Articles tagged as "Sexual transmission and prevention"

Oral PrEP reduces risk of HIV and does not result in riskier sex

Effectiveness and safety of oral HIV pre-exposure prophylaxis (PrEP) for all populations: A systematic review and meta-analysis.

Fonner VA, Dalglish SL, Kennedy CE, Baggaley R, O'Reilly K R, Koechlin FM, Rodolph M, Hodges-Mameletzis I, Grant RM. AIDS. 2016 May 5. [Epub ahead of print]

Objective: Pre-exposure prophylaxis (PrEP) offers a promising new approach to HIV prevention. This systematic review and meta-analysis evaluated the evidence for use of oral PrEP containing tenofovir disoproxil fumarate (TDF) as an additional HIV prevention strategy in populations at substantial risk for HIV based on HIV acquisition, adverse events, drug resistance, sexual behavior, and reproductive health outcomes.

Design: Rigorous systematic review and meta-analysis.

Methods: A comprehensive search strategy reviewed three electronic databases and conference abstracts through April 2015. Pooled effect estimates were calculated using random-effects meta-analysis.

Results: Eighteen studies were included, comprising data from 39 articles and six conference abstracts. Across populations and PrEP regimens, PrEP significantly reduced the risk of HIV acquisition compared to placebo. Trials with PrEP use >70% demonstrated the highest PrEP effectiveness (RR = 0.30, 95% CI: 0.21-0.45, p < 0.001) compared to placebo. Trials with low PrEP use did not show a significantly protective effect. Adverse events were similar between PrEP and placebo groups. More cases of drug-resistant HIV infection were found among PrEP users who initiated PrEP while acutely HIV-infected, but incidence of acquiring drug-resistant HIV during PrEP use was low. Studies consistently found no association between PrEP use and changes in sexual risk behavior. PrEP was not associated with increased pregnancy-related adverse events or hormonal contraception effectiveness.

Conclusion: PrEP is protective against HIV infection across populations, presents few significant safety risks, and no evidence of behavioral risk compensation. The effective and cost-effective use of PrEP will require development of best practices for fostering uptake and adherence among people at substantial HIV-risk.

Abstract access

Editor’s notes: This systematic review is the first to aggregate data from across oral pre-exposure prophylaxis (PrEP) studies, including randomized control trials and observational studies, to present clear evidence on the effectiveness of oral PrEP use. The findings confirm that oral PrEP significantly reduces the risk of acquiring HIV if taken consistently and correctly across populations, countries, and most age groups. Differences in efficacy directly correlate with adherence, which accounts for the lower efficacy seen in some subgroups. Perhaps two of the most compelling analyses presented in this paper relate to resistance and behavioural disinhibition. The risk of resistance was shown to be quite low, and study participants exhibiting resistant HIV either enrolled in the studies during an acute infection stage or acquired resistant strains during the course of the research. Regarding behavioural disinhibition, indicators measured such as rates of sexually transmitted infections revealed that PrEP use in the efficacy trials was not associated with behavioural disinhibition and in some studies, resulted in even safer sexual behaviour than what was reported at baseline. Recently completed demonstration projects have reported increased rates of STIs among gay men and other men who have sex with men. However, in the open-label extensions included in this review, where counselling was more intensive, safer sex practices were maintained, thus suggesting that counselling can be effective in preventing behavioural disinhibition. 

  • share
0 comments.

Sex on the move

Exploring the relationship between population mobility and HIV risk: evidence from Tanzania.

Deane KD, Samwell Ngalya P, Boniface L, Bulugu G, Urassa M. Glob Public Health. 2016 May 27:1-16. [Epub ahead of print]

Migration and population mobility has long been regarded as an important structural driver of HIV. Following initial concerns regarding the spatial spread of the disease, mobile populations are viewed to engage in higher levels of risky sexual behaviours than non-mobile groups. However, beyond the case studies of mineworkers and truck drivers, the statistical evidence is inconclusive, suggesting that the relationship between mobility and risk is not well understood. This study investigated how engaging in specific livelihoods that involve mobility influences sexual behaviour and HIV risk. A qualitative research project, including focus groups and in-depth interviews with key mobile groups, was conducted in Northern Tanzania. The findings show that the patterns and conditions of moving related to the requirements of each different economic activity influence the nature of relationships that mobile groups have whilst away, how and where local sexual networks are accessed, and the practicalities of having sex. This has further implications for condom use. Risk behaviours are also shaped by local sexual norms related to transactional sex, emphasising that the roles of mobility and gender are interrelated, overlapping and difficult to disentangle.

Abstract access  

Editor’s notes: Case studies with truck drivers and mineworkers have clearly shown a relationship between migration, mobility and HIV risk in sub-Saharan Africa. It remains unclear to what extent findings from these case studies can be extrapolated across all mobile populations. Evidence from studies in other populations is inconclusive, inconsistent and in some cases contradictory. This, in part is due to the limitations of the statistical frameworks used which tend to reduce migration to an abstract individual variable and fail to recognise migration as a dynamic socio-economic phenomenon. These frameworks may also inadequately reflect the variability of migratory behaviour offering limited policy conclusions for addressing HIV risk arising from migration or population mobility.

This qualitative study was conducted in North-western Tanzania in a population in which 60% of men and 43% of women were classified as mobile. Data were collected through focus group discussions and individual interviews with both female and male farmers and maize traders.

The findings of this study suggest that patterns and conditions of moving can influence the nature of sexual relationships that mobile individuals have while away. The findings offer important insights for future, more nuanced statistical work. This would include considering why people move, where they go, patterns of movement, the specific economic activities in which they engage, and where they stay while they are away. The findings also highlight the importance of situating the risk behaviours of mobile individuals within the sexual norms and practices around sex and exchange, and particularly transactional sex. The authors note that being mobile may exacerbate gendered and economic inequalities making the relative influences of mobility and sexual norms difficult to disentangle. This further highlights the value of HIV prevention programmes being specifically tailored to the specific needs of mobile populations.

Africa
United Republic of Tanzania
  • share
0 comments.

Preventing risky sexual behaviour and intimate partner violence in adolescents

Effects of PREPARE, a multi-component, school-based HIV and intimate partner violence (IPV) prevention programme on adolescent sexual risk behaviour and IPV: cluster randomised controlled trial.

Mathews C, Eggers SM, Townsend L, Aaro LE, de Vries PJ, Mason-Jones AJ, De Koker P, McClinton Appollis T, Mtshizana Y, Koech J, Wubs A, De Vries H. AIDS Behav. 2016 May 3. [Epub ahead of print]

Young South Africans, especially women, are at high risk of HIV. We evaluated the effects of PREPARE, a multi-component, school-based HIV prevention intervention to delay sexual debut, increase condom use and decrease intimate partner violence (IPV) among young adolescents. We conducted a cluster RCT among Grade eights in 42 high schools. The intervention comprised education sessions, a school health service and a school sexual violence prevention programme. Participants completed questionnaires at baseline, 6 and 12 months. Regression was undertaken to provide ORs or coefficients adjusted for clustering. Of 6244 sampled adolescents, 55.3 % participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviours. Participants in the intervention arm were less likely to report IPV victimisation (35.1 vs. 40.9 %; OR 0.77, 95 % CI 0.61-0.99; t(40) = 2.14) suggesting the intervention shaped intimate partnerships into safer ones, potentially lowering the risk for HIV.

Abstract access

Editor’s notes: Worldwide, HIV is one of the leading causes of death among adolescents. A key objective of the Global Strategy for Women’s, Children’s and Adolescents’ Health, launched in 2015, is to end the HIV epidemic by 2030. In South Africa, the prevalence and incidence of HIV remains high among young South Africans, especially among women. Early sexual debut and condomless sex are risk factors for HIV and other sexually transmitted infections. Another important risk factor in South Africa is the high level of intimate partner violence, which can also increase the risk of HIV infection among women. This cluster randomised trial sought to address these risk factors among young adolescents (average age 13 years) in public high schools in the Western Cape. The education component of the programme comprised 21 sessions delivered weekly immediately after school. One explanation for the lack of an effect on sexual behaviour was sub-optimal exposure to the activity as a result of poor attendance at sessions. Overall, the mean attendance was 8.02 sessions with higher attendance among girls than among boys. Even so, self-reported intimate partner violence – a factor that predisposes HIV infection – was reduced. The investigators suggest that this may be because attendance was higher at earlier sessions, which addressed gender issues, so more participants received exposure to content associated with intimate partner violence than sexual behaviour.

Achieving high, sustained attendance rates at after-school programmes is challenging and as the investigators note, perhaps the most efficient way to ensure that adolescents receive adequate exposure to HIV risk reduction programmes is to embed them in the school curriculum. However, programmes also need to address other structural, social and environmental factors affecting HIV infection.

Africa
South Africa
  • share
0 comments.

Intimate partner violence is a challenge to PrEP adherence

Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: a prospective cohort study.

Roberts ST, Haberer J, Celum C, Mugo N, Ware NC, Cohen CR, Tappero JW, Kiarie J, Ronald A, Mujugira A, Tumwesigye E, Were E, Irungu E, Baeten JM. J Acquir Immune Defic Syndr. 2016 May 26. [Epub ahead of print]

Background: Intimate partner violence (IPV) is associated with higher HIV incidence, reduced condom use, and poor adherence to antiretroviral therapy and other medications. IPV may also affect adherence to pre-exposure prophylaxis (PrEP).

Methods: We analyzed data from 1785 HIV-uninfected women enrolled in a clinical trial of PrEP among African HIV-serodiscordant couples. Experience of verbal, physical, or economic IPV was assessed at monthly visits by face-to-face interviews. Low PrEP adherence was defined as clinic-based pill count coverage <80% or plasma tenofovir levels <40 ng/mL. The association between IPV and low adherence was analyzed using generalized estimating equations, adjusting for potential confounders. In-depth interview transcripts were examined to explain how IPV could impact adherence.

Results: 16% of women reported IPV during a median of 34.8 months of follow-up (IQR 27.0 - 35.0). Overall, 7% of visits had pill count coverage <80% and 32% had plasma tenofovir <40 ng/mL. Women reporting IPV in the past 3 months had increased risk of low adherence by pill count (adjusted RR 1.49, 95% CI 1.17-1.89) and by plasma tenofovir (adjusted RR 1.51, 95% CI 1.06-2.15). Verbal, economic, and physical IPV were all associated with low adherence. However, the impact of IPV diminished and was not statistically significant 3 months after the reported exposure. In qualitative interviews, women identified several ways in which IPV affected adherence, including stress and forgetting, leaving home without pills, and partners throwing pills away.

Conclusion: Women who reported recent IPV in the Partners PrEP Study were at increased risk of low PrEP adherence. Strategies to mitigate PrEP non-adherence in the context of IPV should be evaluated.

Abstract access

Editor’s notes: The high rates of HIV infection in women underscore persistent gender inequalities, in particular that of violence against women. Intimate partner violence (IPV) puts women at increased risk of HIV infection. Further, among women living with HIV, IPV has also been associated with lower rates of treatment uptake and adherence to antiretroviral therapy (ART). The interaction between IPV and HIV is complex, and includes biological, socio-economic and cultural mechanisms. This is the first study to examine the association between IPV and adherence to HIV pre-exposure prophylaxis (PrEP).  Women who had experienced IPV in the past three months were 50% more likely than women who had never experienced IPV to have poor adherence, as measured by both pills counts and drug levels in the blood.  Recent IPV was also associated with an increase in the risk of HIV infection.  Women in the study were in stable, serodiscordant relationships, had enrolled in the study together with their partners, and were using PrEP with their partner’s consent. The proportion of women reporting IPV during the study was much lower than national estimates in the region.  These findings are thus of concern for PrEP demonstration projects focusing on key populations at high risk of HIV, who may experience higher rates of IPV and be less likely to have partner support. 

PrEP is a key element of combination HIV prevention strategies in high-risk populations, but requires high adherence in order to be effective. Programmes focusing on promoting PrEP adherence in women who have experienced violence are urgently needed.  More broadly, HIV prevention programmes should be expanded to integrate IPV prevention as an important component to reducing women’s risk of HIV.

Africa
Kenya, Uganda
  • share
0 comments.

Circumcising young adults: a higher return on investment

Effectiveness of and financial returns to voluntary medical male circumcision for HIV prevention in South Africa: an incremental cost-effectiveness analysis.

Haacker M, Fraser-Hurt N, Gorgens M. PLoS Med. 2016 May 3;13(5):e1002012. doi: 10.1371/journal.pmed.1002012. eCollection 2016.

Background: Empirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach-analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC's cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period.

Methods/findings: The model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold-the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government.

Conclusions: VMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age.

Abstract  Full-text [free] access 

Editor’s notes: Voluntary medical male circumcision is known to be an effective HIV-infection prevention method. While many models and papers have explored the cost and cost-effectiveness of voluntary medical male circumcision at a population level, the authors carry out their analysis using an incremental approach, looking at the expected consequences of circumcising one male individual within a specific year. Their findings are consistent with previous work on the topic, namely that voluntary medical male circumcision is highly effective in countries with high HIV prevalence and is, under many circumstances, cost-saving. They also find that voluntary medical male circumcision is most effective when performed at age 20, and effectiveness declines at higher ages due to diminished direct and indirect effects on HIV incidence.

While it would indeed be wise for countries to consider long-term impacts of programmes, governments often make decisions in the short-term. It is therefore important for governments to understand the benefits of a programme or policy that are accrued during the timeframe of presidential or congressional terms. The findings and the approach used in this study are very important because they present evidence of impact of investment within a government’s current budget process. By providing a way to measure the immediate return on investment, the authors of this paper help inform policymakers in a way that is tangible, pragmatic, and, unfortunately, not often used.  

Africa
South Africa
  • share
0 comments.

Finding out at home: community members’ and healthcare workers’ views on the use of oral HIV self-testing in Kayelitsha, South Africa

'I know that I do have HIV but nobody saw me': oral HIV self-testing in an informal settlement in South Africa.

Martinez Perez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, Stinson K, Van Cutsem G, Ibeto M. PLoS One. 2016 Apr 4;11(4):e0152653. doi: 10.1371/journal.pone.0152653. eCollection 2016.

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.

 Abstract Full-text [free] access

Editor’s notes: This is a qualitative study with services users and healthcare workers from an HIV testing service ran by Médecins Sans Frontières (MSF) in Kayelitsha, South Africa. Couple and individual interviews and focus group discussions were conducted with 20 people. The participants discussed preferences of types of HIV testing and acceptability of HIV home-testing. The aim was to inform the pilot of an activity for the use of an oral HIV self-testing device (OraQuick). OraQuick is self-administered as an oral swab and gives results straightaway. The study sample included people who had previously refused an HIV test in the clinic, people who had received an HIV test in the clinic and agreed to a couple interview with their partners. Key reasons for refusing an HIV test in the clinic included: fear of finding out one’s status, fear of HIV-treated discrimination and concerns about confidentiality in testing services. Clinics were seen by male participants as ‘women’s places’.  Men thought visiting a service for an HIV test could harm one’s reputation. Home-testing was seen as preferable because it afforded more privacy. However, not wanting to know one’s status remains a barrier even with home-testing. There were concerns that partners (of both sexes) could pressure one another to test with OraQuick and tensions could arise in case of serodiscordant results. There were concerns that some users could get confused by a test that detects the presence of HIV in the mouth. This would contradict current awareness that HIV cannot be passed through kissing. False-negative tests could encourage unsafe sex. Participants worried that some people may not link into care and treatment after finding out they are HIV positive with a home-test. The study concludes that home-testing could reach populations (especially male partners of women living with HIV and young people) that do not come forward for testing through other services, including clinic-based and voluntary community testing. Many of the disadvantages of home-testing could be mitigated with appropriate education and pre-test counselling. The pilot study continues.  It is expected that the study will be able to address questions of linkage to care for people who test HIV-positive. 

Africa
South Africa
  • share
0 comments.

Comparing the performance of different community-based measures of viral load as correlates for HIV incidence

Community viral load, antiretroviral therapy coverage, and HIV incidence in India: a cross-sectional, comparative study.

Solomon SS, Mehta SH, McFall AM, Srikrishnan AK, Saravanan S, Laeyendecker O, Balakrishnan P, Celentano DD, Solomon S, Lucas GM. Lancet HIV. 2016 Apr;3(4):e183-90. doi: 10.1016/S2352-3018(16)00019-9. Epub 2016 Mar 11.

Background: HIV incidence is the best measure of treatment-programme effectiveness, but its measurement is difficult and expensive. The concept of community viral load as a modifiable driver of new HIV infections has attracted substantial attention. We set out to compare several measures of community viral load and antiretroviral therapy (ART) coverage as correlates of HIV incidence in high-risk populations.

Methods: We analysed data from a sample of people who inject drugs and men who have sex with men, who were participants of the baseline assessment of a cluster-randomised trial in progress across 22 cities in India (ClinicalTrials.gov number NCT01686750). We recruited the study population by use of respondent-driven sampling and did the baseline assessment at 27 community-based sites (12 for men who have sex with men and 15 for people who inject drugs). We estimated HIV incidence with a multiassay algorithm and calculated five community-based measures of HIV control: mean log10 HIV RNA in participants with HIV in a community either engaged in care (in-care viral load), aware of their status but not necessarily in care (aware viral load), or all HIV-positive individuals whether they were aware, in care, or not (population viral load); participants with HIV in a community with HIV RNA more than 150 copies per mL (prevalence of viraemia); and the proportion of participants with HIV who self-reported ART use in the previous 30 days (population ART coverage). All participants were tested for HIV, with additional testing in HIV-positive individuals. We assessed correlations between the measures and HIV incidence with Spearman correlation coefficients and linear regression analysis.

Findings: Between Oct 1, 2012, and Dec 19, 2013, we recruited 26 503 participants, 12 022 men who have sex with men and 14 481 people who inject drugs. Median incidence of HIV was 0.87% (IQR 0.40-1.17) in men who have sex with men and 1.43% (0.60-4.00) in people who inject drugs. Prevalence of viraemia was more strongly correlated with HIV incidence (correlation 0.81, 95% CI 0.62-0.91; p<0.0001) than all other measures, although correlation was significant with aware viral load (0.59, 0.27-0.79; p=0.001), population viral load (0.51, 0.16-0.74; p=0.007), and population ART coverage (-0.54, -0.76 to -0.20; p=0.004). In-care viral load was not correlated with HIV incidence (0.29, -0.10 to 0.60; p=0.14). With regression analysis, we estimated that to reduce HIV incidence by 1 percentage point in a community, prevalence of viraemia would need to be reduced by 4.34%, and ART use in HIV-positive individuals would need to increase by 19.5%.

Interpretation: Prevalence of viraemia had the strongest correlation with HIV incidence in this sample and might be a useful measure of the effectiveness of a treatment programme.

Abstract access    

Editor’s notes: The ideal metric of impact for a programme looking at the prevention benefits of treatment would be the reduction in HIV incidence in the target population. Incidence is however very difficult to measure. ‘Community viral load’ has been proposed as an alternative. However its estimation using data collected either in a routine clinical setting or from a cohort study can suffer from bias, due to the population included not being representative of the wider population of people living with HIV.

This paper describes a study among gay men and other men who have sex with men and people who inject drugs carried out at 27 sites in India. Participants were recruited using respondent-driven sampling (in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations). At each site incidence was estimated using a multi-assay algorithm designed to identify seroconversion occurring approximately within the last six months. Five community-based measures of viral load were measured at each site. Of these, the prevalence of HIV viraemia (i.e. the proportion of the population with a viral load greater than 150 copies per mL), was most strongly associated with HIV incidence, while mean viral load among people in-care was not associated. This latter finding is important if a case-based surveillance approach using only data collected at clinics is to be used to estimate incidence. Population ART coverage, a measure of the proportion of the site participants on ART was also strongly correlated with incidence. As this can be measured through a simple questionnaire, rather than lab-based assays, it could be an easily and cheaply obtainable correlate for incidence, albeit one potentially prone to response bias.

Asia
India
  • share
0 comments.

HIV genotyping to focus prevention efforts

Near real-time monitoring of HIV transmission hotspots from routine HIV genotyping: an implementation case study.

Poon AF, Gustafson R, Daly P, Zerr L, Demlow SE, Wong J, Woods CK, Hogg RS, Krajden M, Moore D, Kendall P, Montaner JS, Harrigan PR. Lancet HIV. 2016 May;3(5):e231-8. doi: 10.1016/S2352-3018(16)00046-1. Epub 2016 Apr 7.

Background: HIV evolves rapidly and therefore infections with similar genetic sequences are likely linked by recent transmission events. Clusters of related infections can represent subpopulations with high rates of transmission. We describe the implementation of an automated near real-time system to monitor and characterise HIV transmission hotspots in British Columbia, Canada.

Methods: In this implementation case study, we applied a monitoring system to the British Columbia drug treatment database, which holds more than 32 000 anonymised HIV genotypes for nearly 9000 residents of British Columbia living with HIV. On average, five to six new HIV genotypes are deposited in the database every day, which triggers an automated reanalysis of the entire database. We extracted clusters of five or more individuals with short phylogenetic distances between their respective HIV sequences. The system generated monthly reports of the growth and characteristics of clusters that were distributed to public health officers.

Findings: In June, 2014, the monitoring system detected the expansion of a cluster by 11 new cases during 3 months, including eight cases with transmitted drug resistance. This cluster generally comprised young men who have sex with men. The subsequent report precipitated an enhanced public health follow-up to ensure linkage to care and treatment initiation in the affected subpopulation. Of the nine cases associated with this follow-up, all had already been linked to care and five cases had started treatment. Subsequent to the follow-up, three additional cases started treatment and most cases achieved suppressed viral loads. During the next 12 months, we detected 12 new cases in this cluster with reduction in the onward transmission of drug resistance.

Interpretation: Our findings show the first application of an automated phylogenetic system monitoring a clinical database to detect a recent HIV outbreak and support the ensuing public health response. By making secondary use of routinely collected HIV genotypes, this approach is cost-effective, attains near real-time monitoring of new cases, and can be implemented in all settings in which HIV genotyping is the standard of care.

Abstract access

Editor’s notes: HIV genetic sequence data have been used retrospectively to characterise transmission patterns and association with risk factors. This is the first report of the use of such data in real-time to monitor transmission and inform a public health response.  Under current treatment guidelines in British Columbia, an HIV genotype test is routinely done on all individuals at the time of diagnosis.  The results are fed in to an automated monitoring system that can be used detect transmission ‘clusters’ and track their development. The case study demonstrates the value of this system in detecting an outbreak of transmitted drug resistance which was prioritised for public health programmes.  The authors acknowledge the ethical dilemmas associated with using HIV sequence data to inform public health actions. Accordingly, all individuals in the cluster were offered counselling, testing and treatment so as not to focus on any one person. One limitation of the monitoring system is that it relies on information from people who have presented for HIV testing, so people who are undiagnosed or not engaged with care are not represented. Although monitoring based on HIV sequence data is only possible in certain settings, it may provide a cost-effective tool for focused HIV prevention in situations where the data are already being collected as part of the standard care.

Northern America
Canada
  • share
0 comments.

Intimate partner violence among female sex workers living with HIV must be addressed to improve their wellbeing and reduce onward transmission of HIV

A prospective cohort study of intimate partner violence and unprotected sex in HIV-positive female sex workers in Mombasa, Kenya.

Wilson KS, Deya R, Yuhas K, Simoni J, Vander Stoep A, Shafi J, Jaoko W, Hughes JP, Richardson BA, McClelland RS. AIDS Behav. 2016 Apr 19. [Epub ahead of print]

We conducted a prospective cohort study to test the hypothesis that intimate partner violence (IPV) is associated with unprotected sex in HIV-positive female sex workers in Mombasa, Kenya. Women completed monthly visits and quarterly examinations. Any IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the current or most recent emotional partner ('index partner'). Unprotected sex with any partner was measured by self-report and prostate specific antigen (PSA) test. Recent IPV was associated with significantly higher risk of unprotected sex (adjusted relative risk [aRR] 1.91, 95 % CI 1.32, 2.78, p = 0.001) and PSA (aRR 1.54, 95 % CI 1.17, 2.04, p = 0.002) after adjusting for age, alcohol use, and sexual violence by someone besides the index partner. Addressing IPV in comprehensive HIV programs for HIV-positive women in this key population is important to improve wellbeing and reduce risk of sexual transmission of HIV.

Abstract access  

Editor’s notes: Intimate partner violence (IPV) is the most common form of gender-based violence globally. A recent systematic review reported high prevalence of IPV in sub-Saharan Africa, ranging from 30% to 66% among ever partnered women. Negative outcomes associated with IPV include increased risk of HIV infection and there are multiple pathways through which IPV may increase the risk of HIV infection in women. These include reduced sexual relationship power and ability to negotiate condom, and more risky sexual behaviour. Furthermore, IPV may be a marker of relationships with men who have a history of violent behaviour and may be at increased risk of HIV themselves. Women living with HIV are also at increased risk of IPV, which in turn can increase the risk of condomless sex and onward transmission of HIV.

Female sex workers are a key population disproportionately affected by violence, substance abuse and HIV. This longitudinal study of female sex workers in Kenya found a significant association between IPV and condomless sex. It highlights the value of using both self-reported behavioural and biological markers of sexual behaviour to gain a more complete understanding of the relationship between IPV and risky sexual behaviour. Comprehensive HIV programmes must address IPV to improve both the health and well-being of women living with HIV and to reduce sexual transmission of HIV. 

Africa
Kenya
  • share
0 comments.

Combining community-based HIV testing methods to achieve high testing coverage

A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study. 

Chamie G, Clark TD, Kabami J, Kadede K, Ssemmondo E, Steinfeld R, Lavoy G, Kwarisiima D, Sang N, Jain V, Thirumurthy H, Liegler T, Balzer LB, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. Lancet HIV. 2016 Mar;3(3):e111-9. doi: 10.1016/S2352-3018(15)00251-9. Epub 2016 Jan 26.

Background: Despite large investments in HIV testing, only an estimated 45% of HIV-infected people in sub-Saharan Africa know their HIV status. Optimum methods for maximising population-level testing remain unknown. We sought to show the effectiveness of a hybrid mobile HIV testing approach at achieving population-wide testing coverage.

Methods: We enumerated adult (≥15 years) residents of 32 communities in Uganda (n=20) and Kenya (n=12) using a door-to-door census. Stable residence was defined as living in the community for at least 6 months in the past year. In each community, we did 2 week multiple-disease community health campaigns (CHCs) that included HIV testing, counselling, and referral to care if HIV infected; people who did not participate in the CHCs were approached for home-based testing (HBT) for 1-2 months within the 1-6 months after the CHC. We measured population HIV testing coverage and predictors of testing via HBT rather than CHC and non-testing.

Findings: From April 2, 2013, to June 8, 2014, 168 772 adult residents were enumerated in the door-to-door census. HIV testing was achieved in 131 307 (89%) of 146 906 adults with stable residence. 13 043 of 136 033 (9.6%, 95% CI 9.4-9.8) adults with and without stable residence had HIV; median CD4 count was 514 cells per µL (IQR 355-703). Among 131 307 adults with stable residence tested, 56 106 (43%) reported no previous testing. Among 13 043 HIV-infected adults, 4932 (38%) were unaware of their status. Among 105 170 CHC attendees with stable residence 104 635 (99%) accepted HIV testing. Of 131 307 adults with stable residence tested, 104 635 (80%; range 60-93% across communities) tested via CHCs. In multivariable analyses of adults with stable residence, predictors of non-testing included being male (risk ratio [RR] 1.52, 95% CI 1.48-1.56), single marital status (1.70, 1.66-1.75), age 30-39 years (1.58, 1.52-1.65 vs 15-19 years), residence in Kenya (1.46, 1.41-1.50), and migration out of the community for at least 1 month in the past year (1.60, 1.53-1.68). Compared with unemployed people, testing for HIV was more common among farmers (RR 0.73, 95% CI 0.67-0.79) and students (0.73, 0.69-0.77); and compared with people with no education, testing was more common in those with primary education (0.84, 0.80-0.89).

Interpretation: A hybrid, mobile approach of multiple-disease CHCs followed by HBT allowed for flexibility at the community and individual level to help reach testing coverage goals. Men and mobile populations remain challenges for universal testing.

Abstract access

Editor’s notes: Achieving high levels of HIV testing coverage remains a challenge in many parts of sub-Saharan Africa. Conventional facility-based HIV testing models are insufficient to achieve the UNAIDS 90-90-90 targets and maximise the prevention benefits of treatment. This study was able to achieve extremely high levels of HIV testing coverage in a short period of time by strategically combining two community-based testing approaches. By offering testing through multiple-disease community health campaigns (CHC), followed by focused home-based testing (HBT) for individuals who did not attend the CHCs, nearly 90% of adult stable residents accepted HIV testing. This near-universal coverage was achieved in all 32 communities (range 84%‒95%) across two countries, in a variety of settings with different rates of HIV prevalence and of previous testing. Testing uptake in the CHCs varied considerably across the communities (52%‒82%), demonstrating the value of this hybrid approach to expand coverage. Non-stable residents, who were 13% of the population, had low rates of testing uptake (22%). High rates of mobility remain a particular challenge for universal HIV testing coverage, and additional strategies are necessary to engage this group. A potential limitation of a focused approach to HBT is the need for community enumeration.  Still the results illustrate that achieving high HIV testing coverage is feasible with a combination of community-based approaches.

Africa
Kenya, Uganda
  • share
0 comments.