Articles tagged as "Reduce sexual transmission"

Sexual risk reduction and behavioural programme increases uptake of circumcision in hard-to-reach men

A cluster randomized controlled trial to increase the availability and acceptability of voluntary medical male circumcision in Zambia: the Spear and Shield Project.

Weiss SM, Zulu R, Jones DL, Redding CA, Cook R, Chitalu N. Lancet HIV. 2015 May 1;2(5):e181-e189.

Background: Widespread voluntary medical male circumcision in Africa could avert an estimated 3.436 million HIV infections and 300 000 deaths over the next 10 years. Most Zambian men have expressed little interest in the procedure. We tested the effect of the Spear and Shield intervention designed to increase demand for voluntary medical male circumcision among these hard-to-reach men.

Methods: This cluster randomised controlled trial was done between Feb 1, 2012, and Oct 31, 2014, in Lusaka, Zambia, where HIV prevalence is 20.8%. 13 community health centres were stratified by HIV voluntary counselling and testing rates and patient census, and randomly assigned (5:5:3) to experimental (the intervention), control, or observation-only conditions. Community health centre health-care providers at all 13 sites received training in voluntary medical male circumcision. Eligible participants were aged at least 18 years, HIV-negative, uncircumcised, and had not proactively requested or planned for voluntary medical male circumcision at the time of enrolment. Trial statisticians did not participate in randomisation. After voluntary counselling and HIV testing, participants were recruited; female partners were invited to participate. The primary outcomes at the individual level were the likelihood of voluntary medical male circumcision by 12 months post intervention, and condom use after voluntary medical male circumcision among participants receiving the intervention. The trial is registered with ClinicalTrials.gov, number NCT01688167.

Findings: 800 uncircumcised HIV-negative men (400 in the experimental group, 400 in the control group) were enrolled. 161 participants in the experimental group and 96 in the control group had voluntary medical male circumcision (adjusted odds ratio 2.45, 95% CI 1.24–4.90; p=0.02). Condom use was examined in participants who had voluntary medical male circumcision and reported sexual activity within 1 month of a post-circumcision assessment (88 in the experimental group and 64 in the control group). Condom use over time increased in the experimental group (p=0.03) but not in the control group (p=0.2). One patient died in each group; no adverse events related to study participation were reported.

Interpretation: Comprehensive HIV prevention programmes can increase the demand for and uptake of voluntary medical male circumcision services.

Abstract access

Editor’s notes: Voluntary medical male circumcision reduces the risk of HIV acquisition in men by approximately 60%, yet in some high-prevalence countries uptake is low. This presents challenges in meeting WHO targets of 80% coverage. In Zambia, only 37% of the national target has been achieved. In this cluster randomised trial, 13 community health centres were randomised to receive training in the “Spear and Shield” programme, control (training for an equivalent period of time on general disease prevention strategies) or observation only. The Spear and Shield programme consisted of four weekly 90 minute group sessions. Men in the programme group had about 2.5 times the odds of having male circumcision, compared to the control group participants. This increase in uptake of male circumcision was not associated with an increase in sexual risk behaviours. In fact there was an increase in condom use in the programme group. According to WHO, demand creation continues to be the major challenge in meeting male circumcision coverage goals. The authors propose that scaling up an evidence-informed programme such as Spear and Shield, while training community health care workers to perform circumcisions, might be one of the best and most cost-effective ways to significantly reduce HIV rates in high-incidence settings.

Africa
Zambia
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Antiretroviral therapy availability associated with increased HIV disclosure

Antiretroviral therapy availability and HIV disclosure to spouse in Rakai, Uganda: a longitudinal population-based study.

Haberlen SA, Nakigozi G, Gray RH, Brahmbhatt H, Ssekasanvu J, Serwadda D, Nalugoda F, Kagaayi J, Wawer MJ. J Acquir Immune Defic Syndr. 2015 Jun 1;69(2):241-7. doi: 10.1097/QAI.0000000000000600.

Background: A decade after the rollout of antiretroviral therapy (ART) in sub-Saharan Africa, the effects of this structural change on social aspects of HIV, such as rates of HIV disclosure to partners, remain largely unmeasured. We evaluated whether the introduction of ART was associated with disclosure of HIV diagnosis to spouses in Rakai, Uganda, using longitudinal, population-based data.

Methods: We identified individuals in marital/cohabitating unions who were newly diagnosed with HIV in Rakai Community Cohort Study surveys between 2000 and 2008, where ART was introduced in mid-2004. Using discrete-time survival analysis, we assessed the hazard of self-reported HIV disclosure to spouse after diagnosis pre-ART and post-ART rollout, adjusting for individual and union characteristics. Disclosure in the ART period was further stratified by ART initiation.

Results: The analysis included 557 married adults, 264 of whom were diagnosed with HIV before ART was available (2000-2004), and 293 diagnosed after ART was introduced (2005-2008). The cumulative incidence of self-reported disclosure was 75.2% in the post-ART period, compared with 58.3% before ART availability [P < 0.001, adjusted hazard ratio: 1.46 (95% confidence interval: 1.16 to 1.83)]. In the post-ART period, observed disclosure rates were 39% (72 of 184) among those not in HIV care, 65% (82 of 126) among those in pre-ART care, and 85% (64 of 75) among persons on ART (P < 0.001).

Conclusions: Treatment availability and use, especially ART initiation, was associated with increased self-disclosure of HIV diagnosis to partners. ART access may facilitate the prevention of transmission to uninfected partners and linkage to treatment for infected couples.

Abstract access

Editor’s notes: For effective prevention of sexual transmission of HIV, it is important that individuals who are HIV positive disclose their status to their spouses and other sexual partners. However, anticipation of possible negative consequences of disclosure of HIV positive status can be a significant barrier to disclosure. Access to antiretroviral therapy (ART) has increased considerably in low- and middle-income countries since 2003. Longitudinal data on the effect of ART availability and HIV disclosure in general African populations is limited. This study investigated whether increased access to ART has had an impact on disclosure of newly diagnosed HIV infection to spouses by men and women in stable unions in Rakai, Uganda. Although the study population was relatively small, the investigators demonstrated availability of ART was associated with increased self-disclosure of HIV infection to a spouse. It is possible that some disclosures may have been unintended, as it would be difficult to conceal treatment, including frequent clinic visits, from a spouse or co-habiting partner. Even so, the increase in disclosures among both men and women was significant. Furthermore, the desire to access ART was documented as a motivating factor to disclose HIV diagnosis. Although a relatively high rate of disclosure was observed in this study, a substantial subset of adults had not shared their HIV diagnosis with their partners. This highlights the importance of supportive models of care, in addition to ART, to facilitate safe disclosure of HIV infection.      

Africa
Uganda
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Heterosexual anal sex is perceived to be a common practice in southern Tanzania

How long-distance truck drivers and villagers in rural southeastern Tanzania think about heterosexual anal sex: a qualitative study.

Mtenga S, Shamba D, Wamoyi J, Kakoko D, Haafkens J, Mongi A, Kapiga S, Geubbels E. Sex Transm Infect. 2015 Jun 25. pii: sextrans-2015-052055. doi: 10.1136/sextrans-2015-052055. [Epub ahead of print]

Objective: To explore ideas of truck drivers and villagers from rural Tanzania about heterosexual anal sex (HAS) and the associated health risks.

Methods: Qualitative study using 8 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with truck drivers and 16 IDIs and 4 FGDs with villagers from the Morogoro region. Study participants included 24 women and 46 men. Data analysis was performed thematically employing standard qualitative techniques.

Results: Reasons why men would practice HAS included sexual pleasure, the belief that anal sex is safer than vaginal sex, alternative sexual practice, exploration and proof of masculinity. Reasons why women would practice HAS included financial need, retaining a partner, alternative for sex during menses, pregnancy prevention and beauty enhancement because HAS is believed to 'fatten the female buttocks'. Most participants believed that condoms are not needed during HAS. This was linked to the ideas that infections only 'reside in wet places' (vagina) and that the anus is not 'conducive' for condom use; condoms reduce 'dryness' and 'friction' (pleasure) and may 'get stuck inside'.

Conclusions: The study participants reported practices and ideas about HAS that put them at risk for HIV and sexually transmitted infections. Greater attention to education about HAS is urgently needed in Tanzania, where this sexual practice is still regarded as a taboo. This study offers useful information that could be included in sex education programmes.

Abstract access

Editor’s notes: This paper explores the views of truck drivers and villagers on heterosexual anal sex. During in-depth interviews and focus group discussions in the Morogoro region of the United Republic of Tanzania the researchers asked participants about their opinions on sexual practices more broadly and specifically on heterosexual anal sex. The findings reveal that the participants perceive that heterosexual anal sex is becoming a common practice. In discussing why men practice heterosexual anal sex, the participants suggested that sexual pleasure, fulfilment of ideas of masculinity, and sexual exploration were the main reasons. For women, however, the participants suggested that the main reasons were financial, maintaining their relationships, pregnancy prevention, for sex during menstruation, and ‘fattening female buttocks’. When asked about HIV protection, many participants did not perceive that condom protection was feasible or required during heterosexual anal sex. The findings, while based on perceptions of the behaviour of ‘others’ and not on own accounts, suggest that heterosexual anal sex is more widespread in Tanzania than often assumed. And if it is a widespread and unprotected sexual practice, it is an important route of HIV infection.

Africa
United Republic of Tanzania
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Men who have sex with men in sub-Saharan Africa: a review of the evidence

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review.

Dijkstra M, van der Elst EM, Micheni M, Gichuru E, Musyoki H, Duby Z, Lange JM, Graham SM, Sanders EJ. Int Health. 2015 May;7(3):151-162. Epub 2015 Jan 16.

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011-2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online training.

Abstract  Full-text [free] access

Editor’s notes: Same sex practices remain criminalised in sub-Saharan Africa. Gay men and other men who have sex with men face stigma, discrimination, harassment and arrest. Health care workers frequently have no training on issues affecting gay men and other men who have sex with men and are ill-prepared to work sensitively with them. Together these can deter these men from accessing health care and HIV/STI services, increasing their risk of HIV and other poor health outcomes.

This study conducted a systematic review of gay men and other men who have sex with men in sub-Saharan Africa. The findings were used to update an on-line training programme for health care workers in Kenya. This previously comprised modules on i) men who have sex with men and HIV in Africa ii) homophobia: stigma and its effects; iii) sexual identity, coming out and disclosure; iv) anal sex and common sexual practices; v) HIV and STIs; vi) condom and lubricant use; vii) mental health: anxiety, depression and substance use; and viii) risk-reduction counselling. The review updated the training programme with new evidence and two new modules were introduced: ix) ART adherence; and x) community engagement.

Health care workers play a crucial role in reducing stigma and discrimination facing gay men and other men who have sex with men. This systematic review provided a valuable step in updating an important, accessible training programme. Reducing homoprejudice and ensuring health care workers have accurate and up-to-date knowledge are key to improving service uptake by gay men and other men who have sex with men.

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Pooled ribonucleic acid testing to maximize detection of acute HIV infection

Impact of nucleic acid testing relative to antigen/antibody combination immunoassay on the detection of acute HIV infection.

De Souza MS, Phanuphak N, Pinyakorn S, Trichavaroj R, Pattanachaiwit S, Chomchey N, Fletcher JL, Kroon ED, Michael NL, Phanuphak P, Kim JH, Ananworanich J, RV254SEARCH 010 Study Group. AIDS. 2015 Apr 24;29(7):793-800. doi: 10.1097/QAD.0000000000000616.

Objective: To assess the addition of HIV nucleic acid testing (NAT) to fourth-generation (4thG) HIV antigen/antibody combination immunoassay in improving detection of acute HIV infection (AHI).

Methods: Participants attending a major voluntary counseling and testing site in Thailand were screened for AHI using 4thG HIV antigen/antibody immunoassay and sequential less sensitive HIV antibody immunoassay. Samples nonreactive by 4thG antigen/antibody immunoassay were further screened using pooled NAT to identify additional AHI. HIV infection status was verified following enrollment into an AHI study with follow-up visits and additional diagnostic tests.

Results: Among 74 334 clients screened for HIV infection, HIV prevalence was 10.9% and the overall incidence of AHI (N = 112) was 2.2 per 100 person-years. The inclusion of pooled NAT in the testing algorithm increased the number of acutely infected patients detected, from 81 to 112 (38%), relative to 4thG HIV antigen/antibody immunoassay. Follow-up testing within 5 days of screening marginally improved the 4thG immunoassay detection rate (26%). The median CD4 T-cell count at the enrollment visit was 353 cells/µL and HIV plasma viral load was 598 289 copies/ml.

Conclusion: The incorporation of pooled NAT into the HIV testing algorithm in high-risk populations may be beneficial in the long term. The addition of pooled NAT testing resulted in an increase in screening costs of 22% to identify AHI: from $8.33 per screened patient to $10.16. Risk factors of the testing population should be considered prior to NAT implementation given the additional testing complexity and costs.

Abstract access

Editor’s notes: Acute HIV infection (AHI) is generally defined as the time between HIV acquisition and the appearance of detectable antibodies. Individuals with AHI are highly infectious, at least partly due to high viral load. Effective strategies to identify people with AHI could therefore plausibly reduce transmission, although the extent to which AHI drives transmission at a population level continues to be debated. Although the fourth generation immunoassays, incorporating detection of p24 antigen, have been shown to detect infection earlier, there is still a period during which only HIV ribonucleic acid (RNA) can be detected. High costs limit the routine use of HIV RNA testing for this purpose. Pooling samples is one way to potentially reduce costs.

This research was part of a study aimed at detection and treatment of AHI in an urban population of predominantly gay men and other men who have sex with men in Bangkok. Samples that tested negative on fourth generation immunoassay were pooled (median pool size was 14 samples) before undergoing HIV RNA testing. Some 31 pools were positive (0.5% of pools tested) and one positive specimen was then identified from each of those pools. Overall, this constituted only around a quarter of all AHI cases detected. The remainder were defined as AHI on the basis of positive fourth generation but negative second and third generation antibody tests. Individuals detected only by HIV RNA had somewhat lower viral loads than people detected by immunoassay. Follow-up testing illustrated that this was a time when viral load was increasing rapidly. This highlights the potential impact that detection and treatment at this stage could have on reducing onward transmission.

Although interpretation of the study is somewhat complicated by the use of several different assays during the study and complicated algorithms to define outcomes, the basic message seems clear. Fourth generation immunoassays may detect the majority of acute infections. But there may still be a role for pooled HIV RNA testing in certain key populations to maximize detection of AHI. This study was not really designed to evaluate the real world impact of the testing strategy, as follow-up was very tightly controlled and almost all people initiated ART within one week. Although there was some basic costing analysis included, more detailed cost-effectiveness studies will be important to understand whether or not pooled HIV RNA testing has a role in routine practice.

Asia
Thailand
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The need to improve follow-up among voluntary medical male circumcision clients

Implementation and operational research: evaluation of loss-to-follow-up and postoperative adverse events in a voluntary medical male circumcision program in Nyanza Province, Kenya.

Reed JB, Grund J, Liu Y, Mwandi Z, Howard AA, McNairy ML, Chesang K, Cherutich P, Bock N. J Acquir Immune Defic Syndr. 2015 May 1;69(1):e13-23. doi: 10.1097/QAI.0000000000000535.

Background: More than 4.7 million voluntary medical male circumcisions (VMMCs) had been provided by HIV prevention programs in sub-Saharan Africa through 2013. All VMMC clients are recommended to return to the clinic for postoperative follow-up, although adherence is variable. The clinical status of clients who do not return is largely unknown.

Methods: VMMC clients from Nyanza Province, Kenya, aged older than or equal to 13 years, were recruited immediately after surgery from April to October 2012 from high-volume sites. Medical record reviews at 13-14 days after surgery indicated which clients had been adherent with recommended follow-up (ADFU) and which were lost-to-follow-up (LTFU). Clients in the LTFU group received clinical evaluations at home approximately 2 weeks postsurgery. Adverse events (AEs) and AE rates were compared between the ADFU and LTFU groups.

Results: Of 4504 males approached in 50 VMMC sites, 1699 (37.7%) were eligible and enrolled and 1600 of 1699 (94.2%) contributed to follow-up and AE data. Medical record review indicated 897 of 1600 (56.1%) were LTFU, and 762 (84.9%) of these received home-based clinical evaluations. The rate of moderate or severe AE diagnosis was 6.8% in the LTFU group vs. 3.3% in the ADFU group (relative risk = 2.1, 95% confidence interval: 1.3 to 3.4).

Conclusions: The moderate or severe AE diagnosis rate was approximately 2 times higher in the LTFU group. National programs should consider instituting surveillance systems to detect AEs that might otherwise go unnoticed. Providers should emphasize the importance of follow-up and actively contact LTFU clients to ensure care is provided throughout the entire postoperative course for all.

Abstract access 

Editor’s notes: Latest estimates suggest that over nine million men have undergone voluntary medical male circumcision (VMMC) to reduce their risk of HIV infection. In Kenya, VMMC clients are instructed to return to the clinic site within seven days of surgery for follow-up including assessment of adverse events (AEs). In this large study, over half of circumcised men from 50 sites did not return to the clinic for follow-up. These men were more likely to be 18 to 24 years (versus younger or older than this), with little formal education, without access to a car, and using multiple transportation methods. Follow-up of these men at home indicated that they had over twice the risk of a moderate or severe AE compared with individuals who did adhere to recommended follow-up (ADFU).  The difference in risk between the ADFU and LTFU groups was mainly for infection, wound disruption and pain. The study confirms that VMMC clients who do not return to the clinic should not be assumed to be healing without complications, and VMMC programmes should try novel approaches to improve follow-up rates and continue to reinforce the importance of follow-up.

Africa
Kenya
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Community-based rapid testing boosts case finding among MSM in China

Case finding advantage of HIV rapid tests in community settings: men who have sex with men in 12 programme areas in China, 2011.

Zhang D, Qi J, Fu X, Meng S, Li C, Sun J. Int J STD AIDS. 2015 May;26(6):402-13. doi: 10.1177/0956462414542986. Epub 2014 Jul 15.

We sought to describe the advantage of rapid tests over ELISA tests in community-based screening for HIV among men who have sex with men (MSM) in urban areas of China. Data of 31 406 screening tests conducted over six months in 2011 among MSM across 12 areas were analyzed to compare the differences between those receiving rapid testing and ELISA. Rapid tests accounted for 45.8% of these screening tests. The rate of being screened positive was 7.2% among rapid tests and 5.3% for ELISA tests (X(2)= 49.161, p < 0.001). This advantage of rapid test in HIV case finding persisted even when socio-demographic, behavioural, screening recruitment channel and city were controlled for in logistic regression (exp[beta] = 1.42, p < 0.001, 95% CI = 1.27,1.59). MSM who received rapid tests, compared with those tested by ELISA, were less likely to use condoms during last anal sex (50.8% vs. 72.3%, X(2)= 1706.146, p < 0.001), more likely to have multiple sex partners (55.7% vs. 49.5%, X(2)= 238.188, p < 0.001) and less likely to have previously undergone HIV testing (38.8% vs. 54.7%, X(2)= 798.476, p < 0.001). These results demonstrate the robustness of the advantage of rapid tests over traditional ELISA tests in screening for MSM with HIV infection in cooperation with community-based organizations in urban settings in China.

Abstract access

Editor’s notes: The prevalence of HIV among gay men and other men who have sex with men in China has increased from 1% to 5% between 2006 and 2011. The increase in prevalence has motivated the development of a new HIV testing strategy to reach this key population. The China-Gates HIV Programme facilitated partnerships between local government health departments with community-based organizations (CBO) to reach and offer rapid HIV screening tests to gay men and other men who have sex with men in 14 cities and one province. Between July and December 2011, 17 015 men were tested through established HIV testing sites (run solely by the health departments, which used enzyme-linked immunosorbent assay [ELISA] testing) and another 14 391 men were tested at sites which were established, promoted, and run by the government-CBO partnerships. These sites used rapid HIV tests, and referred to the health department for confirmatory testing. After controlling for sociodemographic characteristics, transmission risk factors and geographic location, the odds of testing positive for HIV was 42% higher for men who were screened at partnership sites. This partnership demonstrates an innovative, culturally appropriate and scale-able model. For key populations, partnerships of this nature can lead to earlier treatment initiation and a reduction in secondary transmission.

Asia
China
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Self-report and pill count: unreliable measures of adherence in HIV prevention trials

Accuracy of self-report and pill-count measures of adherence in the FEM-PrEP clinical trial: implications for future HIV-prevention trials.

Agot K, Taylor D, Corneli AL, Wang M, Ambia J, Kashuba AD, Parker C, Lemons A, Malahleha M, Lombaard J, Van Damme L. AIDS Behav. 2015 May;19(5):743-51. doi: 10.1007/s10461-014-0859-z.

Oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) has been evaluated as pre-exposure prophylaxis (PrEP). We describe the accuracy of self-reported adherence to FTC/TDF and pill counts when compared to drug concentrations in the FEM-PrEP trial. Using drug concentrations of plasma tenofovir (TFV) and intracellular tenofovir diphosphate (TFVdp) among a random sub-sample of 150 participants assigned to FTC/TDF, we estimated the positive predictive value (PPV) of four adherence measures. We also assessed factors associated with misreporting of adherence using multiple drug-concentration thresholds and explored pill use and misreporting using semi-structured interviews (SSIs). Reporting use of ≥1 pill in the previous 7 days had the highest PPV, while pill-count data consistent with missing ≤1 day had the lowest PPV. However, all four measures demonstrated poor PPV. Reported use of oral contraceptives (OR 2.26; p = 0.014) and weeks of time in the study (OR 1.02; p < 0.001) were significantly associated with misreporting adherence. Although most SSI participants said they did not misreport adherence, participant-dependent adherence measures were clearly unreliable in the FEM-PrEP trial. Pharmacokinetic monitoring remains the measure of choice until more reliable participant-dependent measures are developed.

Abstract  Full-text [free] access

Editor’s notes: A number of studies have demonstrated that pre-exposure prophylaxis (PrEP) is effective in reducing HIV transmission when adherence is high. Understanding factors affecting adherence, and evaluating methods to best measure adherence are therefore of crucial importance. Despite excellent self-reported adherence, the FEM-PrEP and VOICE trials did not illustrate a benefit of PrEP. In this study, drug concentrations were assessed in 1200 visits from 150 FEM-PrEP trial participants to determine adherence. These results were used to assess the accuracy of three measures of self-reported adherence and also pill counting. All four measures had poor positive predictive value, ranging from 26.2% to 42.4%. There was an increase in misreporting of adherence over time which may be associated with lower adherence levels over time. In semi-structured interviews, most participants said that they did not misreport adherence. The authors call for improvements in methods to reduce socially desirable responses through participant self-report, and examination of the reasons why people join HIV prevention trials. Future trials may also need to consider using drug concentrations in addition to currently used methods to better estimate adherence.

Africa
Kenya, South Africa
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Valuable lessons can be learned from repeat PEP use in female sex workers

Repeat use of post-exposure prophylaxis for HIV among Nairobi-based female sex workers following sexual exposure.

Izulla P, McKinnon LR, Munyao J, Ireri N, Nagelkerke N, Gakii G, Gelmon L, Nangami M, Kaul R, Kimani J. AIDS Behav. 2015 May 13. [Epub ahead of print]

As ART-based prevention becomes available, effectively targeting these interventions to key populations such as female sex workers (FSW) will be critical. In this study we analyze patterns of repeated post-exposure prophylaxis (PEP) access in the context of a large FSW program in Nairobi. During close to 6000 person-years of follow-up, 20% of participants (n = 1119) requested PEP at least once and 3.7% requested PEP more than once. Repeat PEP users were younger, had a higher casual partner volume, and were more likely to use condoms with casual and regular partners, have a regular partner, and test for HIV prior to enrolment. Barriers to PEP included stigma, side effects, and lack of knowledge, suggesting repeated promotion may be required for higher rates of uptake. A small subset of FSW, potentially those with heightened risk perception, showed a higher frequency of PEP use; these individuals may be most amenable to rollout of pre-exposure prophylaxis.

Abstract access

Editor’s notes: Antiretroviral therapy based HIV prevention is growing, particularly the use of Pre-exposure prophylaxis (PrEP) which is effective when adherence is high. However, given the challenges associated with adherence, other options are essential. Post-exposure prophylaxis (PEP) following sexual exposure to HIV is an HIV prevention strategy that could be of benefit in some situations, and is recommended for risky exposure settings. This paper describes PEP use among sex workers in Nairobi. In particular, this paper examined repeat PEP use and the characteristics of female sex workers returning for additional courses of PEP. Interestingly, repeat PEP users seemed to perceive that they were at increased risk of HIV and were also more aware of PEP as a prevention option. Individuals who did not use PEP knew little to nothing about it, were afraid of stigma from community members and health care providers, and were concerned about side effects which they knew about from people on HIV treatment. These are essential factors to take into account when developing an implementation programme for future programmes, and especially PrEP which can learn from the past but will undoubtedly forge new paths in HIV prevention implementation and programming. 

Africa
Kenya
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Transient increase in HIV shedding from male circumcision wounds

HIV shedding from male circumcision wounds in HIV-infected men: a prospective cohort study.

Tobian AA, Kigozi G, Manucci J, Grabowski MK, Serwadda D, Musoke R, Redd AD, Nalugoda F, Reynolds SJ, Kighoma N, Laeyendecker O, Lessler J, Gray RH, Quinn TC, Wawer MJ, Rakai Health Sciences P. PLoS Med. 2015 Apr 28;12(4):e1001820. doi: 10.1371/journal.pmed.1001820. eCollection 2015.

Background: A randomized trial of voluntary medical male circumcision (MC) of HIV-infected men reported increased HIV transmission to female partners among men who resumed sexual intercourse prior to wound healing. We conducted a prospective observational study to assess penile HIV shedding after MC.

Methods and findings: HIV shedding was evaluated among 223 HIV-infected men (183 self-reported not receiving antiretroviral therapy [ART], 11 self-reported receiving ART and had a detectable plasma viral load [VL], and 29 self-reported receiving ART and had an undetectable plasma VL [<400 copies/ml]) in Rakai, Uganda, between June 2009 and April 2012. Preoperative and weekly penile lavages collected for 6 wk and then at 12 wk were tested for HIV shedding and VL using a real-time quantitative PCR assay. Unadjusted prevalence risk ratios (PRRs) and adjusted PRRs (adjPRRs) of HIV shedding were estimated using modified Poisson regression with robust variance. HIV shedding was detected in 9.3% (17/183) of men not on ART prior to surgery and 39.3% (72/183) of these men during the entire study. Relative to baseline, the proportion shedding was significantly increased after MC at 1 wk (PRR = 1.87, 95% CI = 1.12-3.14, p = 0.012), 2 wk (PRR = 3.16, 95% CI = 1.94-5.13, p < 0.001), and 3 wk (PRR = 1.98, 95% CI = 1.19-3.28, p = 0.008) after MC. However, compared to baseline, HIV shedding was decreased by 6 wk after MC (PRR = 0.27, 95% CI = 0.09-0.83, p = 0.023) and remained suppressed at 12 wk after MC (PRR = 0.19, 95% CI = 0.06-0.64, p = 0.008). Detectable HIV shedding from MC wounds occurred in more study visits among men with an HIV plasma VL > 50 000 copies/ml than among those with an HIV plasma VL < 400 copies/ml (adjPRR = 10.3, 95% CI = 4.25-24.90, p < 0.001). Detectable HIV shedding was less common in visits from men with healed MC wounds compared to visits from men without healed wounds (adjPRR = 0.12, 95% CI = 0.07-0.23, p < 0.001) and in visits from men on ART with undetectable plasma VL compared to men not on ART (PRR = 0.15, 95% CI = 0.05-0.43, p = 0.001). Among men with detectable penile HIV shedding, the median log10 HIV copies/milliliter of lavage fluid was significantly lower in men with ART-induced undetectable plasma VL (1.93, interquartile range [IQR] = 1.83-2.14) than in men not on ART (2.63, IQR = 2.28-3.22, p < 0.001). Limitations of this observational study include significant differences in baseline covariates, lack of confirmed receipt of ART for individuals who reported ART use, and lack of information on potential ART initiation during follow-up for those who were not on ART at enrollment.

Conclusion: Penile HIV shedding is significantly reduced after healing of MC wounds. Lower plasma VL is associated with decreased frequency and quantity of HIV shedding from MC wounds. Starting ART prior to MC should be considered to reduce male-to-female HIV transmission risk. Research is needed to assess the time on ART required to decrease shedding, and the acceptability and feasibility of initiating ART at the time of MC.

Abstract  Full-text [free] access

Editor’s notes: Voluntary medical male circumcision (VMMC) decreases the heterosexual acquisition of HIV, herpes simplex virus type 2 and human papillomavirus (HPV) in men. There are also benefits for female partners. Among men living with HIV, VMMC reduces genital ulcer disease and HPV, but it does not reduce the risk of HPV transmission. Further, VMMC increases HIV transmission to female partners among people who engage in sex before wound healing, though not among couples who delay resumption of sex. Men living with HIV may seek VMMC for multiple reasons, and WHO guidelines state that they should not be denied the service if they request it. Despite counselling to abstain from sex until full wound healing, a substantial proportion of men resume sex before this. In this cohort study among HIV-positive men in Uganda, the authors found that penile HIV shedding had a transient increase after VMMC, peaking in the second week after VMMC. By 6 to 12 weeks after surgery, when wounds had healed, HIV shedding was lower than pre-surgery. There was no change in plasma viral load during the study. Among men with HIV shedding, the lowest quantities of shedding were observed among men on ART and with undetectable viral load. The authors highlight the potential role of ART to reduce the risk of HIV transmission following VMMC, for example by considering initiating ART prior to VMMC for men living with HIV, and encouraging adherence to suppress viral load.  With current WHO guidelines, the majority of men living with HIV attending for VMMC will be eligible for ART, and VMMC could be a useful entry point for treatment although this may pose logistical challenges.

Africa
Uganda
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