Articles tagged as "India"

Accelerating initiation of antiretroviral therapy in India in the era of free roll-out

Impact of generic antiretroviral therapy (ART) and free ART programs on time to initiation of ART at a tertiary HIV care center in Chennai, India.

Solomon SS, Lucas GM, Kumarasamy N, Yepthomi T, Balakrishnan P, Ganesh AK, Anand S, Moore RD, Solomon S, Mehta SH. AIDS Care. 2013 Aug;25(8):931-6. doi:10.1080/09540121.2012.748160. Epub 2012 Dec 7.

Antiretroviral therapy (ART) access in the developing world has improved, but whether increased access has translated to more rapid treatment initiation among those who need it is unknown. We characterize time to ART initiation across three eras of ART availability in Chennai, India (1996-1999: pregeneric; 2000-2003: generic; 2004-2007: free rollout). Between 1996 and 2007, 11 171 patients registered for care at the YR Gaitonde Centre for AIDS Research and Education (YRGCARE), a tertiary HIV referral center in southern India. Of these, 5 726 patients became eligible for ART during this period as per Indian guidelines for initiation of ART. Generalized gamma survival models were used to estimate relative times (RT) to ART initiation by calendar periods of eligibility. Time to initiation of ART among patients in Chennai, India was also compared to an HIV clinical cohort in Baltimore, USA. Median age of the YRGCARE patients was 34 years; 77% were male. The median CD4 at presentation was 140 cells/µl. After adjustment for demographics, CD4 and WHO stage, persons in the pregeneric era took 3.25 times longer (95% confidence interval [CI]: 2.53-4.17) to initiate ART versus the generic era and persons in the free rollout era initiated ART more rapidly than the generic era (RT: 0.73; 95% CI: 0.63-0.83). Adjusting for differences across centers, patients at YRGCARE took longer than patients in the Johns Hopkins Clinical Cohort (JHCC) to initiate ART in the pregeneric era (RT: 4.90; 95% CI: 3.37-7.13) but in the free rollout era, YRGCARE patients took only about a quarter of the time (RT: 0.31; 95% CI: 0.22-0.44). These data demonstrate the benefits of generic ART and government rollouts on time to initiation of ART in one developing country setting and suggests that access to ART may be comparable to developed country settings.

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Editor’s notes: This study documents changes in the time from HIV diagnosis until initiation of ART over three defined calendar periods, for ART eligible patients attending a single treatment centre in Chennai, India. Over three periods of time between1996 and 2007 which were characterized by (i) treatment with pre-generics (ii) treatment with generics (iii) free roll-out of ART, there were sequential very substantial reductions in time to treatment, to the extent that in the latter period, the time to treatment was shorter than treatment in a clinical cohort in Baltimore, USA, in adjusted analyses.

Asia
India
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Some evidence of impact from external funding for HIV, TB and malaria - and the need for more

Impact of external funding for HIV, tuberculosis and malaria: systematic review.

de Jongh TE, Harnmeijer JH, Atun R, Korenromp EL, Zhao J, Puvimanasinghe J, Baltussen R. Health Health Policy Plan. 2013 Aug 5. [Epub ahead of print]

Background:  Since 2002, development assistance for health has substantially increased, especially investments for HIV, tuberculosis (TB) and malaria control. We undertook a systematic review to assess and synthesize the existing evidence in the scientific literature on the health impacts of these investments.

Methods and Findings:  We systematically searched databases for peer-reviewed and grey literature, using tailored search strategies. We screened studies for study design and relevance, using predefined inclusion criteria, and selected those that enabled us to link health outcomes or impact to increased external funding. For all included studies, we recorded dataset and study characteristics, health outcomes and impacts. We analysed the data using a causal-chain framework to develop a narrative summary of the published evidence. Thirteen articles, representing 11 individual studies set in Africa and Asia reporting impacts on HIV, tuberculosis and malaria, met the inclusion criteria. Only two of these studies documented the entire causal-chain spanning from funding to programme scale-up, to outputs, outcomes and impacts. Nonetheless, overall we find a positive correlation between consecutive steps in the causal chain, suggesting that external funds for HIV, tuberculosis and malaria programmes contributed to improved health outcomes and impact.

Conclusions:  Despite the large number of supported programmes worldwide and despite an abundance of published studies on HIV, TB and malaria control, we identified very few eligible studies that adequately demonstrated the full process by which external funding has been translated to health impact. Most of these studies did not move beyond demonstrating statistical association, as opposed to contribution or causation. We thus recommend that funding organizations and researchers increase the emphasis on ensuring data capture along the causal pathway to demonstrate effect and contribution of external financing. The findings of these comprehensive and rigorously conducted impact evaluations should also be made publicly accessible.

Keywords: Africa, Asia, Health financing, developing countries, donors, health outcomes, impact

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Editor’s notes: In the current context of resource constraints and after a decade of unprecedented increases in development assistance for health (particularly for HIV, tuberculosis and malaria), donors are increasingly concerned about the value for money of their investments. This study reviewed available evidence on the impact of external funding, finding a paucity of rigorous scientific evaluation data on the efficiency, effectiveness and impact.

The identified HIV studies found associations between programme investments and increased access and adherence to ART, as well as reduced HIV-related mortality, but limited evidence of preventive impacts on rates of HIV infection. There were many study limitations, including the lack of randomization or robust controls, and relatively small (or statistically insignificant) observed effects. Few studies provided a full analysis of effectiveness along the causal chain from inputs to impact, and none considered the potential undesirable effects of external funding.

Although the aims of the study were ambitious, this paper highlights the challenges of documenting the impacts of financial investments, with the authors arguing that future evaluations need to adopt a more systemic approach to impact evaluation that better captures the causal pathway between investment inputs and impacts, as well as broader system-wide effects. 

Africa, Asia
Cameroon, China, India, Kenya, Malawi, Zambia
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Encouraging results of community empowerment interventions among female sex workers

Community empowerment among female sex workers is an effective HIV prevention intervention: a systematic review of the peer-reviewed evidence from low- and middle-income countries.

Kerrigan DL, Fonner VA, Stromdahl S, Kennedy CE., AIDS Behav. 2013 Jul;17(6):1926-40. doi: 10.1007/s10461-013-0458-4.

We conducted a systematic review and meta-analysis of community empowerment interventions for HIV prevention among sex workers in low- and middle-income countries from 1990-2010. Two coders abstracted data using standardized forms. Of 6 664 citations screened, ten studies met inclusion criteria. For HIV infection, two observational studies showed a significantly protective combined effect [odds ratio (OR): 0.84, 95 % confidence interval (CI): 0.709-0.988]. For STI infection, one longitudinal study showed reduced gonorrhoea/chlamydia (OR: 0.51, 95 % CI: 0.26-0.99). Observational studies showed reduced gonorrhoea (OR: 0.65, 95 % CI: 0.47-0.90), but non-significant effects on chlamydia and syphilis. For condom use, one randomized controlled trial showed improvements with clients (ß: 0.3447, p = 0.002). One longitudinal study showed improvements with regular clients (OR: 1.9, 95 % CI: 1.1-3.3), but no change with new clients. Observational studies showed improvements with new clients (OR: 3.04, 95 % CI: 1.29-7.17), regular clients (OR: 2.20, 95 % CI: 1.41-3.42), and all clients (OR: 5.87, 95 % CI: 2.88-11.94), but not regular non-paying partners. Overall, community empowerment-based HIV prevention was associated with significant improvements across HIV outcomes and settings.

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Editor’s notes: In contrast to individual behaviour change interventions, community empowerment is a structural intervention which seeks to address and alter social, political and material conditions surrounding sex work in a given setting.  This is the first systematic review to evaluate the impact of community empowerment as an HIV prevention strategy among sex worker in low- and middle-income countries. This systematic review was conducted as part of a larger World Health Organization (WHO) effort to develop technical guidelines for HIV/STI prevention among sex workers. The results were encouraging, with positive effects of empowerment interventions on outcomes including HIV/STI infection and consistent condom use with clients (but not with regular partners, with whom condom use is generally low).  Encouragingly, all of the studies involved included not only the community empowerment intervention elements as described above, but also core HIV prevention elements: HIV/STI peer education, some form of condom distribution (free or via social marketing), and STI screening, treatment and management. Of the 10 included studies, seven were from India, two from Brazil and one from the Dominican Republic.  The lack of such studies in southeast Asia, or Africa, is striking, and a rigorous evaluation of community empowerment among sex workers in sub-Saharan Africa is warranted.

Asia, Latin America
Brazil, Dominican Republic, India
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Pharmacy records associated with virological outcomes on ART in India

Pharmacy and self-report adherence measures to predict virological outcomes for patients on free antiretroviral therapy in Tamil Nadu, India.

McMahon JH, Manoharan A, Wanke CA, Mammen S, Jose H, Malini T, Kadavanu T, Jordan MR, Elliott JH, Lewin SR, Mathai D., AIDS Behav. 2013 Jul;17(6):2253-9. doi: 10.1007/s10461-013-0436-x

Over 480,000 individuals receive free antiretroviral therapy (ART) in India yet data associating ART adherence with HIV viral load for populations exclusively receiving free ART are not available. Additionally estimates of adherence using pharmacy data on ART pick-up are not available for any population in India. After 12-months ART we found self-reported estimates of adherence were not associated with HIV viral load. Individuals with 100% adherence using pharmacy data predicted HIV viral load, and estimates combining pharmacy data and self-report were also predictive. Pharmacy adherence measures proved a feasible method to estimate adherence in India and appear more predictive of virological outcomes than self-report. Predictive adherence measures identified in this study warrant further investigation in populations receiving free ART in India to allow for identification of individuals at risk of virological failure and in need of adherence support.

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Editor’s notes: India has the third largest burden of HIV in the world and has rapidly scaled up access to antiretroviral therapy through the public health system since 2004. There is a paucity of data on programmatic outcomes from India. This study set out to determine to what extent routine adherence data (based on self-report and pharmacy measures) were associated with virological outcomes at 12 months after ART initiation among 230 adults, predominantly men, in a single urban public sector clinic in Tamil Nadu. There was no evidence that the self-report measures were associated with viral suppression but the likelihood of viral suppression at 12 months was higher if the medication possession ratio (MPR) was 100% or greater [the MPR is a measure comparing the number of days supply of ART dispensed to the number of days since ART start]. Pharmacy measures such as MPR may help identify individuals with poor adherence. Improved access to viral load monitoring remains an important goal for programmes in low- and middle-income countries. 

Asia
India
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Better virological outcomes with efavirenz compared to nevirapine

Outcomes for efavirenz versus nevirapine-containing regimens for treatment of HIV-1 infection: a systematic review and meta-analysis.

Pillay P, Ford N, Shubber Z, Ferrand RA., PLoS One. 2013 Jul 22;8(7):e68995. doi: 10.1371/journal.pone.0068995. Print 2013

Introduction: There is conflicting evidence and practice regarding the use of the non-nucleoside reverse transcriptase inhibitors (NNRTI) efavirenz (EFV) and nevirapine (NVP) in first-line antiretroviral therapy (ART).

Methods: We systematically reviewed virological outcomes in HIV-1 infected, treatment-naive patients on regimens containing EFV versus NVP from randomised trials and observational cohort studies. Data sources include PubMed, Embase, the Cochrane Central Register of Controlled Trials and conference proceedings of the International AIDS Society, Conference on Retroviruses and Opportunistic Infections, between 1996 to May 2013. Relative risks (RR) and 95% confidence intervals were synthesized using random-effects meta-analysis. Heterogeneity was assessed using the I(2) statistic, and subgroup analyses performed to assess the potential influence of study design, duration of follow up, location, and tuberculosis treatment. Sensitivity analyses explored the potential influence of different dosages of NVP and different viral load thresholds.

Results: Of 5011 citations retrieved, 38 reports of studies comprising 114 391 patients were included for review. EFV was significantly less likely than NVP to lead to virologic failure in both trials (RR 0.85 [0.73-0.99] I(2) = 0%) and observational studies (RR 0.65 [0.59-0.71] I(2) = 54%). EFV was more likely to achieve virologic success than NVP, though marginally significant, in both randomised controlled trials (RR 1.04 [1.00-1.08] I(2) = 0%) and observational studies (RR 1.06 [1.00-1.12] I(2) = 68%).

Conclusion: EFV-based first line ART is significantly less likely to lead to virologic failure compared to NVP-based ART. This finding supports the use of EFV as the preferred NNRTI in first-line treatment regimen for HIV treatment, particularly in resource limited settings.

Abstract  Full-text [free] access

Editor’s notes: Efavirenz and nevirapine are key antiretroviral agents, particularly in resource-limited settings. Nevirapine has been widely used, for reasons including safety during pregnancy and lower cost, despite lower potency and a higher risk of hepatotoxicity and severe allergic reactions, than with efavirenz. This article summarizes data on virological outcomes from clinical trials and observational cohort studies comparing efavirenz and nevirapine. The finding that efavirenz is associated with slightly better virological outcomes is not surprising but it is valuable to have the available data summarised. The result, along with recent recommendations allowing efavirenz to be taken throughout pregnancy, and price reductions, supports the move towards efavirenz-based fixed drug combinations as first-line antiretroviral treatment in resource-limited settings.

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Interventions among sex workers associated with reduced risk of syphilis, but not HIV, in pregnant women in India

Female sex work interventions and changes in HIV and syphilis infection risks from 2003 to 2008 in India: a repeated cross-sectional study

Arora P, Nagelkerke NJD, Moineddin R, Bhattacharya M, Jha P, BMJ Open. 2013 Jun 20;3(6). doi:pii: e002724. 10.1136/bmjopen-2013-002724. Print 2013. 

Objectives: We examined if increased spending and coverage of female sex worker (FSW) interventions were associated with declines in HIV or syphilis risk among young pregnant women (as a proxy for new infections in the general population) in the high-burden southern states of India.

Design: Repeated cross-sectional analysis.

Setting: We used logistic regression to relate district-level spending, number of sexually transmitted infections (STIs) treated, FSWs reached or condoms distributed to the declines in the annual risk of HIV and syphilis from 2003 to 2008 among prenatal clinic attendees in the four high-HIV burden states of Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu.

Participants: 386 961 pregnant women aged 15-24 years (as a proxy for incident infections in the adult population).

Interventions: We examined National AIDS Control Organisation (NACO) data on 868 FSW intervention projects implemented between 1995 and 2008.

Primary and secondary outcome measures: HIV or syphilis infection.

Results: HIV and syphilis prevalence declined substantially among young pregnant women. Each additional STI treated (per 1000 people) reduced the annual risk of HIV infection by -1.7% (95% CI -3.3 to -0.1) and reduced the annual risk of syphilis infection by -10.9% (95%CI -15.9 to -5.8). Spending, FSWs reached or condoms distributed did not reduce HIV risk, but each was significantly associated with reduced annual risk of syphilis infection. There were no major differences between the NACO-funded and Avahan-funded districts in the annual risk of either STI.

Conclusions: Targeted FSW interventions are associated with reductions in syphilis risk and STI treatment is associated with reduced HIV risk. Both more and less costly FSW interventions have comparable effectiveness.

Keywords: Infectious Diseases, Public Health

Abstract   Full-text [free] access 

Editor’s notes: This study utilizes data from the large-scale interventions targeted at female sex workers (FSW) in southern India by the Indian Government’s National AIDS Control Organisation (NACO) (1995-2008), and the Gates Foundation Avahan programme (2004 onwards). The authors link FSW intervention spending and coverage to unlinked anonymous HIV and syphilis status in almost 400,000 antenatal clinic attendees aged 15-24 years from 2003-2008.  During this period, there were significant decreases in both HIV and syphilis risk. The decline in risk of both syphilis and HIV was inversely correlated with rate of STI treatment.  In addition, the decline in syphilis risk was significantly associated with the intervention coverage and spending. The strong association with STI treatment underscores the need to maintain a focus on STD treatment to reduce risk of HIV transmission, especially in settings where core epidemiological groups, such as FSW, have high prevalence of STD, in order to interrupt STI transmission from FSW to their male clients, and onwards to the general female population.

Asia
India
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Systematic review of supervised and unsupervised self-testing for HIV

Supervised and Unsupervised Self-Testing for HIV in High- and Low-Risk Populations: A Systematic Review.

Pant Pai N, Sharma J, Shivkumar S, Pillay S, Vadnais C, Joseph L, Dheda K, Peeling RW. PLoS Med. 2013 Apr;10(4):e1001414.doi: 10.1371/journal.pmed.1001414. Epub 2013 Apr 2.

Background: Stigma, discrimination, lack of privacy, and long waiting times partly explain why six out of ten individuals living with HIV do not access facility-based testing. By circumventing these barriers, self-testing offers potential for more people to know their sero-status. Recent approval of an in-home HIV self test in the US has sparked self-testing initiatives, yet data on acceptability, feasibility, and linkages to care are limited. We systematically reviewed evidence on supervised (self-testing and counselling aided by a health care professional) and unsupervised (performed by self-tester with access to phone/internet counselling) self-testing strategies.

Methods and Findings: Seven databases (Medline [via PubMed], Biosis, PsycINFO, Cinahl, African Medicus, LILACS, and EMBASE) and conference abstracts of six major HIV/sexually transmitted infections conferences were searched from 1st January 2000-30th October 2012. 1,221 citations were identified and 21 studies included for review. Seven studies evaluated an unsupervised strategy and 14 evaluated a supervised strategy. For both strategies, data on acceptability (range: 74%-96%), preference (range: 61%-91%), and partner self-testing (range: 80%-97%) were high. A high specificity (range: 99.8%-100%) was observed for both strategies, while a lower sensitivity was reported in the unsupervised (range: 92.9%-100%; one study) versus supervised (range: 97.4%-97.9%; three studies) strategy. Regarding feasibility of linkage to counselling and care, 96% (n = 102/106) of individuals testing positive for HIV stated they would seek post-test counselling (unsupervised strategy, one study). No extreme adverse events were noted. The majority of data (n = 11,019/12,402 individuals, 89%) were from high-income settings and 71% (n = 15/21) of studies were cross-sectional in design, thus limiting our analysis.

Conclusions: Both supervised and unsupervised testing strategies were highly acceptable, preferred, and more likely to result in partner self-testing. However, no studies evaluated post-test linkage with counselling and treatment outcomes and reporting quality was poor. Thus, controlled trials of high quality from diverse settings are warranted to confirm and extend these findings.

Abstract  Full text [free] access

Editor’s notes: The HIV self-testing agenda is gaining prominence due to a number of changing issues: the US FDA approved an oral point-of-care HIV self-test (OraQuick) for over-the-counter sale last year; international policy no longer emphasises individualised, in-depth pre-test counselling; ART is increasingly available worldwide; and the goal of universal access to treatment (Millennium Development Goal 6). These issues have reduced many of the posited barriers to self-testing, but some remain, for example, the possible psychological trauma of a positive result without immediate post-test counselling and greater difficulties in ensuring linkage to appropriate care and treatment. In general, self-testing had high acceptability and accuracy. Only one study looked at intentions to link to care, with no studies reporting actual data on linkage to care. The preferred mode and medium of counselling varied between and within study populations, suggesting a need to tailor strategies. The current lack of high quality studies on self-testing suggests an urgent need for more research on this additional route for maximising HIV testing coverage.

Africa, Asia, Europe, Northern America
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Review of research and policy priorities for self-testing for HIV

A Review of Self-Testing for HIV: Research and Policy Priorities in a New Era of HIV Prevention.

Napierala Mavedzenge S, Baggaley R, Corbett EL. Clin Infect Dis. 2013 Apr 16. [Epub ahead of print]

Inadequate uptake of testing for human immunodeficiency virus (HIV) remains a primary bottleneck toward universal access to treatment and care, and is an obstacle to realizing the potential of new interventions for preventing HIV infection, including treatment for prevention and preexposure prophylaxis. HIV self-testing offers an approach to scaling up testing that could be high impact, low cost, confidential, and empowering for users. Although HIV self-testing was first considered >20 years ago, it has not been widely implemented. We conducted a review of policy and research on HIV self-testing, which indicates that policy is shifting toward a more flexible approach with less emphasis on pretest counseling and that HIV self-testing has been adopted in a number of settings. Empirical research on self-testing is limited, resulting in a lack of an evidence base upon which to base policy recommendations. Relevant research and investment in programs are urgently needed to enable consideration of developing formalized self-testing programs.

Abstract  Full text [free] access

Editor’s notes: This second review of HIV self-testing this month adds to the review by Pant Pai et al. in several ways, including by: highlighting other articles not included in the previous review; including a very helpful summary of current gaps in research on self-testing; and providing details of the Kenyan guidelines on self-testing (Kenya is the first African country to develop guidance on over-the-counter HIV self-testing kits for the general population). Some of the key research gaps highlighted include: the effect of self-testing provision on uptake of HIV testing including repeat testing; levels of harm caused e.g. due to lack of immediate post-test counselling, coercive testing, etc.; how to maximise linkage to care; how to best provide for couples testing; the most appropriate use of social marketing; and how to best utilise mHealth. These two reviews are worth reading in tandem.

Africa, Asia, Europe, Northern America
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Avahan HIV prevention intervention amongst men who have sex with men in India reaches high coverage but evidence for HIV impact is lacking

An assessment of a large-scale HIV prevention programme for high-risk men who have sex with men and transgenders in Andhra Pradesh, India: using data from routine programme monitoring and repeated cross-sectional surveys

Goswami P, Rachakulla HK, Ramakrishnan L, Mathew S, Ramanathan S, George B, Adhikary R, Kodavalla V, Rajkumar H, Paranjape RS, Brahmam G.  BMJ Open. 2013 Apr 8;3(4). doi:pii: e002183. 10.1136/bmjopen-2012-002183. Print 2013.

Objectives:  To assess a large-scale intervention, the Avahan intervention, using an evaluation framework that included programme coverage, condom use and changes in sexually transmitted infection (STI) and HIV prevalence among high-risk men who have sex with men/transgender (HR-MSM/TG) in the state of Andhra Pradesh, India.

Design: Programme monitoring data and results from two rounds of cross-sectional integrated biological and behavioural assessment (IBBA) in 2006 (Round 1) and 2009 (Round 2) were used for current analysis.

Setting: Programme monitoring data and cross-sectional surveys from Andhra Pradesh, India.

Participants: Data from 1 218 and 1 203 participants in Rounds 1 and 2 of the IBBA, respectively, and field level programme monitoring data from the intervention districts.

Primary and secondary outcomes: (1) Assess the reach of intervention in the HR-MSM/TG population; (2) evaluate the association between intervention and the intermediate outcomes (such as condom use and STIs) and (3) assess the association between HIV/STIs and the intervention.

Results: By July 2008, the intervention contacted 83% of the estimated HR-MSM/TG population monthly and 16% were attending the STI clinic monthly. HR-MSM/TG exposed to the intervention were significantly more likely to use condom consistently with a regular male partner (adjusted OR 4.62, 95% CI 1.40 to 15.22). Consistent condom use with all types of male partners increased significantly in survey Round 2 compared with Round 1. The proportion of HR-MSM/TG who tested positive for HIV-1 antibodies was similar in both rounds (15.5% in Round 1 vs 17.3% in Round 2, p=0.52).

Conclusion: The Avahan intervention achieved a good population coverage, and delivered high-intensity peer and STI clinical services in Andhra Pradesh in the highly mobile target population of HR-MSM/TG; this also resulted in positive behavioural outcomes including increased condom use. However, the high prevalence of HIV in this group is an important public health priority.

Abstract Full text [free] access

Editor’s notes: The Avahan HIV prevention intervention in India is the largest intervention of its type for high risk groups, reaching over 300 000 female sex workers and men who have sex with men (MSM) in southern India. Previous analyses have suggested the intervention has increased condom use and decreased HIV transmission in female sex workers and the general population. This study adds to the existing body of evidence by showing that Avahan successfully scaled up intervention services to high coverage amongst MSM (45 000 MSM reached with 83% reached each month) populations and that this increased condom use (Condom use increased between two rounds of cross sectional surveys and was greater amongst those MSM that had been more in contact with the intervention). However, HIV incidence was not measured and there was no control group, with available evidence suggesting that HIV prevalence did not decrease between survey rounds. This could be due to limitations in follow up or the fact that HIV prevalence would have increased without the intervention. Encouragingly, some STIs did decrease. The analysis illustrates that targeted interventions can be brought to scale amongst MSM but highlights the importance of putting a stronger evaluation design in place to ensure that impact can be estimated with more precision. 

Asia
India
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HIV infection increases mortality among HIV-positive pregnant women

The contribution of HIV to pregnancy-related mortality: a systematic review and meta-analysis.

Calvert C, Ronsmans PC. AIDS. 2013 Feb 25. [Epub ahead of print]

Whilst much is known about the contribution of HIV to adult mortality, remarkably little is known about the mortality attributable to HIV during pregnancy. In this paper the proportion of pregnancy-related deaths attributable to HIV based on empirical data was estimated from a systematic review of the strength of association between HIV and pregnancy-related mortality. Studies comparing mortality during pregnancy and the postpartum in HIV-infected and uninfected women were included. Summary estimates of the relative and attributable risks for the association between HIV and pregnancy-related mortality were calculated through meta-analyses. Varying estimates of HIV prevalence were used to predict the impact of the HIV epidemic on pregnancy-related mortality at the population level. 23 studies were included (17 from sub-Saharan Africa). Meta-analysis of the risk ratios (RR) indicated that HIV-infected women had eight times the risk of a pregnancy-related death compared with HIV-uninfected women (pooled RR: 7.74, 95% CI 5.37-11.16). The excess mortality attributable to HIV among HIV-infected pregnant and postpartum women was 994 per 100,000 pregnant women. We predict that 12% of all deaths during pregnancy and up to one year postpartum are attributable to HIV/AIDS in regions with a prevalence of HIV among pregnant women of 2%. This figure rises to 50% in regions with a prevalence of 15%.  The substantial excess of pregnancy-related mortality associated with HIV highlights the importance of integrating HIV and reproductive health services in areas of high HIV prevalence and pregnancy-related mortality.

Abstract access 

Editor’s notes: Millennium Development Goals include commitments to reduce maternal mortality. While HIV is a leading cause of death among women of reproductive age in sub-Saharan Africa, the contribution of HIV infection to overall maternal mortality is Africa has been less described. This analysis of this study indicates that a significant proportion of maternal deaths is due to HIV. While the contribution of HIV to maternal mortality is high in relatively low prevalence settings, it is remarkably and tragically high in high prevalence countries such as is seen in southern Africa: with an estimated 50% of maternal deaths due to HIV infection when prevalence is 15%. This modeling highlights the ongoing essential need to prevent new HIV infections if the MDGs will be met.

Epidemiology, Gender
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