Articles tagged as "Reduce sexual transmission"

South African students support HIV testing in schools

“Students want HIV testing in schools” a formative evaluation of the acceptability of HIV testing and counselling at schools in Gauteng and North West provinces in South Africa.

Madiba S, Mokgatle M. BMC Public Health. 2015 Apr 17;15(1):388. [Epub ahead of print]

Background: The proposal by the South African Health Ministry to implement HIV testing and counselling (HTC) at schools in 2011 generated debates about the appropriateness of such testing. However, the debate has been between the Ministries of Education and Health, with little considerations of the students. The main aim of the study was to assess the students' opinions and uptake of HIV testing and counselling in general, and the acceptability of the provision of HIV testing and counselling in schools. The study also determined the association between socio-demographic characteristics, sexual behaviour, and HIV testing behaviour of the students.

Methods: A survey was conducted among grade 10-12 high school students in North West and Gauteng provinces, South Africa. Seventeen high schools (nine rural and eight urban) were randomly selected for the administration of a researcher-assisted, self-administered, semi-structured questionnaire.

Results: A total of 2970 students aged 14-27 years participated in the study; 1632 (55%) were girls, 1810 (61%) ever had sex, and 1271 (49.8%) had more than one sex partner. The mean age of first sexual activity was 15.6. Half (n = 1494, 50.1%) had been tested for HIV. Having multiple sexual partners, age, and gender were significantly associated with increased odds of having had a HIV test. Fear, being un-informed about HTC, and low HIV risk perceptions were the reasons for not getting tested. The acceptability of HTC at school was high (n = 2282, 76.9%) and 2129 (71.8%) were willing to be tested at school. Appropriateness, privacy, and secrecy were the main arguments for and against HTC at school. One-third (n = 860, 29%) had intentions to disclose their HIV status to students versus 1258 (42.5%) for teachers. Stigma, discrimination and secrecy were the primary reasons students did not intend to disclose.

Conclusions: A high acceptability of HTC and willingness to be tested at school suggest that HIV prevention programs tailored to youth have a high potential of success given the readiness of students to uptake HTC. Bringing HIV testing to the school setting will increase the uptake of HTC among youth and contribute towards efforts to scale up HTC in South Africa.

Abstract  Full-text [free] access

Editor’s notes: Strategies to promote HIV testing, the gateway to all prevention and treatment programmes, are continuously being developed and piloted with the goal of universal knowledge of HIV status. Adolescents, especially those first starting to have sex, are an important population for considering relevant, creative, and accessible testing programmes. This paper presents important insights into whether HIV testing would be acceptable in schools from the perspectives of the learners themselves. Researchers conducting this study in two provinces in South Africa found that only about half the adolescents they interviewed had ever tested, but most would be supportive of HIV tests available in their schools. Fear, lack of information, and risk perception were reasons for not having tested previously. It is possible that just the act of introducing testing to the schools would bring sufficient awareness and accessibility to increase testing rates. Further, it could also be an opportunity for learners to become more knowledgeable about their risk and safer sex practices. Important aspects of testing programmes within schools for consideration would be how to preserve and ensure confidentiality, as well as quality and contextual relevance of service delivery.

HIV testing
Africa
South Africa
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Alcohol and ART do not mix – but how to get the message across?

Qualitative study of changes in alcohol use among HIV-infected adults entering care and treatment for HIV/AIDS in rural southwest Uganda.

Sundararajan R, Wyatt MA, Woolf-King S, Pisarski EE, Emenyonu N, Muyindike WR, Hahn JA, Ware NC. AIDS Behav. 2015 Apr;19(4):732-41. doi: 10.1007/s10461-014-0918-5.

Alcohol has a substantial negative impact on the HIV epidemic in sub-Saharan Africa, particularly in Uganda, where heavy alcohol consumption is common. Using a content analytic approach, this qualitative study characterizes changes in alcohol use among 59 HIV-infected Ugandan adults (>18 years old), who reported any alcohol use in the previous year as they entered HIV care. Most participants reported attempting to cease or reduce alcohol intake over the study period. Reasons for decreased use included advice from clinicians, interference with social obligations, threats to financial security, and negative impact on social standing. Participants reported difficulty abstaining from alcohol, with incentives to continue drinking including desire for social inclusion, stress relief, and enjoyment of alcohol. These contrasting incentives created a moral quandary for some participants, who felt 'pulled' between 'good' and 'bad' influences. Results suggest brief interventions addressing self-identified obstacles to change may facilitate long-term reductions in drinking in this population.

Abstract  Full-text [free] access

Editor’s notes: The heavy consumption of alcohol may facilitate the risk of infection with HIV.  Alcohol use can also affect adherence to antiretroviral therapy and may also have an impact on disease progression. This paper on alcohol use among people initiating antiretroviral therapy in Uganda is an important addition to the literature. As well as using in-depth interviews to gather information from people newly initiated on antiretroviral therapy, the research team also observed clinic consultations and other activities. As a result, the authors can describe in this paper the rather moralistic tone adopted by some counsellors who urged participants to stop drinking alcohol without really explaining why. This contrasted with information provided by clinicians on the risk of alcohol interfering with the absorption of medication; something that participants found much more persuasive. The authors describe the benefits as well as risks associated with alcohol use, noting that these factors are very similar to challenges faced by general populations in other settings. This leads the authors to conclude that - motivational interviewing - an approach to alcohol use reduction which has proved successful in resource-rich settings could work in resource-limited settings like Uganda. Such programmes provide a way for participants to develop strategies to address obstacles to change, while receiving support from trained staff at the clinic. This paper not only provides valuable information from a well-designed study but also provides encouragement for the use of brief programmes in Africa.    

Africa
Uganda
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Re-focusing the response in Niger – a greater need for sex worker programmes?

Reorienting the HIV response in Niger toward sex work interventions: from better evidence to targeted and expanded practice. 

Fraser N, Kerr CC, Harouna Z, Alhousseini Z, Cheikh N, Gray R, Shattock A, Wilson DP, Haacker M, Shubber Z, Masaki E, Karamoko D, Görgens M. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S213-20. doi: 10.1097/QAI.0000000000000456.

Background: Niger's low-burden, sex-work-driven HIV epidemic is situated in a context of high economic and demographic growth. Resource availability of HIV/AIDS has been decreasing recently. In 2007-2012, only 1% of HIV expenditure was for sex work interventions, but an estimated 37% of HIV incidence was directly linked to sex work in 2012. The Government of Niger requested assistance to determine an efficient allocation of its HIV resources and to strengthen HIV programming for sex workers. 

Methods: Optima, an integrated epidemiologic and optimization tool, was applied using local HIV epidemic, demographic, programmatic, expenditure, and cost data. A mathematical optimization algorithm was used to determine the best resource allocation for minimizing HIV incidence and disability-adjusted life years (DALYs) over 10 years. 

Results: Efficient allocation of the available HIV resources, to minimize incidence and DALYs, would increase expenditure for sex work interventions from 1% to 4%-5%, almost double expenditure for antiretroviral treatment and for the prevention of mother-to-child transmission, and reduce expenditure for HIV programs focusing on the general population. Such an investment could prevent an additional 12% of new infections despite a budget of less than half of the 2012 reference year. Most averted infections would arise from increased funding for sex work interventions. 

Conclusions: This allocative efficiency analysis makes the case for increased investment in sex work interventions to minimize future HIV incidence and DALYs. Optimal HIV resource allocation combined with improved program implementation could have even greater HIV impact. Technical assistance is being provided to make the money invested in sex work programs work better and help Niger to achieve a cost-effective and sustainable HIV response.

Abstract access  

Editor’s notes: Niger has a low-level HIV epidemic concentrated in key populations such as female sex workers, with prevalence levels of 17% in 2011. Only around 23% of female sex workers report using a condom at every sexual act, making them a highly vulnerable group. Additionally there are barriers to using the health centres such as service costs, and the geographic distance.

This article summarizes the HIV epidemic and response situation in Niger with a focus on female sex workers, including modelled trends using Optima. It then presents new evidence on different resource allocation scenarios and the projected impact on the HIV epidemic. Optima, a deterministic mathematical model for HIV optimization and prioritization, was applied to local epidemiologic, demographic, programmatic, expenditure, and cost data. 

The optimization function uses an algorithm to find the best allocation of resources to meet the objective of either minimizing HIV incidence or disability-adjusted life years (DALYs) until 2024. Contrary to the current approach of allocating 31% of spending to the general population and less than 1% to female sex workers, the Optima function advocates increased spending on antiretroviral therapy from 27% to 48%. Optima supports a focussed approach to reduce HIV incidence in female sex workers including mapping populations and a “programme intelligence” approach akin to that implemented in India and Nigeria.   

Africa, Asia
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Prevention services need to focus on newly-started sex workers in South India

Changes in HIV and syphilis prevalence among female sex workers from three serial crosssectional surveys in Karnataka state, South India. 

Isac S, Ramesh BM, Rajaram S, Washington R, Bradley JE, Reza-Paul S, Beattie TS, Alary M. BMJ Open. 2015 Mar 27;5(3):e007106. doi: 10.1136/bmjopen-2014-007106.

Objectives: This paper examined trends over time in condom use, and the prevalences of HIV and syphilis, among female sex workers (FSWs) in South India. 

Design: Data from three rounds of cross-sectional surveys were analysed, with HIV and high-titre syphilis prevalence as outcome variables. Multivariable analysis was applied to examine changes in prevalence over time. 

Setting: Five districts in Karnataka state, India. 

Participants: 7015 FSWs were interviewed over three rounds of surveys (round 1=2277; round 2=2387 and round 3=2351). Women who reported selling sex in exchange for money or gifts in the past month, and aged between 18 and 49 years, were included. 

Interventions: The surveys were conducted to monitor a targeted HIV prevention programme during 2004-2012. The main interventions included peer-led community outreach, services for the treatment and prevention of sexually transmitted infections, and empowering FSWs through community mobilisation.  

Results: HIV prevalence declined significantly from rounds 1 to 3, from 19.6% to 10.8%

(adjusted OR (AOR)=0.48, p<0.001); high-titre syphilis prevalence declined from 5.9% to 2.4% (AOR=0.50, p<0.001). Reductions were observed in most substrata of FSWs, although reductions among new sex workers, and those soliciting clients using mobile phones or from home, were not statistically significant. Condom use 'always' with occasional clients increased from 73% to 91% (AOR=1.9, p<0.001), with repeat clients from 52% to 86% (AOR=5.0, p<0.001) and with regular partners from 12% to 30% (AOR=4.2, p<0.001). Increased condom use was associated with exposure to the programme. However, condom use with regular partners remained low. 

Conclusions: The prevalences of HIV infection and high-titre syphilis among FSWs have steadily declined with increased condom use. Further reductions in prevalence will require intensification of prevention efforts for new FSWs and those soliciting clients using mobile phones or from home, as well as increasing condom use in the context of regular partnerships.

Abstract   Full-text [free] access

Editor’s notes: The HIV epidemic in India has remained largely concentrated in key populations, particularly among female sex workers. One of the most high profile HIV prevention efforts in India has been the Avahan AIDS initiative, which in Karnataka State has reached over 60 000 female sex workers since 2004. The initiative involves peer-mediated safer sex communications, intensive management of sexually transmitted infections, and facilitation of safer sex environments. In the final round of a repeat cross-sectional survey conducted between 2004 and 2011, investigators found that nearly all female sex workers were contacted by a peer educator, had seen a condom demonstration, or had visited a programme clinic. In that time, the prevalence of HIV fell from 19.6% to 10.8% (P<0.01) and the prevalence of new syphilis infections fell from 5.9% to 2.4% (P<0.01). However, HIV prevalence among new female sex workers remained high, reflecting the challenges in reaching women starting sex work before they become HIV positive. The programme is notable for its responsiveness to the HIV prevention needs of female sex workers and the current paper confirms continued increases in condom use and preventive services. However, with the changing nature of sex work, current challenges include preventive services for women soliciting sex through mobile phones, and reaching sex workers soon after they start sex work. 

Asia
India
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Oral and vaginal pre-exposure prophylaxis: no evidence of benefit among young African women

Tenofovir-based pre-exposure prophylaxis for HIV infection among African women.

Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, Palanee T, Nakabiito C, van der Straten A, Noguchi L, Hendrix CW, Dai JY, Ganesh S, Mkhize B, Taljaard M, Parikh UM, Piper J, Masse B, Grossman C, Rooney J, Schwartz JL, Watts H, Marzinke MA, Hillier SL, McGowan IM, Chirenje ZM, VOICE Study Team. N Engl J Med. 2015 Feb 5;372(6):509-18. doi: 10.1056/NEJMoa1402269.

Background: Reproductive-age women need effective interventions to prevent the acquisition of human immunodeficiency virus type 1 (HIV-1) infection.

Methods: We conducted a randomized, placebo-controlled trial to assess daily treatment with oral tenofovir disoproxil fumarate (TDF), oral tenofovir-emtricitabine (TDF-FTC), or 1% tenofovir (TFV) vaginal gel as pre-exposure prophylaxis against HIV-1 infection in women in South Africa, Uganda, and Zimbabwe. HIV-1 testing was performed monthly, and plasma TFV levels were assessed quarterly.

Results: Of 12 320 women who were screened, 5029 were enrolled in the study. The rate of retention in the study was 91% during 5509 person-years of follow-up. A total of 312 HIV-1 infections occurred; the incidence of HIV-1 infection was 5.7 per 100 person-years. In the modified intention-to-treat analysis, the effectiveness was -49.0% with TDF (hazard ratio for infection, 1.49; 95% confidence interval [CI], 0.97 to 2.29), -4.4% with TDF-FTC (hazard ratio, 1.04; 95% CI, 0.73 to 1.49), and 14.5% with TFV gel (hazard ratio, 0.85; 95% CI, 0.61 to 1.21). In a random sample, TFV was detected in 30%, 29%, and 25% of available plasma samples from participants randomly assigned to receive TDF, TDF-FTC, and TFV gel, respectively. Independent predictors of TFV detection included being married, being older than 25 years of age, and being multiparous. Detection of TFV in plasma was negatively associated with characteristics predictive of HIV-1 acquisition. Elevations of serum creatinine levels were seen more frequently among participants randomly assigned to receive oral TDF-FTC than among those assigned to receive oral placebo (1.3% vs. 0.2%, P=0.004). We observed no significant differences in the frequencies of other adverse events.

Conclusions: None of the drug regimens we evaluated reduced the rates of HIV-1 acquisition in an intention-to-treat analysis. Adherence to study drugs was low.

Abstract   Full-text [free] access

Editor’s notes: Randomised controlled trials across a range of settings and populations have demonstrated a benefit of antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV acquisition, when adherence is high. This study compared two oral PreP regimens and a vaginal gel against placebo oral/gel among predominantly young, unmarried women in South Africa, Uganda and Zimbabwe. There was no evidence of a difference in HIV incidence between the groups. Although self-reported adherence was good, as estimated by the amount of product returned, or in interviews, tenofovir (TFV) was detected in only 25-30% of plasma samples analysed. TFV detection in plasma at the first quarterly visit was associated with both TFV detection at later visits and lower risk of HIV acquisition. But this may be partly confounded by differences in HIV exposure which were not measured. This trial has important implications for HIV prevention and implementation of programmes with proven efficacy. This includes the fact that HIV incidence continues to be high in some settings despite increasing coverage of ART. There is a need to assess products with sustained delivery of ART, e.g. vaginal rings or injections, and for real-time monitoring of biomarkers for adherence rather than reliance on self-report and returned-product count.

Africa
South Africa, Uganda, Zimbabwe
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Does having an older male partner actually protect women over 30 in KwaZulu-Natal?

Partner age-disparity and HIV incidence risk for older women in rural South Africa.

Harling G, Newell ML, Tanser F, Barnighausen T. AIDS Behav. 2015 Feb 11. [Epub ahead of print]

While sexual partner age disparity is frequently considered as a potential risk factor for HIV among young women in Africa, no research has addressed this question among older women. Our aim was thus to determine whether sex partner age disparity was associated with subsequent HIV acquisition in women over 30 years of age. To achieve this aim we conducted a quantitative analysis of a population-based, open cohort of women in rural KwaZulu-Natal, South Africa (n = 1737) using Cox proportional hazards models. As partner age rose, HIV acquisition risk fell significantly: compared to a same-aged partner, a 5-year older partner was associated with a one-third reduction [hazard ratio (HR) 0.63, 95 % CI 0.52-0.76] and a 10-year older partner with a one-half reduction (HR 0.48, 95 % CI 0.35-0.67) in acquisition risk. This result was neither confounded nor effect-modified by women's age or socio-demographic factors. These findings suggest that existing HIV risk-reduction campaigns warning young women about partnering with older men may be inappropriate for older women. HIV prevention strategies interventions specifically tailored to older women are needed.

Abstract access

Editor’s notes: The effect of partner age disparity is important for the dynamics of HIV transmission. This is because of the potential of transmission across generations, and also that it may reflect power imbalances with associated vulnerabilities and risks. This study is the first to assess HIV risk and partner age disparity in women between the ages of 30 and 50 years. As might be expected, the associations are different to those generally found in young women where having an older partner typically increases HIV risk. In this study, having a partner five years older reduces HIV risk by one third, and having a partner 10 years older reduces HIV risk by half. This is not surprising for several reasons, including that HIV prevalence decreases with older age. But it highlights the need for HIV prevention campaigns that advocate for women to avoid older men, to be nuanced by the age of the woman.  However, it is also notable that in this population, a previous paper showed no evidence of an association of partner age disparity and HIV risk for women aged 15-29. The results illustrate the need to continue to broaden and improve HIV prevention programming and to tailor prevention messages for different age groups, as the traditional ‘risky behaviours’ for young women may not be appropriate for older ages.

Africa
South Africa
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Improved measures of concurrency in South Africa?

Concurrent partnerships in Cape Town, South Africa: race and sex differences in prevalence and duration of overlap.

Beauclair R, Hens N, Delva W. J Int AIDS Soc. 2015 Feb 18;18(1):19372. doi: 10.7448/IAS.18.1.19372. eCollection 2015.

Introduction: Concurrent partnerships (CPs) have been suggested as a risk factor for transmitting HIV, but their impact on the epidemic depends upon how prevalent they are in populations, the average number of CPs an individual has and the length of time they overlap. However, estimates of prevalence of CPs in Southern Africa vary widely, and the duration of overlap in these relationships is poorly documented. We aim to characterize concurrency in a more accurate and complete manner, using data from three disadvantaged communities of Cape Town, South Africa.

Methods: We conducted a sexual behaviour survey (n = 878) from June 2011 to February 2012 in Cape Town, using Audio Computer-Assisted Self-Interviewing to collect sexual relationship histories on partners in the past year. Using the beginning and end dates for the partnerships, we calculated the point prevalence, the cumulative prevalence and the incidence rate of CPs, as well as the duration of overlap for relationships begun in the previous year. Linear and binomial regression models were used to quantify race (black vs. coloured) and sex differences in the duration of overlap and relative risk of having CPs in the past year.

Results: The overall point prevalence of CPs six months before the survey was 8.4%: 13.4% for black men, 1.9% for coloured men, 7.8% black women and 5.6% for coloured women. The median duration of overlap in CPs was 7.5 weeks. Women had less risk of CPs in the previous year than men (RR 0.43; 95% CI: 0.32-0.57) and black participants were more at risk than coloured participants (RR 1.86; 95% CI: 1.17-2.97).

Conclusions: Our results indicate that in this population the prevalence of CPs is relatively high and is characterized by overlaps of long duration, implying there may be opportunities for HIV to be transmitted to concurrent partners.

Abstract  Full-text [free] access

Editor’s notes: The lack of empirical evidence supporting the association between partnership concurrency and HIV prevalence has puzzled many observers. While this study does not resolve this issue, it contributes to the debate in two ways. First, the study documents relatively high concurrency prevalence in three urban communities of Cape Town, along with important gender and racial disparities. Second, the authors argue that concurrency point prevalence, measured six months before the survey as recommended by UNAIDS, does not sufficiently characterise partnership concurrency in a population. Measures of the incidence of concurrency, its cumulative prevalence and the duration of overlaps all quantify different aspects of partnership concurrency that could help elucidate its role in the spread of HIV.

Africa
South Africa
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Further evidence of an association with the injectable contraceptive, depot-medroxyprogesterone acetate with risk of HIV

Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis.

Morrison CS, Chen PL, Kwok C, Baeten JM, Brown J, Crook AM, Van Damme L, Delany-Moretlwe S, Francis SC, Friedland BA, Hayes RJ, Heffron R, Kapiga S, Karim QA, Karpoff S, Kaul R, McClelland RS, McCormack S, McGrath N, Myer L, Rees H, van der Straten A, Watson-Jones D, van de Wijgert JH, Stalter R, Low N. PLoS Med. 2015 Jan 22;12(1):e1001778. doi: 10.1371/journal.pmed.1001778. eCollection 2015.

Background: Observational studies of a putative association between hormonal contraception (HC) and HIV acquisition have produced conflicting results. We conducted an individual participant data (IPD) meta-analysis of studies from sub-Saharan Africa to compare the incidence of HIV infection in women using combined oral contraceptives (COCs) or the injectable progestins depot-medroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN) with women not using HC.

Methods and findings: Eligible studies measured HC exposure and incident HIV infection prospectively using standardized measures, enrolled women aged 15-49 y, recorded ≥15 incident HIV infections, and measured prespecified covariates. Our primary analysis estimated the adjusted hazard ratio (aHR) using two-stage random effects meta-analysis, controlling for region, marital status, age, number of sex partners, and condom use. We included 18 studies, including 37 124 women (43 613 woman-years) and 1830 incident HIV infections. Relative to no HC use, the aHR for HIV acquisition was 1.50 (95% CI 1.24-1.83) for DMPA use, 1.24 (95% CI 0.84-1.82) for NET-EN use, and 1.03 (95% CI 0.88-1.20) for COC use. Between-study heterogeneity was mild (I2 < 50%). DMPA use was associated with increased HIV acquisition compared with COC use (aHR 1.43, 95% CI 1.23-1.67) and NET-EN use (aHR 1.32, 95% CI 1.08-1.61). Effect estimates were attenuated for studies at lower risk of methodological bias (compared with no HC use, aHR for DMPA use 1.22, 95% CI 0.99-1.50; for NET-EN use 0.67, 95% CI 0.47-0.96; and for COC use 0.91, 95% CI 0.73-1.41) compared to those at higher risk of bias (pinteraction = 0.003). Neither age nor herpes simplex virus type 2 infection status modified the HC-HIV relationship.

Conclusions: This IPD meta-analysis found no evidence that COC or NET-EN use increases women's risk of HIV but adds to the evidence that DMPA may increase HIV risk, underscoring the need for additional safe and effective contraceptive options for women at high HIV risk. A randomized controlled trial would provide more definitive evidence about the effects of hormonal contraception, particularly DMPA, on HIV risk.

Abstract  Full-text [free] access

Editor’s notes: As seen in the paper published this month by Ralph et al, observational studies have reported that hormonal contraception, in particular injectable progestins depot-medroxyprogesterone acetate (DMPA), may increase risk of HIV infection. This individual patient data meta-analysis adds further to the evidence. A major strength of the study is the large sample size. It provides sufficient power to examine associations between specific contraceptives and HIV risk and to investigate effect modification in pre-specified sub-group analyses. Furthermore, using individual-level data allowed a consistent approach to coding and adjustment for confounding. If the association is real, this has important implications for sexual and reproductive health in areas of sub-Saharan Africa where the incidence of HIV acquisition and unintended pregnancy is high.

 


 

Hormonal contraceptive use and women's risk of HIV acquisition: a meta-analysis of observational studies.

Ralph LJ, McCoy SI, Shiu K, Padian NS. Lancet Infect Dis. 2015 Jan 8. pii: S1473-3099(14)71052-7. doi: 10.1016/S1473-3099(14)71052-7. [Epub ahead of print]

Background: The evidence from epidemiological research into whether use of hormonal contraception increases women's risk of HIV acquisition is inconsistent. We did a robust meta-analysis of existing data to provide summary estimates by hormonal contraceptive method which can be used to inform contraceptive guidelines, models, and future studies.

Methods: We updated a recent systematic review to identify and describe studies that met inclusion criteria. To ensure inclusion of more recent research, we searched PubMed for articles published after December, 2011, using the terms "hormonal contraception", "HIV/acquisition", "injectables", "progestin", and "oral contraceptive pills". We assessed statistical heterogeneity for these studies, and, when appropriate, combined point estimates by hormonal contraception formulation using random-effects models. We assessed publication bias and investigated heterogeneity through subgroup and stratified analyses according to study population and design features.

Findings: We identified 26 studies, 12 of which met inclusion criteria. There was evidence of an increase in HIV risk in the ten studies of depot medroxyprogesterone acetate (pooled hazard ratio [HR] 1.40, 95% CI 1.16-1.69). This risk was lower in the eight studies done in women in the general population (pooled HR 1.31, 95% CI 1.10-1.57). There was substantial between-study heterogeneity in secondary analyses of trials (n=7, I2 51.1%, 95% CI 0-79.3). Although individual study estimates suggested an increased risk, substantial heterogeneity between two studies done in women at high risk of HIV infection (I2 54%, 0-88.7) precluded pooling estimates. There was no evidence of an increased HIV risk in ten studies of oral contraceptive pills (pooled HR 1.00, 0.86-1.16) or five studies of norethisterone enanthate (pooled HR 1.10, 0.88-1.37).

Interpretation: Our findings show a moderate increased risk of HIV acquisition for all women using depot medroxyprogesterone acetate, with a smaller increase in risk for women in the general population. Whether the risks of HIV observed in our study would merit complete withdrawal of depot medroxyprogesterone acetate needs to be balanced against the known benefits of a highly effective contraceptive.

Abstract access

Editor’s notes: This meta-analysis has similar findings to the individual patient data (IPD) meta-analysis by Morrison et al, also published this month. The study finds that depot medroxyprogesterone (DMPA) is associated with a moderate increase in HIV risk, and little evidence of a risk associated with combined oral contraceptives or norethisterone enanthate (NET-EN). The policy implications of this finding are unclear. As with the IPD analysis, this meta-analysis is based on observational studies and does not provide conclusive evidence that DMPA causes the increased risk of HIV. However, it does provide refined estimates for modelling studies to assess the implications of possible withdrawal of DMPA on maternal and HIV-associated mortality, so that context-specific contraceptive policies can be considered.

Africa
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Incentives for orphans to stay in school: a structural programme for HIV prevention in Zimbabwe

The impact of school subsidies on HIV-related outcomes among adolescent female orphans.

Hallfors DD, Cho H, Rusakaniko S, Mapfumo J, Iritani B, Zhang L, Luseno W, Miller T. J Adolesc Health. 2015 Jan;56(1):79-84. doi: 10.1016/j.jadohealth.2014.09.004.

Purpose: We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years.

Methods: Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status.

Results: The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group.

Conclusions: Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.

Abstract access

Editor’s notes: Structural programmes for HIV prevention potentially offer a means to mitigate the risk factors which are thought to drive the substantially higher rates of HIV observed among adolescent women in low-income settings. In Zimbabwe, female orphans in the programme arm of this randomized control trial were offered a package of school support. This included payment of their school fees. There was low power to assess differences in HIV or HSV-2 prevalence by arm, but there were promising impacts on several important mediating factors for HIV infection. These included sexual debut, marriage, school drop-out, and socioeconomic status. The long follow-up period of five years and the high rate of retention in the study, 88%, are major strengths of this study. The study joins a limited evidence base on structural programmes for adolescent women in sub-Saharan Africa. Future research must re-consider the pathways by which structural determinants of HIV infection operate.

Africa
Zimbabwe
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Context-specific combination HIV prevention for female sex workers

Combination HIV prevention for female sex workers: what is the evidence?

Bekker LG, Johnson L, Cowan F, Overs C, Besada D, Hillier S, Cates W, Jr. Lancet. 2015 Jan 3;385(9962):72-87. doi: 10.1016/S0140-6736(14)60974-0. Epub 2014 Jul 22.

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

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Editor’s notes: Sex workers live within complex contexts of risk when it comes to HIV, other STIs and diseases, and life more broadly. But relatively few large-scale HIV prevention programmes exist for female sex workers. This paper presents a framework for combination HIV prevention among female sex workers. The paper evaluates the effect of activities at the individual, sexual/social network, community, and public policy levels. It models the impact of combining more established individual and structural approaches with biomedical approaches. These include earlier treatment and vaginal or oral PrEP, in South Africa. The model simulations suggest that individual and structural programmes, including condom promotion and distribution programmes, and community-led initiatives, are key in reducing HIV incidence among female sex workers and their clients in South Africa. Expansion of voluntary, effective earlier treatment, together with PrEP could further reduce HIV incidence in this setting.  

Africa
South Africa
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