Articles tagged as "Sexual transmission and prevention"

Benefits of targeting prevention at attendees of HIV testing services, Brazil

Efficient identification of HIV serodiscordant couples by existing HIV testing programs in south Brazil.

Pilcher CD, Bisol CA, Paganella MP, Vallabhaneni S, da Motta LR, Kato SK, Sperhacke RD, Kallas EG, Hecht FM, Diaz RS. PLoS One. 2015; 10(11): e0142638. Published online Nov 12.

Objective: To examine the feasibility of identifying HIV negative at risk individuals in HIV serodiscordant couples, during voluntary HIV testing in South Brazil.

Methods: We surveyed HIV testers at 4 public testing sites in Rio Grande do Sul. We obtained information on risk behaviors and sexual partnerships. HIV testing and testing for recent infection were performed; HIV prevalence and risk behaviors were assessed among subjects who reported having a steady partner who was HIV positive (serodiscordant group) and compared with the general testing population.

Results: Among 3100 patients, 490 (15.8%) reported being in a steady relationship with an HIV positive partner. New HIV infections were diagnosed in 23% of the serodiscordant group (vs. 13% in the general population, p = 0.01); among newly positive subjects, recent HIV infections were more frequent (23/86, 26.7%) among testers with positive partners than among the general testing group (52/334; 15.6%; p = 0.016). Less than half of the serodiscordant testers reported having used a condom during the last sexual intercourse with their HIV-positive partner. Participants with inconsistent condom use with steady partner were four times more likely to test positive for HIV compared to those who reported always using condoms with the steady partner (OR: 4.2; 95% CI: 2.3 to 7.5).

Conclusion: It is highly feasible to identify large numbers of HIV susceptible individuals who are in HIV serodiscordant relationships in South Brazil testing sites. Condom use within HIV serodiscordant couples is low in this setting, suggesting urgent need for biomedical prevention strategies to reduce HIV transmission.

Abstract Full-text [free] access

Editor’s notes: This study from Brazil highlights the fact that asking individuals attending HIV testing services whether they had a steady partner living with HIV can identify a large number of key populations who should be an important focus for HIV prevention services. In this study, a striking proportion (15%) of testers reported that they were in a serodiscordant relationship with an individual living with HIV. This provides an important opportunity to link these key populations to proven prevention services, including medical male circumcision and pre-exposure prophylaxis. There was also clear evidence that these individuals are at high risk of HIV, e.g. they were almost twice as likely to have an acute HIV infection compared with testers with “general population” partners. This suggests that individuals in serodiscordant relationships sought HIV testing services when they thought they had been exposed to a high risk sexual event. The paper does not report the treatment status of the partners living with HIV and it is not clear if participants were asked about this. The authors conclude that it is feasible to identify HIV susceptible individuals at testing sites. It is also important to remember that this is not only to focus on people with a partner living with HIV, but also all people testing HIV-positive. People in the latter group are a key population for prevention too, as they are at risk for transmitting HIV within their steady partnership which was previously concordant HIV-negative.

Latin America
Brazil
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You’re not a man until you’re a father. Young men’s desire for fatherhood and HIV-associated risk

Fatherhood, marriage and HIV risk among young men in rural Uganda.

Mathur, S, Higgins, J. A, Thummalachetty N, Rasmussen, M, Kelley, L, Nakyanjo, N, Nalugoda, F, Santelli, J. S, Cult Health Sex 2015 Nov 5:1-15 (Epub ahead of print)

Compared to a large body of work on how gender may affect young women’s vulnerability to HIV, we know little about how masculine ideals and practices relating to marriage and fertility desires shape young men’s HIV risk. Using life-history interview data with 30 HIV-positive and HIV-negative young men aged 15–24 years, this analysis offers an in-depth perspective on young men’s transition through adolescence, the desire for fatherhood and experience of sexual partnerships in rural Uganda. Young men consistently reported the desire for fatherhood as a cornerstone of masculinity and transition to adulthood. Ideally young men wanted children within socially sanctioned unions. Yet, most young men were unable to realise their marital intentions. Gendered expectations to be economic providers combined with structural constraints, such as limited access to educational and income-generating opportunities, led some young men to engage in a variety of HIV-risk behaviours. Multiple partnerships and limited condom use were at times an attempt by some young men to attain some part of their aspirations related to fatherhood and marriage. Our findings suggest that young men possess relationship and parenthood aspirations that – in an environment of economic scarcity – may influence HIV-related risk.

Abstract access

Editor’s notes: Gender-specific HIV risks are influenced by biological, social and structural factors. In comparison to factors that affect women’s HIV risk, relatively little is known about how constructions on masculinity affect men’s HIV risk, particularly with relation to young men’s desire for marriage and biological children. In the context meeting fertility ideals, men’s demonstration of masculinity within structural contexts of social change and economic instability, may be associated with certain risk behaviours, including multiple partnerships and inconsistent condom use.

This study utilised data from in-depth life history interviews with 30 HIV-positive and HIV-negative young men aged 15-24 years in southern Uganda. Young men who had acquired bio-medically confirmed HIV over the course of the year between June 2010 and June 2011 and their HIV-negative counterparts were pair-matched by gender, marital status, age and village of residence. The sample included married (n=10), never married (n=16) and previously married men (n=4). Respondents participated in two interviews, approximately two to three weeks apart. Interviews were audio recorded.

Three major themes emerged from the interviews. First, respondents mentioned fatherhood and formal marriage as milestones in the transition to adulthood for young men and a crucial part of the masculine ideal in rural Uganda. Second, truncated educational options and limited economic opportunities made it difficult for young men to acquire formal marriages and fulfil their desires for fatherhood. Third, young men who faced obstacles in trying to achieve these masculine ideals often engaged in alternative strategies, such as condomless sex or having multiple partners, to fulfil their desires for marriage and children; these strategies in turn increased young men’s vulnerability to HIV infection. Regardless of their HIV status young men consistently expressed their desire for marriage and children; described similar economic challenges, and pursued alternative strategies for achieving their masculine ideals. The findings of this study illustrate how the confluence of idealised male masculinities and structural inequalities may play a key role in young men’s vulnerability to HIV.

Africa
Uganda
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HIV tests at church-based baby showers raise odds of testing 11-fold for pregnant women

Effect of a congregation-based intervention on uptake of HIV testing and linkage to care in pregnant women in Nigeria (baby shower): a cluster randomised trial.

Ezeanolue EE, Obiefune MC, Ezeanolue CO, Ehiri JE, Osuji A, Ogidi AG, Hunt AT, Patel D, Yang W, Pharr J, Ogedegbe G. Lancet Glob Health. 2015 Nov;3(11):e692-700. doi: 10.1016/S2214-109X(15)00195-3.

Background: Few effective community-based interventions exist to increase HIV testing and uptake of antiretroviral therapy (ART) in pregnant women in hard-to-reach resource-limited settings. We assessed whether delivery of an intervention through churches, the Healthy Beginning Initiative, would increase uptake of HIV testing in pregnant women compared with standard health facility referral.

Methods: In this cluster randomised trial, we enrolled self-identified pregnant women aged 18 years and older who attended churches in southeast Nigeria. We randomised churches (clusters) to intervention or control groups, stratified by mean annual number of infant baptisms (<80 vs ≥80). The Healthy Beginning Initiative intervention included health education and on-site laboratory testing implemented during baby showers in intervention group churches, whereas participants in control group churches were referred to health facilities as standard. Participants and investigators were aware of church allocation. The primary outcome was confirmed HIV testing. This trial is registered with ClinicalTrials.gov, identifier number NCT 01795261.

Findings: Between Jan 20, 2013, and Aug 31, 2014, we enrolled 3002 participants at 40 churches (20 per group). 1309 (79%) of 1647 women attended antenatal care in the intervention group compared with 1080 (80%) of 1355 in the control group. 1514 women (92%) in the intervention group had an HIV test compared with 740 (55%) controls (adjusted odds ratio 11.2, 95% CI 8.77-14.25; p<0.0001).

Interpretation: Culturally adapted, community-based programmes such as the Healthy Beginning Initiative can be effective in increasing HIV screening in pregnant women in resource-limited settings.

Abstract Full-text [free] access

Editor’s notes: HIV testing is a key entry point for prevention of mother-to-child transmission. Community-based, decentralised HIV testing outside health facilities can increase uptake of testing among pregnant women, but this does not always follow through into good linkage to care.

In Nigeria faith-based organisations have a strong social network and a wider presence than health facilities. This trial co-ordinated churches in predominantly Christian southeast Nigeria to identify pregnant women early and organise a baby shower where on-site laboratory tests were provided. To avoid stigma the programme offered testing for five other conditions alongside HIV. Women who tested positive for HIV infection were linked to care and followed up at a post-delivery baby reception at the church. Women in the programme arm were more likely to have an HIV test and if positive they were more likely to access care before delivery and to start ART during pregnancy.

The results illustrate the benefits of engagement with faith-based organisations to reach communities that are poorly served by health facilities. The fact male partners played a role in the baby shower may have increased uptake, as pregnant women are more likely to accept HIV testing when male partners are also involved. The main costs were Mama Packs (a gift of essentials for a safe delivery, presented at the baby shower) and integrated lab tests. The activity was so popular that communities continued with it after the trial ended. The programme is now being adapted for mosques in northern Nigeria and Hindu temples in India. 

Africa
Nigeria
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More savings, more hope, and more HIV-preventive attitudes among vulnerable adolescent youth

Effect of savings-led economic empowerment on HIV preventive practices among orphaned adolescents in rural Uganda: results from the Suubi-Maka randomized experiment.

Jennings L, Ssewamala FM, Nabunya P. AIDS Care. 2015 Nov 7:1-10. [Epub ahead of print]

Improving economic resources of impoverished youth may alter intentions to engage in sexual risk behaviors by motivating positive future planning to avoid HIV risk and by altering economic contexts contributing to HIV risk. Yet, few studies have examined the effect of economic-strengthening on economic and sexual behaviors of orphaned youth, despite high poverty and high HIV infection in this population. Hierarchal longitudinal regressions were used to examine the effect of a savings-led economic empowerment intervention, the Suubi-Maka Project, on changes in orphaned adolescents' cash savings and attitudes toward savings and HIV-preventive practices over time. We randomized 346 Ugandan adolescents, aged 10-17 years, to either the control group receiving usual orphan care plus mentoring (n = 167) or the intervention group receiving usual orphan care plus mentoring, financial education, and matched savings accounts (n = 179). Assessments were conducted at baseline, 12, and 24 months. Results indicated that intervention adolescents significantly increased their cash savings over time (b = $US12.32, +/-1.12, p < .001) compared to adolescents in the control group. At 24 months post-baseline, 92% of intervention adolescents had accumulated savings compared to 43% in the control group (p < .001). The largest changes in savings goals were the proportion of intervention adolescents valuing saving for money to buy a home (DeltaT1-T0 = +14.9, p < .001), pursue vocational training (DeltaT1-T0 = +8.8, p < .01), and start a business (T1-T0 = +6.7, p < .01). Intervention adolescents also had a significant relative increase over time in HIV-preventive attitudinal scores (b = +0.19, +/-0.09, p < .05), most commonly toward perceived risk of HIV (95.8%, n = 159), sexual abstinence or postponement (91.6%, n = 152), and consistent condom use (93.4%, n = 144). In addition, intervention adolescents had 2.017 significantly greater odds of a maximum HIV-prevention score (OR = 2.017, 95%CI: 1.43-2.84). To minimize HIV risk throughout the adolescent and young adult periods, long-term strategies are needed to integrate youth economic development, including savings and income generation, with age-appropriate combination prevention interventions.

Abstract access 

Editor’s notes: This study contributes to the small but growing evidence on the effectiveness of economic strengthening activities for HIV prevention and treatment outcomes. It used a cluster randomised experimental design to evaluate the impact of a savings-led economic empowerment programme for orphaned adolescents on savings behaviour, as well as sexually protective attitudes. The authors report a significant and large impact on cash savings, as well as an increase in HIV-preventive attitudinal scores. This is particularly promising given the need to address the multiple needs of adolescent youth to promote their healthy transition to adulthood.

It is important to note that this study considered attitudinal outcomes, rather than biological or even reported behavioural ones. There are considerable limitations to such measures that often do not reflect actual sexual behaviours. Also, given the significant additional cost and economic benefits of the savings component in the programme arm, a key question remains, namely how incrementally cost-effective it is in achieving HIV and economic development goals. 

Africa
Uganda
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Justification of PrEP use as protection from rape

Negotiating the use of female-initiated HIV prevention methods in a context of gender-based violence: the narrative of rape.

Hartmann M, Montgomery E, Stadler J, Laborde N, Magazi B, Mathebula F, van der Straten A. Cult Health Sex. 2015 Nov 9:1-14. [Epub ahead of print]

Female-initiated methods of HIV prevention are needed to address barriers to HIV prevention rooted in gender inequalities. Understanding the sociocultural context of pre-exposure prophylaxis (PrEP) trials, including gender-based violence, is thus critical. MTN-003C (VOICE-C), a qualitative sub-study of the larger MTN-003 (VOICE) trial, examined sociocultural barriers and facilitators to PrEP amongst women in Johannesburg. We conducted focus-group discussions, in-depth interviews and ethnographic interviews with 102 trial participants, 22 male partners, 17 community advisory board members and 23 community stakeholders. We analysed how discussions of rape are emblematic of the gendered context in which HIV risk occurs. Rape emerged spontaneously in half of discussions with community advisory board members, two-thirds with stakeholders and among one-fifth of interviews/discussions with trial participants. Rape was used to reframe HIV risk as external to women's or partner's behaviour and to justify the importance of PrEP. Our research illustrates how women, in contexts of high levels of sexual violence, may use existing gender inequalities to negotiate PrEP use. This suggests that future interventions should simultaneously address harmful gender attitudes, as well as equip women with alternative means to negotiate product use, in order to more effectively empower women to protect themselves from HIV.

Abstract access 

Editor’s notes: This paper presents qualitative research which explored the broader context of gender-based violence surrounding PrEP use. The study was an ancillary study alongside the VOICE trial at the South Africa site, which evaluated daily oral and vaginal PrEP. Participants in the ancillary study included women participants, male partners and community stakeholders. The authors found that the issue of rape was spontaneously mentioned by the majority of participants, with the exception of male partners. From these discussions of rape, issues of gender norms emerged, which revealed a continuum from what was called gender exploitative and gender accommodating. The context of gender exploitative was expressed as rape as a reflection of women’s vulnerability. In this context women’s vulnerability to rape and HIV provides a rationale for the use of PrEP. This includes protecting them against sexual violence victimisation. The study highlights that rape provides justification for the use of PrEP but reveals that such justification is complex in that women are seen as both vulnerable to rape but also blamed for rape through unacceptable behaviours including drinking alcohol. The authors conclude that the focus on rape by strangers hides women’s vulnerability to sexual violence from partners and argue that any move to legitimise PrEP for the threat of rape may undermine its use in consensual sex and reinforces negative gender norms about women’s vulnerability to strangers. They suggest that initiatives surrounding PrEP need to recognise and challenge harmful gender norms. This study has highlighted that while PrEP has not been imagined as a gendered HIV prevention tool, in contrast to microbicides, it does in fact emerge as a tool that will be gendered in potentially harmful ways. 

Africa
South Africa
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Assessing the risk of HIV in older age in South Africa

HIV after 40 in rural South Africa: a life course approach to HIV vulnerability among middle aged and older adults.

Mojola SA, Williams J, Angotti N, Gomez-Olive FX. Soc Sci Med. 2015 Oct;143:204-12. doi: 10.1016/j.socscimed.2015.08.023. Epub 2015 Aug 17.

South Africa has the highest number of people living with HIV in the world (over 6 million) as well as a rapidly aging population, with 15% of the population aged 50 and over. High HIV prevalence in rural former apartheid homeland areas suggests substantial aging with HIV and acquisition of HIV at older ages. We develop a life course approach to HIV vulnerability, highlighting the rise and fall of risk and protection as people age, as well as the role of contextual density in shaping HIV vulnerability. Using this approach, we draw on an innovative multi-method data set collected within the Agincourt Health and Demographic Surveillance System in South Africa, combining survey data with 60 nested life history interviews and 9 community focus group interviews. We examine HIV risk and protective factors among adults aged 40-80, as well as how and why these factors vary among people at older ages.

Abstract access

Editor’s notes: A growing body of work is documenting the importance of HIV in older age in East and southern Africa. This paper is a valuable addition to the literature. The authors look at how the risk of HIV infection, and the impact of living with HIV, affects women and men aged 40-80 years old. Forty is a relatively young age for a study of older people, but the age span covered by this paper does allow the authors to trace HIV vulnerability for people actively engaged in migrant labour to when they settle, as they age into their 60s and 70s. The finding that risk of HIV-infection and vulnerability to the impact of HIV vary across the life course, is not new. But the findings presented in this paper provide a compelling picture of changing risk. Indeed, the possibility that men in their 60s might be at particular risk of acquiring HIV because of their wives diminishing interest in sex highlights the importance of not assuming only people under 50 are ‘sexually active’. The authors also illustrate the risk that older women face who may prefer to remain celibate but cannot always refuse to have sexual intercourse with their husbands. One notable finding is that older men with a pension are attractive partners for younger women in what the authors describe as a poverty stricken area. The mixture of quantitative and qualitative data the authors use provide both breadth and depth to the findings presented making this both an interesting and informative paper.

Africa
South Africa
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Childhood sexual violence and HIV risk in Tanzania

HIV and childhood sexual violence: implications for sexual risk behaviors and HIV testing in Tanzania.

Chiang LF, Chen J, Gladden MR, Mercy JA, Kwesigabo G, Mrisho F, Dahlberg LL, Nyunt MZ, Brookmeyer KA, Vagi K. AIDS Educ Prev. 2015 Oct;27(5):474-87. doi: 10.1521/aeap.2015.27.5.474

Prior research has established an association between sexual violence and HIV. Exposure to sexual violence during childhood can profoundly impact brain architecture and stress regulatory response. As a result, individuals who have experienced such trauma may engage in sexual risk-taking behavior and could benefit from targeted interventions. In 2009, nationally representative data were collected on violence against children in Tanzania from 13-24 year old respondents (n = 3739). Analyses show that females aged 19-24 (n = 579) who experienced childhood sexual violence, were more likely to report no/infrequent condom use in the past 12 months (AOR = 3.0, CI [1.5, 6.1], p = 0.0017) and multiple sex partners in the past 12 months (AOR = 2.3, CI [1.0, 5.1], p = 0.0491), but no more likely to know where to get HIV testing or to have ever been tested. Victims of childhood sexual violence could benefit from targeted interventions to mitigate impacts of violence and prevent HIV.

Abstract access

Editor’s notes: A growing body of evidence has established an association between sexual violence and increased vulnerability to HIV infection. Childhood sexual violence may increase HIV risk both directly (e.g. forced sex) and indirectly (e.g. through high-risk sex behaviours later in life). This paper examined two questions: is childhood violence exposure associated with (i) high-risk sexual behaviour in early adulthood and (ii) increased/decreased knowledge and uptake of HIV testing services.

A nationally representative sample of females aged 19-24 years were surveyed. Women were excluded from the analyses if they were not sexually active. Some 26.1% of 579 women reported childhood sexual violence (answering yes to one of four questions around unwanted touch / attempted rape / unwanted / coercive sexual intercourse before age 18 years). Childhood sexual violence was associated with (i) low / no condom use with someone other than husband / live in partner and (ii) >1 sexual partner, past 12 months. There was no association with knowledge or uptake of HIV testing services. These findings are consistent with research done elsewhere and suggest childhood sexual violence is associated with increased sexual risk taking behaviours in early adulthood. These findings present evidence for the importance of programmes to reduce childhood exposure to violence and focussed, adolescent-friendly sexual health services.

Africa
United Republic of Tanzania
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Testing for acute HIV infection feasible but impact remains uncertain

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

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

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

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

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

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

Abstract access 

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

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

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

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

Africa
Malawi
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More rigorous evidence necessary on role of peers in adolescent sexual behaviour

Is the sexual behaviour of young people in sub-Saharan Africa influenced by their peers? A systematic review.

Fearon E, Wiggins RD, Pettifor AE, Hargreaves JR. Soc Sci Med. 2015 Oct 9;146:62-74. doi: 10.1016/j.socscimed.2015.09.039. [Epub ahead of print]

Adolescents in sub-Saharan Africa are highly vulnerable to HIV, other sexually transmitted infections (STIs) and unintended pregnancies. Evidence for the effectiveness of individual behaviour change interventions in reducing incidence of HIV and other biological outcomes is limited, and the need to address the social conditions in which young people become sexually active is clear. Adolescents' peers are a key aspect of this social environment and could have important influences on sexual behaviour. There has not yet been a systematic review on the topic in sub-Saharan Africa. We searched 4 databases to find studies set in sub-Saharan Africa that included an adjusted analysis of the association between at least one peer exposure and a sexual behaviour outcome among a sample where at least 50% of the study participants were aged between 13 and 20 years. We classified peer exposures using a framework to distinguish different mechanisms by which influence might occur. We found 30 studies and retained 11 that met quality criteria. There were 3 cohort studies, 1 time to event and 7 cross-sectional. The 11 studies investigated 37 different peer exposure-outcome associations. No studies used a biological outcome and all asked about peers in general rather than about specific relationships. Studies were heterogeneous in their use of theoretical frameworks and means of operationalizing peer influence concepts. All studies found evidence for an association between peers and sexual behaviour for at least one peer exposure/outcome/sub-group association. Of all 37 outcome/exposure/sub-group associations tested, there was evidence for 19 (51%). There were no clear patterns by type of peer exposure, outcome or adolescent sub-group. There is a lack of conclusive evidence about the role of peers in adolescent sexual behaviour in sub-Saharan Africa. We argue that longitudinal designs, use of biological outcomes and approaches from social network analysis are priorities for future studies.

Abstract  Full-text [free] access

Editor’s notes: This is the first quantitative systematic review of the role of peers in shaping young people’s sexual behaviour in sub-Saharan Africa. Each of the 11 higher-quality studies included found evidence for at least one association between a peer exposure and a sexual behaviour outcome. But overall, no clear patterns were found for the conditions in which peer exposures might, or might not, impact sexual behaviour. The mixed findings may highlight inherent difficulties with assessing such associations, such as reverse causation in cross-sectional studies (e.g. selection of peers based on established sexual behaviour), and reliance on self-reported sexual behaviour (likely to be a particular problem among adolescents). One interesting aspect of the paper was the classification of peer exposures into one of six types (including peer approval, peer connectedness, and status within peer networks). Given the likely importance of peers in adolescent behaviour, methods that collect information about specific peers and relationships such as social network analysis, rather than asking about peers in general, could help to identify peer effects.

Africa
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Invitation plus tracing increases male partner testing during pregnancy

Recruiting male partners for couple HIV testing and counselling in Malawi's option B+ programme: an unblinded randomised controlled trial.

Rosenberg NE, Mtande TK, Saidi F, Stanley C, Jere E, Paile L, Kumwenda K, Mofolo I, Ng'ambi W, Miller WC, Hoffman I, Hosseinipour M. Lancet HIV. 2015 Nov;2(11):e483-91. doi: 10.1016/S2352-3018(15)00182-4. Epub 2015 Oct 22.

Background: Couples HIV testing and counselling (CHTC) is encouraged but is not widely done in sub-Saharan Africa. We aimed to compare two strategies for recruiting male partners for CHTC in Malawi's option B+ prevention of mother-to-child transmission programme: invitation only versus invitation plus tracing and postulated that invitation plus tracing would be more effective.

Methods: We did an unblinded, randomised, controlled trial assessing uptake of CHTC in the antenatal unit at Bwaila District Hospital, a maternity hospital in Lilongwe, Malawi. Women were eligible if they were pregnant, had just tested HIV-positive and therefore could initiate antiretroviral therapy, had not yet had CHTC, were older than 18 years or 16-17 years and married, reported a male sex partner in Lilongwe, and intended to remain in Lilongwe for at least 1 month. Women were randomly assigned (1:1) to either the invitation only group or the invitation plus tracing group with block randomisation (block size=4). In the invitation only group, women were provided with an invitation for male partners to present to the antenatal clinic. In the invitation plus tracing group, women were provided with the same invitation, and partners were traced if they did not present. When couples presented they were offered pregnancy information and CHTC. Women were asked to attend a follow-up visit 1 month after enrolment to assess social harms and sexual behaviour. The primary outcome was the proportion of couples who presented to the clinic together and received CHTC during the study period and was assessed in all randomly assigned participants. This study is registered with ClinicalTrials.gov, number NCT02139176.

Findings: Between March 4, 2014, and Oct 3, 2014, 200 HIV-positive pregnant women were enrolled and randomly assigned to either the invitation only group (n=100) or the invitation plus tracing group (n=100). 74 couples in the invitation plus tracing group and 52 in the invitation only group presented to the clinic and had CHTC (risk difference 22%, 95% CI 9-35; p=0.001) during the 10 month study period. Of 181 women with follow-up data, two reported union dissolution, one reported emotional distress, and none reported intimate partner violence. One male partner, when traced, was confused about which of his sex partners was enrolled in the study. No other adverse events were reported.

Interpretation: An invitation plus tracing strategy was highly effective at increasing CHTC uptake. Invitation plus tracing with CHTC could have many substantial benefits if brought to scale.

Abstract access

Editor’s notes: A major challenge to the Option B+ prevention of mother-to-child-transmission programme is retaining women in HIV care. Lack of male partner support may be an important barrier to retention. Couples HIV testing and counselling (CHTC) can increase mutual disclosure, enhance behavioural HIV prevention, and ultimately improve maternal, child and male partner health outcomes.  However, uptake of CHTC in antenatal settings remains low throughout most of sub-Saharan Africa. This randomised controlled trial illustrates that combining an invitation for the male partner to present to the antenatal clinic with active tracing of the partner by the study team greatly increased uptake of CHTC. A unique feature of the programme was that the invitation and tracing messages focused on general health during pregnancy, rather than on HIV, which may have improved acceptability. Even in the invitation alone arm, over half of the male partners presented for CHTC. Both strategies found that over half the men who tested were HIV positive, and the majority were unaware of their status. Women in the invitation plus tracing arm had higher retention in the Option B+ programme at one month than individuals in the invitation alone arm, and were more likely to report safer sex behaviour. 

Although provider-based strategies for increasing couples testing are more expensive than patient-based strategies, they may be very cost-effective in settings of high HIV prevalence where few men are aware of their HIV status. Interestingly, most gains in partner uptake from tracing were a result of telephone contact, which is relatively low cost. Longer term follow-up is necessary to assess whether increases in retention are maintained over time but the results demonstrate the potential for provider-based strategies for increasing CHTC to help achieve UNAIDS 90-90-90 targets.

Africa
Malawi
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