Articles tagged as "Reduce sexual transmission"

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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Effective, long-term programmes for alcohol and sexual risk reduction are yet to be shown

HIV-alcohol risk reduction interventions in sub-Saharan Africa: a systematic review of the literature and recommendations for a way forward.

Carrasco MA, Esser MB, Sparks A, Kaufman MR. AIDS Behav. 2015 Oct 29. [Epub ahead of print]

Sub-Saharan Africa bears 69% of the global burden of HIV, and strong evidence indicates an association between alcohol consumption, HIV risk behavior, and HIV incidence. However, characteristics of efficacious HIV-alcohol risk reduction interventions are not well known. The purpose of this systematic review is to summarize the characteristics and synthesize the findings of HIV-alcohol risk reduction interventions implemented in the region and reported in peer-reviewed journals. Of 644 citations screened, 19 met the inclusion criteria for this review. A discussion of methodological challenges, research gaps, and recommendations for future interventions is included. Relatively few interventions were found, and evidence is mixed about the efficacy of HIV-alcohol risk reduction interventions. There is a need to further integrate HIV-alcohol risk reduction components into HIV prevention programming and to document results from such integration. Additionally, research on larger scale, multi-level interventions is needed to identify effective HIV-alcohol risk reduction strategies.

Abstract access

Editor’s notes: Alcohol and risk of HIV have been shown to be linked, yet little is known about which programmes are best at reducing this risk. This paper features a systematic review updating a previous review published by the authors in 2011. While this update found several more programmes aimed at reducing risky behaviour caused by alcohol use and in more countries than just the one previously, South Africa, the results of the review are largely the same. Most programmes had limited follow-up time of participants and found a dissipating effect over time. Additionally, older models of behaviour change were primarily used as the frameworks upon which these programmes were built. These models focus only on individual behaviour and not on the structural factors further affecting consumption of alcohol and risky sexual behaviour. On a positive note, some studies found moderate success based on location of the programme, clinic versus bar or tavern setting for instance. This review clearly demonstrates the need for further efforts to integrate alcohol risk reduction components into HIV prevention programmes, particularly for populations in which alcohol consumption is common.

Africa
Angola, Nigeria, South Africa, Uganda, Zambia, Zimbabwe
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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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PrEP is effective in a real world setting

Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial.

McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, Sullivan AK, Clarke A, Reeves I, Schembri G, Mackie N, Bowman C, Lacey CJ, Apea V, Brady M, Fox J, Taylor S, Antonucci S, Khoo SH, Rooney J, Nardone A, Fisher M, McOwan A, Phillips AN, Johnson AM, Gazzard B, Gill ON. Lancet. 2015 Sep 9. pii: S0140-6736(15)00056-2. doi: 10.1016/S0140-6736(15)00056-2. [Epub ahead of print]

Background: Randomised placebo-controlled trials have shown that daily oral pre-exposure prophylaxis (PrEP) with tenofovir-emtricitabine reduces the risk of HIV infection. However, this benefit could be counteracted by risk compensation in users of PrEP. We did the PROUD study to assess this effect.

Methods: PROUD is an open-label randomised trial done at 13 sexual health clinics in England. We enrolled HIV-negative gay and other men who have sex with men who had had anal intercourse without a condom in the previous 90 days. Participants were randomly assigned (1:1) to receive daily combined tenofovir disoproxil fumarate (245 mg) and emtricitabine (200 mg) either immediately or after a deferral period of 1 year. Randomisation was done via web-based access to a central computer-generated list with variable block sizes (stratified by clinical site). Follow-up was quarterly. The primary outcomes for the pilot phase were time to accrue 500 participants and retention; secondary outcomes included incident HIV infection during the deferral period, safety, adherence, and risk compensation. The trial is registered with ISRCTN (number ISRCTN94465371) and ClinicalTrials.gov (NCT02065986).

Findings: We enrolled 544 participants (275 in the immediate group, 269 in the deferred group) between Nov 29, 2012, and April 30, 2014. Based on early evidence of effectiveness, the trial steering committee recommended on Oct 13, 2014, that all deferred participants be offered PrEP. Follow-up for HIV incidence was complete for 243 (94%) of 259 patient-years in the immediate group versus 222 (90%) of 245 patient-years in the deferred group. Three HIV infections occurred in the immediate group (1.2/100 person-years) versus 20 in the deferred group (9.0/100 person-years) despite 174 prescriptions of post-exposure prophylaxis in the deferred group (relative reduction 86%, 90% CI 64-96, p=0.0001; absolute difference 7.8/100 person-years, 90% CI 4.3-11.3). 13 men (90% CI 9-23) in a similar population would need access to 1 year of PrEP to avert one HIV infection. We recorded no serious adverse drug reactions; 28 adverse events, most commonly nausea, headache, and arthralgia, resulted in interruption of PrEP. We detected no difference in the occurrence of sexually transmitted infections, including rectal gonorrhoea and chlamydia, between groups, despite a suggestion of risk compensation among some PrEP recipients.

Interpretation: In this high incidence population, daily tenofovir-emtricitabine conferred even higher protection against HIV than in placebo-controlled trials, refuting concerns that effectiveness would be less in a real-world setting. There was no evidence of an increase in other sexually transmitted infections. Our findings strongly support the addition of PrEP to the standard of prevention for men who have sex with men at risk of HIV infection.

Abstract  Full-text [free] access

Editor’s notes: The PROUD study was an open label pragmatic randomised controlled trial designed to assess the effectiveness of pre-exposure prophylaxis (PrEP) in gay men and other men who have sex with men and whether the benefits are counteracted by risk compensation in users of PrEP. During the pilot phase of the study to test the feasibility of a large-scale trial the investigators found an unexpectedly high incidence of HIV infections. It was seven times higher than the national estimate reported for gay men and other men who have sex with men in the UK. The incidence of HIV infection was significantly lower in the group assigned to receive PrEP immediately, compared with the group assigned to receive it after a deferral period of one year. Moreover the reduction in HIV incidence was greater than has been observed in placebo-controlled trials. As a result the trial was stopped early on the recommendation of the trial steering committee. The high incidence of HIV suggests that, despite the broad eligibility criteria, the study population was highly selective and that the offer of PrEP attracted men who were at high risk of HIV and most likely to benefit from it. Despite some limitations, for example, lack of data on adherence and sexual behaviour, the results of this study are encouraging and have important implication for HIV prevention. They indicate that PrEP is effective in a real world setting, particularly in a population that is aware of its risk of HIV infection. Furthermore, there was no evidence of risk compensation among PrEP recipients. 

Europe
United Kingdom
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PEP is an unknown option for women at high risk in Nairobi

Barriers to the uptake of postexposure prophylaxis among Nairobi-based female sex workers.

Olsthoorn AV, Sivachandran N, Bogoch I, Kwantampora J, Kimani M, Kimani J, Kaul R. AIDS. 2015 Sep 13. [Epub ahead of print]

Introduction: Female sex workers (FSWs) in sub-Saharan Africa are at a particularly high risk for HIV infection. Postexposure prophylaxis (PEP) is available as part of an HIV care and prevention program through dedicated FSW clinics in Nairobi, Kenya, but is underutilized. We evaluated PEP knowledge, access, and adherence among clinic attendees.

Methods: An anonymous questionnaire was administered to unselected HIV-uninfected FSWs. Participants were dichotomized into high and low HIV risk categories based on self-reported sexual practices, and prior PEP use, knowledge, and adherence were then evaluated.

Results: One hundred thirty-four HIV-uninfected FSWs participated, with 64 (48%) categorized as being at high risk for HIV acquisition. High-risk FSWs were less likely to have heard of or accessed PEP than lower risk FSWs (37.5 vs. 58.6%, P = 0.014; and 21.9 vs. 40.6%, P = 0.019, respectively). Among higher risk FSWs, those who had accessed PEP were more likely to report treatment for a genital infection (71.4 vs. 42.0%, P = 0.049) or sex with an HIV-infected man (62.5 vs. 37.5%, P = 0.042) during the last 6 months. However, only 35.7% of high-risk women accessing PEP completed a full course of treatment, and noncompleters were more likely to report prior unprotected sex with an HIV-infected man (P = 0.023).

Conclusion: Despite freely available PEP for Nairobi-based FSWs, women at highest risk were less likely to have heard of PEP, access PEP, or complete the full course of therapy once initiated. Program delivery needs to be improved to ensure that FSW most at risk are able to benefit from this resource.

Abstract access

Editor’s notes: There is currently in the field a strong buzz around antiretroviral (ARV)-based prevention following the results from recently completed oral pre-exposure prophylaxis studies (PrEP). This excitement is also driven by the new guidelines from the World Health Organization which recommend immediate treatment of any individual testing HIV positive at any CD4 count and initiation of PrEP for individuals at substantially high risk for acquiring HIV. On the other hand, post-exposure prophylaxis (PEP), involving giving a one month supply of daily ARVs to someone recently exposed or suspected to be exposed to HIV, has been in existence for almost two decades.  Yet despite new WHO guidelines released in 2014 it struggles to be successfully implemented in instances of suspected sexual exposure. This paper presents a case illustrating how despite support from national policy and availability in clinics, women at high risk do not know about PEP and do not access it as they could. This study was able to correlate association of risk and the need to care for children with accessing and completing PEP regimens. This is a valuable insight into how messaging and education around PEP could be constructed. PEP could be a powerful tool in the ARV-based prevention tool box, and the broader combination prevention strategies in countries. However it is clear that efforts to improve access and uptake will need directed attention and excitement along with support for the other prevention options coming on to the market.

Africa
Kenya
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Condoms or PrEP? Women’s decision-making for the prevention of HIV-transmission in Kenya and South Africa

Motivations for reducing other HIV risk-reduction practices if taking pre-exposure prophylaxis: findings from a qualitative study among women in Kenya and South Africa.

Corneli A, Namey E, Ahmed K, Agot K, Skhosana J, Odhiambo J, Guest G. AIDS Patient Care STDS. 2015 Sep;29(9):503-9. doi: 10.1089/apc.2015.0038. Epub 2015 Jul 21.

Findings from a survey conducted among women at high risk for HIV in Bondo, Kenya, and Pretoria, South Africa, demonstrated that a substantial proportion would be inclined to reduce their use of other HIV risk-reduction practices if they were taking pre-exposure prophylaxis (PrEP). To explore the motivations for their anticipated behavior change, we conducted qualitative interviews with 60 women whose survey responses suggested they would be more likely to reduce condom use or have sex with a new partner if they were taking PrEP compared to if they were not taking PrEP. Three interrelated themes were identified: (1) "PrEP protects"-PrEP was perceived as an effective HIV prevention method that replaced the need for condoms; (2) condoms were a source of conflict in relationships, and PrEP would provide an opportunity to resolve or avoid this conflict; and (3) having sex without a condom or having sex with a new partner was necessary for receiving material goods and financial assistance-PrEP would provide reassurance in these situations. Many believed that PrEP alone would be a sufficient HIV risk-reduction strategy. These findings suggest that participants' HIV risk-reduction intentions, if they were to use PrEP, were based predominately on their understanding of the high efficacy of PrEP and their experiences with the limitations of condoms. Enhanced counseling is needed to promote informed decision making and to ensure overall sexual health for women using PrEP for HIV prevention, particularly with respect to the prevention of pregnancy and other sexually transmitted infections when PrEP is used alone.

Abstract access

Editor’s notes: New HIV-prevention methods and messages may be understood differently by different people. For example, the protection from HIV infection for men ‘at about 60%’ that is afforded by medical male circumcision is not always well understood. Some men assume higher protection levels. The authors of this paper describe women’s HIV-prevention method intentions, should pre-exposure prophylaxis (PrEP) be available.  The study is of women’s intention, not actual behaviour, but the findings provide useful insights into the way in which prevention messages are interpreted. In this case, the new method is seen to offer an alternative to using condoms. The authors describe the reasons women give for not using condoms based on their belief that PrEP would protect them from infection. The authors suggest that counselling to inform women of the other benefits of condoms, beyond HIV-infection, is necessary where PrEP is introduced as a HIV-prevention method. This may be so, but underlying the reasons the women gave for not wanting to use condoms was inequitable relationships with their partners. The decision to use condoms often rests mainly with the man. While some women actively disliked condoms because of a reduction in sexual pleasure, many saw not using condoms as a way to sustain their relationship. The authors note that prevention strategies not only need to support women’s choices; but they also need to engage with women who lack choice.  

Africa
Kenya, South Africa
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Male circumcision may reduce HIV transmission among MSM in China

Lower HIV risk among circumcised men who have sex with men in China: Interaction with anal sex role in a cross-sectional study.

Qian HZ, Ruan Y, Liu Y, Milam DF, HM LS, Yin L, Li D, Shepherd BE, Shao Y, Vermund SH. J Acquir Immune Defic Syndr. 2015 Sep 21. [Epub ahead of print]

Background: Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain.

Methods: Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed.

Results: Among 1155 participants (242 known seropositives and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by exam) was associated with 47% lower odds of being HIV seropositive (adjusted odds ratio [aOR], 0.53; 95% confidence interval [CI], 0.27-1.02) after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR, 0.38, 95%CI, 0.09-1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR, 0.54, 95%CI, 0.25-1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR, 0.15; 95%CI, 0.04-0.65). Circumcision was not associated clearly with lower syphilis risk (aOR, 0.91; 95%CI, 0.51-1.61).

Conclusions: Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed.

Abstract access

Editor’s notes: Randomised controlled trials in areas of high HIV prevalence in Africa have demonstrated that voluntary medical male circumcision (VMMC) can reduce heterosexual acquisition of HIV in men by around 60%.  However the evidence is less clear that the protection conferred by VMMC also applies to gay men and other men who have sex with men by reducing HIV acquisition through insertive anal sex. This cross-sectional study of gay men and other men who have sex with men in China suggests that, overall, the odds of being HIV positive among circumcised men were about half that in uncircumcised men, after adjusting for differences in demographic factors and sexual behaviour. Biologically, circumcision is likely to protect gay men and other men who have sex with men who are exclusively or mainly the insertive partner, and among men in this group, there was a slightly larger protective effect, although not statistically significant. This supports a meta-analysis which found a similar finding among gay men and other men who have sex with men who practiced insertive anal sex. There was no association of VMMC and syphilis infection in this population, in line with other studies. The authors note that HIV prevention strategies among gay men and other men who have sex with men are still limited in China, and suggest studies to assess the feasibility of a multicentre randomised controlled trial of the effect of VMMC on HIV acquisition among gay men and other men who have sex with men in this setting.

Asia
China
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