Articles tagged as "Reduce sexual transmission"

In the market for drugs and alcohol: characterising a risk environment in Malawi

Substance use and risky sexual behaviors among young men working at a rural roadside market in Malawi.

Jere DL, Norr KF, Bell CC, Corte C, Dancy BL, Kaponda CP, Levy JA. J Assoc Nurses AIDS Care. 2015 Jul 13. pii: S1055-3290(15)00147-8. doi: 10.1016/j.jana.2015.07.003. [Epub ahead of print]

Using an ecological model, we describe substance use and sexual risk behaviors of young male laborers at a roadside market in Malawi. Data included observations and interviews with 18 key market leaders and 15 laborers (ages 18-25 years). Alcohol, marijuana, and commercial sex workers (CSWs) were widely available. We identified three patterns of substance use: 6 young men currently used, 6 formerly used, and 3 never used. Substance use was linked to risky sex, including sex with CSWs. The market supported risky behaviors through availability of resources; supportive norms, including beliefs that substance use enhanced strength; and lack of restraints. Community-level poverty, cultural support for alcohol, interpersonal family/peer influences, early substance use, and school dropout also contributed to risky behaviors. Parental guidance was protective but not often reported. Local programs addressing substance use and risky sex simultaneously and better national substance use policies and mental health services are needed.

Abstract access

Editor’s notes: There has been a global focus on how substance use and associated risk behaviours contribute to HIV acquisition. Over the last decade there has been emerging evidence to suggest that substance use is increasing in the sub-Saharan African region, which is leading people to engage in risky sexual behaviour associated with HIV transmission. Despite this, there is a continued absence of research which focuses on the causes and practices of substance use, the associated impact and the opportunities to ameliorate the associated harms. This has led to a considerable knowledge gap. This paper provides a case study which offers insights into the factors which promote and sustain the relatively heavy use of marijuana and alcohol in a rural Malawian roadside market among young male labourers.

Adopting Scribener’s ecological model framework, the authors start from the premise that there are multiple level factors (societal, neighbourhood, interpersonal and individual) which shape the behaviour of men working in these markets. Using an ethnographic approach, they provide a rich description of how these multiple levels of risk factors operate and interact to facilitate men’s substance use.

The study found that the availability and use of alcohol and marijuana within the market by young men was widespread and that this was known about and broadly tolerated by key actors and groups involved in the market. The environment of the market is characterised by an ease of opportunity to consume these substances. The environment exhibited cultural norms which appeared to promote the acceptability of this behaviour and the absence of protective mechanisms to minimise the harms. There were two novel findings in the study. The first was how the perceived benefits of alcohol and marijuana use was integrated into expectations that it would help people to gain work and then do their jobs better. The second was that participants often justified their own behaviour by illustrating that it was endorsed by Ngoni culture, predominately in the area where the market was located. As such drinking alcohol was a means to perform young masculinity. This thoughtful research provides valuable evidence to support the need for programmes to include a focus on structural changes, such as availability and regulation of substance use but also in engaging with the presumed cultural norms. These should be considered alongside a more individual orientated approach in order to design a programme that is likely to be successful in reducing the harm of these behaviours. 

Gender, Substance use
Africa
Malawi
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Tenofovir vaginal gel offers significant protection against HSV-2 infection

Tenofovir gel for the prevention of herpes simplex virus type 2 infection.

Abdool Karim SS, Abdool Karim Q, Kharsany AB, Baxter C, Grobler AC, Werner L, Kashuba A, Mansoor LE, Samsunder N, Mindel A, Gengiah TN, Group CT. N Engl J Med. 2015 Aug 6;373(6):530-9. doi: 10.1056/NEJMoa1410649.

Background: Globally, herpes simplex virus type 2 (HSV-2) infection is the most common cause of genital ulcer disease. Effective prevention strategies for HSV-2 infection are needed to achieve the goals of the World Health Organization global strategy for the prevention and control of sexually transmitted infections.

Methods: We assessed the effectiveness of pericoital tenofovir gel, an antiviral microbicide, in preventing HSV-2 acquisition in a subgroup of 422 HSV-2-negative women enrolled in the Centre for the AIDS Programme of Research in South Africa (CAPRISA) 004 study, a double-blind, randomized, placebo-controlled trial. Incident HSV-2 cases were identified by evidence of seroconversion on an HSV-2 IgG enzyme-linked immunosorbent assay between study enrollment and exit. A confirmatory analysis was performed by Western blot testing.

Results: The HSV-2 incidence rate was 10.2 cases per 100 person-years (95% confidence interval [CI], 6.8 to 14.7) among 202 women assigned to tenofovir gel, as compared with 21.0 cases per 100 person-years (95% CI, 16.0 to 27.2) among 222 women assigned to placebo gel (incidence rate ratio, 0.49; 95% CI, 0.30 to 0.77; P=0.003). The HSV-2 incidence rate among the 25 women with vaginal tenofovir concentrations of 10 000 ng per milliliter or more was 5.7 cases per 100 person-years, as compared with 15.5 cases per 100 person-years among the 103 women with no detectable vaginal tenofovir (incidence rate ratio, 0.37; 95% CI, 0.04 to 1.51; P=0.14). As confirmed by Western blot testing, there were 16 HSV-2 seroconversions among women assigned to tenofovir gel as compared with 36 among those assigned to the placebo gel (incidence rate ratio, 0.45; 95% CI, 0.23 to 0.82; P=0.005).

Conclusions: In this study in South Africa, pericoital application of tenofovir gel reduced HSV-2 acquisition in women.

Abstract access 

Editor’s notes: Oral tenofovir is widely used to prevent and treat HIV infection, but application of a topical tenofovir vaginal-gel formulation has not been found to be protective against HIV, likely because of low rates of adherence. In contrast, analyses of tenofovir gel protection against HSV-2, herpes simplex virus, has showed some promise. This paper presents additional data and analyses from the CAPRISA004 study which found the modest effect of protection against HIV, but significant protection against HSV-2 (51% effectiveness). A sub-analysis confirmed that those people with higher vaginal tenofovir concentrations were almost three times less likely to acquire the herpes virus than those people with no detectable drug concentration. In the absence of an effective vaccine or cure for HSV-2 infection, pericoital tenofovir gel has the potential to increase the options for HSV-2 prevention, and have an indirect effect on HIV infection. 

Africa
South Africa
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Antiretroviral therapy coverage associated with reduced HIV incidence in Kenya

Impact of community antiretroviral therapy coverage on HIV incidence in Kenyan female sex workers: a 15-year prospective cohort study.

McClelland RS, Richardson BA, Cherutich P, Mandaliya K, John-Stewart G, Miregwa B, Odem-Davis K, Jaoko W, Kimanga D, Overbaugh J. AIDS. 2015 Jul 31. [Epub ahead of print]

Objective: To test the hypothesis that increasing community antiretroviral therapy (ART) coverage would be associated with lower HIV incidence in female sex workers (FSWs) in Mombasa District, Kenya.

Design: Prospective cohort study.

Methods: From 1998 to 2012, HIV-negative FSWs were asked to return monthly for an interview regarding risk behavior and testing for sexually transmitted infections including HIV. We evaluated the association between community ART coverage and FSW's risk of becoming HIV infected using Cox proportional hazards models adjusted for potential confounding factors.

Results: One thousand four hundred four FSWs contributed 4335 woman-years of follow-up, with 145 acquiring HIV infection (incidence 3.35/100 woman-years). The ART rollout began in 2003. By 2012, an estimated 52% of HIV-positive individuals were receiving treatment. Community ART coverage was inversely associated with HIV incidence (adjusted hazard ratio 0.77; 95% confidence interval 0.61-0.98; P = 0.03), suggesting that each 10% increase in coverage was associated with a 23% reduction in FSWs' risk of HIV acquisition. Community ART coverage had no impact on herpes simplex virus type-2 incidence (adjusted hazard ratio 0.97; 95% confidence interval 0.79-1.20; P = 0.8).

Conclusion: Increasing general population ART coverage was associated with lower HIV incidence in FSWs. The association with HIV incidence, but not herpes simplex virus type-2 incidence, suggests that the effect of community ART coverage may be specific to HIV. Interventions such as preexposure prophylaxis and antiretroviral-containing microbicides have produced disappointing results in HIV prevention trials with FSWs. These results suggest that FSWs' risk of acquiring HIV infection might be reduced through the indirect approach of increasing ART coverage in the community.

Abstract access

Editor’s notes: The individual-level benefit of antiretroviral therapy (ART) on reducing HIV transmission between serodiscordant partners is established, but less is known about a possible population-level effect of ART on key populations such as female sex workers. In this study of 1404 initially HIV-negative female sex workers in Mombasa, Kenya, increased community ART coverage was strongly associated with reduced HIV incidence. HIV incidence was 23% lower for every 10% increase in ART coverage, after adjusting for HIV prevalence and participants’ behavioural characteristics. However, the authors note that HIV incidence was already declining prior to the introduction of ART (from 11.4 cases/100 woman-years in 1998 to 7.6/100 woman-years in 2002), due to other factors including changes in risk behaviour and HIV-prevention efforts in the community. Despite this, the present study suggests that in the setting of ongoing high-quality HIV prevention services, the risk of HIV acquisition among female sex workers is likely to be reduced by increasing ART coverage in the community. Moves to increase coverage of ART in the community will potentially have a substantial HIV prevention benefit on this key population.

Africa
Kenya
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HIV and the relative perception of risk in a fishing site in Uganda

Risk denial and socio-economic factors related to high HIV transmission in a fishing community in Rakai, Uganda: a qualitative study.

Lubega M, Nakyaanjo N, Nansubuga S, Hiire E, Kigozi G, Nakigozi G, Lutalo T, Nalugoda F, Serwadda D, Gray R, Wawer M, Kennedy C, Reynolds SJ. PLoS One. 2015 Aug 26;10(8):e0132740. doi: 10.1371/journal.pone.0132740. eCollection 2015.

Background: In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission is still very high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44%, reaching up to 74% among female sex workers. We explored drivers for the high HIV transmission at Kasensero from the perspective of fishermen and other community members to inform future policy and preventive interventions.

Methods: 20 in-depth interviews including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community were conducted during April-September 2014. Content analysis was performed to identify recurrent themes.

Results: The socio-economic risk factors for high HIV transmission in Kasensero fishing community cited were multiple and cross-cutting and categorized into the following themes: power of money, risk denial, environmental triggers and a predisposing lifestyle and alcoholism and drug abuse. Others were: peer pressure, poor housing and the search for financial support for both the men and women which made them vulnerable to HIV exposure and or risk behavior.

Conclusions: There is a need for context specific combination prevention interventions in Kasensero that includes the fisher folk and other influential community leaders. Such groups could be empowered with the knowledge and social mobilization skills to fight the negative and risky behaviors, perceptions, beliefs, misconceptions and submission attitudes to fate that exposes the community to high HIV transmission. There is also need for government/partners to ensure effective policy implementation, life jackets for all fishermen, improve the poor housing at the community so as to reduce overcrowding and other housing related predispositions to high HIV rates at the community. Work place AIDS-competence teams have been successfully used to address high HIV transmission in similar settings.

Abstract  Full-text [free] access

Editor’s notes: In recent years policy makers and programme implementers have been urged to ‘know your epidemic’. This paper provides a striking illustration of the complexity of responding to the knowledge of a place with high prevalence and incidence. The authors describe the many factors which contribute to high HIV transmission rates. They illustrate why, for example, providing condoms and instruction on safer sex may have limited impact on a man who expresses concerns about drowning while fishing tomorrow. Drowning is a more immediate risk than dying because of AIDS-associated illnesses in the future. The information in this paper is not new. We have known about the different risk factors in fishing sites in Uganda for some time. There is also a considerable body of work on the relative perception of risk. However, what the authors do offer is a clear and well-grounded overview of the many different reasons why people in the study setting are at risk of HIV. They illustrate the vital importance of understanding the context of HIV-transmission; the value of looking beneath the prevalence and incidence figures.

Africa
Uganda
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Longer secondary schooling reduces HIV transmission risk

Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment.

De Neve JW, Fink G, Subramanian SV, Moyo S, Bor J. Lancet Glob Health. 2015 Aug;3(8):e470-7. doi: 10.1016/S2214-109X(15)00087-X. Epub 2015 Jun 28.

Background: An estimated 2.1 million individuals are newly infected with HIV every year. Cross-sectional and longitudinal studies have reported conflicting evidence for the association between education and HIV risk, and no randomised trial has identified a causal effect for education on HIV incidence. We aimed to use a policy reform in secondary schooling in Botswana to identify the causal effect of length of schooling on new HIV infection.

Methods: Data for HIV biomarkers and demographics were obtained from the nationally representative household 2004 and 2008 Botswana AIDS Impact Surveys (N=7018). In 1996, Botswana reformed the grade structure of secondary school, expanding access to grade ten and increasing educational attainment for affected cohorts. Using exposure to the policy reform as an instrumental variable, we used two-stage least squares to estimate the causal effect of years of schooling on the cumulative probability that an individual contracted HIV up to their age at the time of the survey. We also assessed the cost-effectiveness of secondary schooling as an HIV prevention intervention in comparison to other established interventions.

Findings: Each additional year of secondary schooling caused by the policy change led to an absolute reduction in the cumulative risk of HIV infection of 8.1 percentage points (p=0.008), relative to a baseline prevalence of 25.5% in the pre-reform 1980 birth cohort. Effects were particularly large in women (11.6 percentage points, p=0.046). Results were robust to a wide array of sensitivity analyses. Secondary school was cost effective as an HIV prevention intervention by standard metrics (cost per HIV infection averted was US$27 753).

Interpretation: Additional years of secondary schooling had a large protective effect against HIV risk in Botswana, particularly for women. Increasing progression through secondary school could be a cost-effective HIV prevention measure in HIV-endemic settings, in addition to yielding other societal benefits.

Abstract  Full-text [free] access

Editor’s notes: There is conflicting evidence on the association between education and HIV risk, and little causal evidence. Observational studies are limited by strong confounding by factors such as socioeconomic status and psychological traits, while previous randomised trials have been underpowered for HIV incidence. A policy reform in Botswana in 1996 provided a unique opportunity to assess this question. The policy affected specific birth cohorts and meant that the average number of years of schooling increased by nearly one year. The reform was unlikely to have affected HIV risk through mechanisms other than schooling itself. It therefore constitutes a natural experiment to estimate the causal effect of schooling on the risk of HIV infection, through comparison of birth cohorts exposed to the policy reform versus people unexposed. The authors found that, for each additional year of schooling induced by the reform, there was an 8.1 percentage point reduction in the risk of HIV infection. The effect was particularly strong among women, with an 11.6 percentage point reduction. These results translated to a cost of $27 753 per HIV infection averted. Secondary schooling is therefore more expensive than circumcision or treatment as prevention, but of similar cost-effectiveness to the upper range of estimates for pre-exposure prophylaxis. In addition, schooling offers other benefits beyond the reduction of HIV transmission.

Africa
Botswana
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Female migrants may be more at risk of HIV in Kazakhstan

Migrant workers in Kazakhstan: gender differences in HIV knowledge and sexual risk behaviors.

Zhussupov B, McNutt LA, Gilbert L, Terlikbayeva A, El-Bassel N. AIDS Behav. 2015 Jul;19(7):1298-304. doi: 10.1007/s10461-014-0914-9. AIDS Behav. 2015 Jul;19(7):1298-304. doi: 10.1007/s10461-014-0914-9.

This study compares sexual risk behaviors among male and female migrant market vendors in Almaty, Kazakhstan. From the Barakholka Market, 209 male and 213 female market vendors were randomly recruited. Self-reported data were collected through standardized face-to-face interviews. Dry blood spot was used as specimen for syphilis testing. Propensity score stratification was used to estimate adjusted prevalence or rate ratios by gender. Compared to male migrant workers, females had lower HIV knowledge and were less likely to have multiple sexual partners. There was no evidence of a gender difference for prevalence of syphilis, condom use with unsteady partners, and safe sex communication between couples. Associations between mobility patterns and engagement in multiple sexual partnerships were stronger among women than men. Efforts should be made to mitigate the gender differential in HIV knowledge among migrants, especially women. Such efforts need to be implemented in both home and host countries.

Abstract  Full-text [free] access

Editor’s notes: Migration and mobility have been shown to be contributing factors to increased risk of HIV around the world. This is due to a number of factors, but most common are lack of social support, little or no access to services, and language and legal issues. Depending on socio-economic contexts, women and men will often leave their homes for periods of time to trade or work in agriculture or construction in other domestic or international locations. This paper examines the relationship between gender and sexual risk behaviours in Almaty, the financial capital of Kazakhstan. Kazakhstan, and Almaty in particular, is a hub for trade migrants from all over Central Asia. The paper notes the lack of accurate statistics for gender distribution among migrants, but estimates indicate ahigh proportion are women. Overall, the study found that the migrant population surveyed was more likely to have multiple sexual partners than the general population, although the data used as the general population comparison was somewhat dated. Women were less likely to be educated about HIV than men, and while also less likely to have multiple sexual partners than men, the partnerships they did have were closely linked to their mobility and the time spent at market. This study provides important insights into the HIV and sexual risk contexts in this region, and highlights the importance of continuing research there in order to inform HIV prevention and care programmes which can better support population needs. 

Asia
Kazakhstan
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DMPA contraception users more likely than NET-EN users to acquire HIV in South Africa

Risk of HIV-1 acquisition among women who use different types of injectable progestin contraception in South Africa: a prospective cohort study.

Noguchi LM, Richardson BA, Baeten JM, Hillier SL, Balkus JE, Chirenje ZM, Bunge K, Ramjee G, Nair G, Palanee-Phillips T, Selepe P, van der Straten A, Parikh UM, Gomez K, Piper JM, Watts DH, Marrazzo JM. Lancet HIV. 2015 Jul 1;2(7):e279-e287.

Background: Several observational studies have reported that HIV-1 acquisition seems to be higher in women who use depot medroxyprogesterone acetate (DMPA) than in those who do not use hormonal contraception. We aimed to assess whether two injectable progestin-only contraceptives, DMPA and norethisterone enanthate (NET-EN), confer different risks of HIV-1 acquisition.

Methods: We included data from South African women who used injectable contraception while participating in the VOICE study, a multisite, randomised, placebo-controlled trial that investigated the safety and efficacy of three formulations of tenofovir for prevention of HIV-1 infection in women between Sept 9, 2009, and Aug 13, 2012. Women were assessed monthly for contraceptive use and incident infection. We estimated the difference in incident HIV-1 infection between DMPA and NET-EN users by Cox proportional hazards regression analyses in this prospective cohort. The VOICE trial is registered with ClinicalTrials.gov, NCT00705679.

Findings: 3141 South African women using injectable contraception were included in the present analysis: 1788 (56.9%) solely used DMPA, 1097 (34.9%) solely used NET-EN, and 256 (8.2%) used both injectable types at different times during follow-up. During 2733.7 person-years of follow-up, 207 incident HIV-1 infections occurred (incidence 7.57 per 100 person-years, 95% CI 6.61-8.68). Risk of HIV-1 acquisition was higher among DMPA users (incidence 8.62 per 100 person-years, 95% CI 7.35-10.11) than among NET-EN users (5.67 per 100 person-years, 4.35-7.38; hazard ratio 1.53, 95% CI 1.12-2.08; p=0.007). This association persisted when adjusted for potential confounding variables (adjusted hazard ratio [aHR] 1.41, 95% CI 1.06-1.89; p=0.02). Among women seropositive for herpes simplex virus type 2 (HSV-2) at enrolment, the aHR was 2.02 (95% CI 1.26-3.24) compared with 1.09 (0.78-1.52) for HSV-2-seronegative women (pinteraction=0.07).

Interpretation: Although moderate associations in observational analyses should be interpreted with caution, these findings suggest that NET-EN might be an alternative injectable drug with a lower HIV risk than DMPA in high HIV-1 incidence settings where NET-EN is available.

Abstract access

Editor’s notes: In eastern and southern Africa, injectable methods are the most popular contraceptives. But evidence that the injectable progestin depot medroxyprogesterone acetate (DMPA) is associated with an increased risk of HIV-1 acquisition means that alternative injectable contraceptive methods are necessary. This large prospective study used data from the VOICE HIV prevention trial, analysing data from South Africa on 3141 women who had used one of two progestin methods for contraception. HIV incidence was high in the population (7.57/100 person-years overall), and participants who used DMPA were 40% more likely to become HIV positive than women who used norethisterone enanthate (NET-EN) after adjustment for demographic and behavioural confounding variables. Strengths of this study include the comparability across women using progestin methods, and its frequent follow up visits to assess HIV status, contraception use, sexual behaviour and the presence of reproductive tract infections. The results suggest NET-EN might be an alternative injectable contraceptive with a lower risk for HIV-1 acquisition than DMPA.

Africa
South Africa
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Building a PrEP bridge: is it cost-effective?

Cost-effectiveness of pre-exposure prophylaxis targeted to high-risk serodiscordant couples as a bridge to sustained ART use in Kampala, Uganda.

Ying R, Sharma M, Heffron R, Celum CL, Baeten JM, Katabira E, Bulya N, Barnabas RVP. J Int AIDS Soc. 2015 Jul 20;18(4 Suppl 3):20013. doi: 10.7448/IAS.18.4.20013. eCollection 2015.

Introduction: Despite scale-up of antiretroviral therapy (ART) for treating HIV-positive persons, HIV incidence remains elevated among those at high risk such as persons in serodiscordant partnerships. Antiretrovirals taken by HIV-negative persons as pre-exposure prophylaxis (PrEP) has the potential to avert infections in individuals in serodiscordant partnerships. Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV-positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation.

Methods: To estimate the real world delivery costs of PrEP, we conducted micro-costing and time and motion analyses in an open-label prospective study of PrEP and ART delivery targeted to high-risk serodiscordant couples in Uganda (the Partners Demonstration Project). The cost (in USD, in 2012) of PrEP and ART for serodiscordant couples was assessed, with and without research components, in the study setting. Using Ministry of Health costs, the cost of PrEP and ART provision within a government programme was estimated, as was the cost of providing PrEP in addition to ART. We parameterized an HIV transmission model to estimate the health and economic impacts of 1) PrEP and ART targeted to high-risk serodiscordant couples in the context of current ART use and 2) increasing ART coverage to 55% of HIV-positive persons with CD4 ≤500 cells/µL without PrEP. The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years.

Results: The annual cost of PrEP and ART delivery for serodiscordant couples was $1058 per couple in the study setting and $453 in the government setting. The portion of the programme cost due to PrEP was $408 and $92 per couple per year in the study and government settings, respectively. Over 10 years, a programme of PrEP and ART for high-risk serodiscordant couples was projected to avert 43% of HIV infections compared to current practice with an ICER of $1340 per infection averted. This was comparable to ART expansion alone, which would avert 37% of infections with an ICER of $1452.

Conclusions: Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings. The annual cost of PrEP in this programme is less than $100 per serodiscordant couple if implemented in public clinics.

Abstract  Full-text [free] access 

Editor’s notes: Antiretroviral therapy (ART) is an effective way of preventing onward transmission of HIV. However, HIV-negative partners in serodiscordant couples remain at risk during the period before the HIV-positive partner starts ART and in the period between treatment initiation and virologic suppression. Time-limited PrEP is proposed as a means to bridge this gap and reduce the risk of transmission. This study looked at the cost-effectiveness of introducing PrEP in this context. It compared that to the cost-effectiveness of increasing ART coverage. The study also looked at costs in the study clinic which was private, as well as modelled to estimate cost of delivery through the Ministry of Health.

One of the study’s strengths is that it is based on a micro-costing exercise, which had not been done before, on the programmatic costs of PrEP implementation. This is very important as cost-effectiveness studies on this topic can often be based on cost assumptions that are unrepresentative or outdated. This data was then used to model the different scenarios using a dynamic transmission model.

The study found that, in terms of infections averted, combining PrEP and ART and ART scale-up were both very cost-effective. But combining PrEP and ART averted more infections than ART scale-up in relation to the baseline (43% versus 37%, respectively). When looking at disability-adjusted life years (DALYs) averted, combining ART and PrEP was not shown to be cost-effective, but would avert 62% more DALYs than baseline. ART scale-up on the other hand was very cost-effective and would avert 60% more DALYs than baseline.

It is important to note that the study is reliant on a relatively small sample. It seems that only one clinic was sampled and a relatively small number of visits were timed to determine staff costs. Further, the study makes certain assumptions that are left unexplained, such as including the costs of viral load point-of-care tests, which are largely unknown as the technology has yet to be implemented. However, despite these shortfalls, the study is significant because it could help to inform country guidelines on how to target PrEP for specific key populations, in this case serodiscordant couples. A worthwhile follow-up of this study would look at patient-level costs associated with this PrEP delivery strategy, which could potentially have an effect on uptake, and which may vary between key populations.

Health care delivery
Africa
Uganda
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Wide variation in national HIV policies associated with HIV testing and treatment across six African countries

A comparative analysis of national HIV policies in six African countries with generalized epidemics.

Church K, Kiweewa F, Dasgupta A, Mwangome M, Mpandaguta E, Gomez-Olive FX, Oti S, Todd J, Wringe A, Geubbels E, Crampin A, Nakiyingi-Miiro J, Hayashi C, Njage M, Wagner RG, Ario AR, Makombe SD, Mugurungi O, Zaba B. Bull World Health Organ. 2015 Jul 1;93(7):457-67. doi: 10.2471/BLT.14.147215. Epub 2015 Apr 28.

Objective: To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.

Methods: We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.

Findings: There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.

Conclusion: Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.

Abstract  Full-text [free] access

Editor’s notes: Despite evidence on reduction in HIV attributable mortality, concerns still remain on the high attrition rates across the diagnosis-to-treatment cascade. This paper uses a comparative policy analysis to track differences in national HIV policy responses to the HIV epidemic. The methodology used is notable as it offers a helpful conceptual framework for the HIV policy and service factors influencing specific differences in HIV-associated adult mortality across the diagnosis-to-treatment cascade.

The range of policies between countries was unexpected, given the explanation offered by the authors that African countries tend to adopt standards and guidance from WHO. Furthermore, while countries showed progressive elements, no country had the comprehensive policy context necessary for a decisive impact on service access. Important differences were also noted in the influential weight given to some policies, in the timing of policy implementation in some indicators, and in whether WHO national standards were or were not adopted by countries.

These findings are particularly useful in better understanding the incentives and barriers to accessing antiretroviral therapy in different contexts.

Africa
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Careful planning may be the best strategy for safer conception

Benefits of PrEP as an adjunctive method of HIV prevention during attempted conception between HIV-uninfected women and HIV-infected male partners.

Hoffman RM, Jaycocks A, Vardavas R, Wagner G, Lake JE, Mindry D, Currier JS, Landovitz RJ. J Infect Dis. 2015 Jun 19. pii: jiv305. [Epub ahead of print]

Background: Data on effectiveness of preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)-uninfected women attempting conception with HIV-infected male partners are limited to observational studies.

Methods: To explore the benefits of PrEP for conception, we developed a model to estimate the average annual probability of a woman remaining HIV-uninfected and having a child ("successful" outcome) via condomless sex with an HIV-infected male. The outcome likelihood is dependent upon parameters defining HIV-1 infectivity. We simulated 2 scenarios: optimal (condomless sex acts limited to the ovulation window), and suboptimal (acts not limited to ovulation).

Results: In the optimal scenario when the male is on antiretroviral therapy (ART), the average annual probability of the successful outcome is 29.1%, increasing to 29.2% with the addition of PrEP (P = .45). In the suboptimal scenario, the probability is 26.8% with ART alone versus 27.3% with ART/PrEP (P < .0001). Older maternal age reduces the probability of success in both scenarios, particularly after age 30.

Conclusions: In our model, PrEP provides little added benefit when the HIV-infected male partner is on ART, condomless sex is limited to the ovulation window, and other modifiable transmission risks are optimized. Older female age decreases the probability of success by increasing the number of condomless sex acts required for conception.

Abstract access

Editor’s notes: Antiretrovirals (ARVs) have been shown in several studies to be highly effective in preventing both the acquisition of HIV in HIV negative individuals, and the transmission of HIV from HIV positive people to HIV negative people. However, the real-world application of these activities is still being investigated. This paper explores a strategy currently in discussion to use ARVs for safer conception in which the HIV negative partner might take pre-exposure prophylaxis (PrEP) and the HIV positive partner may be taking HIV treatment. The model employed in this paper looked specifically at the added benefit of the HIV negative woman taking PrEP. The results of the model illustrated that there was no added benefit of the woman taking PrEP if her HIV positive partner was taking HIV treatment consistently and they kept the number of condomless sex acts to the minimum required for the best chance of conception. Interestingly, as the woman in the model increases in age so do the number of condomless sex acts required to conceive, thus increasing the risk of acquiring HIV. While this paper illustrated that PrEP may not be worth the added expense, there may be situations where it still can provide added security to couples. Ultimately, models cannot completely account for what happens in real-life, and as the paper counsels, it will be up to physicians and their patients to decide what is best on a case by case basis. 

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