Articles tagged as "India"

Need for further water, sanitation and hygiene programmes among people living with HIV

The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review.

Yates T, Lantagne D, Mintz E, Quick R. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S318-30. doi: 10.1097/QAI.0000000000000487.

Background: Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

Methods: We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

Results: We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

Conclusions: Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

Abstract access 

Editor’s notes: Researchers, implementers, and policy makers have been examining how to better integrate programmes with overlapping burdens of morbidity and mortality. This paper illustrates how access to clean water and good sanitation practices, or lack thereof, can impact the health of people living with HIV. Water, sanitation, and hygiene (WASH) programmes can improve the negative effects poor water quality and bad sanitation have on people living with HIV. They reduce or even eliminate diarrheal infections, which allow for better absorption of HIV treatment medication that leads to a reduction in viral load and increased CD4 counts. While this systematic review revealed evidence on the reduced burden of morbidity that WASH programmes can confer, little has been done in the way of research linking WASH programmes to mortality in people living with HIV, nor how they may affect adherence or retention in care. Side effects of HIV treatment is a common reason why people stop taking medications, and common side effects are nausea and diarrhoea. It is possible that intestinal issues caused by unsafe drinking water could exacerbate the impact of side effects on people already experiencing them, therefore reducing motivation to continue taking their ARVs. This paper also suggests that synergies in cost sharing and increasing cost effectiveness could be achieved by integrating programmes. However further research is necessary to fully understand the logistical and cost implications.

 

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Re-focusing the response in Niger – a greater need for sex worker programmes?

Reorienting the HIV response in Niger toward sex work interventions: from better evidence to targeted and expanded practice. 

Fraser N, Kerr CC, Harouna Z, Alhousseini Z, Cheikh N, Gray R, Shattock A, Wilson DP, Haacker M, Shubber Z, Masaki E, Karamoko D, Görgens M. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S213-20. doi: 10.1097/QAI.0000000000000456.

Background: Niger's low-burden, sex-work-driven HIV epidemic is situated in a context of high economic and demographic growth. Resource availability of HIV/AIDS has been decreasing recently. In 2007-2012, only 1% of HIV expenditure was for sex work interventions, but an estimated 37% of HIV incidence was directly linked to sex work in 2012. The Government of Niger requested assistance to determine an efficient allocation of its HIV resources and to strengthen HIV programming for sex workers. 

Methods: Optima, an integrated epidemiologic and optimization tool, was applied using local HIV epidemic, demographic, programmatic, expenditure, and cost data. A mathematical optimization algorithm was used to determine the best resource allocation for minimizing HIV incidence and disability-adjusted life years (DALYs) over 10 years. 

Results: Efficient allocation of the available HIV resources, to minimize incidence and DALYs, would increase expenditure for sex work interventions from 1% to 4%-5%, almost double expenditure for antiretroviral treatment and for the prevention of mother-to-child transmission, and reduce expenditure for HIV programs focusing on the general population. Such an investment could prevent an additional 12% of new infections despite a budget of less than half of the 2012 reference year. Most averted infections would arise from increased funding for sex work interventions. 

Conclusions: This allocative efficiency analysis makes the case for increased investment in sex work interventions to minimize future HIV incidence and DALYs. Optimal HIV resource allocation combined with improved program implementation could have even greater HIV impact. Technical assistance is being provided to make the money invested in sex work programs work better and help Niger to achieve a cost-effective and sustainable HIV response.

Abstract access  

Editor’s notes: Niger has a low-level HIV epidemic concentrated in key populations such as female sex workers, with prevalence levels of 17% in 2011. Only around 23% of female sex workers report using a condom at every sexual act, making them a highly vulnerable group. Additionally there are barriers to using the health centres such as service costs, and the geographic distance.

This article summarizes the HIV epidemic and response situation in Niger with a focus on female sex workers, including modelled trends using Optima. It then presents new evidence on different resource allocation scenarios and the projected impact on the HIV epidemic. Optima, a deterministic mathematical model for HIV optimization and prioritization, was applied to local epidemiologic, demographic, programmatic, expenditure, and cost data. 

The optimization function uses an algorithm to find the best allocation of resources to meet the objective of either minimizing HIV incidence or disability-adjusted life years (DALYs) until 2024. Contrary to the current approach of allocating 31% of spending to the general population and less than 1% to female sex workers, the Optima function advocates increased spending on antiretroviral therapy from 27% to 48%. Optima supports a focussed approach to reduce HIV incidence in female sex workers including mapping populations and a “programme intelligence” approach akin to that implemented in India and Nigeria.   

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Prevention services need to focus on newly-started sex workers in South India

Changes in HIV and syphilis prevalence among female sex workers from three serial crosssectional surveys in Karnataka state, South India. 

Isac S, Ramesh BM, Rajaram S, Washington R, Bradley JE, Reza-Paul S, Beattie TS, Alary M. BMJ Open. 2015 Mar 27;5(3):e007106. doi: 10.1136/bmjopen-2014-007106.

Objectives: This paper examined trends over time in condom use, and the prevalences of HIV and syphilis, among female sex workers (FSWs) in South India. 

Design: Data from three rounds of cross-sectional surveys were analysed, with HIV and high-titre syphilis prevalence as outcome variables. Multivariable analysis was applied to examine changes in prevalence over time. 

Setting: Five districts in Karnataka state, India. 

Participants: 7015 FSWs were interviewed over three rounds of surveys (round 1=2277; round 2=2387 and round 3=2351). Women who reported selling sex in exchange for money or gifts in the past month, and aged between 18 and 49 years, were included. 

Interventions: The surveys were conducted to monitor a targeted HIV prevention programme during 2004-2012. The main interventions included peer-led community outreach, services for the treatment and prevention of sexually transmitted infections, and empowering FSWs through community mobilisation.  

Results: HIV prevalence declined significantly from rounds 1 to 3, from 19.6% to 10.8%

(adjusted OR (AOR)=0.48, p<0.001); high-titre syphilis prevalence declined from 5.9% to 2.4% (AOR=0.50, p<0.001). Reductions were observed in most substrata of FSWs, although reductions among new sex workers, and those soliciting clients using mobile phones or from home, were not statistically significant. Condom use 'always' with occasional clients increased from 73% to 91% (AOR=1.9, p<0.001), with repeat clients from 52% to 86% (AOR=5.0, p<0.001) and with regular partners from 12% to 30% (AOR=4.2, p<0.001). Increased condom use was associated with exposure to the programme. However, condom use with regular partners remained low. 

Conclusions: The prevalences of HIV infection and high-titre syphilis among FSWs have steadily declined with increased condom use. Further reductions in prevalence will require intensification of prevention efforts for new FSWs and those soliciting clients using mobile phones or from home, as well as increasing condom use in the context of regular partnerships.

Abstract   Full-text [free] access

Editor’s notes: The HIV epidemic in India has remained largely concentrated in key populations, particularly among female sex workers. One of the most high profile HIV prevention efforts in India has been the Avahan AIDS initiative, which in Karnataka State has reached over 60 000 female sex workers since 2004. The initiative involves peer-mediated safer sex communications, intensive management of sexually transmitted infections, and facilitation of safer sex environments. In the final round of a repeat cross-sectional survey conducted between 2004 and 2011, investigators found that nearly all female sex workers were contacted by a peer educator, had seen a condom demonstration, or had visited a programme clinic. In that time, the prevalence of HIV fell from 19.6% to 10.8% (P<0.01) and the prevalence of new syphilis infections fell from 5.9% to 2.4% (P<0.01). However, HIV prevalence among new female sex workers remained high, reflecting the challenges in reaching women starting sex work before they become HIV positive. The programme is notable for its responsiveness to the HIV prevention needs of female sex workers and the current paper confirms continued increases in condom use and preventive services. However, with the changing nature of sex work, current challenges include preventive services for women soliciting sex through mobile phones, and reaching sex workers soon after they start sex work. 

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Out of pocket spending on HIV care in India makes the poor even poorer

Consumption patterns and levels among households with HIV positive members and economic impoverishment due to medical spending in Pune city, India.

Sharma V, Krishnaswamy D, Mulay S. AIDS Care. 2015 Mar 4:1-5. [Epub ahead of print]

HIV infection poses a serious threat to the economy of a household. Out of pocket (OOP) health spending can be prohibitive and can drag households below poverty level. Based on the data collected from a cross-sectional survey of 401 households with HIV+ members in Pune city, India, this paper examines the consumption levels and patterns among households, and comments on the economic impoverishment resulting from OOP medical spending. Analysis reveals that households with HIV positive members spend a major portion of their monthly consumption expenditure on food items. Medical expenditure constitutes a large portion of their total consumption spending. Expenditure on children's education constitutes a minor proportion of total monthly spending. A high proportion of medical expenditure has a bearing on the economic condition of households with HIV positive members. Poverty increases by 20% among the studied HIV households when OOP health spending is adjusted. It increases 18% among male-headed households and 26% among female-headed households. The results reiterate the need of greater support from the government in terms of accessibility and affordability of health care to save households with HIV positive members from economic catastrophe.

Abstract access 

Editor’s notes: This paper describes expenditure patterns for households with one or more people living with HIV. The authors find that medical expenditure within a household with a member living with HIV is relatively high, some 9.6% of total expenditure. Overall, households were economically vulnerable, with health-associated spending often pushing people below the poverty line. This type of research is especially timely in the context of increasing interest in reducing out of pocket expenditure. Further research around the poverty effects of illness is critical to inform policies as universal access to health care becomes a greater international priority.  

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How to reduce attrition among community healthcare workers essential to HIV prevention programmes among female sex-workers

Peer outreach work as economic activity: implications for HIV prevention interventions among female sex workers.

George A, Blankenship KM. PLoS One. 2015 Mar 16;10(3):e0119729. doi: 10.1371/journal.pone.0119729. eCollection 2015.

Female sex workers (FSWs) who work as peer outreach workers in HIV prevention programs are drawn from poor socio-economic groups and consider outreach work, among other things, as an economic activity. Yet, while successful HIV prevention outcomes by such programs are attributed in part to the work of peers who have dense relations with FSW communities, there is scant discussion of the economic implications for FSWs of their work as peers. Using observational data obtained from an HIV prevention intervention for FSWs in south India, we examined the economic benefits and costs to peers of doing outreach work and their implications for sex workers' economic security. We found that peers considered their payment incommensurate with their workload, experienced long delays receiving compensation, and at times had to advance money from their pockets to do their assigned peer outreach work. For the intervention these conditions resulted in peer attrition and difficulties in recruitment of new peer workers. We discuss the implications of these findings for uptake of services, and the possibility of reaching desired HIV outcomes. Inadequate and irregular compensation to peers and inadequate budgetary outlays to perform their community-based outreach work could weaken peers' relationships with FSW community members, undermine the effectiveness of peer-mediated HIV prevention programs and invalidate arguments for the use of peers.

Abstract   Full-text [free] access

Editor’s notes: Many HIV prevention programmes among female sex worker populations recruit female sex workers to act as community health workers. Community health workers act as a bridge between health services and the community, tailoring activities to the local context and encouraging community ownership of programmes. Evidence suggests that female sex workers acting as community health workers can be critical to maximising benefit from HIV prevention programmes. They also provide a network for social and legal advocacy among female sex workers. Yet despite their importance to programmes, attrition among community health workers is often high and little research has been done to investigate why this might be. This paper gathers data from India and finds that an HIV prevention programme paid community health workers much less than they could have earned through sex-work, while the large workload meant they spent far more time on outreach activities than they were paid for. This encouraged attrition of the community health worker workforce, which could have substantially reduced the impact of the HIV prevention programme. The authors suggest that the importance of community health workers to programmes should be reflected by providing sufficient payment for outreach work. Although this study was carried out among a female sex worker population, these findings are relevant anywhere community health workers are used to deliver programmes elsewhere. Furthermore, other research has suggested that an important motivation for community health workers to take on work is to reduce their economic vulnerability. If programmes pay community health workers too little, or unreliably, they can actually increase the economic vulnerability of the very people they are seeking to protect.

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Boosted protease inhibitor monotherapy as second-line ART: a strategy for resource-limited settings?

Lopinavir/ritonavir monotherapy as second-line antiretroviral treatment in resource-limited settings - week 104 analysis of ACTG A5230.

Kumarasamy N, Aga E, Ribaudo HJ, Wallis CL, Katzenstein DA, Stevens WS, Norton MR, Klingman KL, Hosseinipour MC, Crump JA, Supparatpinyo K, Badal-Faesen S, Bartlett JA. Clin Infect Dis. 2015 Feb 18. pii: civ109. [Epub ahead of print]

Objective: ACTG A5230 evaluated lopinavir/ritonavir (LPV/r) monotherapy following virologic failure on first-line regimens in Africa and Asia.

Methods: Eligible subjects had received first-line regimens for at least 6 months and had plasma HIV-1 RNA levels 1000-200 000copies/mL. All subjects received LPV/r 400/100mg twice daily. Virologic failure (VF) was defined as failure to suppress to <400 copies/mL by week 24, or confirmed rebound to >400 copies/mL at or after week 16 following confirmed suppression. Subjects with VF added emtricitabine 200mg/tenofovir 300mg (FTC/TDF) once daily. The probability of continued HIV-1 RNA <400 copies/mL on LPV/r-monotherapy through week 104 was estimated with a 95% confidence interval (CI); predictors of treatment success were evaluated with Cox proportional hazards models.

Results: 123 subjects were enrolled. Four subjects died and 2 discontinued prematurely; 117 /123 (95%) completed 104 weeks. Through week 104, 49 subjects met the primary endpoint; 47 had VF, and 2 intensified treatment without VF. Of the 47 subjects with VF, 41 (33%) intensified treatment, and 39/41 subsequently achieved levels <400 copies/mL. The probability of continued suppression <400copies/mL over 104 weeks on LPV/r-monotherapy was 60% [95% CI 50%, 68%]; 80-85% maintained levels <400 copies/mL with FTC/TDF intensification as needed. Ultrasensitive assays on specimens with HIV-1 RNA level<400 copies/mL at weeks 24, 48 and 104 revealed that 61%, 62% and 65% were suppressed to <40 copies/mL, respectively.

Conclusion: LPV/r monotherapy after first-line virologic failure with FTC/TDF intensification when needed provides durable suppression of HIV-1 RNA over 104 weeks.

Abstract access 

Editor’s notes: First-line antiretroviral therapy failure is increasingly encountered in resource-limited settings. However limited access to viral load monitoring means that treatment failure is often not recognised until immunological or clinical failure occurs. Late switching can lead to the accumulation of resistance mutations. Resistance to nucleoside reverse transcriptase inhibitors (NRTI) is of particular concern as this class remains a component of second-line, boosted protease inhibitor (bPI)-based regimens. Several studies have now looked at boosted protease inhibitor monotherapy as an alternative strategy. A strategy which aims to limit the toxicity and additional cost associated with NRTIs. In general boosted protease inhibitor monotherapy has been found to have inferior virologic outcomes when compared to bPI plus two NRTIs or bPI plus raltegravir.

In this study, while short term virologic outcomes were favourable (87% probability of continued virologic suppression over 24 weeks); longer term outcomes with bPI monotherapy were less good. However, with frequent viral load monitoring, 4-12 weekly, early detection of virologic failure and intensification with two NRTIs, outcomes in the bPI monotherapy arm improved substantially. This strategy warrants further investigation. But without markedly increasing access to viral load monitoring and lowering the cost to allow frequent testing, it is difficult to see how this strategy could be implemented in practice in resource-constrained settings. 

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Don’t ask, don’t tell: concealment as a stigma management strategy in India

'I am doing fine only because I have not told anyone': the necessity of concealment in the lives of people living with HIV in India.

George MS, Lambert H. Cult Health Sex. 2015 Feb 23:1-14. [Epub ahead of print]

In HIV prevention and care programmes, disclosure of status by HIV-positive individuals is generally encouraged to contain the infection and provide adequate support to the person concerned. Lack of disclosure is generally framed as a barrier to preventive behaviours and accessing support. The assumption that disclosure is beneficial is also reflected in studies that aim to identify determinants of disclosure and recommend individual-level measures to promote disclosure. However, in contexts where HIV infection is stigmatised and there is fear of rejection and discrimination among those living with HIV, concealment of status becomes a way to try and regain as much as possible the life that was disrupted by the discovery of HIV infection. In this study of HIV-positive women and children in India, concealment was considered essential by individuals and families of those living with HIV to re-establish and maintain their normal lives in an environment where stigma and discrimination were prevalent. This paper describes why women and care givers of children felt the need to conceal HIV status, the various ways in which people tried to do so and the implications for treatment of people living with HIV. We found that while women were generally willing to disclose their status to their husband or partner, they were very keen to conceal their status from all others, including family members. Parents and carers with an HIV-positive child were not willing to disclose this status to the child or to others. Understanding the different rationales for concealment would help policy makers and programme managers to develop more appropriate care management strategies and train care providers to assist clients in accessing care and support without disrupting their lives.

Abstract access 

Editor’s notes: This paper provides a powerful illustration of the persistence of stigma in the lives of many people living with HIV in India. Using data collected in 2012, the authors illustrate how prejudice and discrimination shape the lives of the women and children included in this study. While access to antiretroviral therapy (ART) provided a way for participants to regain and maintain what is described as ‘normal life’, that same treatment could result in unintended disclosure. Participants spoke of the fear of being seen carrying ART, since illustrations of the pills were widely available at clinics. They described the challenges of disclosing to their children as well as other relatives. Disclosure to wider social networks posed a reputational threat because of the association of HIV with moral laxity. All these are challenges that many people face in other settings too, providing further evidence of the persistence of HIV-associated stigma. The authors also illustrate the unintended consequences of well-meaning policies. One striking illustration came from a participant who was using a free travel pass, available to people living with HIV to collect their treatment. The pass included the word ‘AIDS’ and a ticket collector ridiculed the woman and her husband in front of other passengers because of this evidence of infection. The authors make the point that encouraging disclosure may overlook the importance of concealment as a way to cope with stigma. 

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Late antiretroviral therapy start persists for children under two years of age in low- and middle-income countries

Immunodeficiency in children starting antiretroviral therapy in low-, middle-, and high-income countries.

Koller M, Patel K, Chi BH, Wools-Kaloustian K, Dicko F, Chokephaibulkit K, Chimbetete C, Avila D, Hazra R, Ayaya S, Leroy V, Truong HK, Egger M, Davies MA, IeDEA, NISDI, PHACS and IMPAACT 219C studies.  J Acquir Immune Defic Syndr. 2015 Jan 1;68(1):62-72. doi: 10.1097/QAI.0000000000000380.

Background: The CD4 cell count or percent (CD4%) at the start of combination antiretroviral therapy (cART) is an important prognostic factor in children starting therapy and an important indicator of program performance. We describe trends and determinants of CD4 measures at cART initiation in children from low-, middle-, and high-income countries.

Methods: We included children aged <16 years from clinics participating in a collaborative study spanning sub-Saharan Africa, Asia, Latin America, and the United States. Missing CD4 values at cART start were estimated through multiple imputation. Severe immunodeficiency was defined according to World Health Organization criteria. Analyses used generalized additive mixed models adjusted for age, country, and calendar year.

Results: A total of 34 706 children from 9 low-income, 6 lower middle-income, 4 upper middle-income countries, and 1 high-income country (United States) were included; 20 624 children (59%) had severe immunodeficiency. In low-income countries, the estimated prevalence of children starting cART with severe immunodeficiency declined from 76% in 2004 to 63% in 2010. Corresponding figures for lower middle-income countries were from 77% to 66% and for upper middle-income countries from 75% to 58%. In the United States, the percentage decreased from 42% to 19% during the period 1996 to 2006. In low- and middle-income countries, infants and children aged 12-15 years had the highest prevalence of severe immunodeficiency at cART initiation.

Conclusions: Despite progress in most low- and middle-income countries, many children continue to start cART with severe immunodeficiency. Early diagnosis and treatment of HIV-infected children to prevent morbidity and mortality associated with immunodeficiency must remain a global public health priority.

Abstract access 

Editor’s notes: This article describes trends and determinants of CD4 cell measures at antiretroviral therapy (ART) initiation in about 35 000 children in low, middle, and high-income countries. Temporal trends in CD4 measures at ART initiation are a useful indicator of the health system’s ability to identify and treat eligible children in a timely fashion. They are also a useful measure of responsiveness to guideline changes.

Previous WHO guidelines recommended early ART initiation, regardless of immunologic or clinical thresholds. But the authors found that in 2010, approximately two-thirds of children below two years of age, in low- and middle-income countries were still starting ART with severe immunodeficiency.

Delayed country-level implementation of WHO guidelines, poor access to early infant diagnosis, slow turn-around time of test results, and limited ART availability for infants and young children are all contributing factors to this delayed ART initiation. The authors point out that timely diagnosis of paediatric HIV does not necessarily result in timely ART. The main reasons for this diagnosis to treatment gap include HIV diagnostic tests and paediatric ART being located at separate sites without robust referral mechanisms between services. There are challenges with CD4 measurement to determine eligibility. These include access to tests, turn-around time and interpretation of results and health care worker discomfort with treating children.

Currently, only 22% of children living with HIV in sub-Saharan Africa are receiving ART. To decrease the treatment gap among children, WHO 2013 guidelines recommend universal ART for all children living with HIV, aged below five years of age, irrespective of CD4 count or clinical stage. Removing the requirement for a CD4 measurement also removes the time lag while waiting for CD4 results. Thus the guidelines aim both to increase treatment accessibility and to accelerate treatment initiation for all children. 

HIV Treatment
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Sexual health of the partners of people who inject drugs

'Women at risk': the health and social vulnerabilities of the regular female partners of men who inject drugs in Delhi, India.

Sharma V, Sarna A, Luchters S, Sebastian M, Degomme O, Saraswati LR, Madan I, Thior I, Tun W. Cult Health Sex. 2014 Dec 2:1-15. [Epub ahead of print]

Needle and syringe sharing is common among people who inject drugs and so is unprotected sex, which consequently puts their sex partners at risk of sexually transmitted infections (STIs) including HIV and other blood-borne infections, like hepatitis. We undertook a nested study with the regular female partners of men who inject drugs participating in a longitudinal HIV incidence study in Delhi, India. In-depth interviews were conducted with female partners of 32 men. The interviews aimed to gather focused and contextual knowledge of determinants of safe sex and reproductive health needs of these women. Information obtained through interviews was triangulated and linked to the baseline behavioural data of their partner (index men who injected drugs). The study findings illustrate that women in monogamous relationships have a low perception of STI- and HIV-related risk. Additionally, lack of awareness about hepatitis B and C is a cause of concern. Findings also suggest impact of male drug use on the fertility of the female partner. It is critical to empower regular female partners to build their self-risk assessment skills and self-efficacy to negotiate condom use. Future work must explore the role of drug abuse among men who inject drugs in predicting fertility and reproductive morbidity among their female partners.

Abstract access 

Editor’s notes: This is an interesting study describing the HIV and sexual health needs of female partners of people who inject drugs (PWID). The study’s strengths lie in the innovative way in which female partners of PWID were reached and recruited into the study. Female partners of PWID are a highly hidden group and there has been little research conducted among them, with research focussing mostly on PWID and their HIV risk. Therefore the approach to identifying female partners through an existing cohort of male PWID is highly innovative and provides new information on a hidden population. Findings have important implications for HIV programmes for this population. These include the need to increase uptake of HIV testing, teach the importance of condoms as a contraceptive method and for HIV prevention, as well as dispelling myths that assumed monogamy is a sufficient prevention tool. The paper clearly illustrates that addressing sexual and reproductive health needs of this population is paramount, including addressing problems with infertility and the need for contraceptives. The paper usefully highlights the impact of a male partner’s drug use on the daily lives of their female partner, including increased poverty and high levels of violence.

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Increasing transmitted resistance to antiretroviral therapy in low/middle-income countries - highest prevalence in MSM

Global burden of transmitted HIV drug resistance and HIV-exposure categories: a systematic review and meta-analysis.

Pham QD, Wilson DP, Law MG, Kelleher AD, Zhang L. AIDS. 2014 Nov 28;28(18):2751-62. doi: 10.1097/QAD.0000000000000494.

Objectives: Our aim was to review the global disparities of transmitted HIV drug resistance (TDR) in antiretroviral-naive MSM, people who inject drugs (PWID) and heterosexual populations in both high-income and low/middle-income countries.

Design/methods: We undertook a systematic review of the peer-reviewed English literature on TDR (1999-2013). Random-effects meta-analyses were performed to pool TDR prevalence and compare the odds of TDR across at-risk groups.

Results: A total of 212 studies were included in this review. Areas with greatest TDR prevalence were North America (MSM: 13.7%, PWID: 9.1%, heterosexuals: 10.5%); followed by western Europe (MSM: 11.0%, PWID: 5.7%, heterosexuals: 6.9%) and South America (MSM: 8.3%, PWID: 13.5%, heterosexuals: 7.5%). Our data indicated disproportionately high TDR burdens in MSM in Oceania (Australia 15.5%), eastern Europe/central Asia (10.2%) and east Asia (7.8%). TDR epidemics have stabilized in high-income countries, with a higher prevalence (range 10.9-12.6%) in MSM than in PWID (5.2-8.3%) and heterosexuals (6.4-9.0%) over 1999-2013. In low/middle-income countries, TDR prevalence in all at-risk groups in 2009-2013 almost doubled than that in 2004-2008 (MSM: 7.8 vs. 4.2%, P = 0.011; heterosexuals: 4.1 vs. 2.6%, P < 0.001; PWID: 4.8 vs. 2.4%, P = 0.265, respectively). The risk of TDR infection was significantly greater in MSM than that in heterosexuals and PWID. We observed increasing trends of resistance to non-nucleoside reverse transcriptase and protease inhibitors among MSM.

Conclusion: TDR prevalence is stabilizing in high-income countries, but increasing in low/middle-income countries. This is likely due to the low, but increasing, coverage of antiretroviral therapy in these settings. Transmission of TDR is most prevalent among MSM worldwide.

Abstract access 

Editor’s notes: HIV mutates very rapidly, and many early antiretroviral agents had a low genetic barrier to the development of resistance. Thus the emergence of virus resistant to antiretroviral agents, particularly to early drug classes, was inevitable. Surveillance for drug-resistant virus among people with no prior history of taking antiretroviral drugs (transmitted drug resistance) is essential to monitor the spread of drug resistance at population level.

This systematic review aimed to compare transmitted drug resistance in different geographical regions and between subpopulations of HIV-positive people by likely route of transmission. Transmitted resistance was most prevalent in high income settings. This is not surprising given wide use of suboptimal drug regimens before effective triple therapy was available. Reassuringly, the prevalence of transmitted resistance seems to have stabilised in high-income settings. The increase in transmitted resistance in low and middle income countries is of more concern. It is not surprising, given that first-line regimens comprising two nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor are vulnerable to the development of resistance if the drug supply is interrupted or adherence is suboptimal. In addition, if viral load monitoring is not available, people remain on failing drug regimens for longer, and thus have more risk of transmitting resistant virus.

Within the subpopulations examined in this review, transmitted resistance was consistently higher in men who have sex with men, suggesting that resistance testing prior to treatment is particularly valuable for this population.

Limitations of the review include exclusion of studies that did not compare transmitted resistance between the specified subpopulations, and small sample size in many subgroups.

Continued surveillance for transmitted drug resistance is critical. This is most important in settings where individualised resistance testing is not available. This will ensure that people starting antiretroviral therapy receive treatment that will suppress their viral load effectively. Wider use of viral load monitoring, combined with access to effective second and third line regimens, will also help limit spread of drug resistance.

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