Articles tagged as "Key populations"

Tell it like it is: risky sex after 40

Sexual behaviors and HIV status: a population-based study among older adults in rural South Africa.

Rosenberg MS, Gomez-Olive FX, Rohr JK, Houle BC, Kabudula CW, Wagner RG, Salomon JA, Kahn K, Berkman LF, Tollman SM, Barnighausen T. J Acquir Immune Defic Syndr. 2017 Jan 1;74(1):e9-e17.

Objective: To identify the unmet needs for HIV prevention among older adults in rural South Africa.

Methods: We analyzed data from a population-based sample of 5059 men and women aged 40 years and older from the study Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities (HAALSI), which was carried out in the Agincourt health and sociodemographic surveillance system in the Mpumalanga province of South Africa. We estimated the prevalence of HIV (laboratory-confirmed and self-reported) and key sexual behaviors by age and sex. We compared sexual behavior profiles across HIV status categories with and without age-sex standardization.

Results: HIV prevalence was very high among HAALSI participants (23%, 95% confidence interval [CI]: 21 to 24), with no sex differences. Recent sexual activity was common (56%, 95% CI: 55 to 58) across all HIV status categories. Condom use was low among HIV-negative adults (15%, 95% CI: 14 to 17), higher among HIV-positive adults who were unaware of their HIV status (27%, 95% CI: 22 to 33), and dramatically higher among HIV-positive adults who were aware of their status (75%, 95% CI: 70 to 80). Casual sex and multiple partnerships were reported at moderate levels, with slightly higher estimates among HIV-positive compared to HIV-negative adults. Differences by HIV status remained after age-sex standardization.

Conclusions: Older HIV-positive adults in an HIV hyperendemic community of rural South Africa report sexual behaviors consistent with high HIV transmission risk. Older HIV-negative adults report sexual behaviors consistent with high HIV acquisition risk. Prevention initiatives tailored to the particular prevention needs of older adults are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.

Abstract  Full-text [free] access 

Editor’s notes: This large population-based survey was designed to collect data on well-being, health status, cognitive functioning, and aspects of ageing among men and women 40 years of age or older (40+) in Mpumalanga, South Africa. The survey documented an unexpectedly high HIV prevalence of 23% in this age group. In the 50+ age group, almost one in five people (20%) was HIV-positive. This compares to an overall South African national estimate for adults 50 and over in 2012 of 7.6%, the Africa Centre KwaZulu-Natal estimate of 9.5%, and the previous Agincourt estimate of 16.5% in 2010-11. One explanation is that HIV prevalence among older South Africans is climbing as more people access life-prolonging antiretroviral treatment. In addition to this, each year people with HIV are ageing into the older age group. This study focused on the 40+ age group because life expectancy in the Agincourt study area had been low and collected sexual behaviour information for the previous two-year period, rather than the usual time period of 12 months. Nonetheless, the data obtained through computer-assisted personal interviews reveal ‘recent’ sexual behaviour that both challenges stereotypes that older people are not sexually active and suggests significant risk of HIV transmission and HIV acquisition. Two-thirds reported more than one lifetime sexual partner and although sexual activity did tend to decrease with age, 52% of men and 6% of women age 80 years and older had been sexually active in the previous two years. Only about half of people found to be HIV-positive knew their status (12%). This group of people living with HIV were far more likely to use condoms. This suggests that an offer of HIV testing in ways that can reach older people would assist in avoiding transmission to partners and in accessing antiretroviral therapy. Only one in seven sexually active HIV-negative people 40+ are using condoms in this setting. This highlights the urgent need for awareness raising to foster new sexual norms to avoid HIV acquisition by practising safer sex. It is time to get our heads out of the sand, recognise the sexuality of older people, and work with them to tailor specific HIV strategies to reduce HIV transmission and acquisition – they too are key to ending AIDS. 

Africa
South Africa
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People who inject drugs living with HIV in Russia face more mental health issues and diminished quality of life

Psychiatric symptoms, quality of life, and HIV status among people using opioids in Saint Petersburg, Russia.

Desrosiers A, Blokhina E, Krupitsky E, Zvartau E, Schottenfeld R, Chawarski M. Drug Alcohol Depend. 2017 Mar 1;172:60-65. doi: 10.1016/j.drugalcdep.2016.12.007. Epub 2017 Jan 23.

Background: The Russian Federation is experiencing a very high rate of HIV infection among people who inject drugs (PWID). However, few studies have explored characteristics of people with co-occurring opioid use disorders and HIV, including psychiatric symptom presentations and how these symptoms might relate to quality of life. The current study therefore explored a.) differences in baseline psychiatric symptoms among HIV+ and HIV- individuals with opioid use disorder seeking naltrexone treatment at two treatment centers in Saint Petersburg, Russia and b.) associations between psychiatric symptom constellations and quality of life.

Methods: Participants were 328 adults enrolling in a randomized clinical trial evaluating outpatient treatments combining naltrexone with different drug counseling models. Psychiatric symptoms and quality of life were assessed using the Brief Symptom Inventory and The World Health Organization Quality of Life-BREF, respectively.

Results: Approximately 60% of participants were HIV+. Those who were HIV+ scored significantly higher on BSI anxiety, depression, psychoticism, somatization, paranoid ideation, phobic anxiety, obsessive-compulsive, and GSI indexes (all p<0.05) than those HIV-. A K-means cluster analysis identified three distinct psychiatric symptom profiles; the proportion of HIV+ was significantly greater and quality of life indicators were significantly lower in the cluster with the highest psychiatric symptom levels.

Conclusion: Higher levels of psychiatric symptoms and lower quality of life indicators among HIV+ (compared to HIV-) individuals injecting drugs support the potential importance of combining interventions that target improving psychiatric symptoms with drug treatment, particularly for HIV+ patients.

Abstract access 

Editor’s notes: The higher prevalence of mental health disorders among people living with HIV is well known. This paper focuses on the association of mental health disorders and HIV among people who inject drugs, in St Petersburg, Russian Federation – the city with the highest prevalence of HIV and drug use in the Russian Federation. HIV positive people who inject drugs had significantly higher prevalence of mental health problems than HIV negative people who inject drugs. They had a lower quality of life according to a validated scale, underscoring the need for strong, combination public health programmes to support this vulnerable group. The population studied was selected through existing service provision. Since these individuals were already seeking treatment on their own, there could be many more who are not engaged in care either for HIV treatment or drug use support. This suggests the need to strengthen awareness and services, especially in areas where clean needles and other risk management methods are not yet available.

Europe
Russian Federation
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MSM resilience to HIV

Identifying resilience resources for HIV prevention among sexual minority men: a systematic review.

Woodward EN, Banks RJ, Marks AK, Pantalone DW. AIDS Behav. 2016 Dec 15. [Epub ahead of print]

Most HIV prevention for sexual minority men and men who have sex with men targets risk behaviors (e.g., condom use) and helps <50% of participants. Bolstering resilience might increase HIV prevention's effectiveness. This systematic review identified resilience resources (protective factors) in high-risk, HIV-negative, sexual minority men. We reviewed PsycINFO, PsycARTICLES, MEDLINE, references, and Listservs for studies including sexual minority men with 1+ HIV risk factor (syndemics): childhood sexual abuse, partner abuse, substance abuse, or mental health symptoms. From 1356 articles screened, 20 articles met inclusion criteria. Across the articles, we identified and codified 31 resilience resources: socioeconomic (e.g., employment), behavioral coping strategies (e.g., mental health treatment), cognitions/emotions (e.g., acceptance), and relationships. Resilience resources were generally associated with lower HIV risk; there were 18 low-risk associations, 4 high-risk associations, 8 non-significant associations. We generated a set of empirically based resilience variables and a hypothesis to be evaluated further to improve HIV prevention.

Abstract access  

Editor’s notes: This systematic review sought to identify why gay men and other men who have sex with men, at high-risk of HIV, remain HIV negative. HIV-negative, gay men and other men who have sex with men, with a key risk factor for HIV were identified. These risk factors were childhood sexual abuse, partner abuse, substance abuse or mental health symptoms. The authors sought to identify why such men remain HIV negative. Why they are resilient to infection. Some 20 studies met the inclusion criteria. Four broad categories of resilience were identified; socioeconomic (e.g. degree, full-time job); behavioural coping strategies (e.g. accessing mental health services), cognitions/ emotions (e.g. acceptance of a situation); and relationships (e.g. perceived sufficient social support). Of the 31 sub-categories of resilience resources identified, four were identified as protective for HIV infection: main sex partner is HIV negative, willingness to use PrEP, PrEP acceptance and condom use. Resilience resource research for HIV prevention is a sparse area of study. This study generated a set of resilience variables upon which further research can be built.

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The hope and reality of injecting drug use among people living with HIV in Ukraine

Attitudes toward addiction, methadone treatment, and recovery among HIV-infected Ukrainian prisoners who inject drugs: incarceration effects and exploration of mediators.  

Polonsky M, Rozanova J, Azbel L, Bachireddy C, Izenberg J, Kiriazova T, Dvoryak S, Altice FL. AIDS Behav. 2016 Dec;20(12):2950-2960.

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

Abstract access 

Editor’s notes: Despite reductions in HIV incidence and mortality globally, the epidemic in Ukraine remains volatile and continues to expand, especially among people who inject drugs.  People who inject drugs account for more than 40% of people living with HIV.  At 20%, HIV prevalence among Ukrainian people living in prisons is the highest in Europe, with drug injection of opioids being the major driver of transmission. This is due to a concentration of people who inject drugs among prisoners and other incarcerated people, especially people living with HIV. Programmes focusing on prisoners and other incrcerated people may play a central role in HIV prevention since nearly all of them transition back to the community. Opioid agonist therapies including methadone maintenance therapy have been shown to have many benefits including reducing HIV transmission by over 50% among people who inject drugs.  Despite these benefits, moral biases, stigma and ideological prejudices are barriers to opioid agonist therapies scale-up globally including in Ukraine.  Opioid agonist therapies are available free of charge through national and external Global Fund support. However, scale up of opioid agonist therapies and treatment retention in Ukraine have been low, with only about 2.7% of people who inject drugs enrolled. This has constrained HIV prevention efforts.  Adoption of opioid agonist therapies has been especially slow among criminal justice populations. This study compares attitudes towards opioid agonist therapies among currently and previously incarcerated opioid-dependent people living with HIV in Ukraine.

The study uses data from a survey of people living with HIV conducted in Ukraine to explore attitudes to methadone treatment and intentions to change drug use behaviour before and after release from prison.

This study has important implications for future management of people who inject drugs who are living with HIV.  While staff attitudes may undermine the successful opioid agonist therapies delivery in prisons, the findings of this study suggest that prisoners and other incarcerated people are important foci for programmes that should be done in parallel with staff-based activities. The findings also suggest that optimism about recovery while in prison is falsely elevated. This may contribute to individual inability to comprehend addiction as a chronic relapsing condition, which in the absence of treatment, results in 85% relapsing within 12 months of release. Future programmes should take advantage of individuals’ sobriety while in prison and cultivate their ability to recognise the cycle of addiction and incarceration. This optimism should also be channelled to focus on evidence-based programmes, e.g., methadone maintenance therapy that has been associated with reduced illicit drug relapse, HIV risk-taking and reincarceration. Considerable health marketing work also needs to be done to focus on negative attitudes and prejudices about methadone maintenance therapy at both individual and societal level. This would importantly involve rebranding methadone maintenance therapy as a medical treatment for a chronic relapsing condition.

Europe
Ukraine
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How to keep HIV prevalence low in refugee populations

Predictors of HIV infection: a prospective HIV screening study in a Ugandan refugee settlement.

O'Laughlin KN, Rabideau DJ, Kasozi J, Parker RA, Bustamante ND, Faustin ZM, Greenwald KE, Walensky RP, Bassett IV. BMC Infect Dis. 2016 Nov 23;16(1):695.

Background: The instability faced by refugees may place them at increased risk of exposure to HIV infection. Nakivale Refugee Settlement in southwestern Uganda hosts  68 000 refugees from 11 countries, many with high HIV prevalence. We implemented an HIV screening program in Nakivale and examined factors associated with new HIV diagnosis.

Methods: From March 2013-November 2014, we offered free HIV screening to all clients in the Nakivale Health Center while they waited for their outpatient clinic visit. Clients included refugees and Ugandan nationals accessing services in the settlement. Prior to receiving the HIV test result, participants were surveyed to obtain demographic information including gender, marital status, travel time to reach clinic, refugee status, and history of prior HIV testing. We compared variables for HIV-infected and non-infected clients using Pearson's chi-square test, and used multivariable binomial regression models to identify predictors of HIV infection.

Results: During the HIV screening intervention period, 330 (4%) of 7766 individuals tested were identified as HIV-infected. Refugees were one quarter as likely as Ugandan nationals to be HIV-infected (aRR 0.27 [0.21, 0.34], p < 0.0001). Additionally, being female (aRR 1.43 [1.14, 1.80], p = 0.002) and traveling more than 1 h to the clinic (aRR 1.39 [1.11, 1.74], p = 0.003) increased the likelihood of being HIV-infected. Compared to individuals who were married or in a stable relationship, being divorced/separated/widowed increased the risk of being HIV-infected (aRR 2.41 [1.88, 3.08], p < 0.0001), while being single reduced the risk (aRR 0.60 [0.41, 0.86], p < 0.0001). Having been previously tested for HIV (aRR 0.59 [0.47, 0.74], p < 0.0001) also lowered the likelihood of being HIV-infected.

Conclusions: In an HIV screening program in a refugee settlement in Uganda, Ugandan nationals are at higher risk of having HIV than refugees. The high HIV prevalence among clients seeking outpatient care, including Ugandan nationals and refugees, warrants enhanced HIV screening services in Nakivale and in the surrounding region. Findings from this research may be relevant for other refugee settlements in sub-Saharan Africa hosting populations with similar demographics, including the 9 other refugee settlements in Uganda.

Abstract  Full-text [free] access 

Editor’s notes: The 4% prevalence seen among refugees in this study warrants the introduction of a routine offer of HIV testing and counselling, provider-initiated testing and counselling (PITC), in the outpatient services provided at this refugee settlement in Uganda. Although 7766 people accepted the offer of HIV testing and counselling (HTC), the real extent of the acceptability of this service is unclear because routine service delivery records document simply encounters (23 016 during the study period) rather than unique individuals. There may be challenges in defining and using unique identifiers in refugee settlement health care services but this is one example of their potential utility in helping understand the true burden of disease in these settings. HIV prevalence in refugees accepting testing was not significantly different from that in the general population in their countries of origin. For example, Rwanda 2.3% versus 2.9% and Burundi 1.4% versus 1.0%. The exception was the Democratic Republic of Congo (DRC) with 1.9% of Congolese refugees being HIV-positive compared to 0.8% in the DRC general population, warranting further study to understand this increased HIV risk.

This study reveals lower HIV prevalence among refugees (2%) than among Ugandan nationals availing themselves of the settlement health services (9%). The Ugandans included both refugees and people living in surrounding communities. Ugandans freely come and go from the settlement for job-associated or personal reasons. People testing positive for HIV were more likely to live outside the settlement. The extent of sexual mixing between local Ugandans and refugees from other countries in Nakivale is unknown but providing prevention and treatment services to both populations could help reduce the risk of HIV transmission within the settlement. This study was conducted when the 2010 WHO guidelines of 350 cells/mm3 or WHO stage III/IV for treatment initiation were in effect and antiretroviral therapy was free of charge. However, data are not presented in this paper on the important question of the extent of linkage to care and antiretroviral therapy. These data are now being used worldwide to track progress towards the UNAIDS 90-90-90 treatment target. Refugee settlements in sub-Saharan Africa provide fertile settings for a routine offer of HIV testing and immediate offer of antiretroviral therapy to people found to be HIV-positive, as per current WHO guidelines. This would benefit not only these individuals clinically but would help keep HIV transmission as low as possible in refugee settlements.

Africa
Uganda
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Needle-syringe programmes and treatment will dramatically reduce HIV epidemic among people who inject drugs in Russia and Ukraine

Reducing HIV infection in people who inject drugs is impossible without targeting recently-infected subjects.

Vasylyeva TI, Friedman SR, Lourenco J, Gupta S, Hatzakis A, Pybus OG, Katzourakis A, Smyrnov P, Karamitros T, Paraskevis D, Magiorkinis G. AIDS. 2016 Nov 28;30(18):2885-2890.

Objective: Although our understanding of viral transmission among people who inject drugs (PWID) has improved, we still know little about when and how many times each injector transmits HIV throughout the duration of infection. We describe HIV dynamics in PWID to evaluate which preventive strategies can be efficient.

Design: Due to the notably scarce interventions, HIV-1 spread explosively in Russia and Ukraine in 1990s. By studying this epidemic between 1995 and 2005, we characterized naturally occurring transmission dynamics of HIV among PWID.

Method: We combined publicly available HIV pol and env sequences with prevalence estimates from Russia and Ukraine under an evolutionary epidemiology framework to characterize HIV transmissibility between PWID. We then constructed compartmental models to simulate HIV spread among PWID.

Results: In the absence of interventions, each injector transmits on average to 10 others. Half of the transmissions take place within 1 month after primary infection, suggesting that the epidemic will expand even after blocking all the post-first month transmissions. Primary prevention can realistically target the first month of infection, and we show that it is very efficient to control the spread of HIV-1 in PWID. Treating acutely infected on top of primary prevention is notably effective.

Conclusion: As a large proportion of transmissions among PWID occur within 1 month after infection, reducing and delaying transmissions through scale-up of harm reduction programmes should always form the backbone of HIV control strategies in PWID. Growing PWID populations in the developing world, where primary prevention is scarce, constitutes a public health time bomb

Abstract  Full-text [free] access 

Editor’s notes: This paper presents powerful findings from a mathematical model that sought to estimate how much prevalence of HIV will increase among people who inject drugs in 10-20 years’ time in the absence of HIV treatment and needle-syringe programmes. Findings suggest HIV prevalence will reach 86% in 20 years in the absence of programmes. The paper provides important new information to the growing body of evidence that estimates the impact of needle-syringe programmes and opioid substitution therapy in reducing HIV transmission among people who inject drugs, in the region. The authors focus on the impact of needle-syringe programmes and of the prevention benefits of treatment, reducing transmission among individuals recently acquiring HIV where infectivity is higher in the first month of infection. The estimates provide projections of programme impact in the realities of the current policy environment, given the prohibition of opioid substitution therapy in the Russian Federation. The model focusses on injection transmission routes only and does not consider sexual transmission among people who inject drugs. Therefore, projected estimates of HIV are likely to be underestimates. The paper is important in highlighting the urgent need for needle-syringe programmes and treatment among people who inject drugs in the region and highlighting the crisis in relation to HIV among people who inject drugs in Russia and Ukraine. Modelling estimates such as these are powerful tools to persuade policy makers of the urgent need for programmes.  Importantly the authors recognize the need for structural programmes. They highlight the need to create an enabling environment in which needle-syringe programmes can operate. This environment needs to include supportive policing practices and reducing stigma. 

Europe
Russian Federation, Ukraine
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HIV incidence halved among injecting drugs users in network outreach programme - Ukraine

HIV incidence among people who inject drugs (PWIDs) in Ukraine: results from a clustered randomised trial.

Booth RE, Davis JM, Dvoryak S, Brewster JT, Lisovska O, Strathdee SA, Latkin CA. Lancet HIV. 2016 Oct;3(10):e482-9. doi: 10.1016/S2352-3018(16)30040-6. Epub 2016 Jul 29.

Background: HIV prevalence among people who inject drugs (PWID) in Ukraine is among the highest in the world. In this study, we aimed to assess whether a social network intervention was superior to HIV testing and counselling in affecting HIV incidence among PWID. Although this was not the primary aim of the study, it is associated with reducing drug and sex risk behaviours, which were primary aims.

Methods: In this clustered randomised trial, PWID who were 16 years of age or older, had used self-reported drug injection in the past 30 days, were willing to be interviewed for about 1 hour and tested for HIV, were not too impaired to comprehend and provide informed consent, and, for this paper, who tested HIV negative at baseline were recruited from the streets by project outreach workers in three cities in southern and eastern Ukraine: Odessa, Donetsk, and Nikolayev. Index or peer leaders, along with two of their network members, were randomly assigned (1:1) by the study statistician to the testing and counselling block (control group) or the testing and counselling plus a social network intervention block (intervention group). No stratification or minimisation was done. Participants in the network intervention received five sessions to train their network members in risk reduction. Those participants assigned to the control group received no further intervention after counselling. The main outcome of this study was HIV seroconversion in the intent-to-treat population as estimated with Cox regression and incorporating a gamma frailty term to account for clustering. This trial is registered with ClinicalTrial.gov, number NCT01159704.

Findings: Between July 12, 2010, and Nov 23, 2012, 2304 PWIDs were recruited, 1200 of whom were HIV negative and are included in the present study. 589 index or peer leaders were randomly assigned to the control group and 611 were assigned to the intervention group. Of the 1200 HIV-negative participants, 1085 (90%) were retained at 12 months. In 553.0 person-years in the intervention group, 102 participants had seroconversion (incidence density 18.45 per 100 person-years; 95% CI 14.87-22.03); in 497.1 person-years in the control group 158 participants seroconverted (31.78 per 100 person-years; 26.83-36.74). This corresponded to a reduced hazard in the intervention group (hazard ratio 0.53, 95% CI 0.38-0.76, p=0.0003). No study-related adverse events were reported.

Interpretation: These data provide strong support for integrating peer education into comprehensive HIV prevention programmes for PWID and suggest the value in developing and testing peer-led interventions to improve access and adherence to pre-exposure prophylaxis and antiretroviral therapy.

Abstract  Full-text [free] access 

Editor’s notes: People who inject drugs are at high risk of HIV infection, and, in many settings, are unlikely to have appropriate access to HIV prevention programmes. This study is a secondary, subgroup analysis of a randomised control of a social network programme for people who inject drugs in Ukraine (the primary outcome was HIV risk taking behaviour). The investigators recruited 256 index users, who subsequently recruited fellow members of their injection network to the study. Half (n=128) of the index participants were randomized to a two-week training programme in risk reduction education. These “peer leaders” were trained with the intention that they would disseminate these skills within their injection networks. The HIV incidence was alarmingly high. After 12 months, for the sub-group of participants who were initially HIV-negative, the incidence of seroconversion was 31.9/100 person-years in the control networks and 18.4/100 person-years in the programme networks, representing a 47% reduction in incidence associated with the programme. This study is notable for its randomized design, low attrition, close collaboration with local non-governmental organizations, a study protocol adaptation process which engaged drugs users and dealers, and a biological outcome measure. Further research can consider the economic costs for each averted HIV infection, whether the programme effects varied by other factors, and assessment of the extent to which the risk reduction skills were shared beyond study participants. The very high incidence, even among those receiving the intervention, emphasize the need for much greater investment in harm reduction approaches.

Europe
Ukraine
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Street children are vulnerable to HIV in Tehran, Iran

Prevalence of HIV, HBV and HCV among street and labour children in Tehran, Iran.

Foroughi M, Moayedi-Nia S, Shoghli A, Bayanolhagh S, Sedaghat A, Mohajeri M, Mousavinasab SN, Mohraz M. Sex Transm Infect. 2016 Sep 6. pii: sextrans-2016-052557. doi: 10.1136/sextrans-2016-052557. [Epub ahead of print]

Objectives: The existence of street and working children in Iran is undeniable. The precarious conditions of these children (including disrupted family, poverty, high prevalence of crime among relatives, family members and peers) cause social harm and high-risk behaviours, including drug addiction, selling sex or having sex with adolescents or peers. Here we explore the HIV, hepatitis B and hepatitis C status of street and working children in Tehran.

Methods: One thousand street and labour children, aged 10-18 years, were recruited by using the time-location sampling method, and semistructured questionnaires were used to find demographic information and information on HIV/AIDS-related high-risk sexual behaviours. Blood samples were collected from children, with use of the dried blood sampling method.

Results: 4.5% of children were HIV infected, 1.7% were infected with hepatitis B virus and 2.6% were infected with hepatitis C virus (HCV). Having parents who used drug, infected with HCV and having experience in trading sex significantly increased the likelihood of getting HIV among the street children of Tehran.

Conclusion: HIV prevalence among street children is much higher than general population (<0.1%), and in fact, the rate of positivity comes close to that among female sex workers in Iran. These findings must be an alarm for HIV policymakers to consider immediate and special interventions for this at-risk group.

Abstract access 

Editor’s notes: Relatively few studies have been published on the prevalence of HIV and other communicable diseases in vulnerable populations in Iran. This paper presents results from a prevalence study among street children in Tehran, Iran. Researchers were able to survey 1000 street children, and children exploited by labour between the ages of 10-18, finding an HIV prevalence of 4.5%. The survey data revealed high rates of physical abuse, drug use, and school dropout, but it is not clear whether any of the children were already aware of their HIV status, or how many had acquired HIV perinatally. These important findings point to the imperative for programmes to address the needs of street children in Tehran, and additional research in other areas within the country where similar issues may be prevalent. 

Asia
Iran (Islamic Republic of)
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Changes in sexual risk behaviour and sustained HIV incidence among MSM in the UK

Sexual behaviours, HIV testing, and the proportion of men at risk of transmitting and acquiring HIV in London, UK, 2000-13: a serial cross-sectional study.

Aghaizu A, Wayal S, Nardone A, Parsons V, Copas A, Mercey D, Hart G, Gilson R, Johnson AM. Lancet HIV. 2016 Sep;3(9):e431-40. doi: 10.1016/S2352-3018(16)30037-6. Epub 2016 Jul 14.

Background: HIV incidence in men who have sex with men (MSM) in the UK has remained unchanged over the past decade despite increases in HIV testing and antiretroviral therapy (ART) coverage. In this study, we examine trends in sexual behaviours and HIV testing in MSM and explore the risk of transmitting and acquiring HIV.

Methods: In this serial cross-sectional study, we obtained data from ten cross-sectional surveys done between 2000 and 2013, consisting of anonymous self-administered questionnaires and oral HIV antibody testing in MSM recruited in gay social venues in London, UK. Data were collected between October and January for all survey years up to 2008 and between February and August thereafter. All men older than 16 years were eligible to take part and fieldworkers attempted to approach all MSM in each venue and recorded refusal rates. Data were collected on demographic and sexual behavioural characteristics. We analysed trends over time using linear, logistic, and quantile regression.

Findings: Of 13 861 questionnaires collected between 2000 and 2013, we excluded 1985 (124 had completed the survey previously or were heterosexual reporting no anal intercourse in the past year, and 1861 did not provide samples for antibody testing). Of the 11 876 eligible MSM recruited, 1512 (13%) were HIV positive, with no significant trend in HIV positivity over time. 35% (531 of 1505) of HIV-positive MSM had undiagnosed infection, which decreased non-linearly over time from 34% (45 of 131) to 24% (25 of 106; p=0.01), while recent HIV testing (ie, in the past year) increased from 26% (263 of 997) to 60% (467 of 777; p<0.0001). The increase in recent testing in undiagnosed men (from 29% to 67%, p<0.0001) and HIV-negative men (from 26% to 62%, p<0.0001) suggests that undiagnosed infection might increasingly be recently acquired infection. The proportion of MSM reporting unprotected anal intercourse (UAI) in the past year increased from 43% (513 of 1187) to 53% (394 of 749; p<0.0001) and serosorting (exclusively) increased from 18% (207 of 1132) to 28% (177 of 6369; p<0.0001). 268 (2%) of 11 570 participants had undiagnosed HIV and reported UAI in the past year were at risk of transmitting HIV. Additionally 259 (2%) had diagnosed infection and reported UAI and non-exclusive serosorting in the past year. Although we did not collect data on antiretroviral therapy or viral load, surveillance data suggests that a small proportion of men with diagnosed infection will have detectable viral load and hence might also be at risk of transmitting HIV. 2633 (25%) of 10 364 participants were at high risk of acquiring HIV (defined as HIV-negative MSM either reporting one or more casual UAI partners in the past year or not exclusively serosorting). The proportions of MSM at risk of transmission or acquisition changed little over time (p=0.96 for MSM potentially at risk of transmission and p=0.275 for MSM at high risk of acquiring HIV). Undiagnosed men reporting UAI and diagnosed men not exclusively serosorting had consistently higher partner numbers than did other MSM over the period (median ranged from one to three across surveys in undiagnosed men reporting UAI, two to ten in diagnosed men not exclusively serosorting, and none to two in other men).

Interpretation: An increasing proportion of undiagnosed HIV infections in MSM in London might have been recently acquired, which is when people are likely to be most infectious. High UAI partner numbers of MSM at risk of transmitting HIV and the absence of a significant decrease in the proportion of men at high risk of acquiring the infection might explain the sustained HIV incidence. Implementation of combination prevention interventions comprising both behavioural and biological interventions to reduce community-wide risk is crucial to move towards eradication of HIV.

Abstract access  

Editor’s notes: Despite wide-scale ART coverage, HIV incidence among gay men and other men who have sex with men remains high in many high-income countries, and is increasing in some locations. Although expanded testing and treatment are expected to lower HIV incidence, there are concerns that changes in risk behaviour may offset the impact of ART on HIV transmission. In this paper, the authors illustrate that among gay men and other men who have sex with men in London, the proportion who had tested for HIV in the past year increased considerably over the period 2000 and 2013, with a corresponding decrease in the numbers with undiagnosed HIV.  However, there were increasing rates of condomless anal intercourse in both HIV-negative and HIV-positive men.  Furthermore, men living with HIV who were undiagnosed, and men who were not exclusively serosorting (having sex with partners of the presumed same HIV status), reported increased numbers of sexual partners over the period of the surveys. Despite the increases in recent HIV testing, three percent of men in 2013 incorrectly perceived themselves to be HIV negative. This suggests that many men who are undiagnosed may be recent infections, so could be at high risk of transmission. Previous modelling studies have illustrated that increased sexual risk behaviour, particular among people who are unaware that they are HIV positive, could account for the observed increase in incidence in gay men and other men who have sex with men. The findings of this study demonstrate the importance of core groups to the continued transmission of HIV. Test and treat programmes alone may not be sufficient to reduce HIV incidence in gay men and other men who have sex with men populations. There is the need for appropriately tailored combination prevention programmes in order to make real gains against HIV among gay men and other men who have sex with men.

Europe
United Kingdom
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Migration and HIV – a double synergy

Migration and HIV infection in Malawi.

Anglewicz P, VanLandingham M, Manda-Taylor L, Kohler HP. AIDS. 2016 Aug 24;30(13):2099-105. doi: 10.1097/QAD.0000000000001150.

Objective: To evaluate the assumption that moving heightens HIV infection by examining the time-order between migration and HIV infection and investigate differences in HIV infection by migration destination and permanence.

Methods: We employ four waves of longitudinal data (2004-2010) for 4265 men and women from a household-based study in rural Malawi and a follow-up of migrants (2013). Using these data, we examine HIV status prior to migration. Migrants are disaggregated by destination (rural, town, and urban) and duration (return and permanent); all compared with individuals who consistently resided in the rural origin ('nonmigrants').

Results: HIV-positive individuals have significantly greater odds of migration than those who are HIV negative [odds ratio 2.75; 95% confidence interval (CI) 1.89-4.01]. Being HIV positive significantly increases the relative risk (RR) that respondent will be a rural-urban migrant [RR ratio (RRR) 6.28; 95% CI 1.77-22.26), rural-town migrant (RRR 3.62; 95% CI 1.24-10.54), and a rural-rural migrant (RRR 4.09; 95% CI 1.68-9.97), instead of a nonmigrant. Being HIV positive significantly increases the RR that a respondent will move and return to the village of origin (RRR 2.58; 95% CI 1.82-3.66) and become a permanent migrant (RRR 3.21; 95% CI 1.77-5.82) instead of not migrating.

Conclusion: HIV-positive status has a profound impact on mobility: HIV infection leads to significantly higher mobility through all forms of migration captured in our study. These findings emphasize that migration is more than just an independent risk factor for HIV infection: greater prevalence of HIV among migrants is partly due to selection of HIV-positive individuals into migration.

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Editor’s notes: Previous studies in sub-Saharan Africa have identified that migrants are at greater risk of living with HIV than their non-migrant counterparts. There is however a lack of knowledge of the direction of causality between migration status and HIV status. This longitudinal study enabled analysis of the direction of causality between HIV acquisition and migration.  Individuals living with HIV were significantly more likely to migrate in the future than people who were not living with HIV.  The effect was seen for all types of migration (rural to rural, rural to town (district capital) and rural to urban (regional capital).

The true association between HIV status and migration status may exceed that illustrated as some individuals who were HIV negative at baseline may have become HIV positive prior to migration. The patterns identified could be driven by better healthcare being available in an urban setting. Alternatively individuals may move to avoid HIV-associated stigma in the relative anonymity of an urban environment. Previous research in Malawi has also illustrated that marriage and migration are closely linked. Thus marital dissolution following HIV infection may in part explain the patterns seen.  Further qualitative studies are necessary to investigate such factors.

This study illustrates that an increasing emphasis needs to be placed on HIV prevention in the rural communities from which migrants originate, in addition to focusing on the risk in the urban areas. 

Africa
Malawi
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