Articles tagged as "Reduce sexual transmission"

No evidence that antiretroviral therapy increases risk taking behaviour

Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behaviour: a systematic review and meta-analysis.

Doyle JS, Degenhardt L, Pedrana AE, McBryde ES, Guy R, Stoove MA, Weaver E, Grulich AE, Lo YR, Hellard ME. Clin Infect Dis. 2014 Aug 4. pii: ciu602. [Epub ahead of print]

Background:  Increased global access and use of HIV antiretroviral therapy (ART) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behaviour. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behaviour or diagnosis of sexually transmitted infections (STIs).

Methods: A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared to no ART use in experimental or observational studies. Primary outcomes included: (1) any unprotected sexual intercourse; (2) STI diagnoses; and (3) any unsafe injecting behaviour.

Results: Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; eleven studies containing 16 138 participants reported STI diagnoses; and four studies containing 1 600 participants reported unsafe injecting behaviour. All included studies were observational. Unprotected sex was lower in those receiving ART than those not receiving ART (odds ratio (OR) 0.73, 95%CI 0.64-0.83, p<0.001; heterogeneity I2=79%) in both high-income (n=38) and low-/middle-income country (n=18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR 0.58, 95%CI 0.33-1.01, p=0.053; I2=92%), however there was no difference in injecting risk-taking behaviour with antiretroviral use (OR 0.90, 95%CI 0.60-1.35, p=0.6; I2=0%).

Conclusions: Despite concerns that use of ART might increase sexual or injecting risk-taking, available research suggests unprotected sex is reduced among HIV-infected individuals on treatment. The reasons for this are not yet clear, though self-selection and mutually reinforcing effects of HIV treatment and prevention messages among people on ART are likely.

Abstract access 

Editor’s notes: Use of antiretroviral therapy (ART) may modify risk perception, leading to increases in risk-taking behaviour and HIV transmission. This has important implications for HIV prevention. In particular in low and middle-income countries, where the global burden of HIV is greatest and where access to, and use of, ART is rapidly increasing. This systematic review identified observational studies comparing risk-taking behaviour in people living with HIV using ART, compared with people not using ART. The review found that ART does not appear to increase reported unprotected anal or vaginal intercourse, newly diagnosed sexually transmitted infections, or unsafe injecting behaviour among people on treatment. The observation that reductions in unprotected sex are associated with ART use should be interpreted cautiously as limited data are available to accurately assess a causal relationship. The current practice of providing ART with counselling, education and ongoing clinical care probably offers the optimal strategy of ensuring that individuals on ART minimise risks associated with unsafe sex. 

Africa, Asia, Europe, Northern America, Oceania
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Food vouchers as an incentive for male circumcision in Kenya

Effect of providing conditional economic compensation on uptake of voluntary medical male circumcision in Kenya: a randomized clinical trial


Thirumurthy H, Masters SH, Rao S, Bronson MA, Lanham M, Omanga E, Evens E, Agot K. JAMA. 2014 Aug 20;312(7):703-11. doi: 10.1001/jama.2014.9087.Epub 20 July 2014.

Importance: Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy. 

Objective: To determine whether small economic incentives could increase circumcision prevalence by addressing reported economic barriers to VMMC and behavioral factors such as present-biased decision making.

Design, Setting, and Participants: Randomized clinical trial conducted between June 22, 2013, and February 4, 2014, among 1 504 uncircumcised men aged 25 to 49 years in Nyanza region, Kenya. VMMC services were provided free of charge and participants were randomized to 1 of 3 intervention groups or a control group.

Interventions: Participants in the 3 intervention groups received varying amounts of compensation conditional on undergoing circumcision at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth 200 Kenya shillings (approximately US $2.50), 700 Kenya shillings (approximately US $8.75), or 1 200 Kenya shillings (approximately US $15.00), which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation.

Main Outcomes and Measures: VMMC uptake within 2 months.

Results: Analysis of data for 1 502 participants with complete data showed that VMMC uptake within 2 months was higher in the US $8.75 group (6.6%; 95% CI, 4.3%-9.5% [25 of 381]) and the US $15.00 group (9.0%; 95% CI, 6.3%-12.4% [34 of 377]) than in the US $2.50 group (1.9%; 95% CI, 0.8%-3.8% [7 of 374]) and the control group (1.6%; 95% CI, 0.6%-3.5% [6 of 370]). In logistic regression analysis, the US $8.75 group had significantly higher VMMC uptake than the control group (adjusted odds ratio [AOR] 4.3; 95% CI, 1.7-10.7), as did the US $15.00 group (AOR 6.2; 95% CI, 2.6-15.0). Effect sizes for the US $8.75 and US $15.00 groups did not differ significantly (P = .20).

Conclusions and Relevance: Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation.

Abstract access 

Editor’s notes: Despite considerable scale-up of voluntary medical male circumcision (VMMC), most countries are short of their targets of 80% circumcision prevalence, and novel demand-creation strategies are needed. This study is the first randomised controlled trial to evaluate the effectiveness of a conditional economic compensation on VMMC, and found that incentives were effective in increasing VMMC uptake in this population. The compensation was given in the form of food vouchers of a value approximating transportation costs plus up to about three days’ wages.  The voucher was given if the participant underwent circumcision at one of the study clinics within two months.  The programme was particularly effective among married and older participants, and men at higher risk of acquiring HIV – these are priority groups for scale-up but have been relatively hard to reach in many settings.  The trial shows that such economic incentives are promising for VMMC by addressing economic barriers to uptake. Further rigorous evaluation of these economic-based activities, and the exploration of innovative ways to use economic incentives, for HIV-related behaviours such as HIV-testing and linkage/retention in care should be considered.

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No evidence of increased risk behaviours among recently circumcised men

Risk compensation following male circumcision: results from a two-year prospective cohort study of recently circumcised and uncircumcised men in Nyanza province, Kenya 

Westercamp N, Agot K, Jaoko W, Bailey RC. AIDS Behav. 2014 Sep;18(9):1764-75. doi: 10.1007/s10461-014-0846-4. Epub 22 July 2014.

We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1 588 newly circumcised men and 1 598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30-14 vs. 24-21 % in controls) and increased sexual activity among the youngest participants (18-24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.

Abstract access 

Editor’s notes:  There has always been a concern that scale-up of voluntary medical male circumcision (VMMC) may be accompanied by risk compensation – i.e. an increase in risky behaviour in response to perceived risk reduction. To date, data on risk compensation following VMMC have been from the trial populations (including extended follow-up), and this is the first longitudinal study to assess risk compensation associated with MC in the context of a successful national scale-up in Kenya. The study is reassuring in that it showed no evidence of behavioural risk compensation over two years of follow-up. Further, the men exposed to the VMMC programme (both as circumcised clients and through informational messages as uncircumcised controls), meaningfully shifted towards safer sexual behaviours.  This suggests that, as long as VMMC programmes include emphasis on continuing risk reducing practices, there seems to be little risk compensation following scale-up of male circumcision.

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Taboos around sexual matters impact on Nepalese women’s sexual health

Unveiling the silence: women's sexual health and experiences in Nepal

Menger LM, Kaufman MR, Harman JJ, Tsang SW, Shrestha DK. Cult Health Sex. 2014 Jul 18:1-15. [Epub ahead of print]

Rising rates of HIV in Nepal signal an impending epidemic. In order to develop culturally appropriate and effective actions and programmes to reduce HIV transmission, it is necessary to understand attitudes, behaviours and norms surrounding sexual networking and safer-sex practices in Nepal. Nepali women are thought to be at increased risk of sexually transmitted infections (STIs) and HIV, sexual violence and exploitation and other sexual health disparities due to cultural scripts limiting access to education, ability to control sexual relationships and acceptability in discussing sex and sexual health. The present study comprises a series of interviews with 25 women living in Kathmandu (13 individual interviews and 2 focus-group discussions) about their knowledge and experiences related to sex and sexual health. Interviews were translated and transcribed and two independent coders conducted a thematic analysis. Overall, the women described sex as primarily a male domain. Sex and sexual health were viewed as taboo discussion topics and formal sex education was perceived as minimally available and far from comprehensive in its scope. This formative study can inform future interventions aimed at reducing the spread of STIs/HIV in Nepal and empowering women on issues of sexual health and well-being.

Abstract access 

Editor’s notes: This paper explores the changing norms towards sexual behaviour and sexual health among a number of Nepalese women in the context of a small but growing, HIV epidemic. The authors present evidence for the growing impact of migration among young people on sexual behaviour both for women who are left behind by migrating partners and for those women who migrate. As discussion of sexual matters is taboo among Nepali women, the authors used a snowball sampling technique in which they asked contacts to recommend other women to be interviewed. The findings revealed that the women had poor sexual knowledge, and what knowledge they had was drawn from some classroom teaching or family and friends. Most of the women’s first sexual experience was during marriage and lack of knowledge about sex affected these first experiences. The women also reported poor knowledge about STIs and HIV, although they were aware that condoms and fidelity can protect against HIV. Alongside this, these women had poor access to sexual health care and family planning. This small study reveals the implications for sexual matters remaining taboo for women, which leave them devoid of information to ensure healthy sexual lives.   

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How can we improve the UNAIDS modes of transmission model?

The HIV modes of transmission model: a systematic review of its findings and adherence to guidelines.

Shubber Z, Mishra S, Vesga JF, Boily MC. J Int AIDS Soc. 2014 Jun 23;17:18928. doi: 10.7448/IAS.17.1.18928. eCollection 2014.

Introduction: The HIV Modes of Transmission (MOT) model estimates the annual fraction of new HIV infections (FNI) acquired by different risk groups. It was designed to guide country-specific HIV prevention policies. To determine if the MOT produced context-specific recommendations, we analyzed MOT Results by region and epidemic type, and explored the factors (e.g. data used to estimate parameter inputs, adherence to guidelines) influencing the differences.

Methods: We systematically searched MEDLINE, EMBASE and UNAIDS reports, and contacted UNAIDS country directors for published MOT Results from MOT inception (2003) to 25 September 2012.

Results: We retrieved four journal articles and 20 UNAIDS reports covering 29 countries. In 13 countries, the largest FNI (range 26 to 63%) was acquired by the low-risk group and increased with low-risk population size. The FNI among female sex workers (FSWs) remained low (median 1.3%, range 0.04 to 14.4%), with little variability by region and epidemic type despite variability in sexual behaviour. In India and Thailand, where FSWs play an important role in transmission, the FNI among FSWs was 2 and 4%, respectively. In contrast, the FNI among men who have sex with men (MSM) varied across regions (range 0.1 to 89%) and increased with MSM population size. The FNI among people who inject drugs (PWID, range 0 to 82%) was largest in early-phase epidemics with low overall HIV prevalence. Most MOT studies were conducted and reported as per guidelines but data quality remains an issue.

Conclusions: Although countries are generally performing the MOT as per guidelines, there is little variation in the FNI (except among MSM and PWID) by region and epidemic type. Homogeneity in MOT FNI for FSWs, clients and low-risk groups may limit the utility of MOT for guiding country-specific interventions in heterosexual HIV epidemics.

 Abstract  Full-text [free] access

Editor’s notes: In 2002, the HIV Modes of Transmission model (MoT) was developed by UNAIDS to inform and focus, country-specific HIV prevention policies. The idea behind the model was to use simple mathematical modelling approaches, in combination with country specific data, to predict what the distribution of new HIV infection may look like. In this way, countries would be able to better focus their HIV response. Since its development and through 2012, the MoT has been applied in 29 countries, with the findings being used in many settings to shape priorities. In this study, the authors assess the degree to which the MoT produces different outputs in different epidemic contexts. They explore whether there are key parameters in the model that seem to drive similarities and/or differences in projections between countries. Surprisingly, across a broad range of epidemic settings, they found limited variability in the predicted annual fraction of new HIV infections (FNI) acquired by female sex workers (FSW) (0.04-14.4%). There were higher levels of variability between countries in the projected fraction of new HIV infections among men who have sex with men (0.01-89%) and people who inject drugs (0-82%).

The differences in the MoT projections were largely dependent on whether the country in question was categorised as having a concentrated / low-level epidemic, versus generalised epidemic, as defined by UNAIDS. Differences also arose depending upon whether ‘low risk groups’ were also included in the model. Indeed, for 22 of the 25 studies that included a low-risk group, this group was predicted to have a large annual fraction of new HIV infections (11.8-62.9%). This phenomenon arose, not because of high transmission rates in this group (in comparison to others such as MSM or PWIDs) but because these ‘low risk groups’ are large. They are one third of the total population. These findings may be misleading, as the projected high fraction of transmission is dependent on the assumption that everyone in this ‘low risk group’ does have some risk.

It appears that although the MoT was designed to address an important need, it is likely to have limited utility to guide programming in heterosexually driven epidemics.  To address this limitation, UNAIDS is supporting the HIV Modelling Consortium in their development of a revised MoT model that takes into better consideration risk categorization, data constraints and programmatic needs. The revised model is currently undergoing field testing and will be available for country use in 2015.

Africa, Asia, Europe, Latin America
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Per-act HIV transmission risk during anal sex may be higher than previously thought

Estimating per-act HIV transmission risk: a systematic review.

Patel P, Borkowf CB, Brooks JT, Lasry A, Lansky A, Mermin J. AIDS. 2014 Jun 19;28(10):1509-19. doi: 10.1097/QAD.0000000000000298.

Background: Effective HIV prevention programs rely on accurate estimates of the per-act risk of HIV acquisition from sexual and parenteral exposures. We updated the previous risk estimates of HIV acquisition from parenteral, vertical, and sexual exposures, and assessed the modifying effects of factors including condom use, male circumcision, and antiretroviral therapy.

Methods: We conducted literature searches to identify new studies reporting data regarding per-act HIV transmission risk and modifying factors. Of the 7 339 abstracts potentially related to per-act HIV transmission risk, three meta-analyses provided pooled per-act transmission risk probabilities and two studies provided data on modifying factors. Of the 8 119 abstracts related to modifying factors, 15 relevant articles, including three meta-analyses, were included. We used fixed-effects inverse-variance models on the logarithmic scale to obtain updated estimates of certain transmission risks using data from primary studies, and employed Poisson regression to calculate relative risks with exact 95% confidence intervals for certain modifying factors.

Results: Risk of HIV transmission was greatest for blood transfusion, followed by vertical exposure, sexual exposures, and other parenteral exposures. Sexual exposure risks ranged from low for oral sex to 138 infections per 10 000 exposures for receptive anal intercourse. Estimated risks of HIV acquisition from sexual exposure were attenuated by 99.2% with the dual use of condoms and antiretroviral treatment of the HIV-infected partner.

Conclusion: The risk of HIV acquisition varied widely, and the estimates for receptive anal intercourse increased compared with previous estimates. The risk associated with sexual intercourse was reduced most substantially by the combined use of condoms and antiretroviral treatment of HIV-infected partners.

Abstract access 

Editor’s notes: The study updates the 2005 Centres for Disease Control (CDC) per-act HIV transmission risks with estimates from recent publications. In addition, it summarizes the effects of various co-factors that modify the transmission risks during sexual exposure. These include genital ulcer disease, viral load, disease stage, use of antiretrovirals, condom use and male circumcision. However, estimates from low-income countries on sexual and mother-to-child transmission are very heterogeneous and not included in the analyses. In general, the updated estimates of transmission risks are comparable to figures from the 2005 CDC study. But they also suggest that the transmission probabilities for both receptive and insertive anal intercourse could be higher than previously thought. Further, the study reasserts that the per-act risk for all sexual exposures is substantially attenuated through the use of condoms and antiretrovirals. These new estimates will be important for both modelling studies and prevention programmes. But a better understanding of HIV transmission risks in low-income countries is needed. 

Asia, Northern America, Oceania
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Identifying people most likely to benefit from HIV pre-exposure prophylaxis

HIV pre-exposure prophylaxis in men who have sex with men and transgender women: a secondary analysis of a phase 3 randomised controlled efficacy trial.

Buchbinder SP, Glidden DV, Liu AY, McMahan V, Guanira JV, Mayer KH, Goicochea P, Grant RM. Lancet Infect Dis. 2014 Jun;14(6):468-75. doi: 10.1016/S1473-3099(14)70025-8. Epub 2014 Mar 7.

Background: For maximum effect pre-exposure prophylaxis should be targeted to the subpopulations that account for the largest proportion of infections (population-attributable fraction [PAF]) and for whom the number needed to treat (NNT) to prevent infection is lowest. We aimed to estimate the PAF and NNT of participants in the iPrEx (Pre-Exposure Prophylaxis Initiative) trial.

Methods: The iPrEx study was a randomised controlled efficacy trial of pre-exposure prophylaxis with coformulated tenofovir disoproxil fumarate and emtricitabine in 2 499 men who have sex with men (MSM) and transgender women. Participants aged 18 years or older who were male at birth were enrolled from 11 trial sites in Brazil, Ecuador, Peru, South Africa, Thailand, and the USA. Participants were randomly assigned (1:1) to receive either a pill with active pre-exposure prophylaxis or placebo, taken daily. We calculated the association between demographic and risk behaviour during screening and subsequent seroconversion among placebo recipients using a Poisson model, and we calculated the PAF and NNT for risk behaviour subgroups..

Findings: Patients were enrolled between July 10, 2007, and Dec 17, 2009, and were followed up until Nov 21, 2010. Of the 2 499 MSM and transgender women in the iPrEx trial, 1 251 were assigned to pre-exposure prophylaxis and 1 248 to placebo. 83 of 1 248 patients in the placebo group became infected with HIV during follow-up. Participants reporting receptive anal intercourse without a condom seroconverted significantly more often than those reporting no anal sex without a condom (adjusted hazard ratio [AHR] 5.11, 95% CI 1.55-16.79). The overall PAF for MSM and transgender women reporting receptive anal intercourse without a condom was 64% (prevalence 60%). Most of this risk came from receptive anal intercourse without a condom with partners with unknown serostatus (PAF 53%, prevalence 54%, AHR 4.76, 95% CI 1.44-15.71); by contrast, the PAF for receptive anal intercourse without a condom with an HIV-positive partner was 1% (prevalence 1%, AHR 7.11, 95% CI 0.70-72.75). The overall NNT per year for the cohort was 62 (95% CI 44-147). NNTs were lowest for MSM and transgender women self-reporting receptive anal intercourse without a condom (NNT 36), cocaine use (12), or a sexually transmitted infection (41). Having one partner and insertive anal sex without a condom had the highest NNTs (100 and 77, respectively).

Interpretation: Pre-exposure prophylaxis may be most effective at a population level if targeted toward MSM and transgender women who report receptive anal intercourse without a condom, even if they perceive their partners to be HIV negative. Substance use history and testing for STIs should also inform individual decisions to start pre-exposure prophylaxis. Consideration of the PAF and NNT can aid in discussion of the benefits and risks of pre-exposure prophylaxis with MSM and transgender women.

Abstract access 

Editor’s notes: Pre-exposure prophylaxis (PreP) is the only biomedical prevention activity shown to be effective against acquisition of HIV in men who have sex with men (MSM) and transgender women, in a randomised controlled trial. The US Centers for Disease Control (CDC) and WHO recommend PreP for MSM and transgender women at high risk of HIV infection. However, many health care providers have difficulty assessing risk and neither the CDC nor WHO has yet provided specific behavioural criteria for when to use pre-exposure prophylaxis. The purpose of this study was to identify subpopulations of participants within the iPrEx trial, for whom PreP may have the largest effect on HIV prevention. The findings suggest that MSM and transgender women can be screened for potential eligibility for PreP in clinical practice by asking about recent receptive anal intercourse without a condom. Substance use history and testing for sexually transmitted infections should also be considered, to inform individual decisions to start pre-exposure prophylaxis.

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Combination prevention: the key to effective long term HIV prevention in serodiscordant couples

HIV sexual transmission risk among serodiscordant couples: assessing the effects of combining prevention strategies.

Lasry A, Sansom SL, Wolitski RJ, Green TA, Borkowf CB, Patel P, Mermin J. AIDS. 2014 Jun 19;28(10):1521-9. doi: 10.1097/QAD.0000000000000307.

Background: The number of strategies to prevent HIV transmission has increased following trials evaluating antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP) and male circumcision. Serodiscordant couples need guidance on the effects of these strategies alone, and in combination with each other, on HIV transmission.

Methods: We estimated the sexual risk of HIV transmission over 1-year and 10-year periods among male-male and male-female serodiscordant couples. We assumed the following reductions in transmission: 80% from consistent condom use; 54% from circumcision in the negative male partner of a heterosexual couple; 73% from circumcision in the negative partner of a male-male couple; 71% from PrEP in heterosexual couples; 44% from PrEP in male-male couples; and 96% from ART use by the HIV-infected partner.

Findings: For couples using any single prevention strategy, a substantial cumulative risk of HIV transmission remained. For a male-female couple using only condoms, estimated risk over 10 years was 11%; for a male-male couple using only condoms, estimated risk was 76%. ART use by the HIV-infected partner was the most effective single strategy in reducing risk; among male-male couples, adding consistent condom use was necessary to keep the 10-year risk below 10%.

Conclusion: Focusing on 1-year and longer term transmission probabilities gives couples a better understanding of risk than those illustrated by data for a single sexual act. Long-term transmission probabilities to the negative partner in serodiscordant couples can be high, though these can be substantially reduced with the strategic use of preventive methods, especially those that include ART.

Abstract access 

Editor’s notes: This mathematical modelling study by Lasry et al, seeks to estimate how existing prevention strategies might be used by serodiscordant couples in hetero- and homosexual relationships to obtain optimal reduction in risk of HIV transmission. They illustrate that even modest transmission probabilities for a given type of sex act can accumulate into substantial risk over time. While it is recognised that anal sex poses a high risk for HIV transmission, the projections in this study show the extent of accumulated risk. The study importantly shows that condom use alone, provides quite inadequate protection over time. Not surprisingly given recent evidence, antiretroviral therapy (ART) had the most substantial protective effect. But condom use is an important adjunct to minimise long-term transmission risk. This is not only, but especially with consistent anal sex as in male homosexual, serodiscordant couples. The most important take-home finding of this study in influencing prevention messaging, is its quantitative illustration that combination prevention is the key to effective HIV prevention. 

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HIV-related tweeting: social media for HIV prevention?

Methods of using real-time social media technologies for detection and remote monitoring of HIV outcomes.

Young SD, Rivers C, Lewis B. Prev Med. 2014 Jun;63:112-5. doi: 10.1016/j.ypmed.2014.01.024. Epub 2014 Feb 8.

Objective: Recent availability of "big data" might be used to study whether and how sexual risk behaviors are communicated on real-time social networking sites and how data might inform HIV prevention and detection. This study seeks to establish methods of using real-time social networking data for HIV prevention by assessing 1) whether geolocated conversations about HIV risk behaviors can be extracted from social networking data, 2) the prevalence and content of these conversations, and 3) the feasibility of using HIV risk-related real-time social media conversations as a method to detect HIV outcomes.

Methods: In 2012, tweets (N=553 186 061) were collected online and filtered to include those with HIV risk-related keywords (e.g., sexual behaviors and drug use). Data were merged with AIDSVU data on HIV cases. Negative binomial regressions assessed the relationship between HIV risk tweeting and prevalence by county, controlling for socioeconomic status measures.

Results: Over 9 800 geolocated tweets were extracted and used to create a map displaying the geographical location of HIV-related tweets. There was a significant positive relationship (p<.01) between HIV-related tweets and HIV cases.

Conclusion: Results suggest the feasibility of using social networking data as a method for evaluating and detecting Human immunodeficiency virus (HIV) risk behaviors and outcomes.

 Abstract access 

Editor’s notes: The concept of Big Data refers to data sets so large that they are almost or actually impossible to analyse or manage. Methods for harnessing big data sets, such as from social network sites online, are being developed for a variety of uses. These include understanding consumers for the purposes of building creative product marketing campaigns to predicting outbreaks of influenza. This paper examined the potential for using big data from Twitter to compare with areas of high HIV prevalence in the United States, to predict areas of increasing new HIV infections. There are several limitations for the method used in this paper. However, the idea presents an interesting concept. This study was conducted in a developed country, and while computers may not be readily available in resource limited settings, mobile phones are in use in most populations around the world. With mobile technology becoming increasingly sophisticated, and online social networking becoming more common, even in resource limited settings, this may be a strategy worth considering. It could be used in high HIV incidence networks within countries with high rates of HIV, especially in generalised epidemics. Clearly, this method will require additional research, validation and time to develop, but it could present a novel approach for estimating incidence without expensive testing. 

Northern America
United States of America
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Being a man, being circumcised, in northern Kenya

Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods.

Macintyre K, Andrinopoulos K, Moses N, Bornstein M, Ochieng A, Peacock E, Bertrand J. PLoS One. 2014 May 6;9(5):e83998. doi: 10.1371/journal.pone.0083998. eCollection 2014.

Background: In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high.

Methods and findings: Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their "protection by marriage," cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men.

Conclusions: Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy.

 Abstract  Full-text [free] access 

Editor’s notes:  Queues of young men and boys awaiting medical male circumcision have become a common sight at health centres, during circumcision campaigns in many parts of Africa. The authors of this paper examine why older men, defined as men over 25 years, among the Turkana of northern Kenya, have been reluctant to be circumcised. They highlight the very important role of culture – the Turkana do not have a tradition of circumcision. Neighbouring groups do circumcise, so not being circumcised is a part of being different, of embracing Turkana male identity. In addition, not being circumcised was associated with faithfulness in marriage. If a man is married then there should be no need for protection from infection, since he should not be having sex outside his marriage. However, as other studies have found, concerns about the spread of HIV as well as a desire to be seen as clean and as a role model for younger men, were facilitators of circumcision. As the authors note, appropriate communication messages are important to promote circumcision among older men. But so is an awareness of, and sensitivity to, cultural and masculine identity.

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