential for secondary distribution of HIV self-test kits by multiple populations of women to promote HIV testing in their male partners, and overall, the results indicate that this model is a promising strategy for promoting further HIV-testing, leading the field closer to the UNAIDS 90-90-90 treatment target and improved HIV prevention as well. 

Africa
Kenya
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Unique needs of gay men in sub-Saharan Africa identified with respondent-driven sampling

Respondent-driven sampling as a recruitment method for men who have sex with men in southern sub-Saharan Africa: a cross-sectional analysis by wave.

Stahlman S, Johnston LG, Yah C, Ketende S, Maziya S, Trapence G, Jumbe V, Sithole B, Mothopeng T, Mnisi Z, Baral S. Sex Transm Infect. 2016 Jun;92(4):292-8. doi: 10.1136/sextrans-2015-052184. Epub 2015 Sep 30.

Objectives: Respondent-driven sampling (RDS) is a popular method for recruiting men who have sex with men (MSM). Our objective is to describe the ability of RDS to reach MSM for HIV testing in three southern African nations.

Methods: Data collected via RDS among MSM in Lesotho (N=318), Swaziland (N=310) and Malawi (N=334) were analysed by wave in order to characterise differences in sample characteristics. Seeds were recruited from MSM-affiliated community-based organisations. Men were interviewed during a single study visit and tested for HIV. X2 tests for trend were used to examine differences in the proportions across wave category.

Results: A maximum of 13-19 recruitment waves were achieved in each study site. The percentage of those who identified as gay/homosexual decreased as waves increased in Lesotho (49% to 27%, p<0.01). In Swaziland and Lesotho, knowledge that anal sex was the riskiest type of sex for HIV transmission decreased across waves (39% to 23%, p<0.05, and 37% to 19%, p<0.05). The percentage of participants who had ever received more than one HIV test decreased across waves in Malawi (31% to 12%, p<0.01). In Lesotho and Malawi, the prevalence of testing positive for HIV decreased across waves (48% to 15%, p<0.01 and 23% to 11%, p<0.05). Among those living with HIV, the proportion of those unaware of their status increased across waves in all study sites although this finding was not statistically significant.

Conclusions: RDS that extends deeper into recruitment waves may be a promising method of reaching MSM with varying levels of HIV prevention needs.

Abstract access  

Editor’s notes: The HIV risk profile of gay men and other men who have sex with men have not been well-characterised within sub-Saharan African countries. These key populations are traditionally difficult to reach for purposes of estimating the prevalence of HIV and of behavioural risk factors, and for prevention outreach. This study enrolled recruiters from community based organizations which served gay men and other men who have sex with men in Malawi, Lesotho and Swaziland. Each of these ‘seeds’ could recruit up to three participants. Each subsequent participant could recruit another three participants into a new ‘wave’. The profiles of participants changed in each setting with each additional recruitment wave. Men in Swaziland were less likely to know that anal sex was the riskiest type of sex, men in Malawi were less likely to have ever tested for HIV, and men in Lesotho were less likely to have disclosed their sexual orientation to family members. This type of respondent-driven sampling can be replicated to identify men who are removed from community-based organisations, and to identify their unique service needs. Future research can consider whether the hardest-to-reach men are also people at highest risk of HIV infection.

Africa
Lesotho, Malawi, Swaziland
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Does place of sex change risk behaviours among men who have sex with men?

Is location of sex associated with sexual risk behaviour in men who have sex with men? Systematic review of within-subjects studies.

Melendez-Torres GJ, Nye E, Bonell C. AIDS Behav. 2016 Jun;20(6):1219-27. doi: 10.1007/s10461-015-1093-z.

To understand associations between location of sex and sexual risk, it is most helpful to compare sexual encounters within persons. We systematically reviewed within-subjects comparisons of sexual encounters reported by men who have sex with men (MSM) with respect to location of sex. Within-subjects comparisons of sexual risk and location of sex were eligible if they collected data post-1996 from samples of MSM. We independently screened results and full-text records in duplicate. Of 6336 de-duplicated records, we assessed 138 full-text studies and included six, most of which compared unprotected anal intercourse against other anal intercourse. This small, but high quality, body of evidence suggests that associations between attendance at sex-on-premises venues and person-level sexual risk may be due to overall propensity towards unprotected sex. However, there may be some location factors that promote or are associated with serononconcordant unprotected anal intercourse. Health promoters may wish to focus on person-level characteristics.

Abstract access

Editor’s notes: Venues where gay men and other men who have sex with men, have sex, fit broadly into three categories. These are: i) sex-on premises venues (indoor locations outside the home e.g. bathhouses, saunas, sex clubs, porn cinemas, public sex parties), ii) public sex environments (cruising locations / beats e.g. outdoor parks) and iii) homes of sexual partners. Men will usually have anonymous sexual encounters or sex with casual partners in the first two location categories. Use of specific locations for sex may be associated with specific sexual risk-taking at the person level. However, it is unclear if sexual risk is greater in certain venues compared to others. Is there a ‘location effect’ on sexual risk? Or put in a different way, does the same person behave differently (in terms of sexual risk), depending on the venue where they are having sex? To examine this, it is necessary to compare several sexual encounters within respondents at different sex locations. The authors of this paper systematically reviewed studies which reported within-subjects comparisons analysing the encounter-level association between location of sex and sexual risk behaviours among gay men and other men who have sex with men.

Six studies were included in the final review – four from the United States and two from Australia. It was not possible to conduct a meta-analysis due to differences in defining venue and sexual risk behaviours. Overall, the authors found little evidence of differences between condomless versus protected anal intercourse between public and private locations for sex. Additional studies are necessary, including how smartphone-mediated sex seeking is changing the locations and risk environment where gay men and other men will have sex with men. Research from other countries and contexts is also warranted.    

Northern America, Oceania
Australia, United States of America
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Partner’s knowledge of HIV suppression among male couples in San Francisco

Relationship dynamics and partner beliefs about viral suppression: a longitudinal study of male couples living with HIV/AIDS (the duo project).

Conroy AA, Gamarel KE, Neilands TB, Dilworth SE, Darbes LA, Johnson MO. AIDS Behav. 2016 May 5. [Epub ahead of print]

Accurate beliefs about partners' viral suppression are important for HIV prevention and care. We fit multilevel mixed effects logistic regression models to examine associations between partners' viral suppression beliefs and objective HIV RNA viral load tests, and whether relationship dynamics were associated with accurate viral suppression beliefs over time. Male couples (N = 266 couples) with at least one HIV-positive partner on antiretroviral therapy completed five assessments over 2 years. Half of the 407 HIV-positive partners were virally suppressed. Of the 40% who had inaccurate viral load beliefs, 80% assumed their partner was suppressed. The odds of having accurate viral load beliefs decreased over time (OR = 0.83; p = 0.042). Within-couple differences in dyadic adjustment (OR = 0.66; p < 0.01) and commitment (OR = 0.82; p = 0.022) were negatively associated with accurate viral load beliefs. Beliefs about a partner's viral load may factor into sexual decision-making and social support. Couple-based approaches are warranted to improve knowledge of partners' viral load.

Abstract access

Editor’s notes: This study with male couples in San Francisco examined how accurate a partner’s knowledge about their partner’s viral load status was, and if this changes over time. The study was the first of its kind. The research team enrolled 266 male couples where at least one of the couple was HIV-positive and on ART for >30 days. Most couples (72%) were seroconcordant (both HIV-positive) and 28% were serodiscordant. Participants were mostly white, middle-aged men with low-income levels. Eighty percent were living with their partner. The couples had been together on average 6.6 years. Thus, this sample may differ substantially from other studies with gay men and other men who have sex with men. Approximately 50% of men living with HIV on ART were virally suppressed at each of three visits. However, between 24% (visit one) and 40% (visit three) of men had inaccurate knowledge about their partner’s viral suppression, with most of these people wrongly believing their partner’s viral load to be suppressed when it was not. Surprisingly, these results were similar among serodiscordant and seroconcordant couples. Results did not differ significantly according to most relationship characteristics (relationship satisfaction; commitment; intimacy; equality; constructive communication).

The results are interesting because inaccuracy in partner’s beliefs about viral load suppression may translate into poor decision making around the safety of condomless anal intercourse. In addition, having accurate knowledge of partner viral suppression is important for the provision of social support associate with HIV care and treatment. Qualitative studies are necessary to understand why many men in this study had an inaccurate knowledge about their partner’s viral suppression. And why this inaccuracy increased over time. Understanding these issues and how they translate to other populations will be useful for developing programmes among male couples to reduce HIV transmission and increase partner’s social support associated with HIV care and treatment. 

Northern America
United States of America
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Routine programmatic data used to estimate HIV incidence and service uptake among female sex workers in Zimbabwe

Implementation and operational research: cohort analysis of program data to estimate HIV incidence and uptake of HIV-related services among female sex workers in Zimbabwe, 2009-2014.

Hargreaves JR, Mtetwa S, Davey C, Dirawo J, Chidiya S, Benedikt C, Naperiela Mavedzenge S, Wong-Gruenwald R, Hanisch D, Magure T, Mugurungi O, Cowan FM. J Acquir Immune Defic Syndr. 2016 May 1;72(1):e1-8. doi: 10.1097/QAI.0000000000000920.

Background: HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource.

Methods: Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach.

Results: Data were available for 13 360 women, 31 389 visits, 14 579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the program only once. FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9).

Conclusions: Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.

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Editor’s notes: Female sex workers in resource poor regions have been shown to have higher levels of HIV incidence and prevalence than people in the general population. Due to the highly stigmatised and often illegal nature of their work, these individuals are often marginalised in society. This can lead to poor engagement with the HIV testing and treatment programmes provided for the general population. Targeted outreach programmes for female sex workers such as the “Sisters for Change” programme in Zimbabwe described in this paper, aim to improve the engagement with testing and care for this group.

Collecting reliable data from female sex workers using a convenience sampling approach in order to estimate the prevalence of HIV is challenging due to the difficulty in ensuring the survey sample is representative of the wider female sex worker population. An alternative approach is respondent driven sampling (RDS) in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations. The results from RDS are however complex to analyse and interpret.

This paper presents an alternative approach using routinely collected data. Using the dates of programme visits, HIV tests (conducted both within and outside of the programme) and dates of antiretroviral initiation, the researchers generated estimates of HIV prevalence (number of positive tests/total number of tests) and HIV incidence (time at risk calculated from the first visit to an imputed date of seroconversion). They also identified risk factors associated with socio-demographic parameters or HIV testing history that were associated with a failure to continue engagement with the programme after a first visit. The prevalence and incidence results are consistent with results from a series of RDS surveys previously conducted in Zimbabwe by this research team.

A difficulty highlighted by the authors is that while this method improves on convenience sampling, it is still difficult to know how HIV incidence and prevalence among programme participants compares to that in the wider female sex worker population. 

In summary this paper presents an approach by which similar programmes elsewhere could make better use of routinely collected data in order to generate estimates of impact and also identify sub-groups of female sex workers with poorer engagement with care. This in turn could lead to a more effective targeting of limited resources.

Africa
Zimbabwe
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