Articles tagged as "Reduce sexual transmission"

Research conduct

Applying the principles of knowledge translation and exchange to inform dissemination of HIV survey results to adolescent participants in South Africa

Nixon SA, Casale M, Flicker S, Rogan M. Health Promot Int. 2012 Jan 10. [Epub ahead of print]

It is widely accepted that researchers have an obligation to inform survey participants of research results. However, there is little evidence on the effectiveness of various dissemination strategies. The emerging field of knowledge transfer and exchange (KTE) may offer insight given its focus on techniques to enhance the effectiveness of communicating evidence-based information. To date, knowledge translation and exchange has focused primarily on information exchange between researchers and policy-makers as opposed to study participants; however, there are principles that may be relevant in this new context. This gap in the literature becomes even more salient in the context of public health research where research results can reveal particular misunderstandings or shortcomings in knowledge that threaten to severely compromise participants' health. The objective of this article is to describe how knowledge translation and exchange principles were used to inform dissemination of results of a self-administered sexual health survey to adolescent study participants in a resource-deprived, peri-urban area of South Africa. Strategies for enhancing two-way information exchange included constructing interactive dissemination sessions led by young, isiZulu fieldworkers. Nixon and colleagues also employed techniques to create a safe space for dialogue, encouraged the shared ownership of results and crafted targeted messages. Particularly noteworthy was the benefit accrued by the research team through this process of exchange, including novel explanations for study findings and new ideas for future research.

For abstract access click here.

Editor’s note: This thoughtful article provides a brief overview of the field of knowledge translation and exchange between research producers and research users. This process, based on collaborative engagement, begins with identifying what research questions are relevant, what study design is most appropriate, and how study conduct is proceeding. It goes through to analysis of results, dissemination of findings, and application of the knowledge gained. The example provided here is intriguing. How best do you share survey results with adolescents who have participated in a study and will that process, if successful, promote not only ownership of the results and produce plausible explanations for quantitative survey findings, but will it also promote healthy behaviour itself? What was done here could be considered a best practice for establishing ground rules for a respectful, interactive space for results dissemination. But during the dissemination process qualitative data, in the form of explanations emerging from the adolescents, was not well captured because this component of the research process had been planned as sharing of results. However, reflecting back school-based findings through guessing games, posters, and booklets that could be taken home, and valuing youth expertise in explaining the results went a long way to creating ownership.

National responses
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Adolescents

Treatment outcomes in HIV-infected adolescents attending a community-based antiretroviral therapy clinic in South Africa

Nglazi MD, Kranzer K, Holele P, Kaplan R, Mark D, Jaspan H, Lawn SD, Wood R, Bekker LG. BMC Infect Dis. BMC Infect Dis. 2012 Jan 25;12:21

Very few data are available on treatment outcomes of adolescents living with HIV infection (whether perinatally-acquired or sexually-acquired) in sub-Saharan Africa. The present study therefore compared the treatment outcomes in adolescents with those of young adults at a public sector community-based antiretroviral treatment programme in Cape Town, South Africa. Treatment outcomes of adolescents (9-19 years) were compared with those of young adults (20-28 years), enrolled in a prospective cohort between September 2002 and June 2009. Kaplan-Meier estimates and Cox proportional hazard models were used to assess outcomes and determine associations with age, while adjusting for potential confounders. The treatment outcomes were mortality, loss to follow-up (LTFU), immunological response, virological suppression, and virological failure. 883 patients, including 65 adolescents (47 perinatally infected and 17 sexually infected) and 818 young adults, received antiretroviral treatment. There was no difference in median baseline CD4 cell count between adolescents and young adults (133.5 vs 116 cells/mL; p = 0.31). Overall mortality rates in adolescents and young adults were 1.2 (0.3-4.8) and 3.1 (2.4-3.9) deaths per 100 person-years, respectively. Adolescents had lower rates of virological suppression (<400 copies/mL) at 48 weeks (27.3% vs 63.1%; p < 0.001). Despite this, however, the median change in CD4 count from baseline at 48 weeks of antiretroviral treatment was significantly greater for adolescents than young adults (373 vs 187 cells/muL; p = 0.0001). Treatment failure rates were 8.2 (4.6-14.4) and 5.0 (4.1-6.1) per 100 person-years in the two groups. In multivariate analyses, there was no significant difference in loss-to-follow-up and mortality between age groups but increased risk in virological failure [AHR 2.06 (95% CI 1.11-3.81; p = 0.002)] in adolescents. Despite lower virological suppression rates and higher rates of virological failure, immunological responses were nevertheless greater in adolescents than young adults whereas rates of mortality and loss-to-follow-up were similar. Further studies to determine the reasons for poorer virological outcomes are needed.

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Editor’s note: An adolescent-centred antiretroviral treatment clinic was introduced in this facility in 2008, in recognition of the increasing numbers of perinatally HIV-infected children reaching adolescence. The findings from this study are intriguing, both with respect to adolescents having a higher rate of virological failure and yet better immunological outcomes than young adults and for the differences between adolescents infected perinatally and those infected through sexual transmission. The youngest perinatally-infected adolescents had been born in 2001, before the advent of PMTCT programmes in South Africa. They tended to have better responses to antiretroviral treatment than adolescents who had been infected sexually and lower loss to follow-up, possibly because of stronger family and friend support systems¾they were more likely to attend the treatment facility with the support of parents. The next step is to collect information on side effects to therapy, drug resistance, and adherence, particularly what makes it easier and what makes it harder for adolescents who are embarking on lifelong treatment to take their medications regularly.

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Adolescents

HIV knowledge and sexual risk behaviour among street adolescents in rehabilitation centres in Kinshasa; DRC: gender differences

Mudingayi A, Lutala P, Mupenda B. Pan Afr Med J. 2011;10:23. Epub 2011 Oct 17

Street children, common in Africa, are increasingly vulnerable to alcohol and drugs of abuse and lack access to both healthcare and knowledge about HIV and AIDS. This study assessed the level of knowledge about sexually transmitted infections (STIs), including HIV, among street adolescents in the Democratic Republic of the Congo. A random sampling of 200 street children (10-25 years of age) was selected from 17 rehabilitation centres in Kinshasa, and a structured questionnaire was administered to all participants in their respective centres. High knowledge, knowledge or awareness of condoms, was defined when a participant gave more than 67% of correct responses. Chi square analysis was used to test differences between the sexes. The knowledge level of respondents was high. 54.3% of males and 45.7% of girls have heard about HIV, and unprotected sex was cited as a mode of transmission by 42.9% of males and 57.1% of females. A high number of children reported a previous sexual experience. Satisfying a natural bodily need was the main reason for having sex. However, the use of condoms is still low in both sexes (26.2 versus 59.3%, p<0.01). Neither gender reported a reason why they are not using a condom. This study highlights the high knowledge about HIV among street adolescents, which contrasts with low condom use and high past sexual experiences with a high number of sexual partners and sexual contacts. Policies targeting these findings are warranted to reverse such trends.

For abstract access click here. 

Editor’s note: There is no doubt that street youth in Kinshasa are a key population at risk for arrest and vulnerable to HIV exposure. The researchers sought to overcome their mistrust by using self-administered questionnaires and assistance from peers not participating in this study to help those who were illiterate. However, there are inconsistencies in this article that are of concern. The results section states that the most common mode of transmission in males is by contacts with urine/stool (30.5%), a figure that contrasts with the 25.9% for urine/stool contact shown in the results table and with the 42.9% cited in both the table and the abstract for unprotected sex, seemingly boys’ most common answer for mode of HIV transmission. But perhaps the most concerning is the view that the level of HIV knowledge in the study participants was high. Only half of these street children (54% of boys and 46% of girls) had heard of HIV, despite what is described as comprehensive HIV education given to these children in the rehabilitation centres in which the study took place.

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Ageing and HIV

What do we know about older adults and HIV? A review of social and behavioural literature

Sankar A, Nevedal A, Neufeld S, Berry R, Luborsky M, AIDS Care. 2011 Oct;23(10):1187-207. Epub 2011 Jun 14

The fastest growing segment of the USA HIV population is people aged 50 and older. This heterogeneous group includes people with diverse pathways into HIV-positive status in later life, including aging with the disease as well as later life-acquired infections. As people with HIV live into older ages, solving problems of successful secondary prevention and ongoing treatment requires more specific knowledge of the particular aging-related contextual sociocultural, psychosocial, and personal factors salient to the situations of persons living with HIV. Greater knowledge of these factors will help solve challenges to reducing psychological burden and promoting health maintenance for people with HIV. Yet, the current literature on aging and HIV remains nascent. To assess the state of knowledge of the sociocultural and behavioural factors associated with aging with HIV, Sankar and colleagues conducted a systematic critical content review of peer-reviewed social and behavioural research on aging and HIV to answer the question, "How have older age, and social, cultural, and behavioural aspects of the intersection of HIV and age been addressed in the literature?" They searched First Search, Proquest, Psych Info, Pub Med, Wilson Select Plus, and World Cat and identified 1549 articles. They then reviewed these to select peer-reviewed articles reporting results of research on the social and behavioural aspects of living with HIV at age 50 and older. Fifty-eight publications were identified that met study inclusion criteria. While few publications reported clear age-related differences, there were significant ethnic differences in living with HIV in later life and also differences among older people when groups were defined by mode of transmission. Findings are discussed in light of constructs from gerontology which may contribute to clarifying how later life, life course stage, and psychological development intersect with, influence, and are influenced by HIV disease and long-term anti-retroviral therapy use.

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Editor’s note: Some have estimated that by 2015, 50% of all people living with HIV in the USA will be 50 years of age or older, as antiretroviral therapy extends people’s life spans and new infections continue in this age group. In 2007, 15% of new HIV infections in the USA were among people aged 50 years and older. Other reviews have addressed the interactions between biological aging, HIV disease processes, and antiretroviral therapy. This literature review focuses on how life course stage (socially-constructed expectations, eras, and transitions) and psychological development stage (e.g. capacity to adapt to changing demands) complement chronological age (the body’s biological age) in our understanding of aging and HIV. It reviews the diverse settings and conditions of the lives of older American adults living with HIV (ethnicity, mode of HIV acquisition, income, social support, etc.) and their experiences with disclosure, stigma, and ageism. Stereotypes of asexuality in the 50+ age group, held by health care providers, policy makers, and the public, delay diagnosis and treatment initiation and do not address HIV prevention needs with age-appropriate information and counselling. Beyond the biological aspects of aging and of HIV Infection, complex social, physical, economic, cultural, and psychological interrelationships influence the resilience and strengths of people in not only coping with HIV but in accomplishing their own life stage specific goals and aspirations.

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Vaccines

Antibody-based protection against HIV infection by vectored immunoprophylaxis

Balazs AB, Chen J, Hong CM, Rao DS, Yang L, Baltimore D., Nature. 2011 Nov 30;481(7379):81-4. doi: 10.1038/nature10660

Despite tremendous efforts, development of an effective vaccine against human immunodeficiency virus (HIV) has proved an elusive goal. Recently, however, numerous antibodies have been identified that are capable of neutralizing most circulating HIV strains. These antibodies all exhibit an unusually high level of somatic mutation 6, presumably owing to extensive affinity maturation over the course of continuous exposure to an evolving antigen. Although substantial effort has focused on the design of immunogens capable of eliciting antibodies de novo that would target similar epitopes 8–10, it remains uncertain whether a conventional vaccine will be able to elicit analogues of the existing broadly neutralizing antibodies. As an alternative to immunization, vector-mediated gene transfer could be used to engineer secretion of the existing broadly neutralizing antibodies into the circulation. Balazs and colleagues describe a practical implementation of this approach, which they call vectored immunoprophylaxis (VIP), which in mice induces lifelong expression of these monoclonal antibodies at high concentrations from a single intramuscular injection. This is achieved using a specialized adeno-associated virus vector optimized for the production of full-length antibody from muscle tissue. The authors show that humanized mice receiving VIP appear to be fully protected from HIV infection, even when challenged intravenously with very high doses of replication-competent virus. Their results suggest that successful translation of this approach to humans may produce effective prophylaxis against HIV.

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Editor’s note: Immunodeficiencies in humanized mice such as these NSG mice permit a wide range of primary human cells to be grafted without rejection. The mice lack mature T cells, B cells, and natural killer cells. They are deficient in multiple cytokine signaling pathways and have many defects in innate immunity. This makes them an excellent model for testing vaccines against HIV challenge. Following the recent identification of several neutralising antibodies (see HIV This Week issues 73 and 85), researchers have focused on how to make a vaccine that would generate these antibodies in humans. The approach described here, called vector immunoprophylaxis or VIP, has produced exciting results. The mice were grafted with human B cells and then adenovirus vectors expressing b12 or VRC01 were injected intramuscularly, with the mice being monitored for expression of antibodies over time. The mice were populated with human mononuclear cells and were then challenged intravenously with replication-competent HIV. Those that had generated high concentrations of antibody were protected from a challenge dose 100 times higher than necessary to infect the majority of animals. This VIP approach produced full-length antibodies identical in sequence to those produced by the human immune system. This approach could potentially be used for effective prophylaxis against any infectious disease for which broadly neutralising antibodies can be isolated but, in the first instance, the eye is on the prize of HIV.

HIV Treatment
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Discordant couples

Outside sexual partnerships and risk of HIV acquisition for HIV uninfected partners in African HIV serodiscordant partnerships

Ndase P, Celum C, Thomas K, Donnell D, Fife KH, Bukusi E, Delany-Moretlwe S, Baeten JM, J Acquir Immune Defic Syndr. 2012 Jan 1;59(1):65-71.

As African countries scale up couples HIV testing, little is known about sexual behaviours and HIV risk for HIV-uninfected partners in known HIV serodiscordant relationships. Ndase and colleagues conducted a prospective study of 3,380 HIV serodiscordant partnerships from 7 African countries. Self-reported sexual behaviour data were collected quarterly from HIV-uninfected partners. The proportion of HIV-uninfected partners reporting sex with their known primary HIV infected partner decreased during follow-up (from 93.5% in the prior month at baseline to 73.2% at 24 months, p<0.001). Simultaneously, an increasing proportion reported sex with an outside partner (from 3.1% to 13.9%, p<0.001). A small proportion (<5%, stable throughout follow-up) reported sex with the infected partner and an outside partner in the same month (concurrent). Unprotected sex was more common with outside partners than with their primary known HIV infected partners (risk ratio 4.6; 95% CI 4.2-5.2). HIV incidence was similar for those reporting sex only with their primary HIV-infected partner compared to those who reported an outside partner (2.87 vs. 3.02 per 100 person-years, p=0.7), although those who had outside partners were more likely to acquire HIV that was virologically distinct from that of their primary partner (p<0.001). For uninfected members of HIV-serodiscordant couples, sex with the infected partner declined as sex with outside partners increased, likely reflecting relationship dissolution and risk shifting from a known infected partner. Risk reduction messages for HIV uninfected partners in serodiscordant partnerships should include strategies to reduce HIV acquisition from outside partners.

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Editor’s note: HIV-negative people in serodiscordant partnerships rarely have contact with health care providers after receiving their initial HIV-negative test result. As well, little is known about the evolution of sexual practices in serodiscordant couples after they learn their serostatus. This study, analysing data from a herpes suppression trial (the HIV-positive partner also had herpes simplex virus-2 infection) provides useful information about sexual practices both within and outside the couple over time. Sex within couples declined for both men (94% to 73%) and women (92% to 74%) during the 2 years after they learned their results and sex with an outside partner increased for both men (4% to 19%) and women (0.5% to 4%). Of note, when an outside partner was reported by the HIV-negative partner in a quarterly interview there was little concurrency less than 5% reported sex both within and outside the couple in the previous month. There was a steady increase over time for both men and women in the proportions reporting no sexual activity and reporting sexual activity only with outside partners. The most striking finding is low reported condom use with outside partners, reflecting risk perceptions that may not mirror true risk. Of the 21 people reporting outside partners who seroconverted, 18 acquired HIV outside the partnership while of the 130 reporting no outside partners who seroconverted, 105 of these infections could be biologically linked to the seropositive partner. As the scaling up of HIV testing and counselling proceeds, more serodiscordant couples will learn their status an estimated 50% of people living with HIV in sub-Saharan Africa have a partner who is not infected. Tailored counselling for these couples can help them support each other to better perceive their HIV transmission and acquisition risks to protect themselves and others.

Andorra
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Male circumcision devices

The safety profile and acceptability of a disposable male circumcision device in Kenyan men undergoing voluntary medical male circumcision

Musau P, Demirelli M, Muraguri N, Ndwiga F, Wainaina D, Ali NA, J Urol. 2011 Nov;186(5):1923-7. Epub 2011 Sep 23

Musau and colleagues set out to establish the safety and effectiveness as well as the acceptability of the Alisklamp® device for male circumcision among Kenyan men. To qualify for this hospital based, prospective, interventional cohort study one needed to be an uncircumcised adult male who was HIV-negative with no comorbid factors or genitourinary anomalies precluding circumcision. A total of 58 men were recruited from a population of 90. Outcome measures were the safety profile of Alisklamp® and its efficiency and acceptability by participants. All 58 procedures were completed without device malfunction, haemorrhage or undesirable preputial excision. Mean ± SD procedure time was 2.43 ± 1.36 ®minutes and mean device removal time was 15.8 ± 7.4 seconds. There were 2 adverse events, including mild edema and superficial wound infection related to poor hygiene in 1 case each. All men resumed routine activity immediately after circumcision. Of the 58 participants 25.9% experienced mild nocturnal erectile pains that required no medication. During 6-week follow-up all men were satisfied with the procedure, tolerated the device well, and would recommend it to a friend. Alisklamp® has an excellent safety profile and excellent acceptability among men who undergo circumcision using the device. This technique is easy to teach and it would prove to be a handy device to scale up the rate of male circumcision. Based on these findings the device merits a comparative clinical trial.

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Editor’s note: Male circumcision surgical devices have the potential to improve the cost-effectiveness of male circumcision, although referral to a standard surgical set-up will be needed for some men for whom a device will not be appropriate. This is the first study of use of the Alisklamp® device for male circumcision of adult men in sub-Saharan Africa and the results are promising. Although local anaesthesia is required for device placement, the average procedure time was about 2.5 minutes for placement and 16 seconds for removal. The next steps for this device will be a clinical trial and a field trial, after which it can be evaluated by the WHO Technical Advisory Group on Innovations in Male Circumcision that has a mandate to examine data on new circumcision devices formally submitted to it. Although over 1.3 million medical male circumcisions have been performed since the 2007 WHO/UNAIDS recommendations, an estimated 19 million remain to be completed by 2015. There is no doubt that, when approved, medical devices for male circumcision can help accelerate the scale-up.

Health care delivery
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Male circumcision devices

Safety and efficacy of the PrePex™ Device for rapid scale up of male circumcision for HIV prevention in resource-limited settings

Bitega JP, Ngeruka ML, Hategekimana T, Asiimwe A, Binagwaho A, J Acquir Immune Defic Syndr. 2011 Dec 15;58(5):e127-34

Bitega and colleagues assessed the safety and efficacy of the PrePex device for nonsurgical circumcision in adult males, as part of a comprehensive HIV prevention program in Rwanda. They conducted a single-centre 6-week non-controlled study in which healthy men underwent circumcision using the PrePex device, which employs fitted rings to clamp the foreskin, leading to distal necrosis. In the first phase of the study, the feasibility of the procedure was tested on 5 subjects in a sterile environment; in the main phase, an additional 50 subjects were circumcised in a non-sterile setting, by physicians or a nurse. Outcome measures included the rate of successful circumcision, time to complete healing, pain, and adverse events. In the feasibility phase, all 5 subjects achieved complete circumcision without adverse events. In the main phase, all 50 subjects achieved circumcision with 1 case of diffuse edema following device removal, which resolved with minimal intervention. Pain was minimal except briefly during device removal (day 7 after placement in most cases). The entire procedure was bloodless, requiring no anaesthesia, no suturing, and no sterile settings. Subjects had no sick/absent days associated with the procedure. Median time for complete healing was 21 days after device removal. There were no instances of erroneous placement and no mechanical problems with the device. The PrePex device was safe and effective for nonsurgical adult male circumcision without anaesthesia or sterile settings, and may be useful in mass circumcision programs to reduce the risk of HIV infection, particularly in resource-limited settings.

For abstract access click here.

Editor’s note: As noted in the Editor’s notes on the Shang Ring in HIV This Week Issue 92, WHO and UNAIDS recommend three surgical techniques for adult male circumcision: the forceps guided method, the sleeve resection method, and the dorsal slit method (http://www.malecircumcision.org). In the absence of task sharing and other methods to optimise the volume and efficiency of male circumcision service delivery, these methods entail 20 to 30 minutes of surgical time. Given the millions of adult male circumcisions that countries are aiming to achieve by 2015, there is tremendous interest in the potential time-saving features of medical devices. The PrePex™ device has many advantages: no need for injected anaesthesia, no sutures, no crushing or cutting of live foreskin, and a short procedure time of about 5 minutes for placement and removal 7 days later. This is a slow compression device that compresses the foreskin, cutting off circulation distally. The Rwanda team reported results at ICASA in December on their field trial of 590 nurse-administered PrePex™ male circumcisions with good results on safety and effectiveness. The PrePex™ device received approval from the USA Food and Drug Agency in January 2012 and slow compression devices are now being evaluated by WHO for pre-qualification.

Health care delivery
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